Current through September 21, 2024
(a) Restraint
includes physical, chemical, and mechanical restraints, as further defined in
this Section.
(b) The entire plan
of care team shall agree to the use of restraints, confirmed with a signature
from the participant, legally authorized representative, and all providers
involved, and be consistent with this Section.
(c) When the use of positive behavior
supports is not effective in modifying or changing a participant's challenging
behavior, the participant's plan of care team may implement a restraint
protocol to supplement the positive behavior support plan, subject to the
provisions of this Section.
(d)
Providers shall not use aversive techniques to modify a person's behavior.
Aversive techniques include any intervention that causes pain, harm,
discomfort, or social humiliation for the purpose of modifying or reducing a
behavior.
(e) A provider serving
more than five (5) participants with restraints in their plans is required to
have one (1) employee complete training on positive behavior supports through
any program approved by the Division. An additional employee shall be certified
for every ten (10) additional participants with restraints in their
plan.
(f) The plan of care team
shall review the participant's plan thoroughly to ensure the individualized
plan of care is not so restrictive that it repeatedly provokes behaviors that
lead to the use of restraints.
(g)
When restraints are deemed necessary, the individualized plan of care shall
include a restraint protocol that includes:
(i) If a person other than the participant
authorizes the use of restraint, the legal document, court order, guardianship
papers, or medical orders that demonstrate this authority; and
(ii) For any restraint imposed, demonstration
that the standards outlined in Section
4(h)(i) of this Chapter
are met.
(h) The case
manager shall reconvene the participant's plan of care team if any restraints
are used in the previous calendar quarter. When convened under this Section,
the team shall review all restraints for the previous quarter and develop a
plan to reduce the number of restraints performed. On a quarterly basis, the
case manager shall report data received from the provider concerning the number
of restraints performed on the participant.
(i) The provider shall notify the case
manager within one (1) business day of any use of an emergency restraint that
is not written in a participant's individualized plan of care. A case manager
who receives notice of restraint under this provision shall call a team meeting
within two (2) weeks to discuss the incident and decide if the individualized
plan of care shall be modified to include a crisis intervention protocol and a
revised positive behavior support plan.
(j) Restraints shall only be performed by an
individual trained and certified in restraint usage.
(k) Providers employing restraints shall:
(i) Adopt policies and procedures that:
(A) Identify the provider's chosen certifying
entity consistent with subsection (l) of this Section;
(B) Specify the types of restraints that may
be used by provider staff; and
(C)
Establish provider-specific training requirements for staff.
(ii) Adhere to all state and
federal statutes, rules, and regulations regarding the use of
restraints.
(iii) Only utilize
restraints approved by the provider's chosen certifying entity recognized in
subsection (l) of this Section, unless the restraints are prohibited in
subsection (d) of this Section.
(l) The provider and provider staff shall
maintain certification, and provider shall require ongoing training for
employees in de-escalation techniques, crisis prevention and intervention, and
proper restraint usage from entities certified to conduct the training, such as
Crisis Prevention Intervention (CPI), MANDT, or other entity approved by the
Division.
(m) Restraints shall only
be used in emergency circumstances to ensure the immediate physical safety of
the participant, a provider staff member, or other persons, and when less
restrictive positive behavior supports have been determined to be ineffective.
Providers shall only use restraints when the risk of injury without restraint
is greater than the risk associated with the restraint. Restraints may include,
but are not limited to, the following:
(i) A
chemical restraint, which is any drug that is administered to manage a
participant's behavior in a way that reduces the safety risk to the participant
or others, has the temporary effect of restricting the participant's freedom of
movement, and is not a standard treatment for the participant's medical or
psychiatric condition.
(A) A chemical
restraint shall not be used unless ordered by a licensed medical professional
chosen by the participant or any legally authorized representative(s), and
administered by a person licensed to administer the medication.
(B) Standing orders for chemical restraints
are prohibited, except when deemed necessary to prevent extreme reoccurring
behavior by a participant's plan of care team and limited to one (1) month. A
standing order shall include clarification on the circumstances of its usage by
the licensed medical professional.
