214-RICR-40-00-4
214-RICR-40-00-4. Residential Child Care Regulations for Licensure (version Periodic Refile, 01/02/2002 to 06/07/2010)
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Child Care Regulations:
Addendum A
Regulations Regarding the Use of
Crisis Intervention, Restraint and
Seclusion Within Covered Residential
Facilities
State of Rhode Island
Department of Children, Youth and
Families
2
State of Rhode Island Department of Children, Youth and Families
Child Care Regulations: Addendum A - Regulations Regarding the Use of
Crisis Intervention, Restraint and Seclusion Within Covered Residential
Facilities
Effective Date: October 1, 2001
I.
Statement of Intent
A.
The Department of Children, Youth and Families (DCYF), in accordance with
RIGL 42-72.9 and the Federal Children’s Health Act of 2000, promulgates these
regulations to be used by all residential programs licensed by the Department
regarding the use of crisis intervention restraint and seclusion. It is the
responsibility of each Covered Facility and/or parent agency to ensure that they
adopt facility and agency specific policies which incorporate all applicable federal
and state laws and regulations relative to the use of physical restraint, mechanical
restraint, chemical restraint and seclusion.
The intent of these regulations is to set clear minimal standards and expectations
for providers and their staff to meet in order to develop safe and therapeutic
environments for children and youth in the care of the Covered Facility. These
regulations are to ensure that every child and youth who is placed in a Covered
Facility receives the least intrusive, most clinically appropriate intervention,
which is sufficient to ensure his/her safety and promote healthy growth and
development.
It is the State’s belief that every child has the right to be free from the use of
seclusion or restraint of any form as a means of coercion, discipline or retaliation
by staff. The Department recognizes that the use of restraint and seclusion poses
an inherent risk to the physical safety and psychological well-being of the
involved child or youth and to the staff. Therefore, restraint and seclusion are to
be used only in circumstances where a child, due to his or her current behavior,
poses an imminent risk of harm to him/herself or others, including staff. Non-
physical interventions are the first choice of intervention unless safety issues
demand an immediate physical response.
Pursuant to these regulations, the Department intends to work with Covered
Facilities in an effort to increase the proactive interventions available and used by
staff in order to reduce the use of restraint and seclusion. The Department
recognizes that agency leaders and program managers play an important role in
creating healthy, supportive environments which minimize circumstances that
give rise to restraint and seclusion use and which maximize safety when these are
used. The Department also recognizes the important role of family members in
the child’s/youth’s treatment planning and decisionmaking when appropriate.
The Department intends that, with the exception of situations where the
participation of family members may have a deleterious effect on the individual
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child and his/her rights, Covered Facilities will develop policies and practices
which increase the positive participation of family members.
B.
Pursuant to these regulations, standards are set forth and defined for:
1.
approved models of crisis intervention and physical restraint training,
2.
the training of trainers within approved model(s);
3.
the use of crisis intervention and de-escalation methods;
4.
the use of physical, mechanical and chemical restraints, and the
circumstances under which their use would be permissible;
5.
the use of seclusion and the circumstances under which it would be
permissible;
6.
post-restraint debriefing;
7.
documentation, reporting and quality assurance; and
8.
program level sanctions for non-compliance.
II.
Definitions
In addition to terms defined elsewhere in the Child Care Regulations, the following terms are
defined for use in this addendum:
A.
“Covered Facility” means any agency, organization, or public or private entity
that provides any of the following for children and which is granted a license by
the Department of Children, Youth and Families: residential treatment, including
in-house educational programming; in-patient or residential psychiatric treatment
for mental illness; and group or shelter home care. The term "Covered Facility"
does not include the public school system, psychiatric hospitals, or the Rhode
Island Training School for Youth;
B.
“Parent Agency” means the agency or organization of which a Covered Facility is
a legal subsidiary.
C.
“Nationally Recognized Training Program” means a crisis intervention and
restraint training program, which at a minimum has the following attributes:
1.
a clearly written curriculum which focuses on prevention and de-
escalation of crisis in order to reduce the likelihood of the use of restraint;
2.
a process by which individuals involved in a restraint can effectively
debrief the trauma of the event;
3.
physical restraint methods which have been reviewed by a multi-
disciplinary group of professionals;
4.
a method by which individuals are required to be certified as trainers in
the model and by which trainers are required to be re-certified at least
once every three years;
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5.
a method by which the effectiveness of individual trainers are evaluated
and by which such evaluations are used in determining the individual’s
ongoing status as a certified trainer;
6.
is developed by an organization which has the capacity to ensure quality
in training and in the evaluation of the practical application of the model
and which utilizes such evaluations to modify the curriculum and the
restraint procedures as necessary to ensure the application of state-of-the-
art principals in the non-restraint and restraint aspects of the curriculum
(the Department has a responsibility to periodically assess the ability of
each organization to conduct such evaluation and quality assurance); and
7.
demonstrated safe and effective utilization of the model.
D.
