Florida Administrative Code
65 - DEPARTMENT OF CHILDREN AND FAMILIES
65E - Mental Health Program
Chapter 65E-9 - LICENSURE OF RESIDENTIAL TREATMENT CENTERS
Section 65E-9.013 - Restraint, Seclusion, and Time Out
Universal Citation: FL Admin Code R 65E-9.013
Current through Reg. 50, No. 187; September 24, 2024
(1) General requirements.
(a) Providers shall
comply with guidelines for the use of restraint, seclusion and time-out as
specified in Chapter 394, F.S., in addition to the guidelines specified in this
rule.
(b) Restraint or seclusion
shall not result in harm or injury to the child and shall be used only:
1. To ensure the safety of the child or
others during an emergency safety situation; and
2. Until the emergency safety situation has
ceased and the child's safety and the safety of others can be ensured, even if
the restraint or seclusion order has not expired.
(c) Restraint or seclusion shall not be used
for purposes of punishment, coercion, discipline, convenience, or retaliation
by staff or to compensate for inadequate staffing.
(d) An order for restraint or seclusion shall
not be issued as a standing order or on an as-needed basis.
(e) Restraint or seclusion shall be used in a
manner that is safe and proportionate to the severity of the behavior and the
child's chronological and developmental age; size; gender; physical, medical
and psychiatric condition, including current medications; and personal history,
including history of physical or sexual abuse.
(f) Only staff who have completed a
competency-based training program that prepares them to properly use restraint
or seclusion shall apply these procedures to children.
(g) Restraint that impedes respiration (e.g.,
choke hold or basket hold), places weight on the child's upper torso, neck,
chest or back, or restricts blood flow to the head is prohibited.
(h) Ambulatory or walking restraints (e.g.,
shackles that bind the ankles and waist-wrist shackles) may only be used during
transportation under the supervision of trained staff. The use of ambulatory or
walking restraints is prohibited except for purposes of off-premise
transportation.
(i) The provider's
medical or clinical director shall be responsible for providing oversight of
ongoing monitoring, quality improvement and staff training in the use of
restraint and seclusion and in the use of less intrusive, alternative
interventions.
(2) Provider procedures. The provider's procedures shall address the use of restraint, seclusion and time-out. A copy of the procedures shall be provided to children and their parents or guardians, foster parents and guardian ad litem, if applicable, upon admission, to all staff, and to the department. The procedures shall include provisions for implementing the requirements of this section and the provider's strategies to:
(a)
Reduce and strive to eliminate the need for and use of restraint and
seclusion;
(b) Prevent situations
that might lead to the use of restraint or seclusion;
(c) Use alternative, non-intrusive techniques
in the prevention and management of challenging behavior;
(d) Train staff on how restraint and
seclusion are experienced by children and the effect they have on children with
a history of trauma; and
(e)
Preserve the child's safety and dignity when restraint or seclusion is
used.
(3) Authorization of restraint or seclusion.
(a) Restraint or
seclusion shall be used and continued only pursuant to an order by a board
certified or board eligible psychiatrist licensed under Chapter 458, F.S., or
licensed physician with specialized training and experience in diagnosing and
treating mental disorders and who is the child's treatment team physician. If
the child's treatment team physician is unavailable, the physician covering for
the treatment team physician may meet these qualifications. Physicians allowed
to order seclusion and restraint, pursuant to this rule, must be trained in the
use of emergency safety interventions prior to ordering them.
(b) The ordering physician shall order the
least restrictive intervention that is most likely to be effective in resolving
the emergency safety situation.
(c)
If the ordering physician is not available on-site to order the use of
restraint or seclusion, a verbal telephone order shall be obtained by, at a
minimum, a registered nurse or other licensed staff, such as a licensed
practical nurse (LPN), at the time the restraint or seclusion is initiated or
immediately after it ends. At the time the order is received, the registered
nurse or other licensed staff, such as an LPN, shall consult with the ordering
physician about the child's physical and psychological condition. The order and
consultation shall be documented in the child's case file. If an emergency
exists where restraint or seclusion is needed but the physician is not present
or available by telephone, a psychiatric nurse, advanced nurse practitioner,
physician assistant, or registered nurse may apply the restraint or place the
child in seclusion, with follow up information provided to the physician as
soon as is reasonably possible.
(d)
The verbal order given by the physician shall be followed with their signature
verifying the verbal order within seven calendar days and the signed
verification shall be maintained in the child's case file.
