Ala. Admin. Code r. 580-2-9-.23

Child and Adolescent Seclusion and Restraint

This regulation establishes detailed standards for the use of seclusion and restraint with children and adolescents in community-based settings certified by the Alabama Department of Mental Health. Certified organizations must develop written policies emphasizing prevention, limiting restraint/seclusion to genuine emergencies, obtaining proper clinical authorization, conducting continuous monitoring, and completing debriefing and administrative review within 24 hours of each episode. The rule also addresses staff training, documentation requirements, and special protections for consumers who are deaf, hard of hearing, or have limited English proficiency.

Ala. Admin. Code r. 580-2-9-.23 - Child and Adolescent Seclusion and Restraint 

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Because of the high-risk nature of seclusion and restraint
 procedures and the potential for harm to consumers, the DMH MI Division Policy
 on Restraint and Seclusion is included here to place the standards within the
 proper context.

(1)

 Children/adolescents residing or receiving treatment in a community-based
 setting certified by the Alabama Department of Mental Health have the right to
 be free of restraint and seclusion. Restraint and seclusion are safety
 procedures of last resort. Restraint and seclusion are not therapeutic
 interventions and are not interventions implemented for the purpose of behavior
 management.

(2)

 Children/adolescents may be placed in seclusion or physically restrained only
 in emergency situations when necessary to:
(a)

 Prevent the child/adolescent from physically harming self or others.

(b)
 Less restrictive alternative treatment
 interventions have been unsuccessful or are determined not to be
 feasible.

(c)
 When authorized by a
 qualified individual.

(3)
 The Alabama Department of Mental Health
 requires that any organization certified by DMH develop special safety
 procedures that reflect the policy above. Mechanical restraints are prohibited.
 Additionally, procedures must be developed which address standards of care as
 required in this section.

(4)

 Seclusion refers to the placement of a consumer alone in any room from which
 the consumer is physically prevented from leaving.

(5)
 Restraint includes both physical
 restraint and chemical restraint.

(6)
 Physical Restraint is the direct
 application of physical force to a consumer without the consumer's permission
 to restrict his or her freedom of movement.

(7)
 Chemical Restraint is the use of any drug
 to manage a consumer's behavior in a way that reduces the safety risk to the
 consumer or others or to temporarily restrict the consumer's freedom of
 movement and is not a standard treatment dosage for the consumer's medical or
 psychiatric condition.

(8)
 Time-out
 means the restriction of a consumer for a period of time to a designated area
 from which the consumer is not physically prevented from leaving for the
 purpose of providing the consumer an opportunity to regain
 self-control.

(9)
 Sentinel Event is
 an unexpected occurrence involving a child/adolescent receiving treatment for a
 psychological or psychiatric illness that results in serious physical injury,
 psychological injury, or death (or risk thereof).

(10)
 The standards for restraint and
 seclusion do not apply in the following circumstances with the exception that
 the standard section that addresses staff competence and training is applicable
 under these circumstances:
(a)
 To the use of
 restraint associated with acute medical or surgical care.

(b)
 When a staff member(s) physically
 redirects or holds a child without the child's permission, for 15 minutes or
 less in outpatient/non-residential programs.

(c)
 To time-out less than 15 minutes in
 length for residential programs and under 30 minutes in length for outpatient
 programs implemented in accordance with the procedures described in (35)(a)-(c)
 of this section.

(d)
 To instances
 when the consumer is to remain in his or her unlocked room or other setting as
 a result of the violation of unit/program rules of regulations consistent with
 organizational policy(ies) and procedure(s). Organizational policies and
 procedures shall require that room restriction be for a specified time and be
 limited to no longer than 12 hours. Should the consumer decide not to comply
 and leave the area, seclusion/restraint cannot be instituted unless the
 criteria are met.

(e)
 To protective
 equipment such as helmets, and

(f)

 To adaptive support in response to assessed physical needs of the individual
 (for example, postural support, orthopedic appliances).

(11)
 The organization must have written
 policies and procedures that support the protection of consumers and reflect
 the following:
(a)
 Emphasize prevention of
 seclusion and restraint.

