Fillable Westside Regional Center - SIR Vendor LTC Reporting Form

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Westside Regional Center - SIR Vendor LTC Reporting Form

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The Westside Regional Center - SIR Vendor LTC Reporting Form form is 2 pages long and contains:

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  • 63 check-boxes
  • 55 other fields

Country of origin: US
File type: PDF

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Reporting Vendor/ Long-term Care
Provider Name:
Vendor Number:
Client Name:
Date:
CONFIDENTIAL CLIENT INFORMATION – W&I CODE, SECTION 4514
Report to Regional Center
Special Incident Report and Other Observations and Events
1.
2.
3.
4.
5.
INSTRUCTIONS
Notify Westside Regional Center (WRC) of all special incidents within 24-hours verbal report, (310) 258-4000
Submit written report within 48-hours,
WRC SIR Fax 1-877-254-6903 or email to sir@westsiderc.org
Notify applicable licensing (CCL, DHS, APS, Ombudsman, Police) entity per regulations.
Notify responsible person, (i.e., parent, guardian, conservator) per requirements.
Submit SIR updates to WRC within 30-days
Consumer Name:
Sex:
Date of Birth: UCI Number Date of Report:
M
F
Check Applicable
Verbal
Non- Verbal
Ambulatory Non-Ambulatory Conserved Yes
No
Date of Incident:
Time of Incident:
Site of Incident:
SPECIAL INCIDENTS (TITLE 17, §54327) OTHER OBSERVATIONS AND EVENTS
Death of a consumer (regardless of where or
when)
The consumer was a victim of a crime (regardless
of where or when)
The consumer is missing and the vendor has
filed a missing persons report with a law
enforcement agency
Reasonably suspected abuse, exploitation or neglect:
Behavioral Crisis episode:
Use of restrictive behavior intervention/ physical containment , Chemical
restraint drug used to control behavior (not to treat medical condition) I.D. Team
Staffing within 24-Hours required per H&S Code 1180-1180.6
(Restraint/Seclusion) WIC §4659.2
Complete Post Emergency Restraint (PER) form
MANDATED REPORT REQUIRED Other Behavior episode:
Failure to provide: Medical care for
Physical Abuse
Sexual
Fiduciary
Psychological
Physical Restraint
Chemical Restraint
physical and mental health needs;
Prevent malnutrition or dehydration;
Protect from health and safety hazards;
Assist in personal hygiene or the
provision of food, clothing or shelter; or
Exercise the degree of care that a
reasonable person would exercise in
the position of having the care and
custody of an elder or dependent adult.
Verbal aggression
Aggressive act to self
Aggressive act to consumer
Aggressive act to staff
Aggressive act to family/visitor
Property damage
Suicide episode:
Attempt
Threat
Unplanned / Unscheduled hospitalization due to: Other occurrence involving:
Respiratory illness
Seizure-related
activity
Cardiac-related
activity
Internal infection
Diabetes-related
Wound/ skin care
Nutritional deficiencies
Involuntary psychiatric
admission
Alleged violation of
consumer's rights
Other sexual incident:
Sexual harassment
Inappropriate sexual contact
Earthquake
Vehicular accident
Pregnancy
Medical Emergency
Emergency room visit
Seizure
Injury Unknown Origin
Fire
Other:_
A serious injury or accident including:
Other Consumers/ Staff Present: (Include the full name and relationship )
Laceration(s) requiring sutures
Fractures
Dislocations
Burns, bites, puncture wounds, internal bleeding, or
medication reactions requiring medical treatment
beyond first aid
ANY medications errors (Complete Medication Error
Diagnostic form)
Medical Treatment: (If yes, describe)
Yes
No
Where Administered?
V. 8.13.2019
Vendor Type (check one): CCF: LTC: CPP/CRDP: SLS: OTHER:
Client Name:
Date:
CONFIDENTIAL CLIENT INFORMATION – W&I CODE, SECTION 4514
Reporting Vendor/ Long-term Care
Provider Name:
Vendor Number:
(Attach a separate page for additional information if necessary)
Description of Incident (Include possible cause of incident / who, what , when where, how & why)
Immediate Action Take by Service Provider/ Staff (Vendor/Administrator/Licensee/Other)
Plan To Prevent Further Occurrences
Submit Follow-Up Plan within 30-days/ Comments
Report Submitted By:
Contact Date
Name :
Vendor Address :
Reviewed by Name:
Other Agencies/Individuals Notified/
Contact Name:
Contact Date
Regional Center
Vendoring Regional Center notified for all
Title 17 reportable incidents
Licensing (DSS /DHS)):
Parent/Guardian/Conservator:
Physician/Hospital:
Child/Adult Protective Services: include name
& reference #
Long-Term Care Ombudsman
Police/Sheriff: report #
Disability Rights California per WIC §4659.2
California Department of Development (DDS)
V. 8.13.2019
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Westside Regional Center - SIR Vendor LTC Reporting Form

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Completed 26 May 2020

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