“Service Provider” means any person employed or contracted by a Covered
Facility to provide direct care, residential treatment, education or direct
supervision of children;
E.
“Program Manager” means the person who is identified as having direct
responsibility for the day-to-day management of the operations of a Covered
Facility;
F.
"Therapeutic Physical Restraint" (the term physical restraint is used
interchangeably with this term throughout this section) means the acceptable use
of a staff member's body to immobilize or reduce the free movement of a
child/youth's arms, legs, torso or head in order to ensure the physical safety of a
child/youth or other individual in the facility. The term does not include: (1)
briefly holding a person in order to calm or comfort the person; (2) restraint
involving the minimum contact necessary to safely escort the person from one
area to another. This definition does not apply to interactions with individuals
which are brief and focus on redirection or assistance within daily living
activities, including the use of physical escorts.
G.
"Mechanical Restraint" means any approved mechanical restriction that
immobilizes or reduces the free movement of a child’s/youth's arms, legs, torso or
head in order to hold a child/youth safely including: (1) medical devices,
including, but not limited to, supports prescribed by a health care provider to
achieve proper body position or balance; (2) helmets or other protective gear used
to protect a person from injuries due to a fall; or (3) helmets, mitts and similar
devices used to prevent self-injury when the device is part of a documented
treatment plan and is the least restrictive means available to prevent such self-
injury.
H.
"Life threatening physical restraint" means any physical restraint or hold on a
child that restricts the flow of air into a person's lungs, whether by chest
compression or any other means, or which may otherwise result in death.
I.
"Chemical restraint" means a medication used to control behavior or restrict the
patient's freedom of movement and is not a standard treatment for the child's
medical or psychiatric condition.
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J.
"Seclusion" means the involuntary confinement of a person in a room in a
Covered Facility, whether alone or with staff supervision, in a manner that
prevents the person from leaving. This definition does not pertain to the use of
"time out" as an acceptable form of short term behavioral management nor does it
pertain to Covered Facilities where the terms of seclusion are defined pursuant to
particular judicial decrees.
K.
"Time-out" means a brief separation from the group, not to exceed twenty (20)
minutes, designed to de-escalate the child. During "time-out" a child's freedom of
movement is not restricted and the child need not be directly supervised, but must
be visually monitored. This is not intended to restrict programs from using
procedures such as room restrictions or privilege restrictions which are a defined
part of the program’s behavior management and positive reinforcement methods.
L.
“Emergency” means any event in which a child or youth placed in a Covered
Facility poses an imminent or immediate risk of harm to the physical safety of
himself or other individuals.
M.
“Serious physical injury” means any injury which requires diagnostic or treatment
services from a licensed medical provider and does not include injuries which can
be appropriately treated through recognized first aid techniques which can be
administered by a person who is not a licensed medical provider.
N.
“Monitoring” (restraint and seclusion) means (a) direct observation or (b)
observation by way of video monitoring within physical proximity sufficient to
provide aid as needed.
O.
“Monitoring” (time-out) means the intermittent visual observation of a resident
who has been briefly separated from the group under the time-out procedure
defined by RIGL 42-72.9-3(8).
P.
“Assessment” means the evaluation of the physical condition of a child/youth
who is being restrained or secluded by a trained and competent staff member.
Q.
“Assistance” means the help provided by staff to individuals in meeting the
behavior criteria for the prevention of restraint or seclusion or for the
discontinuation of the restraint or seclusion.
III.
Leadership
A.
Parent Agency and Covered Facility leaders are expected to take an active role in
creating an environment that minimizes circumstances that give rise to restraint
and seclusion use and that maximizes safety when they are used. This leadership
includes:
1.
Ensuring staff understand that the use of restraint and seclusion poses an
inherent risk to the physical safety and psychological well-being of the
individual and staff. Therefore, restraint and seclusion are to be used only
in an emergency, when there is an immediate or imminent risk that a
child/youth will harm him/herself or others. Non-physical interventions
are the first choice as an intervention, unless safety issues demand an
immediate physical response.
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2.
Ensuring staff understand that the use of restraint and seclusion has the
potential to produce serious consequences, such as physical and
psychological harm, loss of dignity, violation of an individual’s rights and
even death and that reducing the use of restraint and seclusion is a
paramount responsibility of all staff.
B.
Agency and Covered Facility leaders are expected to ensure the sufficient
allocation of resources , the provision of initial and ongoing training and the
integration of the use of restraint and seclusion into performance improvement
activities as methods to focus on the creation of a positive environment and the
reduction of the use of restraint and seclusion.
IV.
Approved Nationally Recognized Models of Crisis Intervention and Physical Restraint
Training
A.
Covered Facilities are required to use only nationally recognized crisis
intervention and physical restraint training programs which are approved by the
Department.
B.
The Department shall make available to Covered Facilities and other interested
parties a list of approved training models no later than January 1 of each calendar
year.
1.