(e) The ordering physician shall be available
to staff for consultation, at least by telephone, throughout the period of the
intervention.
(f) Each order for
restraint or seclusion shall:
1. Be limited to
no longer than the duration of the emergency safety situation;
2. Not exceed two hours for children or
adolescents ages nine through seventeen or one hour for children under age
nine; and
3. Be documented, whether
verbal or written, and maintained in the child's case file.
(g) If restraint or seclusion exceeds a total
of six hours within a 24-hour period for a child age nine through seventeen or
a total of three hours for a child under age nine, there must be a written
explanation as to why the child was not transferred to a more acute
program.
(h) If a child requires
the use of seclusion or restraint at any time during their stay, the treatment
team shall formally review and actively address their use during the child's
regularly scheduled treatment team review meetings, no less frequently than two
times per month, until deemed no longer necessary. The reviews shall assess the
frequency, patterns and trends, and identify ways to prevent the need for
seclusion and restraint use. The treatment team's review of and efforts to
eliminate seclusion and restraint use with a specific child shall be documented
as part of the child's treatment team review. In addition, if a child is
restrained a total of two times within a thirty day period, or is in seclusion
a total of three times within a thirty day period, the treatment team will
oversee the development and monitor the implementation of a formal
child-specific plan to aggressively address the need for seclusion and
restraint use with that child.
(i)
Within one hour of the initiation of restraint or seclusion, the ordering
physician or other licensed practitioner, as permitted by the state and
facility, (including a psychiatric nurse, advanced nurse practitioner,
physician assistant, or registered nurse) trained in the use of emergency
safety interventions, shall conduct a face-to-face assessment of the physical
and psychological well being of the child, including:
1. The child's physical and psychological
status;
2. The child's current
behavior;
3. The appropriateness of
the intervention measures; and
4.
Any physical or psychological complications resulting from the
intervention.
(j) Each
order for restraint or seclusion shall include:
1. The ordering physician's name;
2. The date and time the order was obtained;
and
3. The emergency safety
intervention ordered, including the length of time for which the physician
authorized its use, which length of time shall not exceed the time limits set
forth in subsection 65E-9.013(3)(f)
1.-.3, F.A.C.
(4) Documentation. Staff shall document the intervention in the child's record, with documentation completed by the end of each shift during which the intervention begins and continues. Documentation shall include:
(a) Each order for restraint or
seclusion;
(b) The time the
emergency safety intervention began and ended;
(c) The specific circumstances of the
emergency safety situation, the rationale for the type of intervention
selected, the less intrusive interventions that were considered or tried and
the results of those interventions;
(d) Time-specific assessments of the child's
physical and psychological condition;
(e) The name, position, and credentials of
all staff involved in or witnessing the emergency safety
intervention;
(f) Time and date of
notification of the child's parent or guardian and guardian ad litem;
(g) The behavioral criteria and assistance
provided by staff to help the child meet the criteria for discontinuation of
restraint or seclusion;
(h) Summary
of debriefing of the child with staff;
(i) Description of any injuries sustained by
the child during or as a result of the restraint or emergency safety
intervention and treatment received for those injuries;
(j) Review and revise, if necessary, the
child's treatment plan, including a description of procedures designed to
prevent the future need for and use of restraint or seclusion; and
(k) Before restraint or seclusion were
ordered for the child, the ordering physician assessed whether there were
pre-existing medical conditions or physical disabilities, history of sexual or
physical abuse, or current use of psychotropic medication that could present a
risk to the child and results of such review are documented in the order for
restraint or seclusion and the child's record.
(5) Consultation with treatment team physician. If the physician ordering the use of restraint or seclusion is not the child's treatment team physician, the ordering authorized to receive the verbal order shall:
(a) Consult with the
child's treatment team physician as soon as possible and inform the team
physician of the emergency safety situation that required the child to be
restrained or placed in seclusion; and
(b) Document in the child's record the date
and time the team physician was consulted.
(6) Notification.
(a) Notification upon admission. At
admission, the provider shall:
1. Explain and
provide a written copy of the provider's procedures regarding the use of
restraint and seclusion to the child, the child's parent or guardian, and
guardian ad litem, if applicable. The provider shall document that the child
and the parent or guardian, and guardian ad litem were informed of the
provider's policies on the use of restraint and seclusion. This documentation
shall be filed in the child's record.
2. Communicate the procedures in a language
the child and the parent or guardian understand, including American Sign
Language or through an interpreter or translator if needed.
