2.F.1.a-b.
The organization implements a policy for each program that identifies:
- How it will respond to unsafe behaviors of the persons served
- Whether, and under what circumstances:
- Seclusion is used
- Restraints are used
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2.F.2.a-c.
As applicable to the population served, all direct service personnel receive documented competency-based training:
- At orientation
- At least annually
- That addresses prevention of unsafe behaviors, including:
- Contributing factors or causes that may lead to unsafe behaviors
- Health conditions that may contribute to unsafe behaviors
- How interpersonal interactions may impact the behaviors of the persons served, including:
- How persons served interact with each other
- How personnel interact with the persons served
- How personnel interact with each other
- Use of alternative interventions in an effort to avoid the use of seclusion or restraint
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2.F.3.a-e.
Policies are implemented that specify:
- Seclusion or restraint is used only as a safety intervention of last resort to prevent harm to the person served or others
- Seclusion or restraint is not used as coercion, discipline, convenience, or retaliation by personnel
- Seclusion or restraint is not used in lieu of adequate programming or staffing
- Orders for all seclusion or restraint are administered by personnel who are competent in the proper techniques
- Standing orders authorizing the use of seclusion or restraint are not issued
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2.F.4.a-c.
All personnel involved in the direct administration of seclusion or restraint receive documented, competency-based training that is provided by persons or entities qualified to conduct such training:
- At orientation
- At least annually
- That addresses:
- The circumstances under which seclusion or restraint is indicated
- Interventions to be used for seclusion or restraint that minimize harm, including:
- Interventions done by an individual
- Interventions done by a team
- Signs of physical distress in a person who is being secluded or restrained
- Risks of seclusion or restraint:
- To the persons served
- To personnel
- Including:
- Physical risks
- Psychological risks
- First aid
- Cardiopulmonary resuscitation (CPR)
- How to continually assess for the earliest release of the seclusion or restraint
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2.F.5.a-d.
The program implements a plan to eliminate the use of seclusion and/or restraint that:
- Includes:
- The role of leadership
- Use of data to inform practice
- Development of a workforce culture that supports resiliency and well-being
- Input regarding the use of seclusion and/or restraint from:
- Persons served
- Families
- Advocates
- Consideration of the results of the debriefing process
- Identification of environmental factors that may contribute to unsafe behaviors
- Actions to be taken to minimize environmental factors that may contribute to unsafe behaviors
- Identification of specific strategies to prevent crises
- Timelines to reduce the use of seclusion and/or restraint
- Is shared with:
- Personnel
- Persons served
- Other stakeholders
- Is reviewed at least annually, including:
- Progress made in reduction of use
- Areas needing improvement
- Is updated as needed
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2.F.6.a-e.
Written procedures for seclusion and restraint are implemented that include protocols for:
- Children and youth
- Adults
- Special populations
- Individual interventions
- Team interventions, including:
- Defining team leadership
- Assigning team duties
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2.F.7.a-b.
Written procedures are implemented that address:
- Risk assessment of each person served:
- Including:
- Medical history
- Trauma history
- History of unsafe behaviors resulting in seclusion or restraint
- Identification of interventions that have been successful in interrupting unsafe behaviors, when applicable
- That results in identification of:
- Risks associated with the potential use of seclusion or restraint
- Precautions to be taken
- Including:
- When applicable, identification of actions to be taken by personnel to de-escalate unsafe behaviors, including:
- Documentation in the record of the person served
- Communication with program personnel
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2.F.8.a-h.
When seclusion or restraint is used, documentation in the record of the person served demonstrates:
- Less-restrictive interventions were attempted prior to the use of seclusion or restraint
- Administration in a safe manner, with consideration given to the history of the person served
- Personnel communication to the person served that the purpose of the seclusion or restraint is to keep him/her and others safe
- Monitoring by trained personnel in accordance with established protocols, including face-to-face monitoring when there is simultaneous use of seclusion and restraint
- Ongoing reevaluation of the person served to determine whether seclusion or restraint is still needed
- Removal of the person served from the seclusion or restraint as soon as the threat of harm is no longer present
- Immediate medical attention for any injury resulting from seclusion or restraint
- Notification as soon as possible of the initial use of seclusion or restraint to:
- The family
- The treating practitioner
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2.F.9.a-h.
Written procedures regarding orders are implemented that specify:
- Seclusion or restraint is ordered by a physician or designated qualified practitioner who has training and competence in the prevention and management of unsafe behaviors
- A physician or designated qualified practitioner provides face-to-face evaluation of the person served within one hour of the order for seclusion or restraint being given
- An order for seclusion or restraint does not exceed one hour for a child or youth or four hours for an adult
- Orders for renewal may only occur following a face-to-face evaluation by a physician or designated qualified practitioner
- Orders for seclusion or restraint may be renewed for a total of up to 24 hours
- After 24 hours, a new order is required following a face-to-face evaluation by a physician or designated qualified practitioner
- All orders are entered into the record of the person served as soon as possible but not more than two hours after implementation
- The physician or designated qualified practitioner signs all orders within the time period mandated by law
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2.F.10.a-c.
If there is a room designated for the use of seclusion or restraint:
- It provides for:
- The safety of the person served
- Continuous, face-to-face observation
- Access to bathroom facilities, directly or through escort
- It promotes the privacy and dignity of the person served
- There is an identified procedure for exit in case of emergency
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2.F.11.a-c.
Following the use of seclusion or restraint, a debriefing process:
- Is initiated as soon as possible and no more than 24 hours after the incident
- Includes, unless contraindicated:
- The person served
- All involved personnel
- Family members
- Others observing the incident, when permitted
- Is documented, including:
- A description of the incident
- From the perspective of the person served, what he/she experienced
- The antecedents of the incident
- An assessment of contributing factors
- Actions taken by personnel in an attempt to avoid the use of seclusion or restraint
- The reasons for the use of seclusion or restraint
- The specific intervention used
- The person’s reaction to the intervention
- Actions that could make future use of seclusion or restraint unnecessary
- Modifications made to the individualized plan to address issues or behaviors that impact the need to use seclusion or restraint, as applicable
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2.F.12.a-c.
A written procedure is implemented that addresses leadership review of all uses of seclusion or restraint:
- After every occurrence
- Within a designated timeframe
- To determine:
- Compliance with applicable policies and procedures
- The need for performance improvement
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2.F.13.a-b.
A documented analysis of the program’s use of seclusion and/or restraint:
- Is conducted at least annually
- Addresses:
- Trends, including:
- Patterns of use
- History of use by personnel
- Environmental contributing factors
- Program design contributing factors
- Areas in need of performance improvement
- Trends, including:
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