Each Covered Facility is required to identify one model from this list to be
used within the Covered Facility except as otherwise authorized by the
Department.
a)
Program Managers must ensure that all staff working within that
Covered Facility are trained in this model in accordance with these
regulations; and
b)
When intervening with a physical restraint, staff must limit their
use of physical restraint techniques to those taught in the training
model identified to the Department as being the model used in that
Covered Facility.
2.
Parent Agencies which operate more than one Covered Facility may
identify a different nationally recognized training model for each Covered
Facility and may provide cross-training to all Parent Agency Service
Providers in each model. However, each Covered Facility is limited to
utilizing one identified crisis intervention and restraint model within that
Covered Facility except as otherwise authorized by the Department.
3.
Covered facilities are required to ensure that any training in crisis
intervention and restraint for their staff is provided by a person(s) who is
recognized as a “certified” trainer in that model by the organization which
developed the model and provides the training of trainers in the model.
The Covered Facility must further ensure the following:
a)
The trainer(s) has been certified or recertified as a trainer in the
most current version of the model within the past three (3) years;
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b)
The trainer has at a minimum annually conducted one (1) complete
training in the model for which they are certified since their last
date of certification or recertification, and
c)
The Covered Facility has on file documentation as to the
certification status of every trainer they use for the teaching of
crisis intervention and restraint to Service Providers.
d)
Covered facilities are not permitted to “blend” one or more
approved nationally recognized models for use by staff in the
Covered Facility.
e)
Covered facilities are not permitted to develop or use crisis
intervention and restraint models which have been developed by
the Covered Facility, the program’s Parent Agency or by another
treatment provider unless that model is identified as an approved
model by the Department.
C.
Procedures for approval of adaptations to approved nationally recognized models
of crisis intervention and restraint:
1.
Covered facilities and/or their Parent Agency may make a written request
to the Director of the Department or his/her designee for the adaptation of
a particular model if they believe that such adaptation is clinically
necessary for the safe operation of the program and to ensure a safe
environment for the children and youth served by the program. Such a
request must include the following:
a)
Identification of the extent to which the Covered Facility and/or
Parent Agency has provided adequate training for staff in the
identified model and has ensured that staff are effectively
implementing the model;
b)
Identification of the reasons as to why the Covered Facility and/or
Parent Agency finds the interventions provided in this model to be
clinically inadequate for the population served or to not provide for
the development and maintenance of a safe environment;
c)
A clear written and pictorial description of the intervention(s) to be
modified or added for use in this Covered Facility;
d)
Evidence that the Covered Facility and/or Parent Agency has
discussed this alteration to the model with the organization that
developed the model and provides the training of trainers in the
specified model and that the organization has either agreed to the
alteration or clearly identified to the Covered Facility and/or
Parent Agency any concerns regarding the alteration and whether
or not the organization endorses the alteration;
e)
Evidence that the Covered Facility and/or Parent Agency has
developed this alteration with the participation of a multi-
disciplinary group of professionals.
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2.
Upon receiving such a request, the Director and/or his/her designee will
review the submitted material. He/She may convene a panel of experts to
assist in this review and may request a demonstration of the proposed
technique. The Director will provide a written decision to the Covered
Facility and/or Parent Agency within sixty (60) business days of the
receipt of the written request.
D.
Addition/Deletion of crisis intervention and restraint models from the approved
list of nationally recognized training models.
1.
Parent Agencies and/or Covered Facilities may submit to the Department
recommendations for nationally recognized crisis intervention and
physical restraint training models to be added to the list of approved
models.
Such submissions must be in writing and at a minimum must include the
following:
a)
Copy of the curriculum for the recommended model, including any
audiovisual material available for use by trainers;
b)
Contact information for the organization which developed the
model and provides the training of trainers for the specified
model.
2.
The Department shall review all submitted requests on an annual basis
and may convene a panel of experts to assist in this review. Training
models which are approved shall be added to the next edition of the list of
approved nationally recognized training models.
3.
The Department retains the right to add or remove nationally recognized
training models from the list of approved models at any time.
a)
When moving to remove a training model from the approved list,
the Department shall notify providers of this decision at least one
hundred and twenty days (120) in advance of the removal, unless
the Department identifies the need for removal as an emergency
situation.
b)
When removing a training model from the approved list, the
Department shall work with the Covered Facilities and/or Parent
Agencies which are directly affected in helping them to transition
to another training model from the approved list.
4.
Parent agencies and/or Covered Facilities are required to report to the
Department any changes to the approved model that they utilize which are
made by the organization which certifies trainers in that model. Such
notification must take place with thirty (30) days of the receipt of the
changes by the Parent Agency and/or Covered Facility.
E.
The Department has the responsibility to periodically assess the ability of each
organization which has an approved training model to conduct evaluation and
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quality assurance assessments on the model which are used to improve the
model’s effectiveness.
F.
Nothing in this section is intended to preclude Parent Agencies and Covered
Facilities from using state-of-the-art prevention and intervention methods which
are focused on avoiding the use of any type of restraint or seclusion which may
be in addition to methods taught in the Covered Facilities approved curriculum.
