Current through Register Vol. 49, No. 6, March 15, 2024
(1) General
Principles and Practices. The organization shall implement written policies and
procedures to prevent and respond to disruptive behaviors, behavioral crises,
and psychiatric crises that may occur with individuals served, staff, visitors,
and others. All efforts shall be made to minimize retraumatization of persons
served or others involved in a disruptive situation, including consideration as
to whether the program is suitable to meet the individual's needs.
(A) Policies and procedures shall indicate
whether time-out, seclusion, and restraint are used in the organization, by
whom, and under what circumstances, including protocols for their use with
children/youth, adults, and individuals with special needs.
(B) Organizations may prohibit by policy and
practice the use of time-out, seclusion, and restraint and must have policies
and procedures for addressing disruptive behaviors, behavioral crises, and
psychiatric crises.
(C) All
policies and procedures must be-
1. Approved
by the organization's board of directors;
2. Available to all program staff and service
providers;
3. Available to
individuals served and parents/guardians, family members, and other natural
supports, as appropriate;
4.
Developed with input from individuals served and, whenever possible,
parents/guardians, family members, and other natural supports; and
5. Consistent with department regulations
regarding individual rights.
(D) As applicable to the population served,
all staff and volunteers having direct contact with individuals served shall
receive documented initial and ongoing competency-based training on
evidence-based and best practice interventions to prevent disruptive behaviors
and behavioral crises and to address them in the least restrictive manner if
they occur.
(E) All organizations
shall prohibit by policy and practice-
1.
Aversive conditioning of any kind-the application of startling, unpleasant, or
painful stimulus or stimuli that have a potentially harmful effect on an
individual in an effort to decrease maladaptive behavior;
2. Withholding of food, water, or bathroom
privileges;
3. Painful
stimuli;
4. Corporal punishment
(such as use of pepper spray, mace, Taser, stun gun);
5. Techniques that obstruct the individual's
airways or impairs breathing;
6.
Techniques that restrict the individual's ability to communicate;
7. Use of time-out or other disciplinary
action for staff convenience; and
8. Chemical restraints-use of a medication to
sedate or limit an individual's ability to participate in treatment rather than
treat the symptoms of a behavioral health disorder as prescribed and specified
in the individual treatment plan. Medication used as prescribed and as
indicated in the individual's treatment plan to treat symptoms of a behavioral
disorder, including aggressive behavior, is not considered chemical restraint.
(2) Seclusion
and Restraint. Recognizing there are times when other interventions such as
de-escalation or a change in the physical environment are not successful and
there is imminent danger of serious harm to the individual or others, seclusion
or restraint may be necessary to ensure safety. Any emergency safety
interventions used by the organization must promote the rights, dignity, and
safety of individuals being served. Organizations utilizing seclusion and
restraint must obtain a separate written authorization from the department, in
addition to complying with all other requirements of this rule. The department
may issue such authorization on a time-limited basis subject to renewal.
(A) Staff of the organization shall assure
seclusion and restraint are only used when an individual's behavior presents an
immediate risk of danger to themselves or others and no other safe or effective
treatment intervention is possible. These measures shall only be implemented
when alternative, less restrictive interventions have failed or cannot be
safely implemented. Crisis prevention techniques shall be used to de-escalate
such occurrences, when possible. Seclusion and restraint are never used as
treatment interventions. They are emergency/security measures to maintain
safety when all other less restrictive interventions are inadequate.
(B) The use of seclusion or restraint shall
be in accordance with the order of the organization's attending physician or
clinical director. Staff shall notify the attending physician or clinical
director at the earliest possible time when a situation has a significant
likelihood of leading to seclusion or restraint. If seclusion or restraint is
initiated prior to obtaining an order, staff must obtain an order
immediately.
(C) Standing or pro re
nata (PRN) orders for seclusion or restraint are not allowed.
