February 7, 2001

Department of Health and Family Services
Division of Children and Family Services

To: Area Administrators/Assistant Area Administrators
Bureau Directors
County Department of Community Programs Director
County Departments of Developmental Disabilities
       Services Directors
County Departments of Human Services Directors
County Departments of Social Services Directors
Direct Services Supervisors
DOC/Division of Juvenile Corrections
Licensing Chiefs/Section Chiefs
Residential Care Centers for Children and Youth
Tribal Chairpersons/Human Services Facilitators
Wisconsin Association of Family and Children Agencies
From: Susan N. Dreyfus
Re: Revised Death Reporting Form and Procedures

Attached is a revised form, CFS-2183 - Residential Care Center Resident Death Determination, used for reporting to the Department the death of a resident that may be related to the use of a physical restraint or seclusion, a psychotropic medication, or is a suspected suicide. Licensed Residential Care Centers for Children and Youth (RCCs) are required to report deaths fitting the above-described circumstances (reportable deaths) to the Department within 24 hours after the death occurs, or, from the time the death becomes known to the RCC. The requirement for reporting such deaths is found under ss. 48.60 (5), Wis. Stats. Notification of a reportable death must be made to the Department via a completed CFS-2183. Pages 3 and 4 of the attached CFS-2183 provide guidelines to assist you in determining if there is reasonable cause to believe that a resident’s death may be related to the use of restraint or seclusion, the use of psychotropic medication or is a suspected suicide and must, therefore, be reported via this form.

The attached CFS-2183 form is effective immediately and replaces all previously issued forms used for reportable deaths. Please discard old forms. You can use the attached form to make additional copies, or the form is available on the Department’s Web Site: http://www.dhfs.state.wi.us. Go to Licensing, Child Care, General Information, Forms. The e-version of the form can be completed on-line but, because a signature is required, it must be printed and cannot be electronically mailed.

The completed and signed CFS-2183 should be faxed to the appropriate Bureau of Regulation and Licensing (BRL) regional office chief. A list of BRL regional office contact information, including fax numbers, is attached. If a fax machine is not available, please telephone the regional chief to report the death and to arrange for delivery of the CFS-2183.

Wisconsin statute requires that the Department investigate a death no later than 14 days after the date the death is reported to the Department. All reportable death investigations are on-site investigations. The Department has the authority and responsibility to conduct a thorough investigation using whatever customary means and techniques are, at the licensing staff’s judgement, appropriate and warranted. These may include, but are not limited to individual interviews with staff, residents and other persons; a review of records; a review of policies and procedures of the facility; and inspection of any buildings and their contents.

If you have any questions following your review of the attached materials, please contact the appropriate Bureau of Regulation and Licensing regional chief listed on the attached list.

Bureau of Regulation and Licensing
1 W. Wilson St., P.O. Box 8916
Madison, WI 535708-8916


CFS-2183 Residential Care Center Resident Death Determination form

Bureau of Regulation and Licensing Regional Office Contact Information

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