Service Providers
Special Incident Reporting
A 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. Per CCR TITLE17 §54327
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
Special Incident Reporting Forms
The forms below can be used to meet reporting requirements. Service providers/ vendors must fill in the appropriate document, sign it, and submit the completed report via email (preferred) or via fax. An electronic signature is accepted for the Special Incident Report (SIR) via Adobe PDF. Please make sure that the submitted document(s) are legible.
When you email the SIR, the email MUST be signed and encrypted in order to stay in compliance with HIPAA regulations. Include who you made a verbal report to at WRC and the date. This method should be used if you have already reported a SIR to an SC by telephone, but need to meet the requirements for submission of the written report. HIPAA does not prohibit the electronic transmission of Personal Health Information (PHI). Electronic communications, including email, are permitted, although HIPAA-covered entities must apply reasonable safeguards when transmitting e-PHI to ensure the confidentiality and integrity of data. March 14, 2021, See 45 C.F.R. § 164.530(c). This includes end-to-end encryption. Failure to meet these requirements could result in a heavy fine per violation.
- Vendor Reporting Instructions SIR 5.6.21
- NEW*WRC SIR Vendor LTC Reporting 8-24-21
- WRC Post Emergency Restraint Report PERR modified V8.12.20
- Report of Suspected Dependent Adult/ Elder Abuse – SOC 341
- Medication Error Report Diagnostic Tool
- WRC COVID-19 Form For Vendor/Providers Employee/Staff
- WRC COVID-19 Form For Consumer
COVID-19 Reporting
WRC is requesting that vendors or Long-Term Care providers complete a form for known or suspected cases of Coronavirus Disease 2019 (COVID-19) among clients and/ or the staff who support them in Residential, Long-Term Care Supported Living, or Independent Living. This does not replace the SIR form; it is a supplemental form to track the COVID-19.
What you need to know about COVID-19:
Coronavirus Disease 2019, also referred to as COVID-19, is a type of virus that has caused a recent outbreak of respiratory illness. The virus is thought to spread mainly from person-to-person:
- Droplets produced through coughing, sneezing, and talking
- Close personal contact, such as caring for an infected person
Fully 1/3 of people who get COVID-19 do not show any symptoms but can still spread the virus. That means you have to treat everyone you meet as if they could be infected and pass the virus on to you. It also means you might be infected and not know it. COVID-19 may also spread by touching a surface or object that has the virus on it and then touching the mouth, nose, or eyes, but this is not thought to be the main way the virus spreads.
Recognize the symptoms of COVID-19
People who have COVID-19 and do have symptoms have reported a range of illness from mild symptoms to severe illness which may require admission to the hospital or even lead to death. Symptoms include:
- Fever (above 100.4 F) or chills
- Cough
- Shortness of breath or difficulty breathing
- Fatigue
- Muscle or body aches
- Headache
- New loss of taste or smell
- Sore throat
- Congestion or runny nose
- Nausea or vomiting
- Diarrhea
Based upon available information to date, those at high-risk for severe illness from COVID-19 include:
- People aged 65 years and older
- People who live in a nursing home or long-term care facility
People of all ages with underlying medical conditions, particularly if not well controlled, including:
- People with chronic lung disease or moderate to severe asthma
- People who have serious heart conditions
- People who are immunocompromised (i.e. cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications
- People with severe obesity (body mass index [BMI] of 40 or higher)
- People with diabetes
- People with chronic kidney disease undergoing dialysis
- People with chronic kidney disease undergoing dialysis
Other at-risk populations:
- People who are pregnant should be monitored since they are known to be at risk with a severe viral illness, however, to date data on COVID-19 has not shown an increased risk
- People with developmental and behavioral disorders such as ADHD, Autism, Cerebral Palsy, Fetal Alcohol Spectrum Disorder (FASD), Fragile X, Intellectual Disability, Learning Disorder, Tourette Syndrome
- If you have one of the disability types listed below, you might be at increased risk of becoming infected or having an unrecognized illness.
- People who have limited mobility or who cannot avoid coming into close contact with others who may be infected, such as direct support providers and family members
- People who have trouble understanding information or practicing preventive measures, such as hand washing and social distancing
- People who may not be able to communicate symptoms of illness
DDS Directive for SIR Related to COVID-19: 5/25/2020
Effectively immediately, providers and regional centers must complete a special incident report for any of the following events, even if the incident does not otherwise meet the California Code of Regulations, Title 17 reporting criteria:
- An individual tests positive for COVID-19;
- An individual receives medical attention at a hospital, emergency room, or urgent care clinic due to COVID-19 symptoms; or
- An individual’s death is related to COVID-19, either by confirmed COVID-19 positive testing or by medical diagnosis unconfirmed by testing.