(b)

 Demonstrate restraint or seclusion use is limited to situations in which there
 is immediate, imminent risk of a child/adolescent harming self or
 others.

(c)
 Implemented only when
 less restrictive alternative treatment interventions have been unsuccessful or
 are determined not to be feasible and documented in the consumer
 record.

(d)
 Is never used as
 coercion, discipline, or for staff convenience.

(e)
 Is limited to situations with adequate,
 appropriate clinical justification.

(f)
 Is used only in accordance with a written
 order.

(g)
 Seclusion and restraint
 may not be used in lieu of effective communication with consumers who are deaf,
 hard of hearing, or have limited English proficiency. In the case of consumers
 who are deaf and who use sign language to communicate, restraints must be
 applied in a way that leaves at least one hand free to sign.

(12)
 Non-physical interventions
 are always considered the most appropriate and preferred intervention. These
 may include redirecting the child/ adolescent's focus, verbal de-escalation, or
 directing the child/ adolescent to take a time-out.

(13)
 Utilization of restraint, seclusion,
 timeouts, and other techniques associated with the safety of the consumer or
 used to help him/her gain emotional control shall be implemented and documented
 in accordance with all applicable requirements and documentation shall be
 maintained in the consumer record. The consumer's parent/legal guardian will be
 asked at intake for the frequency with which they would like such information
 shared with them, and consumer records shall reflect that notifications conform
 with requests.

(14)
 The initial
 assessment of each consumer at the time of admission or intake assists in
 obtaining all of the following information about the consumer that could help
 minimize the use of restraint or seclusion. Such information is documented in
 the consumer record. The program informs the family/legal guardian about use
 and reporting. The following information is obtained/provided: 
 
(a)
 Techniques, methods, or tools that would
 help the consumer control his or her behavior. When appropriate, the consumer
 and/or family/legal guardian assist in the identification of such
 techniques.

(b)
 Pre-existing
 medical conditions or any physical disabilities and limitations that would
 place the consumer at greater risk during restraint or seclusion including
 developmental age and history, psychiatric condition, and trauma
 history.

(c)
 Any history of sexual
 or physical abuse that would place the consumer at greater psychological risk
 during restraint or seclusion.

(d)

 If the consumer is deaf and uses sign language, provision shall be made to
 assure access to effective communication and that techniques used will not
 deprive the consumer of a method to communicate in sign language.

(e)
 The consumer and/or family/legal guardian
 is informed of the organization's philosophy on the use of restraint and
 seclusion to the extent that such information is not clinically
 contraindicated.

(f)
 The role of
 the family/legal guardian, including their notification of a restraint or
 seclusion episode, is discussed with the consumer and, as appropriate, the
 consumer's family/legal guardian. An agreement will be made with the
 family/legal guardian at intake regarding notification.

(15)
 Seclusion/physical restraint may be
 authorized only by order of a licensed independent practitioner (LIP),
 preferably the one who is primarily responsible for the consumer's care or by a
 qualified registered nurse. The person authorizing seclusion or restraint meets
 the requirements and such is verifiable in the personnel records. Chemical
 restraint may be ordered only by a licensed physician, certified registered
 nurse practitioner, or licensed physician's assistant. The authorization for
 each instance is documented in the consumer record. 
 
(a)
 A licensed independent practitioner is
 defined as an individual permitted by law and by the organization to provide
 care and services, without direction or supervision, within the scope of the
 individual's license and consistent with individually granted clinical
 privileges.

(b)
 In Alabama such
 individuals include: MD, DO, licensed psychologist, licensed professional
 counselor, licensed certified social worker, licensed marriage and family
 therapist, Master's level nurse in psychiatric nursing, certified registered
 nurse practitioner, and physician assistant.

(c)
 A qualified Registered Nurse is one who
 has successfully completed a DMH approved psychiatric management course and who
 as at least one year psychiatric nursing experience.

(16)
 In the event that a consumer who is
 deaf, hard of hearing, or limited English proficient must be restrained,
 effective communication shall be established by a staff member fluent in the
 consumer's language of choice. If the consumer's preferred language is sign,
 the staff member shall hold an Intermediate Plus level or higher on the Sign
 Language Proficiency Interview or be a qualified interpreter. The manner of
 communication is documented in the consumer record. A consumer who is deaf must
 have at least one hand free during physical restraint.

