(A)
This rule is
applicable to all certified providers and licensed class one residential
providers. The purpose of this rule is to state the general standards
applicable to the use of seclusion, mechanical restraint, or physical
restraint.
The provisions of this rule and rule
5122-26-16.1 of the
Administrative Code are not applicable to forensic restrictions imposed by
correction and law enforcement authorities for security (non-clinical care)
purposes. The use of restraint or seclusion by correction, law enforcement or
other staff for the purposes of clinical care is subject to the provisions of
this rule.
A provider which prohibits the use of
seclusion and restraint will develop a policy stating such.
(B)
The
provision of a physically and psychologically safe environment is a basic
foundation and requirement for effective mental health and addiction services
treatment. Adopting trauma informed treatment practices, creating calm
surroundings and establishing positive, trusting relationships are essential to
facilitating a person's treatment and recovery.
The goal of reducing and minimizing the
use of seclusion and restraint is one that will be shared and articulated by
the provider's leadership. The elevation of oversight by leadership of each use
of seclusion or restraint in order to investigate causality, ascertain
relevancy of current policies and procedures, and identify any associated
workforce development issues, is core to the successful achievement of this
goal.
Seclusion and restraint are intrusive
techniques to be used by trained, qualified staff as a last resort in order to
control dangerous and potentially harmful behaviors and to preserve safety.
Best practices include careful early assessment of a person's history,
experiences, preferences, and the effectiveness or ineffectiveness of past
exposure to these methods. Best practices will be based on understanding and
consideration of the individual's history of traumatic experiences as a means
to gain insight into origins and patterns of the individual's
actions.
Use of seclusion or restraint will be
subject to performance improvement processes in order to identify ways in which
the use of these methods can be decreased or avoided and more positive,
relevant and less potentially dangerous techniques used in their
place.
When individuals experience repeated or
sustained use of these methods, leadership should evaluate all causative
factors and consider alternative treatment interventions and possible transfer
to or placement in a more structured treatment setting with the capacity to
meet individual needs with reduced exposure to these intrusive
interventions.
(C)
The following definitions apply to rules
5122-26-16 to
5122-26-16.1 of the
Administrative Code and are in addition to those contained in rule
5122-24-01 of the Administrative
Code:
(1)
"Advance directives" means a legal document used by an adult
to direct in advance the mental or physical health treatment in the event the
adult lacks the capacity to make such decisions. Two types of advance
directives related to mental health treatment are: a "Declaration for Mental
Health Treatment" subject to the requirements of Chapter 2135. of the Revised
Code, and a "Durable Power of Attorney for Health Care" subject to the
requirements of sections
1337.11 to
1337.17 of the Revised
Code.
(2)
"Behavior management" means the utilization of
interventions that are applied in a systematic and contingent manner in the
context of individual or group programs to change or manage behavior or
facilitate improved self-control. The goal of behavior management is not to
curtail or circumvent an individual's rights or human dignity, but rather to
support the individual's recovery and increase the individual's ability to
exercise those rights.
(3)
"Comfort rooms," (formerly known as quiet or time-out
rooms), are adapted sensory rooms that provide sanctuary from stress or can be
places for persons to experience feelings within acceptable
boundaries.
(4)
"Individual crisis plan" means a written plan that
allows the person to identify coping techniques and share with staff what is
helpful in assisting to regain control of the person's behavior in the early
stages of a crisis situation. It may also be referred to as a "behavior support
plan."
(5)
"Mechanical restraint" means any method of restricting
a person's freedom of movement, physical activity, or normal use of his or her
body, using an appliance or device manufactured for this
purpose.
(6)
"Physical restraint", also known as "manual restraint,"
means any method of physically restricting a person's freedom of movement,
physical activity, or normal use of the person's body without the use of
mechanical restraint devices. Transitional holds are not physical
restraint.
(7)
"PRN (pro re nata)" means as the situation
demands.
(8)
"Prone Restraint" means all items or measures used to
limit or control the movement or normal functioning of any portion, or all, of
an individual's body while the individual is in a face-down position. Prone
restraint may include either physical (also known as manual) or mechanical
restraint.
(9)
"Qualified person" means an employee or volunteer who
carries out the agency's tasks under the agency's administration and/or
supervision, and who is qualified to utilize or participate in the utilization
of seclusion or restraint by virtue of the following: education, training,
experience, competence, registration, certification, or applicable licensure,
law, or regulation.
