Special treatment procedures

A facility shall have written policies and procedures regarding implementation of special treatment procedures. Special treatment procedures must be therapeutic and meaningful interventions and may not be used for punishment, for the convenience of employees, or as substitute for therapeutic programming. Upon admission, the facility shall inform the child and the person who may lawfully act on behalf of the child of the facility policy on restraint and seclusion procedures during an emergency safety situation. The facility shall provide education to the children, providing each child the opportunity to express the child's opinion and educating the child on alternative behavior choices to avoid the use of special treatment procedures. Alternatives to behaviors must be documented in each child's individual person-centered treatment plan. The health, safety, and well-being of children receiving care and treatment in the facility must be properly safeguarded. A physician shall review the use of special treatment procedures. 1. Timeout. Employees shall supervise the use of timeout procedures at all times, and shall document the use of timeout procedures in the child's file. The use of the resident's bedroom for timeout is prohibited. 2. Physical escort. Employees shall supervise the use of physical escort procedures at all times and shall document the use of physical escort in the child's file. 3. Physical restraints. a. Physical restraints must be ordered by a psychiatrist or other physician, a licensed psychologist, a licensed clinical social worker, or a nurse who holds advanced licensure in psychiatric nursing. Staff authorized to order physical restraint must be trained in the use of emergency interventions. A psychiatrist or other physician, a licensed psychologist, a licensed clinical social worker, or a nurse who holds advanced licensure in psychiatric nursing must review and sign the order within forty-eight hours after the ordered physical restraint. Physical restraints may be imposed only in emergency circumstances and must be used with extreme caution to ensure the immediate physical safety of the child, an employee, or others after all other less intrusive alternatives have failed or have been deemed inappropriate; b. All physical restraints must be applied by employees who are certified in the use of restraints and emergency safety interventions; and c. The facility shall have established protocols that require: (1) Entries made in the child's file as to the date, time, employee involved, reasons for the use of, and the extent to which physical restraints were used, and which identify less restrictive measures attempted; (2) Notification within twelve hours of the individual who lawfully may act on behalf of the child; and (3) Face-to-face assessment of children in physical restraint completed by a psychiatrist or other physician, a licensed psychologist, a licensed clinical social worker, a nurse who holds advanced licensure in psychiatric nursing, or other licensed health care professional or practitioner who is trained in the use of safety, emergency interventions. The face-to-face assessment must be documented in the child's case file and include assessing the mental and physical well-being of the child. The face-to-face assessment must be completed as soon as possible, and no later than one hour after the initiation of physical restraint or seclusion. 4. Seclusion. Seclusion must be ordered by a psychiatrist or other physician, a licensed psychologist, a licensed clinical social worker, or a nurse who holds advanced licensure in psychiatric nursing. Staff authorized to order seclusion must be trained in the use of emergency interventions. A psychiatrist or other physician, a licensed psychologist, a licensed clinical social worker, or a nurse who holds advanced licensure in psychiatric nursing must review and sign the order within forty-eight hours after the ordered seclusion. Seclusion may be imposed only in emergency circumstances after all other less intrusive alternatives have failed or have been deemed inappropriate. Seclusion is to be used with extreme caution, and only to ensure the immediate physical safety of the child, an employee, or others. A child's bedroom may not be used for seclusion. If seclusion is indicated, the facility shall ensure that: a. The proximity of the employee allows for visual and auditory contact with the child at all times; b. Employees conduct assessments of the child every fifteen minutes and document the assessments in the child's case file; c. The seclusion room is not locked, or is equipped with a lock that only operates with an employee present such as a push-button lock that only remains locked while it is being pushed; d. All nontherapeutic objects are removed from the area in which the seclusion occurs; e. All fixtures within the room are tamperproof, with switches located outside the room; f. Smoke-monitoring or fire-monitoring devices are an inherent part of the seclusion room; g. Security mattresses used are made of fire-resistant material; h. The room is properly ventilated; i. Notification of the individual who lawfully may act on behalf of the child is made within twelve hours of a seclusion and is documented in the child's case file; j. A child under special treatment procedures is provided a similar diet that other children in the facility are receiving; k. No child remains in seclusion: (1) For more than four hours in a twenty-four-hour period; and (2) Without physician approval; l. Seclusion is limited to the maximum time frame per episode for fifteen minutes for children aged nine and younger and one hour for children aged ten and older; and m. Face-to-face assessment of children in seclusion is completed by a psychiatrist or other physician, licensed psychologist, a licensed clinical social worker, a nurse who holds advanced licensure in psychiatric nursing, or other licensed health care professional or practitioner who is trained in the use of safety, emergency interventions. The face-to-face assessment must be documented in the child's case file and include assessing the mental and physical well-being of the child. The face-to-face assessment must occur no later than one hour after the initiation of seclusion. 5. Within twenty-four hours of each use of seclusion or physical restraint, the facility shall conduct a face-to-face discussion which includes the child and all employees involved in the emergency intervention, except when the involvement of a particular employee may jeopardize the wellbeing of the child, and which: a. Evaluates and documents in the child's case file the well-being of the child served and identifies the need for counseling or other therapeutic services related to the incident; b. Identifies antecedent behaviors and modifies the child's individual person-centered treatment plan as appropriate; and c. Analyzes the incident and identifies needed changes to policy and procedures, employee training, and strategies that could have been used by an employee, by the child, or by others which could prevent the future use of seclusion or physical restraint. 6. Within twenty-four hours after the use of physical restraint or seclusion, all employees involved in the emergency safety intervention, and appropriate supervisory and administrative employees, shall conduct a debriefing session that includes, at a minimum a review and discussion of: a. Precipitating factors to the emergency situation; b. Alternative techniques that might have prevented the use of physical restraint or seclusion; c. The procedures, if any, that employees are to implement to prevent any recurrence of the use of physical restraint or seclusion; and d. The outcomes of the intervention, including any injuries that may have resulted from the use of the physical restraint or seclusion. 7. Employees shall document in the child's record both the face-to-face discussion and debriefing sessions identified in subsections 5 and 6 and the names of employees involved, employees excused, and any changes to the child's treatment plan as a result of the face-to- face discussion and debriefing. The facility also shall document that the person who may lawfully act on behalf of the child was notified. 8. Special treatment procedure training. Each facility must have policies and procedures regarding annual training in the use of all special treatment procedures listed in this section, which comply with the standards set forth by the facility's accrediting body.