(A) Each
inpatient psychiatric service
provider shall
is
to comply with all applicable TJC,
HFAP
ACHC
, or DNV
requirements; or
mandates and federal, state, and local laws and
regulations
, regarding
patient care,
safety, sanitation, and fire protection.
(1) A
building inspection shall
is to be made upon application for an initial
license,
and
repeated whenever renovations or changes in the building are made that would
affect either the maximum number of licensed patient beds or substantially
change the services provided by the inpatient psychiatric service provider,
or whenever
as well
as when the department deems a building
inspection is necessary.
(2)
If an inpatient psychiatric service provider occupies part of a building, the
entire building shall
is to be inspected except where there is a fire
wall or other fire resistant separation between the part of the building to be
licensed and the rest of the building. If this fire separation does not exist
the total building shall
is to be used to determine safety for inspection
purposes only.
(3) A building
inspection shall
is
to be performed by a local certified building inspector or, where none is
available, by the chief of the
division of factory
and building inspection of the Ohio department of industrial
relations
bureau of building code compliance in
the Ohio department of commerce.
(4) The inpatient psychiatric service
provider shall
is
to be inspected annually by a certified fire authority or, where none is
available, by the division of state fire marshal of
in the Ohio
department of commerce. Copies of annual inspections shall
are to be
maintained by the inpatient psychiatric service provider for a period of at
least three years or until the next on-site licensure survey.
(5) The inpatient psychiatric service
provider's food service shall
is to be inspected annually by the authorized
local municipal county health department. Copies of annual inspections
shall
are to
be maintained by the inpatient psychiatric service provider for a period of at
least three years or until the next on-site licensure survey.
(6) If the inpatient psychiatric service
provider's water supply and sewage disposal is not part of a municipal system,
it shall
is
to comply with applicable state or local regulations, rules, codes, or
ordinances.
(B) Each
inpatient psychiatric service provider shall
is to provide
an environment that is clean, safe, aesthetic, and therapeutic. Appropriate
space, equipment, and facilities
shall
are to be available to provide services.
(1) If smoking is permitted, a separate, enclosed area shall
is to be used
for smoking;
(2) Each
patient's
sleeping room
shall
is to have
a
all of the following:
(a)
Window
A window, with
an operable covering for privacy, that has a view to the outdoors;
(b)
Minimum
A minimum of
one hundred net square feet of usable floor space per bed for single occupancy,
and a minimum of eighty net square feet of usable floor space per bed for
multi-occupancy;
(c)
Minimum
A
minimum of a bed, chair, storage for personal belongings, and other
therapeutic furnishings as appropriate; and
(d)
Degree
A degree of
privacy from other patients if there is more than one bed in the
room.
(3)
Child/adolescent patients shall
are not to share
the same sleeping room with adult patients.
(4) For all patients, a safe and secure
storage area for personal belongings accessible to the patient
shall
is to
be provided. Personal belongings that may pose safety issues for patients may
be placed in a safe and secure storage area accessible to patients through a
request of staff.
(5) Each
inpatient psychiatric service provider shall
is to provide
common
patient areas that adequately meet
patient needs and program
requirements
mandates.
(a) There
shall
is to
be a minimum of eighty total square feet of usable social space per licensed
bed to include:
(i)
Patient
A patient
lounge area totaling at least thirty square feet per licensed bed, including
separate smoking and non-smoking areas if smoking is permitted in the lounge
area;
(ii)
Patient
A
patient
activity area totaling at least thirty square feet per licensed
bed which may include indoor recreation areas;
(iii) Dining room facilities to meet patient
needs;
(iv)
Patient
A
patient
kitchen area to include a sink, a refrigerator, and cooking
facilities as appropriate to patient need; and
(v)
Patient
A patient
laundry area.
(6) Patient lounge, activity, and dining
areas may
are
to be shared spaces as appropriate to patient need. Child/adolescent
patients shall
are
to be provided the use of a patient lounge area appropriate for their use
separate from adult use of patient lounge areas.
(7) There
shall
are to be
private areas to include
all of the following:
(a)
Private
A private area
for visitation from family members, significant others, or other
persons;
(b)
Private
A
private area for telephone use;
(c)
Group
A group therapy
area as appropriate to patient need; and
(d) Private areas to include places and times
for personal privacy.
(8) Each inpatient psychiatric service
provider shall
is
to provide an environment that is accessible to persons with disabilities
and make reasonable accommodations in accordance with all applicable federal,
state and local laws and regulations.
