Behavioral Health Standard 2.F – Promoting Nonviolent Practices

2.F.1.a-b.

The organization implements a policy for each program that identifies:

  1. How it will respond to unsafe behaviors of the persons served
  2. Whether, and under what circumstances:
    1. Seclusion is used
    2. 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:

  1. At orientation
  2. At least annually
  3. That addresses prevention of unsafe behaviors, including:
    1. Contributing factors or causes that may lead to unsafe behaviors
    2. Health conditions that may contribute to unsafe behaviors
    3. How interpersonal interactions may impact the behaviors of the persons served, including:
      1. How persons served interact with each other
      2. How personnel interact with the persons served
      3. How personnel interact with each other
    4. 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:

  1. Seclusion or restraint is used only as a safety intervention of last resort to prevent harm to the person served or others
  2. Seclusion or restraint is not used as coercion, discipline, convenience, or retaliation by personnel
  3. Seclusion or restraint is not used in lieu of adequate programming or staffing
  4. Orders for all seclusion or restraint are administered by personnel who are competent in the proper techniques
  5. 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:

  1. At orientation
  2. At least annually
  3. That addresses:
    1. The circumstances under which seclusion or restraint is indicated
    2. Interventions to be used for seclusion or restraint that minimize harm, including:
      1. Interventions done by an individual
      2. Interventions done by a team
    3. Signs of physical distress in a person who is being secluded or restrained
    4. Risks of seclusion or restraint:
      1. To the persons served
      2. To personnel
      3. Including:
        1. Physical risks
        2. Psychological risks
    5. First aid
    6. Cardiopulmonary resuscitation (CPR)
    7. 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:

  1. Includes:
    1. The role of leadership
    2. Use of data to inform practice
    3. Development of a workforce culture that supports resiliency and well-being
    4. Input regarding the use of seclusion and/or restraint from:
      1. Persons served
      2. Families
      3. Advocates
    5. Consideration of the results of the debriefing process
    6. Identification of environmental factors that may contribute to unsafe behaviors
    7. Actions to be taken to minimize environmental factors that may contribute to unsafe behaviors
    8. Identification of specific strategies to prevent crises
    9. Timelines to reduce the use of seclusion and/or restraint
  2. Is shared with:
    1. Personnel
    2. Persons served
    3. Other stakeholders
  3. Is reviewed at least annually, including:
    1. Progress made in reduction of use
    2. Areas needing improvement
  4. 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:

  1. Children and youth
  2. Adults
  3. Special populations
  4. Individual interventions
  5. Team interventions, including:
    1. Defining team leadership
    2. Assigning team duties
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2.F.7.a-b.

Written procedures are implemented that address:

  1. Risk assessment of each person served:
    1.  Including:
      1. Medical history
      2. Trauma history
      3. History of unsafe behaviors resulting in seclusion or restraint
      4. Identification of interventions that have been successful in interrupting unsafe behaviors, when applicable
    2. That results in identification of:
      1. Risks associated with the potential use of seclusion or restraint
      2. Precautions to be taken
  2. When applicable, identification of actions to be taken by personnel to de-escalate unsafe behaviors, including:
    1. Documentation in the record of the person served
    2. 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:

  1. Less-restrictive interventions were attempted prior to the use of seclusion or restraint
  2. Administration in a safe manner, with consideration given to the history of the person served
  3. Personnel communication to the person served that the purpose of the seclusion or restraint is to keep him/her and others safe
  4. Monitoring by trained personnel in accordance with established protocols, including face-to-face monitoring when there is simultaneous use of seclusion and restraint
  5. Ongoing reevaluation of the person served to determine whether seclusion or restraint is still needed
  6. Removal of the person served from the seclusion or restraint as soon as the threat of harm is no longer present
  7. Immediate medical attention for any injury resulting from seclusion or restraint
  8. Notification as soon as possible of the initial use of seclusion or restraint to:
    1. The family
    2. The treating practitioner
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2.F.9.a-h.

Written procedures regarding orders are implemented that specify:

  1. 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
  2. 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
  3. An order for seclusion or restraint does not exceed one hour for a child or youth or four hours for an adult
  4. Orders for renewal may only occur following a face-to-face evaluation by a physician or designated qualified practitioner
  5. Orders for seclusion or restraint may be renewed for a total of up to 24 hours
  6. After 24 hours, a new order is required following a face-to-face evaluation by a physician or designated qualified practitioner
  7. All orders are entered into the record of the person served as soon as possible but not more than two hours after implementation
  8. 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:

  1. It provides for:
    1. The safety of the person served
    2. Continuous, face-to-face observation
    3. Access to bathroom facilities, directly or through escort
  2. It promotes the privacy and dignity of the person served
  3. 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:

  1. Is initiated as soon as possible and no more than 24 hours after the incident
  2. Includes, unless contraindicated:
    1. The person served
    2. All involved personnel
    3. Family members
    4. Others observing the incident, when permitted
  3. Is documented, including:
    1. A description of the incident
    2. From the perspective of the person served, what he/she experienced
    3. The antecedents of the incident
    4. An assessment of contributing factors
    5. Actions taken by personnel in an attempt to avoid the use of seclusion or restraint
    6. The reasons for the use of seclusion or restraint
    7. The specific intervention used
    8. The person’s reaction to the intervention
    9. Actions that could make future use of seclusion or restraint unnecessary
    10. 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:

  1. After every occurrence
  2. Within a designated timeframe
  3. To determine:
    1. Compliance with applicable policies and procedures
    2. 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:

  1. Is conducted at least annually
  2. Addresses:
    1. Trends, including:
      1. Patterns of use
      2. History of use by personnel
      3. Environmental contributing factors
      4. Program design contributing factors
    2. Areas in need of performance improvement
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