Any special approvals required in this section pertain to the addition of methods
of physical restraint which are not a part of the Covered Facilities approved
curriculum.
V.
Training and Supervision
A.
In addition to any training, supervision and evaluation requirements set forth
elsewhere in these Child Care Regulations, each Covered Facility and/or Parent
Agency must meet the requirements set forth in this section relative to orientation,
training and supervision and requirements pertaining to the use of crisis
intervention and restraint.
B.
Training:
1.
New Service Providers
a)
Each Covered Facility must ensure that every new Service
Provider successfully completes the training prescribed below in
regard to crisis intervention and restraint prior to that Service
Provider being authorized to be solely responsible for any child or
children in the care of the Covered Facility. Covered Facilities
and/or Parent Agencies must also ensure that all new Service
Providers are given the opportunity to complete such training
within thirty (30) days from their date of hire. The required new
Service Provider training includes, but is not limited to:
(1)
A minimum of sixteen (16) hours of training in the Covered
Facility’s approved crisis intervention and restraint model
or the prescribed number of minimum hours identified
within the model, whichever is greater.
(a)
Such training shall include role-playing in de-
escalation, demonstration by the Service Provider of
each hold and self-protection method taught, and
written pre-training and post-training tests.
(b)
Successful completion of this training must be
verified by a written sign-off from the trainer
stating that the Service Provider has successfully
completed the training program and that he/she can
competently implement the components of the
training program. A copy of this documentation
shall be kept in the Service Provider’s personnel
file.
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(2)
When not included as a part of the Covered Facility’s
approved crisis intervention and restraint training model,
each Service Provider shall also successfully complete
training in the following:
(a)
Avoidance of power struggles;
(b)
Aggressive behavior related to a medical condition;
(c)
Physiological impact of restraint;
(d)
Monitoring physical signs of distress and obtaining
medical assistance;
(e)
Legal issues;
(f)
Positional asphyxia;
(g)
Self protection techniques;
(h)
Process for obtaining approval for continued
restraint;
(i)
Documentation;
(j)
Investigation of injuries and complaints.
2.
Annual Training: Each Covered Facility and/or Parent Agency shall
ensure that all staff, on a minimum of an annual basis, receive a minimum
of eight (8) hours of refresher training in the Covered Facility’s approved
crisis intervention and restraint model or the prescribed number of
minimum hours of refresher training identified within the model,
whichever is greater.
a)
Such training shall include role-playing in de-escalation,
demonstration by the Service Provider of each hold and self-
protection method taught, and written pre-training and post-
training tests.
b)
Successful completion of this training must be verified by a written
sign-off from the trainer stating that the Service Provider has
successfully completed the training program and that he/she can
competently implement the components of the training program.
A copy of this documentation shall be kept in the Service
Provider’s personnel file.
3.
It is the responsibility of the Covered Facility and/or Parent Agency to
ensure that any and all Relief Staff utilized by the Covered Facility who
may not be regular employees of the Covered Facility and/or Parent
Agency have successfully completed the same training required of the
regular Service Providers for the Covered Facility and/or Parent Agency.
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4.
No employee or Relief Staff member for the Covered Facility shall
participate in a restraint if they have not successfully completed the
required training in crisis intervention and restraint.
C.
Supervision:
1.
Each Covered Facility and/or Parent Agency shall ensure that the use of
crisis intervention and restraint is routinely addressed in individual and/or
group supervision with all Service Providers and clinical staff. Such
supervision shall focus on analyzing individual interventions as well as
patterns of intervention to identify ways to increase the effective use of
prevention methods and further reduce the use of restraint within the
Covered Facility.
2.
Each Covered Facility and/or Parent Agency shall ensure that every
Service Provider’s annual performance evaluation include an evaluation of
the Service Provider’s use of crisis intervention and restraint.
VI.
Use of Restraint, Seclusion, Time Out and Behavioral Modification
A.
Covered facilities must develop written policies and procedures regarding their
focus on creating a positive environment to reduce the use of restraint or
seclusion and must submit these to the Department for review and approval.
1.
These policies must promote optimal resident functioning in a safe and
therapeutic manner and must minimize the adverse consequences of the
use of restraint or seclusion.
2.
These policies must minimally address trainer certification, staff training,
alternative intervention strategies, de-escalation techniques, internal and
external reporting requirements including the obtaining of informed
consent relative to the use of restraint from the child/youth’s
parent/guardian, data collection and use of data for quality assurance
purposes.
3.
Each Covered Facility is expected to have a process for regular review
and, as appropriate, modification of these policies.
4.
Each Covered Facility must ensure that all Service Providers thoroughly
review and understand these policies and procedures. Documentation that
these policies and procedures have been reviewed with each Service
Provider by a staff member in a supervisory position must be included in
each Service Provider’s personnel file. Such review and documentation
shall occur within thirty (30) days of hire and annually thereafter.
B.
