TransparencyPost-Emergency Restraint Report Forms
It is necessary for ACRC to evaluate the appropriate use of emergency intervention procedures including restraint. Service providers shall submit the Post Restraint Reporting form along with the SIR they submit for a restraint. Questions regarding this can be directed to Julie Rachfal, SIR Coordinator jrachfal@altaregional.org or (916) 978-6337.
Post-Emergency Restraint Report Form-SIR - ARM Level
Post-Emergency Restraint Report Form-SIR - CCH/EBSH
Special Incident Reporting (SIR) Forms/Documents
Service providers have the responsibility to report incidents that impact a client’s health and/or safety while the client is receiving services or supports, or if the client is a victim of a crime, or dies, regardless of when or where the incident occurred. Please refer to Title 17, Section 54327 for reporting requirements. Below are forms and SIR resources to assist service providers with meeting the mandate.
Forms:
Instructions for Completing ACRC SIR Form
- Mandated Reporting Requirements Flow Chart -SIR
- Under Vendored Care
- Special Incident Reporting Requirements
- ACRC Shared Information Report Instructions
- Vendor Special Incident Report List
- Special Incident Reporting Training Booklet
- Incidents of Behavioral Restraints Seclusion and Involuntary Emergency Medication
- Vendor Supplement Information of Types of SIRs
- Read more
Residential Provider Forms
When it comes to documentation, providers of residential services must comply with ACRC Vendor Agreements and Title 17 Regulations. Service providers must have a Client file for each resident, a Personnel file for each employee and a Residential Facility file for the home itself.
- Client File Table of Contents
- Residential Progress Review
- Recent Picture/Physical Description (format optional)
- Client Weight Record (format optional)
- Seizure Record (format optional)
- Dental Visit- (must use this form)
- Physician Visit (must use this form)
- Physician Order (format optional)
- Facility/Physician Telephone Communication Form (format optional)
- Appointment Summary (format optional)
- Medication Reason for Use (must use this form)
- Medication Transfer Sheet (must use this form)
- PRN Medication Record (format optional)
- PRN Authorization Letter (must use form)
- On-Going Notes (format optional)
- Daily Activity Log (format optional)
- Direct Care Staffing Checklist (format optional)
- Direct Support and Professional Training Certification Information
- Residential File Table of Contents
- Weekly Staff Schedule (format optional)
- Weekly Resident Accountability (format optional)
- Fire Drill Record (format optional)
- Consultant Log (must use this form)
- Mandated Reporting for Children
- Mandated Reporting for Elderly and Dependent Adults
- Behavior Consultation Guideline and Form
- Grievance Form (must use this form)
- ACRC Personal and Incidental Funds Instruction Manual
- Looking at Service Quality Provider Handbook
- Residential Behavior Consultation Log
- Read more