Providers and regional centers should only report COVID-19 related incidents that meet these requirements and clearly indicate in the incident description box the reporting criteria met. If you have any questions regarding this Directive, please contact Leslie Morrison at (916) 214-3706 or lesliemorrison@dds.ca.gov . Click here for an updated list of COVID-19 symptoms from the Center for Disease Control & Prevention (CDC).
Reporting Requirements & Related Laws
- Mandated Reporter Flowchart for Long-Term Facilities
- Guidance for Reporting Incidents Related to COVID-19
- DDS Directive: Amended Requirements for Reporting Special Incidents Related to COVID-19 in SANDIS Revised 5/22/2020
- Checklist: Medication Administration
- New Expanded Reporting Requirements for Special Incidents – 2017 Letter to Service Providers/ Vendors
- Notice to All APS Mandated Reporters
- Regional Center Responsibilities for Reporting -Welfare and Institutions Code Section 4659.2
- Use of Seclusion and Behavioral Restraints in Facilities – Health and Safety Code 1180 – 1180.6
- Serious Bodily Injury – Welfare and Institutions Code Section 15630.67
- Vendor SIR Reporting Title 17 Regulations
- DDS Risk Management & Mitigation webpage
Risk Management Tools
Regional Center staff, Service Providers and families may find the documents listed below useful in both preventing and reporting Special Incident Reports (SIRs).
- Checklist: Aspiration/ Aspiration Pneumonia
- Checklist: Impaction & Severe Constipation
- Checklist: Insulin Dependent Diabetes
- Checklist: Epilepsy
- Checklist: Gastronomy Tube (G-Tube) Feeding
- Checklist: Osteoporosis
- Checklist: Staphylococcus “Staph” Infection
- Checklist: Weight Management
- Clinical Professionals – Medical Risks Factors and Prevention of Falls and Fractures
- Incident Response Card
- Incident Response Checklist
- Preventative Action Checklist
- Preventing Falls
- Preventing Falls and Fractures – Information for Supporters and Providers
- 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
- Risk Management Training Manual
- 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.
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.
Semi-Annual Risk Management SIRs
Mortality and Non-Mortality Special Incident Reports Combined
This semi-annual report summarizes mortality and non-mortality special incident rates for individuals with developmental disabilities served by regional centers.
Mortality Special Incident Reports
This semi-annual report summarizes mortality special incident rates for individuals with developmental disabilities served by regional centers.
Non-Mortality Special Incident Reports
This semi-annual report summarizes non-mortality special incident rates for individuals with developmental disabilities served by regional centers.
Resource Links
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.
Center for Disease Control and Prevention (CDC) has a COVID-19 webpage for Direct Service Providers (i.e. personal care attendants, direct support professionals, paraprofessionals, therapists, and others)
Department of Developmental Services for COVID-19 Information and Resources page provides links to general information about COVID-19, approved changes to increase flexibility for providers, resources and more.
DDS Health Toolkit: Bridge to Wellness is a new website that provides information and tools related to health and safety for self-advocates, direct support professionals (DSPs), and vendors or providers.
Department of Developmental Services (DDS) SafetyNet is a website with health and safety information for individuals with developmental disabilities and for the people who support them. On this site you will find: articles, slideshows, and videos; tools to use in your everyday life; links to online resources; and more!
Official California Legislative Information – This site is maintained by the Legislative Counsel of California and contains up-to-date information on law, legislative sessions, and bill information.
Preventative Health Campaign – Flu and pneumonia are common causes of serious illness and even death, and these diseases are largely preventable. The best way to prevent flu and pneumonia is to get vaccinated. The California Department of Developmental Services is launching a campaign to get everyone with a developmental disability vaccinated for flu, and everyone vaccinated for pneumonia if they are 65 years old or older, as well as those from 19 to 64 years old who have a chronic health condition. DDS has created materials for this campaign. These materials include informational brochures on the flu vaccine and the pneumonia vaccine, and a poster, in English, Chinese, Spanish, Tagalog, and Vietnamese. Campaign materials, related videos, and articles are also available on the DDS SafetyNet Website.
Informational Videos by Westside
Practical Tips to Manage Stress and Anxiety During the Pandemic
In this webinar geared towards regional center service providers, Dr. Mayra Mendez presents on coping tools to manage stress-related anxiety. Specifically, she discusses isolation, grief and loss of people, activities, income, and social connections due to COVID-19.
Presenter: Dr. Mayra Mendez, Ph.D.
Recorded Live: June 10, 2020