Reporting of Client/Patient/Resident Death

• Client/Patient/Resident Death Determination, F-62470 (PDF)

  Submit the completed form by fax or email to:

  Department of Health Services
  Division of Quality Assurance/Office of Caregiver Quality
  Fax: 608-264-6340

  Email: DHSCaregiverIntake@dhs.wisconsin.gov

• DQA Numbered Memo 16-008 (PDF) – Centralized Reporting of Client/Patient/Resident Death Determination

The reporting requirements are found under:

• Community-Based Residential Facility – Wis. Stat. § 50.035(5)(b)
• Adult Family Home – Wis. Admin. Code § DHS 88.03(5)(e)1
• Adult Day Care Centers – Wis. Admin. Code § DHS 105.14(2)(k)
• Nursing Home – Wis. Stat. § 50.04(2t)(b)
• Treatment Facility (mental health or substance abuse program/service) – Wis. Stat. § 51.64(2)(a)

• Hospital Restraint/Seclusion Deaths: 42 CFR § 482.13(g) (PDF)

  In accordance with requirements at 42 CFR § 482.13(g), Death Reporting Requirements, all patient deaths associated with restraint or seclusion (except 2-point soft wrist restraints that must be recorded in an internal hospital log or other system) in a hospital are required to be reported to the Centers for Medicare & Medicaid Services (CMS) Regional Office (RO).

  CMS Memo QSOG-20-04-Hospital-CAH DPU (PDF), "Electronic Form CMS-10455, Report of a Hospital Death Associated with Restraint or Seclusion," provides information on the process that hospitals (including rehabilitation or psychiatric distinct part units in critical access hospitals) must use to report a patient death associated with restraint or seclusion, using an electronic report form. The electronic version of Form CMS-10455 is replacing the paper version starting December 2, 2019. Beginning January 1, 2020, the CMS RO resource mailboxes will no longer accept paper versions of Form CMS-10455.

  Questions regarding reporting of hospital restraint or seclusion deaths may be directed to the CMS Chicago Region Office at 312-353-9804.

  Note: A hospital may have a mental health inpatient unit certified under Wis. Admin. Code §§ DHS 61.71 or DHS 61.79 or a medically monitored/managed treatment program certified under DHS 75.06, DHS 75.10, or DHS 75.11. A death in these settings must be reported to DHS via the Client/Patient/Resident Death Determination, F-62470 if there is reasonable cause to believe that the death was related to the use of restraint/seclusion, psychotropic medications, or was a suicide.

• Hospice Restraint/Seclusion Deaths: 42 CFR § 418.110(p)

  A hospice must report restraint/seclusion deaths directly to the Centers for Medicare & Medicaid Services (CMS), Office of the Regional Administrator (Chicago Regional Office) at 312-886-6432.

  The hospice must report:

  • Each unexpected death that occurs while a patient is in restraint or seclusion.
  • Each unexpected death that occurs within 24 hours after the patient has been removed from restraint or seclusion.
  • Each death known to the hospice that occurs within one week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient's death.

• Residential Care Centers for Children and Youth

  Refer to Wisconsin Department of Children and Families (DCF), Child Welfare Licensing Series Memo 2017 – 04L, Reporting Serious Incidents (Re-issued) (PDF). A death that is related to a psychotropic medications, physical restraint/seclusion or is a suicide must be reported using form DCF-F-CFS-2183-E, Resident Care Center Statutorily Reportable Death (Word). The death should also be reported as a serious incident using form DCF-F-CFS2146-E, Serious Incident Report (Word). Forms can be found at the Child Welfare Licensed Facility Forms and Publications website.

Wisconsin Suicide Prevention Plan

Suicide in Wisconsin: Impact and Response (PDF) – Wisconsin Data and the Wisconsin Suicide Prevention Plan, Released September, 2020. Suicide continues to grow as a public health issue in Wisconsin:

• 887 Wisconsin residents died by suicide in 2018.
• The suicide rate in Wisconsin increased 40% from 2000 to 2017.
• 271 adolescents (ages 10-19) died by suicide from 2013-2017.
• 71% of all deaths by firearms in Wisconsin from 2013 through 2017 were suicide deaths.
• The suicide rate was highest among individuals ages 45-54, 2013-2017.
• Veterans accounted for almost 1 in every 5 suicide deaths 2013-2017.

More information on Wisconsin data as well as the state's suicide prevention plan are found on the Department of Health Services (DHS) Suicide Prevention webpage.

Zero Suicide in Wisconsin

The Zero Suicide framework is a system-wide, organization commitment to safer suicide care in health and behavioral health systems. The Zero Suicide Toolkit is a detailed guide to Zero Suicide implementation and strategy.

For more information, please visit the Zero Suicide Wisconsin website or attend the Zero Suicide training.

Suicide Prevention Resources

Suicide Prevention Resources and Organizations

• DHS Wisconsin Suicide Prevention webpage
• Zero Suicide Toolkit – Suicide Prevention Resource Center (SPRC)
• Prevent Suicide Wisconsin and the Prevent Suicide Wisconsin Steering Committee
• Suicide Care Training Options – SPRC
• Question, Persuade, Refer, Train (QPRT): Suicide Triage QPR Institute
• Preventing Suicide in Emergency Department Patients Suicide, Prevention Resource Center
• Engaging People with Lived Experience

Evidence-based Tools

• Columbia Suicide Severity Rating Scale (C-SSRS)
• Safety Plan Template – Stanley-Brown
• Counseling on Access to Lethal Means (CALM) – free web-based training

Evidence-based Treatments

• Assessing and Managing Suicide Risk (AMSR) Suicide Prevention Resource Center
• Chronological Assessment of Suicide Events (CASE) Shawn Shea, PhD
• Collaborative Assessment and Management of Suicidality (CAMS) CAMS-care, LLC
• Dialectical Behavior Therapy (DBT) Behavioral Tech: A Linehan Institute Training Company
• Recognizing & Responding to Suicide Risk American Association of Suicidology

Safer Care Transitions

• Promote Social Connectedness and Support
• Safe Care Transitions
• Continuity of Care for Suicide Prevention: The Role of Emergency Departments (PDF)
• Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care