Covered facilities are not permitted to use seclusion or restraint as a means of
coercion, discipline, convenience or retaliation by staff.
C.
Covered facilities are not permitted to use restraint or seclusion as substitutes for
direct care, activities or other services.
D.
No child/youth may be restrained solely for non-compliance with a program rule,
staff directive or other expectation.
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E.
In accordance with RIGL 42-72.9-4(C)(8), restraints may not be written as a
standing order or on an “as needed” (PRN) basis.
F.
The physical condition of a child/youth must be assessed throughout the duration
of the incident. Such assessment may be conducted by a service provider who is
directly involved in the restraint or seclusion but only if it is not practicable for
another staff person to perform this duty.
G.
Unless otherwise prescribed elsewhere in these regulations or applicable state
laws and/or Federal laws or regulations, the Covered Facility and/or Parent
Agency shall ensure that a supervisory or senior staff person with training in
crisis intervention, restraint and seclusion who is competent to conduct a face-to-
face assessment will assess the mental and physical well-being of a child/youth
being restrained or secluded and assure that the restraint or seclusion is being
conducted in a safe manner and in accordance with the Covered Facility’s crisis
intervention and restraint policies and procedures.
1.
Such an assessment shall take place as soon as is practicable, but in no
case later than one (1) hour after the initiation of the restraint or seclusion,
and
2.
A supervisory or senior staff person shall continue to monitor the situation
by minimally conducting follow-up face-to-face assessments every fifteen
(15) minutes for the duration of the restraint or seclusion.
H.
The Covered Facility must ensure that all children/youth directly and indirectly
involved in a restraint or seclusion are provided the opportunity to debrief the
incident as soon as practicable but no longer than within twenty-four (24) hours
of the incident.
I.
The use of restraint, seclusion or time out must not unduly hinder the evacuation
of the resident in the case of a fire or other facility emergency.
J.
Use of Therapeutic Physical Restraint
1.
Unless the Covered Facility obtains a variance prior to implementation,
the use of any form of restraint other than physical restraint is prohibited.
2.
Therapeutic Physical Restraint of a child/youth may be used only when
each of the following criteria are met:
a)
In emergency circumstances where a child/youth is demonstrating
by his/her actions that he/she is at immediate or imminent risk of
physically harming him/herself or others; and
b)
Less restrictive interventions have not succeeded in de-escalating
the situation.
3.
It is the responsibility of the Program Manager for the Covered Facility,
and the Covered Facility’s Parent Agency, to ensure the following:
a)
That all Service Providers who may be engaged in physically
escorting or physically restraining a child/youth in their care have
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received the appropriate training, as outlined elsewhere in this
section, in the Covered Facility’s crisis intervention and restraint
model prior to being required to physically escort or physically
restrain a child/youth in their care;
b)
Pursuant to RIGL 42-72.9-4(A), no Service Provider may use a life
threatening physical restraint on any child at any time. In addition,
other procedures that are expressly prohibited include any restraint
procedure which involve choke holds, headlocks, full nelsons,
half-nelsons, hog-tying or the use of pressure points to inflict pain;
c)
The use of physical restraint is viewed by staff as an intervention
of last resort to be imposed only in emergency circumstances to
prevent immediate or imminent risk of harm to the physical safety
of the child or other individuals in the facility. The staff
member(s) involved in the restraint must be able to show that less
restrictive interventions were attempted to de-escalate the
child/youth with limited or no success in maintaining safety.
d)
In accordance with the procedures relative to the termination of a
restraint and debriefing outlined in the crisis intervention and
restraint training program used by the Covered Facility, physical
restraints are removed at the earliest possible time that the child
can commit to safety and no longer poses a threat to him/herself or
others.
4.
For those Covered Facilities which also contain a school program and in
accordance with RIGL 42-72.9-4(C)(4), that, except in emergency
situations as defined by these regulations, the use of restraint in the school
program be done in accordance with the child’s Individual Educational
Plan (IEP).
K.
Use of Mechanical Restraint
1.
The use of mechanical restraint is considered by the Department to be a
more restrictive intervention than the use of physical restraint.
2.
The use of mechanical restraint is authorized in accordance with RIGL 42-
72.9-4(C)(2) and is limited to those Covered Facilities which have
received the express approval from the Department for the use of
mechanical restraints pursuant to statute. Such use will be limited to those
devices defined in RIGL 42-72.9-4(C)(2) that are devices specifically
designed for the restraint of humans for conducting medical procedures
and only when the use of mechanical restraint and the circumstances and
conditions of such use is identified within the child/youth’s treatment
plan. No Covered Facility shall be granted authority to use any type of
handcuffs or leg irons.
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a)
Such Covered Facilities must develop policies and procedures
regarding the use of mechanical restraint and submit those to the
Department for review and approval.
b)
Covered Facilities authorized to use mechanical restraints shall
ensure that such restraints are used only when each of the
following criteria are met:
(1)
In emergency circumstances where a child/youth is
demonstrating by his/her actions that he/she is at immediate
or imminent risk of physically harming him/herself or
others; and
(2)
The use of less restrictive interventions have been
attempted and documentation exists that such interventions
were not successful.