3. Include in the procedures contact
information, including phone number and mailing address, of the Advocacy Center
for Persons with Disabilities, Inc.
4. Consult with the child's parent or
guardian and foster parent and guardian ad litem, if applicable to determine if
there are any known physical or psychological risks that would rule out the use
of such interventions for the child. The results of such interview shall be
documented in the child's record.
(b) Notification of use of restraint or
seclusion.
1. As soon as possible, but no
later than 24 hours after the initiation of each emergency safety intervention,
the provider shall notify the parent or guardian that the child has been
restrained or placed in seclusion.
2. The provider shall document in the child's
record that the parent or guardian was notified, including the date and time of
notification and the name of the staff person providing the
notification.
(7) Monitoring of the child during and immediately after restraint.
(a) Staff trained
in the use of emergency safety interventions shall be physically present and
continually visually assessing and monitoring the physical and psychological
well-being of the child and the safe use of restraint throughout the duration
of the emergency safety intervention.
(b) If the emergency safety situation
continues beyond the time limit of the physician's order for the use of
restraint, the staff person authorized to receive the verbal order, as
identified in paragraph
65E-9.013(4)(c),
F.A.C., shall immediately contact the ordering physician to receive further
instructions or new orders for the use of restraint and shall document such
notification in the child's case file.
(c) A physician, or other licensed staff
member as identified in paragraph
65E-9.013(4)(i),
F.A.C., trained in the use of emergency safety interventions, shall evaluate
and record the child's physical condition and psychological well-being
immediately after the restraint is removed.
(8) Monitoring of the child during and immediately after seclusion.
(a) Staff trained
in the use of emergency safety interventions and in assessment of suicide risk
shall be physically present in or immediately outside the seclusion room,
continually visually assessing, monitoring, and evaluating the physical and
psychological well-being of the child in seclusion. Video or auditory
monitoring shall not be used as substitutes for this requirement.
(b) If the emergency safety situation
continues beyond the time limit of the physician's order for the use of
seclusion, the staff person authorized to receive the verbal order, as
identified in paragraph
65E-9.013(3)(c),
F.A.C., shall immediately contact the ordering physician to receive further
instructions or new orders for the use of seclusion and such notification shall
be documented and maintained in the child's case file.
(c) A physician or other licensed staff
member, as identified in paragraph
65E-9.013(3)(i),
F.A.C., trained in the use of emergency safety interventions, shall evaluate
the child's physical condition and psychological well-being immediately after
the child is removed from seclusion and documentation of such evaluation shall
be maintained in the child's case file.
(d) Staff shall immediately obtain medical
treatment from qualified medical personnel for a child injured during or as a
result of an emergency safety intervention.
(9) Discontinuation of restraint or seclusion. As early as feasible in the restraint or seclusion process, the child shall be told the rationale for restraint or seclusion and the behavior criteria necessary for its discontinuation that ensures the safety of the child and others. Restraint or seclusion shall be discontinued as soon as the child meets the behavioral criteria.
(10) Post-restraint or seclusion practices.
(a)
After the use of restraint or seclusion, staff involved in an emergency safety
intervention and the child shall have a face-to-face discussion, which is also
known as a debriefing. Whenever possible, subject to staff scheduling, this
discussion shall include all staff involved in the intervention. The child's
parent or guardian shall be invited to participate in the discussion. The
provider shall conduct the discussion in a language that is understood by the
child and the child's parent or guardian. The discussion shall provide both the
child and staff the opportunity to discuss the circumstances resulting in the
use of restraint or seclusion and strategies to be used by the staff, the
child, or others to prevent the need for the future use of restraint or
seclusion. The discussion must occur within 24 hours of the emergency
intervention, subject to the following exceptions:
1. Allowances may be made to accommodate the
schedules of the parent(s) or legal guardian(s) of the child when they request
an opportunity to participate in the debriefing and when staff deem their
participation appropriate.
2.
Allowances may be made to accommodate shift changes, vacation schedules,
illnesses, and all applicable federal, state, and local labor laws and
regulations.
(b) After
the use of restraint or seclusion, the staff involved in the emergency safety
intervention, and appropriate supervisory and administrative staff, shall
conduct a debriefing session that includes a review and discussion of:
1. The emergency safety situation that
required the intervention, including a discussion of the factors that caused or
preceded the intervention;
2.
