Reporting Requirements for Programs and Facilities
Within 24 hours after the death of a client or learning of a death:
The program or facility that was providing care, treatment or services to the client is required under Wisconsin statutes to notify the Department of Health Services (DHS) if there is cause to believe that the death was related to:
- the use of a physical restraint or seclusion
- the use of one or more psychotropic medications
- a suspected suicide.
Notification to DHS must be reported to by completing the Client/Patient/Resident Death Determination, F-62470 (PDF).
Form F-62470 includes guidelines to assist programs and facilities in determining if there is reasonable cause to believe the client/patient/resident death may be related to the use of restraint/seclusion, the use of psychotropic medication or is a suspected suicide.
- Section II on page 1 lists the provider types required to report
- Section V on pages 4-5 provides "General Information and Death Determination Guidelines"
Submit the completed form by fax or email to:
Department of Health Services
Division of Quality Assurance/Office of Caregiver Quality
- 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
- Nursing Home – Wis. Stat. § 50.04(2t)(b)
- Treatment Facility (mental health or substance abuse program/service) – Wis. Stat. § 51.64(2)(a)
For questions regarding reporting requirements, please email or call the Office of Caregiver Quality at 608-261-8319.
to other Agencies
- Hospital Restraint/Seclusion Deaths: 42 CFR & 482.13(g)
A death associated with restraint and/or seclusion in a hospital is to be reported directly to the Centers for Medicare & Medicaid Services (CMS) Regional Office. Pursuant to 42 CFR §482.13(g) and CMS S&C: 14-27-Hosptial-CAH/DPU, all hospitals (including rehabilitation or psychiatric distinct part units in Critical Access Hospitals) must use form CMS-10455 to submit required reports.
Submit the CMS-10455 report to CMS Region 5 (Chicago):
- via fax at 443-380-8952 or
- via confidential email to email@example.com.
Questions regarding reporting of hospital restraint/seclusion deaths may be directed to CMS Region 5 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 (PDF) 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 1 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 2016-04, Reporting Serious Incidents. Report Serious Incidents to DCF using form DCF-F-CFS2146-E which can be found at the Child Welfare Licensed Facility Forms and Publications website.