(3)
The use of mechanical restraint has been ordered in writing
by a physician and is administered in accordance with the
standards adopted by a Medicaid-approved accrediting
agency or commission.
(4)
The application of the mechanical restraint apparatus is
done by service providers who, by way of documentation
existing in their personnel files, are trained and certified in
the use of the restraint apparatus, alternatives to the use of
such apparatus, methods of preventing the use of such
apparatus and any potential medical complications which
could arise from the use of such apparatus.
(5)
In circumstances where a mechanical restraint is used with
a child/youth, the Covered Facility and/or Parent Agency
must ensure that a face-to-face assessment is conducted by
a licensed practitioner within one (1) hour of the
commencement of the mechanical restraint.
3.
The Department reserves the right to deny and/or withdraw any Covered
Facility’s authorization for use of mechanical restraints.
4.
Nothing within these regulations is intended to limit the use of mechanical
restraint for medically necessary procedures associated with acute medical
or surgical care or with standard medical practices that include limitation
of mobility or temporary immobilization related to medical, dental,
diagnostic or surgical procedures and the related post-procedure care (for
example, surgical positioning, IV arm boards, radiotherapy procedures,
protection of surgical and treatment sites in pediatric patients).
L.
Use of Chemical Restraint
1.
The use of chemical restraint is considered by the Department to be a
more restrictive intervention than the use of physical restraint, seclusion
and/or mechanical restraint.
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2.
In accordance with RIGL 42-72.9-4(C)(6) and the Federal Children’s
Health Act of 2000, the use of chemical restraint is authorized in
accordance with RIGL 42-72.9-4(C)(6) and is limited to those Covered
Facility’s which have received the express approval from the Department
for the use of chemical restraint pursuant to statute. The use of chemical
restraint may be authorized only when such use and the circumstances and
conditions of such use is identified within the child/youth’s treatment
plan.
a)
Such Covered Facilities must develop policies and procedures
regarding the use of chemical restraint and submit those to the
Department for review and approval.
b)
Covered Facilities authorized to use chemical restraints shall
ensure that such restraints are used only when each of the
following criteria are met:
(1)
In emergency circumstances where a child/youth is
demonstrating by his/her actions that he/she is at immediate
or imminent risk of physically harming him/herself or
others; and
(2)
The use of less restrictive interventions have been
attempted and documentation exists that such interventions
were not successful.
(3)
The use of chemical restraint has been ordered in writing
by a physician and is administered in accordance with the
standards
adopted
by
the
Joint
Commission
on
Accreditation of Healthcare Organizations (JCAHO).
3.
The person administering and monitoring the use of the chemical restraint
is an appropriately licensed practitioner who is duly trained in the
administration of such medication.
4.
The Department reserves the right to deny and/or withdraw any Covered
Facility’s authorization for use of chemical restraints.
M.
Use of Seclusion
1.
In accordance with RIGL 42-72.9-5 (A)(2), the simultaneous use of
seclusion and mechanical or chemical restraint is prohibited.
2.
Nothing in this section shall be construed to limit the use of “time-out” as
defined elsewhere in these regulations and RIGL 42-72.9-3(8).
3.
The use of seclusion is limited to those Covered Facility’s which have
received written authorization from the Department for the use of such an
intervention.
a)
Such programs must develop policies and procedures, including
their rationale for using seclusion, regarding the use of seclusion
and submit those to the Department for review and approval.
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b)
In accordance with RIGL 42-72.9-5, the Federal Children’s Health
Act of 2000 and these regulations, no service provider may cause
the involuntary placement of a child/youth in seclusion unless each
of the following conditions are met:
(1)
The Covered Facility in which they are employed is
authorized by the Department to use seclusion with clients;
and
(2)
Documentation exists in the Service Provider’s personnel
file certifying that the Service Provider has been trained in
the use of restraint and seclusion, alternatives to use of
such interventions, methods of preventing use of such
interventions and any potential medical complications
which could arise from the use of such seclusion.
(3)
An emergency circumstance exists whereby a child/youth
is demonstrating by his/her actions that he/she is at
immediate or imminent risk of physically harming
him/herself or others;
(4)
The use of less restrictive interventions have been
attempted and documentation exists that such interventions
were not successful; and
(5)
The room used for the purposes of seclusion meets the
following criteria:
(a)
The entrance to the room is unlocked;
(b)
The room is lighted and well-ventilated;
(c)
The room is at a minimum fifty(50) square feet in
area; and
(d)
The room contains an observation window the
dimensions of which permit a child/youth to be in
view regardless of where she/he is positioned in the
room.
c)
The condition of the child/youth in seclusion must be continually
assessed, monitored and re-evaluated and the seclusion must be
ended at the earliest possible time, considering the physical safety
of the child being secluded and other individuals in the facility.
