Free Request for Use of Restraints, Isolation, or Protective Equipment as Part of a Behavior Support Plan-F-62607 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62607 (Rev. 04/09)

STATE OF WISCONSIN Chapters 50.02(2) and 51.61(1)(i), Wis. Stats. DHS 83.32(3)(g) and 94.10, Wis. Admin. Code

REQUEST FOR USE OF RESTRAINTS, ISOLATION, OR PROTECTIVE EQUIPMENT AS PART OF A BEHAVIOR SUPPORT PLAN
Although completion of this form is voluntary, all the information requested on this form needs to be submitted as part of the approval process.
Name - Consumer Current Address - Consumer City Birth Date Type of Request

New
State

Review
Zip Code

Name - Guardian Current Residence - Consumer

Telephone Number - Guardian

Personal Residence (same address as above) Licensed or Certified Facility (Provide name and address below.) Other (Describe and provide address below.)
Street Address City State Facility Type Zip Code

Name - Facility

Facility Address

Telephone Number

City

State

Zip Code

FAX Number

Is the consumer's proposed placement other than the current residence?
Name ­ Facility

Yes (Provide name below.)
Facility Type

No

Address ­ Facility

Telephone Number

City

State

Zip Code

FAX Number

Name ­ Agency Submitting This Request Agency Contact Person Telephone Number FAX Number

Date Submitted E-mail Address

Address ­ Agency

City

State

Zip Code

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DEFINITIONS
Check "Yes" or "No," if the following apply. Yes No Physical Restraints Any device, garment, or physical hold that (a) restricts voluntary movement of a person's body or access to any part of the body and (b) cannot be easily removed by the individual. Physical or social separation from others by actions of staff but does not include separation in order to prevent the spread of communicable disease or cool down periods in an unlocked room as long as presence in the room by the resident is voluntary The application of a device to any part of a person's body that prevents tissue damage or other physical harm due to a person's behavior and cannot be easily removed by the individual.

Isolation

Protective Equipment

If the answer to any of the above definitions is "Yes," continue. PERSONAL SUMMARY
Type of Employment

Support Systems

Interests

Dislikes

HEALTH CONSIDERATIONS
Diagnoses

Health Concerns

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MEDICATIONS
Medication Dose Purpose Prescribing Physician

HEALTH PROVIDERS
Specialty Primary Physician Psychiatrist Psychologist / Therapist Neurologist
Other

Name

Address

Telephone

Other

Other

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TARGET BEHAVIOR
Describe or attach the person's challenging behaviors and the situations in which they occur.

Describe or attach the frequency and intensity of the above behaviors.

Describe or attach the patterns that have been observed when the behavior occurs, i.e., what triggers the behavior.

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Describe or attach the plan currently being done proactively to prevent these behaviors from occurring.

PREVIOUS SUPPORT STRATEGIES OR INTERVENTIONS
List and explain or attach previous support strategies or interventions, when they were tried, how long they were tried, and the outcomes. 1. Support Strategy

Outcome

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2.

Support Strategy

Outcome

3.

Support Strategy

Outcome

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4.

Support Strategy

Outcome

CURRENT AND PROPOSED STRATEGIES
Describe or attach the current and proposed strategies and safeguards for target behaviors. Include staffing patterns, level of supervision, restrictions, or limitations. Attach the current support plan / behavioral support plan, OT and PT evaluations, physicians orders, informed consent by the consumer or guardian.

WHAT IS THE NEED?
Explain or attach why the current strategies are ineffective. Describe what more is needed.

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RISKS & BENEFIT
Describe a risk and benefit analysis for the use of the restraint, isolation, or protective equipment.

RESTRAINTS, ISOLATION, OR PROTECTIVE EQUIPMENT Identify proposed procedure or device and why these strategies are needed.
ATTACH RELEVANT PHOTOS, MANUFACTURER SPECIFICATIONS, OR LITERATURE. Plan Procedure / Device Purpose
(Specify where procedure or device used, when, length of time, etc.)

Desired Outcome

PHYSICIAN ORDERS
Include written authorization by a physician, identifying the type of restraint ordered, the indication for its use, and the time period for its application.

INTERVENTION
Describe or attach the sequential process during which less restrictive measures will be used that precedes the use of restraints.

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REDUCTION AND ELIMINATION PLAN FOR RESTRAINTS, ISOLATION, OR PROTECTIVE EQUIPMENT
Describe or attach the plan for reducing and eventually eliminating the need for restraints.

TRAINING
Describe or attach the plan to provide initial and on-going training for staff. Identify who will conduct the training, his/her credentials, the duration of training, and how the training will be documented.

REVIEW
Describe or attach how the plan will be monitored, documented, and reviewed.

INDIVIDUALS HAVING INPUT INTO THE SUPPORT PLAN
Name Relationship to Consumer

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PLAN REVIEW
Plan Reviewed By Consumer, if not under guardianship * Guardian, if applicable * Placing Agency * Provider Agency * Behavior Consultant or Specialist Primary Physician Other Other Name Signature Date Reviewed

* Required signatures