Service Providers
Special Incident Reporting
SIR Vendor LTC reporting form revised 8.13.19_FINALMedication Error Diagnostic Tool with SIRA Special Incident Report, or SIR, is a formal report that is filed with the regional center. Service providers/ Vendors have the responsibility to report incidents to the regional center 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.
The regional center must be notified verbally of an incident within 24 hours of occurrence and written report received within 48 hours of incident. ALL Special Incident Reports (SIRs) must be emailed or faxed to:
SIR EMAIL: SIR@westsiderc.org
SIR FAX NUMBER: (877) 254-6903
Vendor may fill in the document, print, sign and email or fax to WRC SIR Email or Fax .
*UPDATE: As of January 1, 2017 vendor responsibilities when reporting Special Incidents involving the use of restraints have CHANGED. WRC revised our Special Incident Reporting Form to include reference to these changes in a fillable PDF document. We have also made the Post Emergency Restraint Response form a PDF fillable document. Please discard all other versions of WRC SIR Form and use this revised document.
Forms
Below are forms service providers can use to meet the mandate.
SIR Vendor LTC reporting form revised 8.13.19_FINAL
WRC Restraint Reporting form_modified 4.8.19 revised **NEW** Post Emergency Restraint Report (PERR)
Use of Restraint Reporting letter -*This letter explains your new reporting responsibilities-
SIR TIP SHEET 1-23-19 v2 Outside Agency Reporting Contact information
Vendor SIR Reporting Title 17 Regulations
Medication_Error Diagnostic Tool_WRC
Risk Management Tools
Service providers may find the documents listed below useful in both preventing and reporting SIRs.
Risk Assessment Evaluation & Planning
Risk Assessment Evaluation & Planning Worksheet
Risk Assessment Inventory: Falls
Risk Assessment Inventory: Major Depression
Risk Assessment Inventory: Osteoporosis
Risk Assessment Inventory: Physical & Nutritional Management
Risk Assessment Inventory: Skin Breakdown
Risk Assessment Inventory: Substance Abuse
Specific Clinical Risk Factors: Aspiration Pneumonia
Specific Clinical Risk Factors: GI Problems in People with Developmental Disabilities
Mandated Reporting Links
Adult Protective Services (APS) – State mandated Title XX service program which mandates the prompt investigation of all situations involving elders (age 65 or older) and dependent adults (physically or mentally impaired 18-64 year old) who are reported to be endangered by physical, sexual or financial abuse, abandonment, isolation, abduction, neglect or self-neglect or hazardous living conditions. Online reporting is accessible here.
California Poison Control System (CPCS) is the statewide provider of immediate, free and expert treatment advice and assistance over the telephone in case of exposure to poisonous, hazardous or toxic substances. Call us toll-free – 1-800-222-1222, 24 hours a day, 7 days a week, 365 days a year.
Department of Child and Family Services (DCFS) – Mandated reporters may now complete Child Abuse Reporting online.. It is necessary to make a phone report first and receive a reference number that will allow you to log in to the Mandated Reporters site to complete the written report.
Long Term Care Ombudsman – An Ombudsman is an individual who is trained and State-certified to objectively investigate and resolve complaints made by individuals against abuses. The Long Term Care OMBUDSMAN Program is a free and confidential service that maintains and improves the quality of life for resident in long-term care facilities.
Official California Legislative Information – Site is maintained by the Legislative Counsel of California and contains up-to-date information on law, legislative sessions, and bill information.
Restrains and Seclusion – This is the Senate Bill regarding use of restraints and seclusion in final version in H&S Code section 1180.3. (a)This section shall apply to psychiatric units of general acute care hospitals, acute psychiatric hospitals, psychiatric health facilities, crisis stabilization units, community treatment facilities, group homes, skilled nursing facilities, intermediate care facilities, community care facilities, and mental health rehabilitation centers. It is considered a “Best Practice” for all consumers.