CRW Restrictive Procedures QR9500

REVISED 10/14/22

Agency/Provider name:

W#:

Sample #

Individual's Name:

Reviewer name:

Review participant incident/injury reports from the past 6 months. Look for incidents where either a restraint/physical hold or a restrictive intervention/discipline was applied. Select any 2 of these types of incidents and record the date and type of incident. Refer to the participant's behavior management plan, agency training records, and agency's behavior management policies to complete the worksheet.

  • The restrictive procedure that was applied must appear in either the participant's Implementation Strategy or Behavior Management Plan.
  • Informed consent of the participant/guardian must be obtained for all restrictive procedures.
  • All Restrictive Procedures including psychotropic medications must be approved annually by the HRC

Behavior Treatment In Residential Child Care Facilities

Incident #1 Date:  _ Restraint _ Restrictive Intervention

Incident #2 Date: _ Restraint _ Restrictive Intervention

Incident #1 - - Incident #2 - - Requirement Comment/Notes Remediation on/Required by
Yes No N/A Yes No N/A 1. Was the restriction/discipline reviewed by the administrator/designee within 48 hours of implementation? - -
- - - - - 1. Was the restriction/discipline reviewed by the administrator/designee within 48 hours of implementation? - -
- - - - - - 2. If the procedure was disapproved by an administrator, was appropriate corrective action implemented? - -
- - - - - -

3. Staff who implemented the restrictive procedure have received training in the procedure (Select at least 1 staff member who was involved in each incident and check their training records)

Incident 1- Staff:
Trained:

Incident 2- Staff:
Trained:

 - -
- - - - - - 4. If the individual was injured because of the restrictive procedure, proper medical attention was provided and an Unusual Incident Report was filed with DCFS. - -
- - - - - - 5. Restraint was only applied when a participant presented a threat of physical harm to themselves or others - -
- - - - - - 6. If restraint was used 5 or more times during a rolling 30-day period then an Unusual Incident Report was filed with DCFS. - -
- - - - - - 7. The Restrictive Intervention(s)/Discipline(s) were avoided: verbal abuse, verbal threats, derogatory remarks, corporal punishment, withholding of food, withholding of visits/calls from family and professionals, withholding clothing (unless indicated for safety reasons), withholding sleep or exercise, imposing exercise, forcing child to take uncomfortable position, discipline for toileting accidents, withholding educational services, withholding personal hygiene items, mechanical devices. - -
- - - - - - 8. If restrictive intervention included removal of privileges, property, or assignment of additional tasks, then the duration was limited to less than one month. - -
- - - - - - 9. If restrictive intervention included restricting the participant to his/her room, then restriction was for periods not to exceed 3 hours per day. - -
- - - - - 10. If restrictive intervention included withholding the participant's personal spending money, then these guidelines were followed:
  • Oral warning was given that spending money could be reduced
  • Duration limited to not more than one month
  • Opportunities provided to earn the money back
  • Records maintained so any unearned money can be
  • returned at discharge
 - -
- - - - - - 11. Restrictive Intervention/discipline was imposed within 24 hours of the agency learning of the behavior. - -

Reviewer supplemental notes: