Tenn. Comp. R. & Regs. 0940-03-09-.16 - INTERNAL REVIEWS

(1) The mental health residential treatment facility must provide and document three (3) types of reviews.

(a) Service Recipient Review:

1. A licensed practitioner or mental health personnel who can initiate isolation, mechanical restraint, or physical holding restraint must review the episode upon termination of the intervention with the service recipient. When deemed appropriate by the facility, his or her parent, guardian, temporary caregiver, or legal custodian, as appropriate, of an unemancipated child, or the conservator, attorney-in-fact under a durable power of attorney which authorizes health care, or surrogate decision-maker of an adult selected under T.C.A. §§ 33-3-219 and 220 may participate if available. The review must occur as soon as possible, but no later than twenty-four (24) hours after termination of isolation, mechanical restraint, or physical holding restraint. The review must address the episode; any identified reasons for the behavior, and identify ways to alleviate any related trauma. Staff must document in the service recipient's record that this review took place and must include the names of staff who were present, the names of any staff excused, and any changes to the service recipient's treatment plan as a result of the review. Documentation from the review may also be maintained in the mental health residential treatment facility records.

2. If a review is clinically contraindicated, the rationale for the conclusion must be documented in the service recipient's record.

(b) Episode Review:

1. Within twenty-four (24) hours of termination of isolation, mechanical restraint, or physical holding restraint, staff, including supervisory or administrative staff, must review the episode to determine the circumstances requiring the use, how it might be addressed differently, alternative techniques that might have prevented the use, any procedures that need to be implemented to prevent recurrence, and the outcome of the episode. Any injury to the service recipient or staff during the implementation or use of the isolation, mechanical restraint, or physical holding restraint must be included in the review and a plan must be developed to prevent future injuries. The review must also address any need to change the service recipient's treatment plan, opportunities for performance improvements and any need for alleviation of staff trauma associated with the episode. The staff review must include staff involved in the episode and, if possible, other staff who witnessed or have knowledge about the episode or the service recipient. The mental health residential treatment facility supervisor or designee may, for good cause, allow an exception to the review within twenty-four (24) hours, but the review must be concluded within five (5) business days of the episode. Staff must document in the service recipient's record that the review occurred and must include the names of staff who were present, the names of any staff excused, and any changes to the service recipient's treatment plan as a result of the review. Documentation from the review may also be maintained in the mental health residential treatment facility records.

(c) Systematic Review:

1. The mental health residential treatment facility must develop and implement a process for systematic review of all isolation, mechanical restraint, or physical holding restraint episodes and the identification of trends of use of isolation, mechanical restraint, or physical holding restraint.

Notes

Tenn. Comp. R. & Regs. 0940-03-09-.16

Original rule filed March 3, 2008; effective May 17, 2008.

Authority: T.C.A. §§ 4-4-103, 4-5-202 and 204, 33-1-302, 305, 309, and 33-3-120; 42 C.F.R. §483.370(b) and (c).