(9) Each
inpatient psychiatric service
provider shall
is
to develop policies and procedures regarding services designed to assist
deaf/hard of hearing persons as well as persons for whom English is not the
primary language.
(a) Services
shall
are to
be provided at such a level so that the
patient and
patient's family or
significant others are not denied the benefits of participation in the
inpatient psychiatric service provider's treatment program. Services
shall
will
comply with all applicable state
,
and federal
and
HIPAA guidelines regarding the maintenance of
patient confidentiality.
As applicable, such services
shall
are to consist of but
may
are not
to be limited to availability of
all of the following:
(i) Qualified interpreters with demonstrated
ability or certification;
(ii)
Telecommunication devices for the deaf or hard of hearing; and
(iii) Television closed caption
capability.
(b) Such
services shall
are
to be available to patients and their family members or significant
others who are receiving services. Specifically for emergency services, the
inpatient psychiatric service provider shall
is to have
policies and procedures that address the need for immediate accessibility to
qualified interpreters, telecommunication devices for the deaf/hard of hearing,
and/or
and
other assistance with communication.
(c) Direct care staff and treatment team
members shall
are
to be trained in issues relating to barriers to traditional
verbal/English communication.
(d)
Services to assist patients and families of patients or significant others
shall
are to
be available at no charge to the patient, family,
or significant others.
(10) Each inpatient psychiatric service
provider shall
is
to implement a falls prevention program that is monitored through its
quality improvement process.
(C) Each
inpatient psychiatric service
provider shall
is
to have a sufficient number of professional, administrative, and support
staff to meet both census needs and
patient needs.
(1) Staffing for all services
shall
is to
reflect the volume of patients, patient acuity, and the level of intensity of
the services provided to ensure that desired outcomes of care are achieved and
negative outcomes are avoided.
(2)
Staffing of any organized patient activity (e.g., rehabilitation therapy
services or nursing services provided to groups of patients),
shall
is to be sufficient to ensure
safety and may be dependent on the type, duration, and location of the activity and the immediate
accessibility of other staff.
(3)
For nursing services:
(a) A 1:4 minimum
nursing staff-to-patient ratio shall
is to be maintained as an overall average in any
four week period with the exception of night hours when patients are
sleeping.
(b) For reasons of
safety, at least two staff
shall
members are
to be present at all times.
(c) A registered nurse
must
is to be
on site twenty-four hours each day, seven days a week.
(d) A registered nurse
must
is to be
available for direct patient care when needed.
(D) Each
inpatient psychiatric service
provider shall
is
to meet all applicable medicare conditions of participation
(including
42 C.F.R.
482.13(e)), TJC,
HFAP
ACHC
, or
DNV standards for
seclusion and
restraint in addition to
the
complying with
all of the following
provisions:
(1) The following
shall
are not
to be used under any circumstances:
(a) Behavior management interventions that
employ unpleasant or aversive stimuli such as: the contingent loss of the regular meal, the
contingent loss of bed, and the contingent use of unpleasant substances or
stimuli such as bitter tastes, bad smells, splashing with cold water, and loud,
annoying noises;
(b) Any technique
that obstructs the airway or impairs breathing;
(c) Any technique that obstructs
vision;
(d) Any technique that
restricts the individual's ability to communicate;
(e) Any technique that causes an individual
to be retraumatized based on an individual's history of traumatic
experiences;
(f) Weapons and law
enforcement
restraint devices, as defined by
CMS in appendix A of its
interpretive guidelines to
42 C.F.R. 482.13(f)
482.13(e)
and found in
manual publication No. 100-7,
"
Medicare
CMS
State Operations
Manual, Appendix A - Survey Protocol,
Regulations and Interpretive Guidelines for Hospitals,"
, November 20, 2015
July 21,
2023, revision, used by any
hospital staff or
hospital-employed security
or law enforcement personnel, as a means of subduing a
patient to place that
patient in
patient restraint/
seclusion; and
(g) Chemical restraint.
; and
(h)
Prone
restraint.
(2)
Position in physical or mechanical
restraint.
An individual is to be placed in a
position that allows airway access and does not compromise respiration.
Hospital staff are not authorized to utilize prone restraint.
(a) An individual shall be placed in
a position that allows airway access and does not compromise
respiration.
(i) The use of prone restraint is
prohibited.
(ii) A transitional hold shall be
limited to the minimum amount of time necessary to safely bring the person
under control, at which time staff shall either terminate the transitional
hold, and begin the post-restraint process required by this rule, or, if the
individual cannot safely be released from the transitional hold, re-position
the individual into an alternate restraint position.