Alternative, less intrusive techniques that might have prevented the need for
the restraint or seclusion;
3. The
procedures, if any, that staff are to implement in the future to prevent any
recurrence of the use of restraint or seclusion; and
4. The outcome of the intervention, including
any injuries that resulted from the use of restraint or seclusion and the
treatment provided for those injuries.
(c) Staff shall document in the child's
record that both debriefing sessions took place and shall include in that
documentation the names of staff present for the debriefing, names of staff
excused from the debriefing, and any changes to the child's treatment plan or
facility procedures that resulted from the debriefings.
(d) The provider shall maintain a record of
each emergency safety situation, the interventions used, and their outcomes.
These records shall be maintained in a manner that allows for the collection
and analysis of data for agency monitoring and provider performance improvement
and shall be available for such purposes upon request.
(e) Staff shall document in the child's
record all injuries that occur during or as a result of an emergency safety
intervention, including injuries to staff resulting from that
intervention.
(f) Staff involved in
an emergency safety intervention that results in an injury to a child or staff
shall meet with supervisory staff and evaluate the circumstances that caused
the injury and develop a plan to prevent future injuries.
(g) The provider shall immediately notify the
child's parent or guardian of any serious occurrence, including a child's
death, a serious injury to a child, or a suicide attempt. The provider shall
also report the serious occurrence to the Department, the agency, and the state
advocacy council the same day or no later than close of business the next
business day for a serious occurrence that occurs after 5:00 p.m. or over a
weekend. The report shall include the name of the child involved in the serious
occurrence, a description of the occurrence, and the name, street address, and
telephone number of the facility.
(11) Time-out.
(a) Time-out shall be used only for the
purpose of providing a child with the opportunity to regain self-control and
not as a consequence or punishment.
(b) If time-out is used with a child,
child-specific guidelines for the use and duration of time-out, based on the
professional judgment of the child's treatment team, shall be specified in the
child's treatment plan, upon consideration of the child's age, maturity,
health, and other factors. In addition, the child's parent or guardian shall
sign an informed consent form detailing the circumstances under which time-out
will be used and how the procedure is to be implemented.
(c) Time-out shall be initiated only by staff
who have completed competency-based training in the use of time-out and such
training shall be documented in their personnel record.
(d) Time-out may take place either in or away
from the area of activity or other children, such as in the child's
room.
(e) The designated area shall
be a room or area that is part of the living environment the child normally
inhabits or has access to during routinely scheduled activities and from which
the child is not physically prevented from leaving.
(f) If the child requires physical contact in
order to move to the area or room, staff shall end the contact immediately once
the child is in the designated area.
(g) The child shall not be physically
prevented from leaving the time-out area.
(h) The criterion for being able to end
time-out without further intervention shall be specified to the child at this
time in a neutral manner.
(i)
Time-out shall be terminated after the child meets the behavioral criterion for
the specified time period, which shall not exceed 5 minutes at a time. If the
child meets the criterion earlier, staff shall end the procedure
immediately.
(j) If the child has
not been able to meet the criterion for exiting time-out within 30 minutes,
staff shall notify the ranking clinician on duty or on-call, who shall assess
how the procedure was implemented, assess the child's condition, and determine
whether to end the procedure, reduce the exit criterion, or continue the
procedure.
(k) When time-out is
imposed, staff shall directly and continuously observe the child.
(l) The child's treatment team shall review
the use of time-out during that child's treatment team meetings, but no less
frequently than two times per month. This review shall consist of assessing the
frequency, patterns and trends, questioning the function(s) of the behavior(s)
that resulted in the use of time-out, possible ways to prevent the behavior(s)
and the appropriateness of the exit criteria used.
(m) For each instance that time-out is used,
staff who initiate the procedure shall document in the child's record:
1. The circumstances leading to the use of
time-out;
2. The specific behavior
criteria explained to the child that would allow for discontinuation of
time-out;
3. When and how the child
was informed of the behavior criteria;
4. The time the procedure started and ended;
and
5. Any injuries sustained and
treatment provided for those injuries.
(n) A separate time-out log shall be
maintained that records:
1. The
shift;
2. The staff who initiated
the process;
3. The time the
procedure started and ended;
4. The
date and day of the week of each episode;
5. The age and gender of the child;
and
6. Client
ID.
Specific Authority 394.875(8) FS. Law Implemented 394.875 FS.
New 7-25-06, Amended 9-24-08.
Disclaimer: These regulations may not be the most recent version. Florida may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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