(17)
 Orders for the use of restraint and
 seclusion have the following characteristics: 
 
(a)
 Are limited to 1 hour.

(b)
 Are not written as a standing order or on
 an as needed basis (that is, PRN).

(c)
 Specify the behavioral criteria necessary
 to be released from seclusion/restraint. It is documented that consumers are
 released as soon as the behavioral criteria are met.

(18)
 Agency written policies and procedures
 require every effort to be made to terminate seclusion/restraint at the
 earliest time it is safe to do so. Time-limited orders do not mean that
 restraint or seclusion must be applied for the entire length of time for which
 the order is written. Efforts to terminate seclusion/restraint shall be
 documented in the consumer's record including when seclusion/restraint is
 appropriately terminated sooner than the timeframe for the order
 ends.

(19)
 When restraint or
 seclusion is terminated before the time-limited order expires, that original
 order can be used to reapply the restraint or seclusion if the individual is at
 imminent risk of physically harming himself or herself or others, and
 non-physical interventions are not effective.

(20)
 At the time the initial order for
 restraint or seclusion expires, the consumer receives an in-person
 re-evaluation conducted by a Licensed Independent Practitioner (LIP),
 preferably the one who is primarily responsible for the consumer's care or by a
 Qualified Registered Nurse. Documentation in the consumer record shall address
 all of the following requirements of the in-person evaluation: 
 
(a)
 The consumer's psychological
 status.

(b)
 The consumer's
 psychological status.

(c)
 The
 consumer's physical status as assessed by a RN, MD, DO, CRNP, or PA.

(d)
 The consumer's behavior.

(e)
 The appropriateness of the intervention
 measures. 

(f)
Any complications
 resulting from the intervention.

(g)
 The need for continued
 seclusion/restraint.

(h)
 The need
 for immediate changes to the consumer's course of care such as the need for
 timely follow-up by the consumer's primary clinician or the need for medical,
 psychiatric, or nursing evaluation for needed medication changes.

(21)
 If the restraint or seclusion
 is to be continued at the time of the re-evaluation, the following procedures
 must be followed and documented in the consumer record: 
 
(a)
 A new written order is given by a
 Licensed Independent Practitioner or by a Qualified Registered Nurse as defined
 above, preferably by the one who is responsible for the care of the
 consumer.

(b)
 When next on duty,
 the licensed independent practitioner evaluates the efficacy of the
 individual's treatment plan and works with the consumer to identify ways to
 help him or her regain self-control.

(c)
 If the order is continued past the first
 hour, the case responsible licensed independent practitioner will be notified
 within 24 hours of the consumer's status.

(22)
 Consumers in restraint or seclusion are
 monitored to ensure the individual's physical safety through continuous in-
 person observation by an assigned staff member who is competent, fluent in the
 preferred language of the consumer (spoken or signed), and trained in
 accordance with the standard. The items in (21) are checked and documented
 every 15 minutes. If the consumer is in restraint, a second staff person is
 assigned to observe him/her.

(23)

 Within 24 hours after a restraint or seclusion has ended, the consumer and
 staff who were involved in the episode and who are available participate in a
 face-to-face debriefing about each episode of restraint or seclusion. To the
 extent possible, the debriefing shall include: 
 
(a)
 All staff involved in the intervention
 except when the present of a particular staff person may jeopardize the
 well-being of the consumer.

(b)

 Other staff and the consumer's personal representative(s) as specified in the
 notification agreement may participate in the debriefing.

(c)
 The facility must conduct such discussion
 in a language that is understood by the consumer and the consumer's personal
 representative(s).

(d)
 The
 debriefing must be documented in the consumer record. The debriefing is used
 to:
1.
 Identify what led to the incident and
 what could have been handled differently.

2.
 Ascertain that the consumer's physical
 well-being, psychological comfort, and right to privacy and communication were
 addressed.