(10)
"Seclusion" means the involuntary confinement of a
person alone in a room where the person is physically prevented from
leaving.
(11)
"Sensory rooms" means appealing physical spaces painted
with soft colors with the availability of furnishings and objects that promote
relaxation and/or stimulation.
(12)
"Time-out" means
an intervention in which staff compel a person to remove them self from regular
programming to a specified place for a specified period of time. Time-outs are
allowed in areas away from activity, which may include time out rooms, other
identified space in the facility, or the client's bedroom. Time-out is not
seclusion or restraint.
(13)
"Transitional hold" means a brief hold, without undue
force, of a person in order to calm or comfort them; or holding a person's hand
to safely escort them from one area to another. At no time may a transitional
hold be a prone, mechanical, or physical restraint as defined in this rule.
Transitional holds are not seclusion or restraint.
(D)
Policies and
procedures
(1)
The provider will establish policies and procedures that
reflect the provisions of this rule and rule
5122-26-16.1 of the
Administrative Code. The provider will document if and how the inclusion of
clients and families in the development of such policies
occurred.
(2)
Policies and procedures governing the use of seclusion
or restraint will include attention to preservation of the person's health,
safety, rights, dignity, and wellbeing during use. Additionally:
(a)
Respect for the
person will be maintained when such methods are utilized;
(b)
Use of the
environment, including the possible addition of comfort, soothing and sensory
rooms, will be designed to assist in the person's development of emotional
self-management skills; and,
(c)
The number of
appropriately trained staff available to apply or initiate seclusion or
restraint will be adequate to ensure safety. The use of non-agency employed law
enforcement personnel, e.g., local law enforcement, to substitute for the lack
of sufficient numbers of appropriately trained staff in such situations is
prohibited.
(3)
Policies and procedures will include the mailing
address and toll-free phone number of disability rights Ohio.
(E)
General requirements
(1)
Seclusion or
restraint will not be used unless it is in response to a crisis situation,
i.e., where there exists an imminent risk of physical harm to the individual or
others, and no other safe and effective intervention is identified.
(a)
Seclusion and
restraint will not be used as behavior management interventions, to compensate
for the lack of sufficient staff, as a substitute for treatment, or as an act
of punishment or retaliation.
(b)
Absent a
co-existing crisis situation that includes the imminent risk of physical harm
to the individual or others, the destruction of property by an individual, in
and of itself is not adequate grounds for the utilization of seclusion or
restraint.
(2)
The following will not 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 restricts the individual's ability to communicate, including consideration
given to the communication needs of individuals who are deaf or hard of
hearing;
(c)
Any technique that obstructs vision;
(d)
Any technique
that causes an individual to be retraumatized based on an individual's history
of traumatic experiences;
(e)
Any technique that obstructs the airways or impairs
breathing;
(f)
Use of mechanical restraint on individuals under age
eighteen;
(g)
A medication that is used as a restraint to control
behavior or restrict the individual's freedom of movement and is not a standard
treatment or dosage for the individual's medical or psychiatric condition or
that reduces the individual's ability to effectively or appropriately interact
with the world around the individual;
(h)
The use of
handcuffs or weapons such as pepper spray, mace, nightsticks, or electronic
restraint devices such as stun guns and tasers, other than the use of handcuffs
or other devices used by corrections and law enforcement personnel for security
purposes;
The presence of weaponry in an agency
poses potential hazards, both physical and psychological, to clients, staff and
visitors. Utilization by the agency of non-agency employed armed law
enforcement personnel (e.g., local police) to respond to and control
psychiatric crisis situations, will be minimized to the extent possible;
and
(3)
Seclusion and
restraint will be utilized in a manner that is safe, proportionate, and
appropriate to the severity of the behavior.
(4)
The choice of the
least restrictive, safe and effective use of seclusion or restraint for an
individual is determined by the person's assessed needs, including a
consideration of any relevant history of trauma or abuse, risk factors as
identified in paragraph (H)(3) of this rule, the effective or ineffective
methods previously used with the person and, when possible, upon the person's
preference.
(5)
Each person will be informed of the agency's philosophy
on the use of seclusion or restraint as well as of the presence of any agency
policies and procedures addressing their use by the agency. This disclosure
will occur upon admission or intake unless it is not clinically warranted;
however the person will be provided the disclosure as soon as clinically
warranted. The person's parent, custodian, or guardian will be provided these
disclosures at admission or intake. This explanation will be in a language that
the client and their parent, custodian or guardian understand, including
American sign language if appropriate. A copy of the policies and procedures
will be provided in writing to the person and to their parent, custodian or
guardian when applicable. The agency will maintain written acknowledgment from
the client or from their parent, custodian or guardian that they have been
informed of the agency's policies and procedures on seclusion or
restraint.
