ISSA Visiting Notes: Revision of Form

Department of Human Services
Division of Developmental Disabilities
Information Bulletin

ISSA Visiting Notes: Form Revision


As part of the guidelines for Individual Service and Support Advocacy (ISSA) providers, the Department requires the use of a Visiting Notes form. This form has been revised to comply with expectations from the Centers for Medicare and Medicaid Services regarding the use of restraint and seclusion.

Revised Form

The Division has revised this form to include item #18 requiring the ISSA staff to confirm that the individual is free from unauthorized use of restraint and seclusion.  Please see attached ISSA Visiting Notes Tool (doc)

Use of the Revised Form 

This form is to be used by the ISSAs during quarterly visits as required by the Medicaid Waivers for individuals with developmental disabilities. In monitoring for unauthorized use of restraint and seclusion, ISSAs should interview individuals and guardians, talk with staff, review records (including progress notes) and be alert for an individual's unexplained injuries, red marks, abrasions, etc.

Reporting of Unauthorized Use of Restraint or Seclusion or Injuries Resulting from the Use of Restraint

Any findings of unauthorized use of restraint and seclusion, or of injuries to individuals resulting from the use of restraint regardless of authorization, are to be reported via the Referral to DHS Division of Developmental Disabilities for Monitoring and/or Technical Assistance form. Attach the Visiting Notes form with the referral and submit both within two business days to:

Division of Developmental Disabilities
Bureau of Quality Management
319 East Madison, Suite 4J
Springfield, IL 62701

Fax: (217) 782-9444

Findings should be documented on the Visiting Notes form, discussed with the provider and addressed as necessary. Addressing the findings may include reporting potential abuse to the appropriate entity, working with the provider to develop or modify behavior plans and/or any additional action that may be appropriate to the specific circumstances.

The Division will track and analyze reports received from the ISSAs. The Division will monitor both the provider's and ISSA's activities through these reports, identify additional remediation needs, and implement systemic changes when necessary.

Links to Requirements Regarding Restraint and Seclusion

Effective Date

This version of the Visiting Notes form may be used effective immediately with the release of this Informational Bulletin; however, this version must be used beginning August 1, 2011. Earlier versions of the form dated on or after August 1, 2011 will not be acceptable to regulatory compliance reviewers.