Virginia Administrative Code
Title 12 - HEALTH
Agency 35 - DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES
Chapter 115 - REGULATIONS TO ASSURE THE RIGHTS OF INDIVIDUALS RECEIVING SERVICES FROM PROVIDERS LICENSED, FUNDED, OR OPERATED BY THE DEPARTMENT OF BEHAVIORAL
Part III - Explanation of Individual Rights and Provider Duties
Section 12VAC35-115-110 - Use of seclusion, restraint, and time out
Universal Citation: 2 VA Admin Code 35-115-110
Current through Register Vol. 41, No. 3, September 23, 2024
A. Each individual is entitled to be completely free from any unnecessary use of seclusion, restraint, or time out.
B. The voluntary use of mechanical supports to achieve proper body position, balance, or alignment so as to allow greater freedom of movement or to improve normal body functioning in a way that would not be possible without the use of such a mechanical support, and the voluntary use of protective equipment are not considered restraints.
C. The provider's duties.
1. Providers shall meet with the individual
or the individual's authorized representative upon admission to the service to
discuss and document in the individual's services record his preferred
interventions in the event his behaviors or symptoms become a danger to himself
or others and under what circumstances, if any, the intervention may include
seclusion, restraint, or time out.
2. Providers shall document in the
individual's services record all known contraindications to the use of
seclusion, time out, or any form of physical or mechanical restraint, including
medical contraindications and a history of trauma, and shall flag the record to
alert and communicate this information to staff.
3. Seclusion may be used only in an emergency
and only in facilities operated by the department; residential facilities for
children that are licensed under the Regulations for Children's Residential
Facilities (12VAC35-46); inpatient hospitals; and crisis receiving centers or
crisis stabilization units that are licensed under Part VIII (12VAC35-105-1830 et seq.) of
12VAC35-105.
4. Providers shall not
use seclusion, restraint, or time out as a punishment or reprisal or for the
convenience of staff.
5. Providers
shall not use seclusion or restraint solely because criminal charges are
pending against the individual.
6.
Providers shall not use a restraint that places the individual's body in a
prone (face down) position.
7.
Providers shall not use seclusion or restraint for any behavioral, medical, or
protective purpose unless other less restrictive techniques have been
considered and documentation is placed in the individual's safety plan, the
crisis ISP, or the ISP that these less restrictive techniques did not or would
not succeed in reducing or eliminating behaviors that are self-injurious or
dangerous to other people or that no less restrictive measure was possible in
the event of a sudden emergency.
8.
Providers that use seclusion, restraint, or time out shall develop written
policies and procedures that comply with applicable federal and state laws and
regulations, accreditation and certification standards, third party payer
requirements, and sound therapeutic practice. These policies and procedures
shall include at least the following requirements:
a. Individuals shall be given the opportunity
for motion and exercise, to eat at normal meal times and take fluids, to use
the restroom, and to bathe as needed.
b. Trained, qualified staff shall monitor the
individual's medical and mental condition continuously while the restriction is
being used.
c. Each use of
seclusion, restraint, or time out shall end immediately when criteria for
removal are met.
d. Incidents of
seclusion and restraint, including the rationale for and the type and duration
of the restraint, shall be reported to the department as provided in
12VAC35-115-230 C.
9. Providers shall comply with all
applicable state and federal laws and regulations, certification and
accreditation standards, and third party requirements as they relate to
seclusion and restraint.
a. Whenever an
inconsistency exists between this chapter and federal laws or regulations,
accreditation or certification standards, or the requirements of third party
payers, the provider shall comply with the higher standard.
b. Providers shall notify the department
whenever a regulatory, accreditation, or certification agency or third party
payer identifies problems in the provider's compliance with any applicable
seclusion and restraint standard.
10. Providers shall ensure that only staff
who have been trained in the proper and safe use of seclusion, restraint, and
time out techniques may initiate, monitor, and discontinue their use.
11. Providers shall ensure that a qualified
professional who is involved in providing services to the individual reviews
every use of physical restraint as soon as possible after it is carried out and
documents the results of his review in the individual's services
record.
12. Providers shall ensure
that review and approval by a qualified professional for the use or
continuation of restraint for medical or protective purposes is documented in
the individual's services record. Documentation includes:
a. Justification for any restraint;
b. Time-limited approval for the use or
continuation of restraint; and
c.
Any physical or psychological conditions that would place the individual at
greater risk during restraint.
13. Providers may use seclusion or mechanical
restraint for behavioral purposes in an emergency only if a qualified
professional involved in providing services to the individual has, within one
hour of the initiation of the procedure:
a.
Conducted a face-to-face assessment of the individual placed in seclusion or
mechanical restraint and documented that alternatives to the proposed use of
seclusion or mechanical restraint have not been successful in changing the
behavior or were not attempted, taking into account the individual's medical
and mental condition, behavior, preferences, nursing and medication needs, and
ability to function independently;
b. Determined that the proposed seclusion or
mechanical restraint is necessary to protect the individual or others from
harm, injury, or death;
c.
Documented in the individual's services record the specific reason for the
seclusion or mechanical restraint;
d. Documented in the individual's services
record the behavioral criteria that the individual must meet for release from
seclusion or mechanical restraint; and
e. Explained to the individual, in a way that
he can understand, the reason for using mechanical restraint or seclusion, the
criteria for its removal, and the individual's right to a fair review of
whether the mechanical restraint or seclusion was permissible.
14. Providers shall limit each
approval for restraint for behavioral purposes or seclusion to four hours for
individuals age 18 and older, two hours for children and adolescents ages nine
through 17, and one hour for children under age nine.
15. Providers shall not issue standing orders
for the use of seclusion or restraint for behavioral purposes.
16. Providers shall ensure that no individual
is in time out for more than 30 minutes per episode.
17. Providers shall monitor the use of
restraint for behavioral purposes or seclusion through continuous face-to-face
observation, rather than by an electronic surveillance device.
D. For purposes of this section, "safety plan," "crisis individualized services plan," or "crisis ISP" shall have the same meaning as those terms are described in 12VAC35-105-1860 and 12VAC35-105-1870.
Statutory Authority: §§ 37.2-302 and 37.2-400 of the Code of Virginia.
Disclaimer: These regulations may not be the most recent version. Virginia 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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