Form CMS-R-306 Death Reporting Worksheet

PSYCHIATRIC RESIDENTIAL TREATMENT FACILTIES (PRTF)
DEATH REPORTING WORKSHEET
CONTACT INFORMATION
RO contact’s name
Date of RO contact
RO contact’s phone number
Facility contact
Facility contact’s phone number
PROVIDER INFORMATION
PRTF Name
Medicaid Number
Address
ZIP Code
PATIENT INFORMATION
Name
Date of Birth
Medicaid Number
Admitting Diagnoses
Date of Admission
Date/time of Death
Cause of Death
Did the facility conduct a root cause
analysis? (If so, please describe)
NOTE: PRTFs may provide the following information over the telephone, or to the
State Agency (SA) during its investigation
NOT RESTRAINT/SECLUSION RELATED - Yes___

No____

If yes to prior question, please specify length of time in restraints/seclusion:
Circumstances Surrounding the Death:
Results of any facility investigation:

RESTRAINT or SECLUSION INFO
Restraint Method:
Personal:
Mechanical:
Drug used as Restraint:
Seclusion:

NOT RESTRAINT RELATED
Accident:
Medical Condition:
Other:

Reason(s) for Restraint or Seclusion use:

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PSYCHIATRIC RESIDENTIAL TREATMENT FACILTIES (PRTF)
DEATH REPORTING WORKSHEET
RESTRAINT or SECLUSION INFO
NOT RESTRAINT RELATED
Less restrictive methods of behavior management considered:
Restraint/Seclusion order date/time:
Quote actual restraint or seclusion order(s)
Was the restraint or seclusion ordered by: Physician___ Other Licensed Practitioner_______
Were staff trained in the use of emergency safety interventions: Yes _______ No_______
Was the resident’s treatment team physician contacted (unless same as ordering physician)
N/A - same as ordering physician__
Yes______ No______
___
Was the resident evaluated immediately
after restraint removed or removed from seclusion?
Yes______ No______ NA
Monitoring method(s), frequency, last date/time monitored:
Last date/time of assessment:
Additional Information/Comments: (NOT RESTRAINT/SECLUSION RELATED)

Action Information

Facility Information

Other agencies the provider notified (SMA, DHS, SA, etc.):
Agency/date/time:
Agency/date/time:
Agency/date/time:
Agency/date/time:
Agency/date/time:
SA Action(s)
Date of receipt of restraint/seclusion death report from PRTF:
___________________________
Date of Survey: ________________________
RO Actions(s)

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PSYCHIATRIC RESIDENTIAL TREATMENT FACILTIES (PRTF)
DEATH REPORTING WORKSHEET
RESTRAINT or SECLUSION INFO

NOT RESTRAINT RELATED

Date of receipt of restraint/seclusion death report from PRTF:
___________________________
Date sent as a complaint to SA (if applicable)
________________________________________

CO Audit(s)
Date of receipt of initial restraint/seclusion death report from RO:
________________________
Date of receipt of restraint/seclusion death report worksheet:
____________________________
Person recording the information:
_________________________________________________
PRA Disclosure Statement
This information is being collected to assist the Centers for Medicare & Medicaid
Services (CMS) with monitoring of deaths in psychiatric residential treatment facilities
(PRTF) as well as the use of restraints and seclusion. This mandatory information
collection (42 U.S.C. 1396a) will be used at an aggregate level to monitor the overall
safety of children residing in PRTFs and the appropriate implementation of behavioral
interventions and the safe use of restraint and seclusion, only as necessary. Under the
Privacy Act of 1974 any personally identifying information obtained will be kept private
to the extent of the law. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid
Office of Management and Budget (OMB) control number. The control number for this
project is 0938-0833 (Expires: TBD). Public burden for all of the collection of
information requirements under this control number is estimated to range from 5
minutes to 8 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding this
burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn:
Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

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