(a)
Adult clients will be offered the opportunity to give
consent for the notification of their use to a family member or significant
other.
(b)
For minor clients, the agency will obtain contact
information in order to notify the parent, custodian or guardian. The agency
may allow the parent, custodian or guardian to specify certain hours during
which they do not want to be notified.
(6)
The inclusion of
clients (including children), families, and external advocates in various roles
and at all provider levels to assist in reducing the use of seclusion or
restraint will be considered.
(F)
Staff training.
The provisions of this paragraph are applicable to all staff whose normal
duties are to interact with those persons served by the provider and any other
staff involved in the use of seclusion and restraint.
Staff will be trained and demonstrate
competency before participating in any seclusion or restraint
intervention.
(1)
The agency will mandate staff to have ongoing education
and training. Staff training will include training exercises in which staff
members successfully demonstrate in practice the techniques they have learned
for managing emergency situations. Staff will have training in and demonstrated
knowledge of:
(a)
Techniques to identify staff and individual behaviors,
events, and environmental factors that may trigger seclusion or
restraint.
(b)
The use of nonphysical intervention skills, such as
de-escalation, mediation conflict resolution, active listening, and verbal and
observational methods, as alternatives to the use of seclusion and
restraint.
(c)
The safe use of restraint and seclusion
(d)
The ability to
recognize and respond to signs of physical distress in individuals who are
restrained or in seclusion, including attention to vitals, and certification in
cardiopulmonary resuscitation and first aid. After initial certification, staff
will be recertified either according to the time frame of a national first aid
certifying body, e,g, the American red cross, or annually.
(e)
Recognize signs
of distress in youth to help reduce the use of seclusion and restraint through
the use of trauma assessments, detection of early warning signs, and the
development of calming/soothing plans and other strategies to help youth
self-regulate. The calming/soothing plans will be documented in the
individualized treatment plan.
(2)
Individuals
providing staff training will:
(a)
Be qualified to do so by education, training, and
experience.
(b)
Document that staff received training and demonstrated
competency. This will occur before staff participate in any seclusion or
restraint intervention, and on an on-going basis:
(i)
Staff will be
certified and recertified in cardiopulmonary resuscitation. Staff certified by
programs approved by the American red cross or the American heart association
will be recertified in accordance with time frames established by the
certifying entity.
(ii)
Staff will be certified and recertified in first aid.
Staff certified by programs approved by the American red cross or the American
heart association will be recertified in accordance with time frames
established by these entities. Staff certification under other programs will be
recertified at least once every twelve months unless a longer time frame is
approved by the department.
(iii)
Non psychiatric
residential treatment facility (PRTF) staff will demonstrate all other
competencies as in paragraph (F)(1) of this rule at least once every twelve
months. PRTF staff will demonstrate competencies as in paragraph (F)(1) of this
rule at least once every six months.
(3)
The agency will
document in the staff personnel records that the training and demonstration of
competency were successfully completed. Documentation will include the date
training was completed and the name of persons certifying the completion of
training.
(4)
All training programs and materials used by the agency
will be available for review by the department.
(G)
Documentation.
(1)
The presence of advance directives or client
preferences addressing the use of seclusion or restraint will be determined and
considered, and documented in the ICR. If the provider will be unable to
utilize seclusion or restraint in a manner in accordance with the person's
directives or preferences, the provider will notify the individual, including
the rationale, and document such in the ICR.
(2)
In conjunction
with the person's active participation, an individual crisis plan will be
developed at the time of admission and incorporated in the person's ITP for
each child or adolescent resident of a department licensed residential facility
or psychiatric residential treatment facility, for each client known to have
experienced seclusion or restraint, for an individual who is at risk of harming
themselves, and when otherwise clinically indicated.
The plan will be based on the initial
behavioral health assessment, and will include and be implemented, as feasible,
in the following order:
(a)
Identification of the methods or tools to be used by
the client to de-escalate and manage his or her own aggressive
behavior;
(b)
Identification of techniques and strategies for staff
in assisting the person to maintain control of his or her own behavior;
and
(c)
Identification, in order of least restrictive to most
restrictive, of the methods or tools to be used by staff to de-escalate and
manage the client's aggressive behavior.