4.
The Department reserves the right to deny and/or withdraw any Covered
Facility’s authorization for use of seclusion.
N.
Use of Time-Out
1.
Covered Facilities are permitted to use “time-out”, as defined in these
regulations, for purposes of prevention of crises and behavior
management.
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2.
Any child/youth who is placed in “time out” must be in a location which
can be visually monitored by a service provider. The distance from the
closest service provider to the child/youth who is in “time-out” may vary
according to factors such as age, developmental level and potential for
stimuli from others but, at no point shall the child/youth who is in “time-
out” be outside of the direct line of vision or reasonable speaking distance
of the closest service provider.
3.
Nothing in these regulations shall be construed to limit the use of
procedures such as room restrictions or privilege restrictions which are a
defined part of the program’s behavior management and positive
reinforcement methods.
O.
Use of Behavior Modification Procedures
1.
Nothing in these regulations shall be construed to limit the use of
Behavior Modification Procedures which are a part of a Covered Facility’s
Behavior Modification Program provided such program is principally
focused on positive reinforcement and is approved by the Department.
2.
The use of aversive techniques within the context of behavioral treatment
interventions is prohibited. Aversive techniques include, but are not
limited to the following:
a)
Noxious, painful, intrusive stimuli or activities that result in pain;
b)
Any form of noxious, painful or intrusive spray or inhalant;
c)
Electric shock;
d)
Water spray to the face
e)
Pinches and deep muscle squeezes;
f)
Shouting, screaming or attempting to verbally frighten or threaten
or the use of obscene language
g)
Withholding adequate sleep;
h)
Withholding adequate shelter or bedding;
i)
Withholding bathroom facilities;
j)
Withholding meals, essential nutrition or hydration;
k)
Facial or auditory screening devices; and
l)
Use of chemical restraints except under conditions described
elsewhere in these regulations.
VII.
Documentation, Reporting and Quality Assurance
A.
Each Covered Facility shall develop and adopt policies and procedures that
establish monitoring, documentation, reporting and internal review of the use of
restraint and seclusion. These policies must minimally address the requirements
for the training and supervision of Service Providers regarding the use of restraint
18
and seclusion, documentation, procedures for the reporting of incidents to the
Department and quality assurance outlined in these regulations. Such policies
must
also
address
procedures
for
the
notification
of
incidents
to
parent(s)/guardian(s)
B.
Each Covered Facility must ensure that these policies and procedures are
thoroughly reviewed with each Service Provider during their initial thirty (30)
days of employment. Documentation that such a review has occurred is to be
placed in each Service Provider’s employee file with that person’s signature
affirming that they have reviewed and understand these policies and procedures.
C.
Documentation:
1.
In accordance with RIGL 42-72.9-6, any use of physical, mechanical or
chemical restraint or seclusion must be documented using an Incident
Report (IR) and must be documented in a progress note in the child’s
medical, educational, treatment or case record maintained by the covered
facility.
a)
Progress notes may more generally describe the incident provided
that the note references the specific IR on which the details of the
incident are clearly identified. Otherwise the progress note must
contain the same level of detail of the incident as is described
below for IR documentation.
b)
All IR’s shall include the following information:
(1)
Date, day of the week, time of day and the activity in which
the child/youth was involved at the time of the incident;
(2)
The following information on all children/youth who were
restrained during the incident:
(a)
Name
(b)
Date of Birth
(c)
Admission Date
(3)
Name and contact information for any other persons who
may have been directly involved in or witnesses to the
incident provided those persons are identifiable to the
Covered Facility and willing to provide such information;
(4)
A sequential identification of the antecedents to the
incident, including attempts by service providers to prevent
and de-escalate the situation prior to choosing to restrain or
seclude the child/youth;
(5)
In the case of those Covered Facilities who have been
granted permission to use mechanical or chemical restraint
or seclusion, a description of the use of all less restrictive
interventions, including other forms of restraint, or reasons
19
why such interventions were deemed to be unlikely to be
successful with this particular child/youth in this situation;
(6)
A detailed description of the nature of the restraint and its
duration, including documentation that the required
monitoring and assessment of the child/youth has been
completed in accordance with these regulations;
(7)
A brief description of the debriefing of the restraint with
the child/youth involved;
(8)
A description of any injuries and/or death occurring due to
or resulting during the restraint and all emergency and
medical interventions on the part of staff and qualified
medical providers to address these;
(9)
A description of the effect, if any, on the child’s
established medical, educational or treatment plan (i.e.,
changes in treatment plan, medication adjustment, change
in placement, etc.);
(10)
A place where the service provider completing the form
can print their name and title and a signature/date line for
said service provider.
(11)
Places for supervisory and administrative signatures,
including
space
for
the
printing
of
the
supervisor’s/administrator’s name, title and the date of their
review of the IR.
c)
All IR’s are to be completed as soon as practicable, preferably by
the service provider who was most directly involved in the
incident. However, in no circumstances shall the IR be completed
later than the end of the shift in which the incident of restraint or
seclusion took place.
