DSL MEMO SERIES 2001-32

December 26, 2001

STATE OF WISCONSIN
Department of Health and Family Services
Division of Supportive Living

To:
Alcohol and Drug Abuse Coordinators
Area Administrators / Assistant Area Administrators
Bureau Directors/Section Chiefs
Certified AODA Treatment Facilities / Programs
Certified Mental Health Inpatient Facilities
Certified Mental Health Outpatient Facilities / Programs
Certified Mental Health Outpatient Clinics
Community Based Residential Facilities
Community Support Programs
County Departments of Community Programs Directors
County Departments of Human Services Directors
County Departments of Social Services Directors
County Departments of Developmental Disabilities Services Directors
Facilities for the Developmentally Disabled
Mental Health Coordinators
Tribal Chairpersons / Human Services Facilitators
Wisconsin Hospitals
Wisconsin Nursing Homes

From:
Sinikka McCabe, Administrator
Division of Supportive Living

Re: Revised Death Reporting Form DSL-2470 (Supplements DSL Info Memo 2000-14 dated December 7, 2000)

Toward the end of CY 2000 the revised death reporting procedures and reporting form DSL 2470 (12/2000) were issued to all licensed and certified providers with BQA Memo 00-054 dated
November 10, 2000. All of these materials were also sent to county agencies and Tribal Chairpersons / Human Services Facilitators with DSL INFO MEMO 2000 – 15 dated December 7, 2000. A supplemental BQA memo 01-054 on Pronouncement of Death, Scene Preservation, Reporting Requirements and Removal of Bodies will be issued on December 28, 2001. These reporting procedures should be followed for all reportable deaths.

Attached is a more recently revised reporting form DSL 2470 (rev. 08/2001). The only change in this form is the addition of point number 4 under "C. Physical Restraints and Seclusion" on page 2. Point number 4 asks if the client was in a prone position when a physical restraint was used. This question is added because national data of reportable deaths appears to draw a connection between the death of a person when a physical restraint is applied when the person is in a prone position.

Starting January 15, 2002, use this revised form when reporting a death to the Department. Please discard all previously issued death reporting forms with issue dates of (12/2000), (05/1996) and (07/1994). We continue to receive discontinued reporting forms from 1994 and 1996. This makes it difficult to maintain a uniform database.

When completing the identifying information on page 1 of the revised form, please be sure to insert in the space titled "Number – Provider Type" the correct number that corresponds to your program type from the "Provider Type and Number" list on page 2. Also, the box for "Self Report" should be checked if the person reporting the death is a representative (usually an employee) of the provider listed after the client’s name.

The revised Client / Patient Death Determination Form DSL 2470 (Rev. 08/2001)may be obtained via the Department of Health and Family Services’ Web Site at: http://www.dhs.wisconsin.gov/forms1/F6/F62470.pdf

The Death Reporting Procedures and revised reporting form DSL 2470 (rev.08/2001) may also be obtained by contacting:

Curtis Wittwer, Training Coordinator
Division of Supportive Living
P.O. Box 7851
Madison, WI 53707-7851
(608) 267-4896 (voice)
wittwcd@wisconsin.gov

For more information about the death reporting procedures or reporting form, please contact the Central Office Coordinator, Michael A. Peters.

Regional Office Contact:
Area Administrators

Central Office Contact:
Michael A. Peters
Coordinator of Special Investigations
Division of Supportive Living
1 West Wilson Street
P.O. Box 7851, Room 558
Madison, WI 53707-7851
(608) 266-6989 (voice)
Email: peterma@wisconsin.gov

cc
Consumer Organizations
NAMI of Wisconsin and Local Affiliates
State Council on Alcohol and Other Drug Abuse
Wisconsin Coalition for Advocacy
Wisconsin Council on Developmental Disabilities
Wisconsin Council on Mental Health

Return to Numbered Memos Index