Louisiana Administrative Code
Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE
Part II - Nursing Facilities
Subpart 3 - Standards for Payment
Chapter 103 - Standards for Payment for Intermediate Care Facilities for the Mentally Retarded (ICF/MR)
Subchapter F - Health Services
Section II-10341 - Client Behavior

Universal Citation: LA Admin Code II-10341

Current through Register Vol. 50, No. 9, September 20, 2024

NOTE: The federal regulations pertaining to this Section are 42 CFR 483.420, 483.440, and 483.450. The state laws pertaining to this Section are R.S. 40.2009.2-RS. 40:2009.20 and R.S. 403.2.

A. Written Policies and Procedures

1. A facility must develop and implement written policies and procedures for the management of conduct between staff and clients. These policies and procedures will:

a. specify conduct to be allowed and not allowed by staff and/or clients;

b. provide for client choice and self determination to the extent possible;

c. be readily available to all clients, parent(s), staff, and legal guardians;

d. be developed with the participation of clients to the extent possible.

2. A facility must develop and implement written policies and procedures for the management of inappropriate client behavior. These policies and procedures must:

a. specify all facility approved interventions to manage inappropriate client behavior;

b. designate these interventions on a hierarchy ranging from the most positive and least restrictive to the least positive and most restrictive;

c. insure that, prior to the use of more restrictive techniques, the client's record document that programs incorporating the use of less intrusive or more positive techniques have been tried first and found to be ineffective;

d. address the use of:

i. time-out rooms;

ii. physical restraints;

iii. drugs used to manage inappropriate behavior;

iv. application of painful or noxious stimuli;

v. the staff members who may authorize use of a particular intervention;

vi. a mechanism for monitoring and controlling use of the intervention.

B. Interventions to Manage Inappropriate Client Behavior

1. Safety and Supervision. Interventions to manage inappropriate client behavior must be used within sufficient safeguards and supervision to insure that the safety, welfare, and civil and human rights of clients are adequately protected. These interventions must:

a. never be used for disciplinary purposes, for the convenience of staff, or as a substitute for an active treatment program;

b. never include corporal punishment;

c. never include discipline of one client by another except as part of an organized system of self government as set forth in facility policy.

2. Individual Plans and Approval. Individual programs to manage inappropriate client behavior must be incorporated into the client's individual program plan and must be reviewed, approved, and monitored by the Specially Constituted Committee. Written informed consent by the client or legal representative is required prior to implementation of a behavior management plan involving any risks to client's rights. (See §10343, Client Rights, which addresses informed consent.)

3. Standing Programs. Standing or as needed programs to control inappropriate behavior are not permitted. To send a client to his room when his behavior becomes inappropriate is not acceptable unless part of a systematic program of behavioral interventions for the individual client.

4. Time-out Rooms

a. Use of time-out rooms is not permitted in group or community homes.

b. In institutional settings, it is permitted only when professional staff is on-site and only under the following conditions:

i. the placement in a time-out room is part of an approved systematic behavior program as required in the individual program to manage inappropriate behavior discussed under Subsection B above; emergency placement is not allowed;

ii. the client is under direct constant visual supervision of designated staff;

iii. if the door to the room is closed, it must be held shut only by use of constant physical pressure from a staff member;

iv. placement in time-out room does not exceed one hour;

v. clients are protected from hazardous conditions while in time-out rooms;

vi. a record is kept of time-out activities.

5. Physical Restraint. Physical restraint is defined as any manual method or physical or mechanical device that the individual cannot remove easily and which restricts free movement. Examples of manual methods include: therapeutic or basket holds and prone or supine containment. Examples of physical or mechanical devices include: barred enclosure which must be no more than 3 feet in height and must be; chair with a lap tray used to keep an ambulatory client seated; wheelchair tied to prevent movement of a wheelchair mobile client; straps used to prevent movement while client is in chair or bed. Physical restraints can be used only:

a. when absolutely necessary to protect the client from injuring himself or others in an emergency situation;

b. when part of an individual program plan intended to lead to less restrictive means of managing the behavior the restraints are being used to control;

c. as a health related protection prescribed by a physician but only if absolutely necessary during a specific medical, dental, or surgical procedure or while a medical condition exists;

d. when the following conditions are met:

i. orders for restraints are not obtained for use on a standing or on an as needed basis;

ii. restraint authorizations are not in effect longer than 12 consecutive hours and are obtained as soon as possible after restraint has occurred in emergency situations;

iii. clients in restraints are checked at least every 30minutes and released as quickly as possible. Record of restraint checks and usage is required;

iv. restraints are designed and used so as not to cause physical injury and so as to cause the least possible discomfort;

v. opportunities for motion and exercise are provided for not less than 10 minutes during each two-hour period and a record is kept; and

vi. restraints are applied only by staff who have had training in the use of these interventions.

6. Drugs. Drugs used for control of inappropriate behavior may be used only under the following conditions:

a. drugs must be used only in doses that do not interfere with the client's daily living activities;

b. drugs used for control of inappropriate behavior must be approved by the interdisciplinary team, the client, legal representative, and specially constituted committee. These drugs must be used only as part of the client's individual program plan that is directed toward eliminating the behavior the drugs are thought to control;

c. prior to the use of any program involving a risk to client protection and rights, including the use of drugs to manage inappropriate behavior, written informed consent must be obtained from:

i. client; or

ii. family, legal representative, or advocate if client is a minor or client is mentally unable to understand the intended program or treatment.

d. informed consent consists of permission given voluntarily on a time limited basis not to exceed 365 days by the client or the legally appropriate party after having been informed of the:

i. specific issue treatment or procedure;

ii. client's specific status with regard to the issue;

iii. attendant risks regarding the issue;

iv. acceptable alternatives to the issue;

v. right to refuse;

vi. consequences of refusal.

e. drugs must not be used until it can be justified that the beneficial effects of the drug on the client's behavior clearly outweighs the potentially harmful effects of the drug;

f. drugs must be clearly monitored in conjunction with the physician, the pharmacist, and facility staff;

g. unless clinical evidence justifies that this is contraindicated, drugs for control of inappropriate behavior must be gradually reduced at least annually in a carefully monitored program conducted in conjunction with the interdisciplinary team.

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:153.

Disclaimer: These regulations may not be the most recent version. Louisiana 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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