D.
Reporting Requirements
1.
Nothing in this section affects the statutory requirements of service
providers and/or Covered Facilities to report incidents of possible abuse or
neglect resulting from an incident of restraint or seclusion or any other
statutory reporting requirements. All reporting requirements in this
section are in addition to such statutory requirements.
2.
Unless noted otherwise in these regulations, the Covered Facility shall, on
a monthly basis, forward to the DCYF Program Monitor for that Covered
Facility copies of all Incident Reports involving the use of restraint or
seclusion. Said reports must be received by the Program Monitor no later
than the 5th business day of the month for reports for the preceding month.
3.
Incidents Requiring Immediate Notification to the Department
20
a)
The Covered Facility’s Program Manager, or his/her superior, shall
immediately report directly to the Director of the Department or
his/her designee any use of restraint or seclusion which results in
the serious physical injury of a child as defined in these
regulations, or the death of a child.
b)
The Director of the Department or his/her designee shall, upon
receiving and verifying such report, immediately forward to the
Office of the Child Advocate any incidence of restraint or
seclusion which results in the serious physical injury or death of a
child.
4.
Urgent Need for Notification: Each Covered Facility shall, within 24
hours of the conclusion of a restraint or seclusion (or by the beginning of
the next business day, whichever comes first), report to the child/youth’s
social caseworker or probation officer any incident of restraint or
seclusion which results in injury to any person, provided said injury does
not fall under the immediate procedures defined above for incidents
resulting in the serious physical injury or death of a child/youth, or
allegations of abuse.
5.
Facility Logs and Annual Compilation of Data
a)
Weekly Log: Each Covered Facility shall maintain a separate
weekly log regarding the use of physical, mechanical or chemical
restraint or seclusion on a child in their care and the nature of the
emergency that necessitated its use. Such logs must minimally
contain the same information required on the IR and may be made
up of copies of the IRs for that week.
b)
Annual Compilation of Restraint and Seclusion Data
(1)
No later than the first (1s) Monday of February of each
year, each Covered Facility shall report to the Director of
the Department an aggregate compilation of the incidents
of restraint and seclusion within that program during the
previous calendar year.
(2)
This annual report shall include the following aggregated
categories for the reporting year:
(a)
Total number of children/youth served by the
Covered Facility;
(b)
Total number of children/youth who were restrained
and secluded;
(c)
Total number of incidents of physical restraint with
the average duration for all physical restraints and
broken out by gender, race and age of child/youth;
21
(d)
If applicable, the total number of incidents of
mechanical restraint, broken down by type of
mechanical device used, with the average duration
of all mechanical restraints and broken out by
gender, race and age of child/youth;
(e)
If applicable, the total number of incidents of
chemical restraint with the average duration of all
mechanical restraints and broken out by gender,
race and age of child/youth;
(f)
If applicable, the total number of incidents of
seclusion with the average duration of all seclusion
incidents and broken out by gender, race and age of
child/youth;
(g)
A description of how this data was used throughout
the reporting year to identify trends with staff, both
individually and as a group, and residents, both
individually and as a group, in order to reduce the
use of restraint and seclusion within the Covered
Facility.
(3)
Covered Facilities may include in this report any other
descriptive information which they believe is important to
understanding the data presented.
(4)
Pursuant to RIGL 42-72.9-6(B)(2), the annual report of
each Covered Facility shall be a public record and therefore
Covered Facilities shall not include in it information which
can identify specific children/youth, staff or others.
(5)
This annual report shall be signed by the Program Manager
for the Covered Facility and the chief executive of the
Parent Agency.
E.
Quality Assurance
1.
Each Covered Facility shall develop methods by which the use of restraint
and seclusion is monitored and internally reviewed to identify patterns and
practices of service providers as a group or as individuals. Such methods
shall include mechanisms by which data acquired by these reviews will be
used to positively affect practices within the Covered Facility and within
individual service providers.
2.
The Director of the Department reserves the right to develop and institute
a committee which, in addition to other duties, would serve to review the
use of restraint and seclusion within all Covered Facilities and make
recommendations to him/her regarding any changes to regulations,
policies or practices within the Department, within all Covered Facilities
or within individual Covered Facilities. This Committee may include
22
representatives of the Department, representatives of other state agencies,
representatives of Covered Facilities, parents of youth involved or
previously in the system of care, youth involved or previously involved in
the system of care and other individuals deemed necessary by the
Director.
VIII. Penalties for Covered Facilities Due to Non-Compliance
A.
In accordance with RIGL 42-72.9-8, any Covered Facility that does not comply
with the provisions of the statute and, by extension, these regulations, shall be
subject to licensing action by the Department which may include license
revocation.
B.
Any Covered Facility upon which the Department imposes a licensing action is
entitled to utilize the Department’s Administrative Appeals Process and any other
legal remedies granted by State or Federal Statutes to appeal the decision of the
Department.