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
Vendors of residential services must comply with ACRC Vendor Agreements and Title 17 Regulations. Service providers must have a Resident file for each resident, a Personnel file for each employee and a Residential Facility file for the home itself.
- P&I Reimbursement Policy
- ACRC Personal and Incidental Funds Instruction Manual
- Individual Emergency Intervention Plan
- Functional Assessment and Behavior Intervention Plan
- Residential Services Provider (RSP) Review of Client Progress on IPP Objective
- Resident Chart Table of Contents
- Client Rights
- Individual Consultant Log Form
- On-Going Notes
- Behavior Consultation Log
- HCBS Final Rules Signature
- Special Incident Report
- Centrally Stored Medication and Destruction
- Resident Personal Property and Valuables
- PRN Administration Record
- Medication Reason for Use
- Medication Administration Record (MAR)
- Weight Record
- Seizure Record
- Physician Visit
- Medication Transfer
- Grievance Procedure
- Dental Visit
- Consultation Hours Log
- Recent Photo and Physical Description
- Personnel Table of Contents
- On Site Orientation and On the Job Training Checklist
- Facility File Table of Contents
- Weekly Staff Schedule
- Weekly Resident Accountability
- Looking at Service Quality Provider Handbook
- Monthly Fire Drill Record
- Behavior Consultation Quarterly Progress Update Report
- Read more