(3)
The provider will
conduct an initial or comprehensive assessment for each child or adolescent
resident of a department licensed residential facility, for each client known
to have experienced seclusion or restraint, for an individual who is at risk of
harming him/herself, and when otherwise clinically indicated for the following
which may place the person at greater risk of physical or psychological injury
as a result of the use of seclusion or restraint:
(b)
Chronological and
developmental age;
(d)
Culture, race,
ethnicity, and primary language;
(e)
History of
physical or 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 or alcohol use;
(g)
Physical disabilities; and
(h)
Psychiatric
condition.
(H)
Logs and
notifications.
(1)
A log will be maintained for department review of each
incident of mechanical restraint, seclusion, and physical restraint, and for
time-outs exceeding sixty minutes per episode. The log will include, at
minimum, the following information:
(b)
The date, time
and type of method or methods utilized, i.e., seclusion, mechanical restraint,
physical restraint, or time-out. The log of mechanical restraint will also
include the type of mechanical restraint device used;
(c)
The duration of
the method or methods; and
(d)
The outcome of
the intervention.
(2)
Pursuant to rules
5122-26-13 and
5122-30-16 of the Administrative
Code, the provider will notify the department of each:
(a)
Instance of
physical injury to a client or resident that is restraint-related, e.g.,
injuries incurred when being placed in seclusion or restraint or while in
seclusion or restraint, with the exception of injury that is self-inflicted,
i.e. a client or resident banging their own head;
(b)
Death that occurs
while a person is restrained or in seclusion;
(c)
Death occurring
within twenty four hours after the person has been removed from restraints or
seclusion, and
(d)
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.
(I)
Episode review
and performance improvement.
(1)
Each incident of seclusion or restraint will be
clinically and administratively reviewed. Such review will be
documented.
(2)
The provider will collect the following data on all
instances of the use of seclusion or restraint and integrate the data into
performance improvement activities.
(a)
Staff involved, including staff member who initiated
the seclusion or restraint;
(b)
Duration of the
method;
(c)
Date, time and shift each method was
initiated;
(e)
Type of method,
including type of physical hold or mechanical restraints
utilized;
(f)
Client age, race, gender and ethnicity;
(g)
Client and staff
injuries;
(h)
Number of episodes per client; and
(i)
Use of
psychotropic medications during an intervention of seclusion or
restraint.
(3)
Data will be aggregated and reviewed at least
semi-annually by providers and at least quarterly by department licensed
residential facilities or certified addiction treatment residential/withdrawal
management providers. The results of the review will be maintained in writing.
Data will be reviewed:
(a)
For analysis of trends and patterns of use;
and
(b)
To identify opportunities to reduce the use of
seclusion or restraint episodes per client.
(4)
The results of
data reviews and performance improvement activities will be shared with staff
at least semi-annually with the goal of reducing the use of seclusion or
restraint.
(J)
Plan to eliminate seclusion or restraint.
(1)
A provider which
utilizes seclusion or restraint will develop a plan designed to reduce its use.
The plan will include attention to the following strategies:
(a)
Identification of
the role of leadership;
(b)
Use of data to inform practice;
(c)
Workforce
development;
(d)
Identification and implementation of prevention
strategies;
(e)
Identification of the role of clients (including
children), families, and external advocates; and
(f)
Utilization of
the post seclusion or restraint debriefing process.
(2)
A written status
report will be prepared annually, and reviewed by leadership.
(K)
Staff
actions commonly known as therapeutic, supportive or directional touch,
utilized to direct an individual to another area without the use of force and
which do not restrict an individual's freedom of movement, are not considered
restraint and are not subject to the provisions of this rule.
(L)
Each provider
utilizing seclusion or restraint is responsible for identifying and adopting
systems of seclusion and restraint techniques; and will assure that chosen
systems meet all standards set forth in rules
5122-26-16 and
5122-26-16.1 of the
Administrative Code and that staff that perform seclusion or restraint are
trained in the proper use of those systems.
Replaces: 5122-26-16
Notes
Ohio Admin. Code
5122-26-16
Effective:
10/20/2023
Five Year Review (FYR) Dates:
10/20/2028
Promulgated
Under: 119.03
Statutory Authority: 5119.36
Rule
Amplifies: 5119.36
Prior Effective Dates: 01/01/1991, 04/16/2001,
01/01/2012, 04/01/2016, 10/31/2019