The use of transitional hold shall
not be utilized with mechanical restraint.
(b) The use of transitional hold
shall be subject to the following requirements:
(i) Applied only by staff who have
current training on the safe use of transitional hold, including how to
recognize and respond to signs of distress in the individual.
(ii) The weight of the staff shall
be placed to the side, rather than on top of the individual. No transitional
hold shall allow staff to straddle or bear weight on the individual's torso
while applying the restraint, i.e. no downward pressure may be applied that may
compromise the individual's ability to breathe.
(iii) No transitional hold shall
allow the individual's hands or arms to be under or behind his/her head or
body. The arms must be at the individual's side.
(iv) No soft device, such as a
pillow, blanket or other item, shall be used to cushion the client's head,
since such a device may restrict the individual's ability to
breathe.
(v) All staff involved in the
procedure must constantly observe the individual's respiration, coloring, and
other signs of distress, listen for the individual's complaints of breathing
problems, and immediately respond to assure safety.
(vi) After conclusion of the
transitional hold, the hospital shall monitor and document the condition of the
individual at least every fifteen minutes, for two hours. The inability to
complete the fifteen minute monitoring and rational shall be
documented.
(3)
The
inpatient psychiatric service provider shall
is to identify,
educate
, and approve staff members to use
seclusion or
restraint. Competency of staff in the use and documentation of
seclusion or
restraint methods
shall
is to be routinely evaluated. The results of
evaluations
shall
are to be maintained by the
inpatient psychiatric
service provider for a minimum of three years for each staff member identified.
Staff shall
are to have
appropriate training prior to utilizing seclusion or restraint, and, at a
minimum, annually thereafter. The exception to annual training is a first aid
or CPR training/certification program of a nationally recognized certifying
body, e.g., the american red cross or american
heart association, when that certifying body establishes a longer time frame
for certification and renewal.
(a)
Staff shall
are
to be trained in and demonstrate competency in the safe application of
all seclusion or restraint interventions he or she is authorized to
perform, including specific training in utilization
of transitional holds, if applicable;
(b) Staff shall
are to be
trained in and demonstrate competency in choosing the least restrictive
intervention based on an individualized assessment of the patient's behavioral
and/or medical status or condition;
(c) Staff shall
are to be
trained in and demonstrate competency in recognizing and responding to signs of
physical distress in clients who are being secluded or restrained;
(d) Staff shall
are to be
trained and certified in first aid and CPR;
(e) Staff shall
are to be
trained in and demonstrate competency in recognizing and responding to signs of
physical distress in clients who are being secluded or restrained;
(f) Staff authorized to take vital signs and
blood pressure shall
are to be trained in and demonstrate competency in
taking them and understanding their relevance to physical safety and
distress;
(g) Staff
shall
are to
be trained in and demonstrate competency in assessing circulation, range of
motion, nutrition, hydration, hygiene, and toileting needs; and
(h) Staff shall
are to be
trained in and demonstrate competency in helping a client regain control to
meet behavioral criteria to discontinue seclusion or restraint.
(4) The presence of advance
directives or client preferences addressing the use of seclusion or restraint
shall
is to be
determined and considered, and
as well as documented in the medical record. If the
inpatient psychiatric service provider will be unable to utilize seclusion or
restraint in a manner in accordance with the patient's directives or
preferences, the provider shall
is to notify the patient, including
give the
rationale, and document such in the ICR
(5) In each
patient's
medical record, upon
admission and upon any relevant changes in the
patient's condition, any
perceived medical or psychiatric contraindications for the possible use of
seclusion or
restraint shall
is to be documented. The specific
contra-indication shall
contraindication is to be described and
shall
is to
take into account the following which may place the
patient at greater risk for
such use:
(a) Gender;
(b)
Age
Chronological and
developmental age;
(c)
Developmental issues
Physical body size;
(d) Culture, race, ethnicity, and primary
language;
(e) History of physical,
sexual abuse, or psychological trauma;
(f) Medical and other conditions that might
compromise physical well-being, e.g., asthma, epilepsy, obesity, lung and heart
conditions, an existing broken bone, pregnancy, and drug/alcohol use;
and
(g) Physical disabilities.
; and
(h)
Psychiatric
condition.