(D) Orders for seclusion or restraint shall
be individualized to each event, define specific time limits, and be ended at
the earliest possible time. Orders shall not exceed four (4) hours for adults,
two (2) hours for children/youth age nine (9) to seventeen (17), and one (1)
hour for children under age nine (9). If there is a need for continuing
seclusion or restraint beyond the time limits specified herein, the attending
physician or clinical director must write a new order for seclusion or
restraint.
(E) Seclusion and
restraint shall only be implemented by staff who are trained and competent in
the proper techniques for administering/applying the form of seclusion or
restraint ordered and for providing ongoing monitoring and assessment of
individuals for their safety and well-being. At a minimum, initial and periodic
training shall include:
1. Techniques to
identify individual behaviors, events, and environmental factors that may
trigger circumstances requiring the use of seclusion or restraint;
2. The use of nonphysical intervention
skills;
3. Use of the least
restrictive intervention based on an individualized assessment of the
individual's medical and/or behavioral status or condition;
4. The safe application and use of all types
of seclusion or restraint used by the organization, including how to recognize
and respond to signs of physical and psychological distress;
5. Clinical identification of specific
behavioral changes that indicate restraint or seclusion is no longer
necessary;
6. Monitoring the
physical and psychological well-being of the individual who is secluded or
restrained, including but not limited to, respiratory and circulatory status,
skin integrity, vital signs, and any special requirements specified in the
organization's policies and procedures associated with face-to-face
evaluations; and
7. The use of
First Aid techniques and certification in CPR, including required periodic
recertification.
(F) When
an individual is being secluded or restrained, trained staff shall continually
observe and assess him or her to assure appropriate care and treatment
including, but not limited to:
1. Attention to
vital signs;
2. Need for meals and
liquids;
3. New for bathing and use
of the restroom; and
4. Need for
seclusion or restraint to continue.
(G) Staff observing the individual shall
immediately notify the attending physician or clinical director if his or her
behavior has improved such that seclusion or restraint can be ended. Use of
seclusion or restraint shall be discontinued when the attending physician or
clinical director determines the need for the intervention is no longer present
or the individual's needs can be addressed using less restrictive
methods.
(H) All orders for
seclusion or restraint must be documented in the individual record as soon as
possible and shall include, but is not limited to:
1. Reason for the intervention;
2. Staff who ordered the
intervention;
3. Type of
intervention used;
4. Starting and
ending time;
5. Regular
observations of the individual, including any resulting injuries or other
issues as a result of the intervention;
6. Notification of parent/guardian, as
applicable;
7. Notification of
healthcare provider, as applicable; and
8. Modifications to the treatment plan as a
result of the intervention.
(I) The organization's clinical director
and/or performance improvement coordinator shall review every episode of
seclusion or restraint within seventy-two (72) hours of the occurrence to
ensure policies and procedures were followed and identify any areas needing
improvement. A written report on the organization's overall use of emergency
safety interventions, including progress made in reducing their use, shall be
prepared at least annually and reviewed by organizational
leadership.
(3) Behavior
Modification Plans. Behavior modification plans are designed to assist
individuals in being successful while engaged in services and minimize
inappropriate behaviors. Behavioral expectations, procedures, and consequences
shall be clearly defined and explained to the individual served.
(A) The need for a behavior modification plan
shall be evaluated upon-
1. Any incident of
seclusion or restraint;
2. The use
of time-out two (2) or more times per day; or
3. The use of time-out three (3) or more
times per week.
(B) The
behavior modification plan shall be developed with the individual served and
his or her parents/guardian and family members/natural supports, as
appropriate.
(C) The plan shall
identify what the individual is attempting to communicate or achieve through
his or her behavior before identifying interventions to change it.
(D) The plan shall be reevaluated within the
first seven (7) days after it is developed, and every seven (7) days
thereafter, to determine whether inappropriate behavior is being reduced and
more functional alternatives achieved by the individual.
(E) The plan shall be reevaluated within the
first seven (7) calendar days and every seven (7) days thereafter to determine
whether maladaptive and unacceptable behaviors are being reduced and more
functional alternatives acquired.
*Original authority: 630.050, RSMo 1980, amended 1993, 1995
and 630.055, RSMo 1980.