(C) If a provider uses three (3) or more
chemical restraints on a participant within a consecutive six (6) month period,
the participant's plan of care team shall arrange for the participant to see
his or her treating medical professional for a formal medical review in case
the treatment plan needs to change. The participant's plan of care team shall
meet to determine if the positive behavior support plan or crisis intervention
protocol needs to change. The formal medical review shall be documented in the
participant's file with the restraining provider and the case manager. If it is
determined that the treatment plan or individualized plan of care will not be
changed, then the case manager shall document the reasons it is not being
changed in the individualized plan of care.
(D) Chemical restraints shall not be used on
persons under the age of eighteen (18).
(ii) A mechanical restraint, which is any
device attached or adjacent to a participant's body that he or she cannot
easily move or remove that restricts freedom of movement or normal access to
the body.
(A) Mechanical restraints shall
only be used under the direct supervision of a licensed medical professional
for the purpose of medical treatment procedures when compliance is deemed
necessary to protect the health of the participant.
(B) Mechanical restraints shall not be used
on persons under the age of eighteen (18).
(iii) A physical restraint, which is the
application of physical force without the use of any device, for the purpose of
limiting the free movement of a participant's body. Physical restraint does not
include briefly holding a participant, without undue force, in order to calm or
comfort him or her, or holding a participant's hand to safely escort him or her
from one area to another.
(n) Seclusion is the involuntary confinement
of a participant alone in a room or an area from which the participant is
physically prevented from leaving. Seclusion is prohibited, and may result in
sanctions, including the repayment of funds for waiver services.
(o) A provider using restraints shall:
(i) Maintain internal documentation to track
and analyze each use of a restraint, its antecedents, reason(s) for the
restraint, the participant's reaction to the restraint, and actions that may
make future restraints unnecessary;
(ii) Implement additional supports with the
participant in an effort to minimize restraints;
(iii) Use appropriate de-escalation
techniques to redirect or mitigate a behavior before restraints
occur;
(iv) Address and correct
staff using restraints incorrectly;
(v) If an injury occurs as a result of a
restraint, conduct staff retraining within five (5) business days if the injury
being detected;
(vi) Hold a
debriefing meeting with the participant, legally authorized representative, and
case manager as soon as practicable after an incident to discuss the use of the
restraint. Legally authorized representatives may be part of the participant's
debrief discussion either by phone or in person;
(vii) Within five (5) business days of the
event, provide case managers with a copy of the provider's completed internal
tracking form, or notify the case manager that the electronic form is available
for viewing;
(viii) Send a copy of
the completed internal tracking form to the legally authorized representative
within five (5) business days or notify the legally authorized representative
that the electronic form is available for viewing;
(ix) Submit a critical incident report to the
Division for each instance when a restraint is used, as outlined in Section
20(b) of this Chapter;
and
(x) Regularly collect and
review all available data regarding the use of restraints and work to reduce
their duration and frequency, and eliminate their occurrence.
(p) The case manager shall
follow-up on each incident within two (2) business days of notification of the
incident to ensure the participant is safe and uninjured, ensure the
participant's restraint protocol and positive behavior support plan were
implemented appropriately, and verify that documentation demonstrates that less
restrictive intervention techniques were used prior to the use of restraint.
The case manager shall also report any suspected non-compliance to the
Division.
(q) The Division may
request a team meeting with the provider, case manager, and legally authorized
representative to review any incident of restraint performed by a provider or
provider staff.
(r) Restraints
shall not be used for the following purposes:
(i) For the convenience of the
provider;
(ii) To coerce,
discipline, force compliance, or retaliate against a participant; or
(iii) As a substitute for a habilitation
program or in quantities that interfere with services, treatment, or
habilitation.
(s) The
following restraints are prohibited:
(i) A
restraint that is contraindicated by the person's medical or psychological
condition;
(ii) A restraint
procedure or device that obstructs a person's airway or constricts the person's
ability to breathe;
(iii) A supine
or prone restraint including, but not limited to, restraining a person on the
floor, in a bed, in any form of reclined chair, or using any other horizontal
flat surface; and
(iv) Any
physical, mechanical, or chemical restraint not provided for in this
Section.
(t) Any
violation of subsection (r) or (s) may result in immediate sanctions of the
provider.
(u) Any restraint shall
be time-limited and removed immediately when the participant no longer presents
a risk of immediate harm to self or others.