(6)
Orders
shall
are
to be written only by an individual with specific
clinical
privileges/authorization
to order seclusion and
restraint, granted by the
inpatient psychiatric service provider
to order seclusion and restraint, and who
is a:
(a) Psychiatrist or other physician;
or
(b)
Physician's
Physician
assistant,
certified nurse practitioner
, or
clinical nurse specialist authorized in accordance with his or her scope of
practice and as permitted by applicable law or regulation.
Countersignatures to telephone orders
for seclusion or restraint are to be signed within twenty-four hours by an
individual with specific clinical privileges/authorization to order seclusion
and restraint, granted by the hospital, and who is a psychiatrist or other
physician, physician assistant, certified nurse practitioner, or clinical nurse
specialist.
(c) Countersignatures to telephone
orders for seclusion and/or restraint shall be signed within twenty four hours
by an individual with specific clinical privileges/authorization granted by the
hospital to order seclusion and restraint, and who is a psychiatrist or other
physician, physician's assistant, certified nurse practitioner, or clinical
nurse specialist
(7) Following the conclusion of each
incident
of
seclusion or
restraint, the
patient and staff
shall
are to
participate in a debriefing.
(a) The
debriefing shall
is
to occur within twenty-four hours of the incident unless the client
refuses, is unavailable, or there is a documented clinical
contraindication.
(b) The following
shall
are to
be invited to participate unless such participation is clinically
contraindicated and the rationale is documented in the clinical record:
(i) For a child/adolescent client, the
family, or custodian or guardian, or
.
(ii) For
an adult client, the client's family or significant other when the client has
given consent, or an adult client's guardian, if applicable.
(8) As part of the
inpatient psychiatric service provider's performance improvement process, a
periodic review and analysis of the use of seclusion and restraint
shall
is to be
performed.
(9) The
inpatient
psychiatric service provider shall
is to maintain an ongoing log of its
seclusion and
restraint utilization for departmental review
. A
log
shall
is
to be maintained for
department review of each
incident of mechanical
restraint,
seclusion, and physical
restraint, and for time-out exceeding sixty
minutes per episode. The log
shall
is to include, at minimum, the following
information
.
:
(a) The person's name or other
identifier;
(b) The date, time
, and type of method utilized, i.e.,
seclusion,
physical
or
restraint, mechanical
restraint, or time-out. The log
of physical and mechanical
restraint shall
is to also
describe the type of intervention as follows:
(i) For mechanical restraint, the type of
mechanical restraint device used;
(ii) For physical
restraint, the type of hold
or holds
; and
as
follows:
(a)
Transitional hold, and/or
(b)
Physical restraint; and
(c) The duration of the method or
methods.
If both transitional hold and
physical restraint are utilized during a single episode of restraint, the
duration in each shall be included on the log. For example, a physical
restraint that begins with a one minute transitional hold, followed by a three
minute physical restraint shall be logged as one restraint, indicating the
length of time in each restraint type.
If restraint is necessary as a means of
safely transporting an individual to seclusion, either a separate order for
restraint and a separate order for seclusion is needed or, alternatively, one
order may be used that delineates a separate restraint and a separate
seclusion.
If the restraint or seclusion episode
is concluded, and the patient's behavior necessitates initiating another
restraint or seclusion, then a new order needs to be obtained, even if the
ending time of the original order has not passed.
(10) Plan to reduce
seclusion and
restraint.
(a) A
inpatient psychiatric service
provider which
that utilizes
seclusion or
restraint
shall
is to
develop a plan designed to reduce its use. The plan
shall
is to include
attention to the following strategies:
(i)
Identification of the role of leadership;
(ii) Use of data to inform
practice;
(iii) Workforce
development;
(iv) Identification
and implementation of prevention strategies;
(v) Identification of the role of clients
(including children), families, and external advocates; and
(vi) Utilization of the post seclusion or
restraint debriefing process.
(b) A written status report
shall
is to be
prepared annually, and reviewed by
leadership.
(E) Pursuant to rule
5122-14-14 of the Administrative
Code, the
hospital shall
is to notify the
department of
each
all of the
following:
(1)
Instance
Each
instance of physical injury to a patient that is restraint-related, e.g.,
injuries incurred when being placed in seclusion and/or restraint or while in
seclusion or restraint, with the exception of injury that is self-inflicted,
i.e., a patient banging his/her own
head;
(2)
Death
Each
death that occurs while a person is restrained or in seclusion;
(3)
Death
Each death
occurring within twenty four hours after the person has been removed from
restraint or seclusion,
; and
(4)
Death
Each
death where it is reasonable to assume that a person's death may be
related to or is a result of such seclusion or restraint.
