Pennsylvania Code
Title 55 - HUMAN SERVICES
Part VIII - Intellectual Disability and Autism Manual
Subpart A - Statements of Policy
Chapter 6000 - STATEMENTS OF POLICY
Subchapter R - PROCEDURES FOR SURROGATE HEALTH CARE DECISION MAKING
STATUTES
Appendix I - ABBREVIATED INCIDENT REPORT

Restraint

The data entry screen is to include the following information:

* DEMOGRAPHICS (prepopulated from HCSIS demographics)

Name of the individual for whom the Restraint was used.

Individual's Base Service Unit (BSU) number.1

1 If the individual is not registered with a County MH/MR Program, the report is to list the county or state where the person is/was a resident.

* CATEGORIZATION

Secondary category of Restraint.

Date of the Restraint.

Time in Restraint.

Time out of Restraint.

* RESTRAINT INCIDENT INFORMATION

Restraint agent.

Antecedent to the Restraint.

Reason for the Restraint.

Indication if the Restraint was used on a planned or emergency basis.

Authorizing Staff.

Indication if Prone (face down) Restraint was used.

Indication if another Incident Report was filed as a result of the Restraint.

If another Incident Report was filed the Incident ID number.

This appendix cited in 55 Pa. Code § 6000.923 (relating to incidents to be reported within 72 hours).