3.
 Facilitate timely
 clinical follow-up with the consumer's primary therapist as needed to address
 trauma.

4.
 When indicated, modify
 the individual's treatment plan.

(24)
 Within 24 hours after a restraint or
 seclusion has ended or the next business day in a community-based
 non-residential program, appropriate supervisory staff, administrative staff,
 and the case responsible Licensed Independent Practitioner shall perform an
 administrative review. To the extent that it is possible, the review should
 include all staff involved in the intervention, when available. The
 administrative review is used to:
(a)
 Identify
 the procedures, if any, that staff are to implement to prevent any recurrence
 of the use of restraint or seclusion.

(b)
 Discuss the outcome of the intervention,
 including any injuries that may have resulted from the use of restraint or
 seclusion.

(c)
 Staff must document
 in the consumer's record that the review sessions took place and must include
 in that documentation the names of staff who were present for the review, names
 of staff excused from the review, and any changes to the consumer's treatment
 plan that result from the review.

(d)
 The review shall include particular
 attention to the following:
1.
 Multiple
 incidents of restraint and seclusion experienced by a consumer within a 12-hour
 timeframe.

2.
 The number of
 episodes for the consumer.

3.

 Adequacy of communication in instances of restraint or seclusion of consumers
 who are deaf, hard of hearing, or limited English proficient.

4.
 Instances of restraint or seclusion that
 extend beyond 2 consecutive hours.

5.
 The use of psychoactive medications as an
 alternative to, or to enable discontinuation of restraint or
 seclusion.

(25)
 In order to minimize the use of
 restraint and seclusion, all direct care staff as well as any other staff
 involved in the use of restraint and seclusion receive annual training in and
 demonstrate an understanding of the following before they participate in any
 use of restraint/seclusion:
(a)
 The underlying
 causes of threatening behaviors exhibited by the consumers they
 serve.

(b)
 That sometimes a
 consumer may exhibit an aggressive behavior that is related to a medical
 condition and not related to his or her emotional condition, for example,
 threatening behavior that may result from delirium in fevers,
 hypoglycemia.

(c)
 That sometimes
 inability to effectively communicate due to hearing loss or limited English
 proficiency leads to misunderstanding or increased frustration that may be
 misinterpreted as aggression.

(d)

 How their own behaviors can affect the behaviors of the consumers they
 serve.

(e)
 The use of
 de-escalation, mediation, self-protection and other techniques, such as
 time-out.

(f)
 Recognizing signs of
 physical distress in consumers who are being held, restrained, or
 secluded.

(g)
 The viewpoints of
 consumers who have experienced restraint or seclusion are incorporated into
 staff training and education in order to help staff better understand all
 aspects of restraint and seclusion use. Whenever possible, consumers who have
 experienced seclusion or restraint contribute to the training and education
 curricula and/or participate in staff training and education.

(26)
 Staff who are authorized to
 physically apply restraint or seclusion receive the training and demonstrate
 competency described in
 
580-2-9-.23
(27)
.
 Staff who are authorized to physically apply restraint or seclusion receive
 annual training in and demonstrate competency every 6 months in the safe use of
 restraint, including physical holding techniques.

(27)
 Staff who are authorized to perform the
 15 minute monitoring of individuals who are in restraint or seclusion receive
 the training and demonstrate the competence cited above and also receive
 ongoing training and demonstrate competence in: 
 
(a)
 Taking and recording vital
 signs.

(b)
 Effective
 communication.

(c)
 Offering and
 providing nutrition/hydration.

(d)

 Checking for adequate breathing, circulation and range of motion in the
 extremities.

(e)
 Providing for
 hygiene and elimination needs.

(f)

 Providing physical and psychological comfort.

(g)
 Assisting consumers in meeting behavior
 criteria for the discontinuation of restraint or seclusion.

(h)
 Documenting behavior and informing
 clinical staff of behavior indicating readiness for the discontinuation of
 restraint or seclusion.

(i)

 Recognizing when to contact a medically trained licensed independent
 practitioner or emergency medical services.

(j)
 Recognizing signs of injury associated
 with seclusion and restraint.

(k)

 Recognizing how age, developmental considerations, gender issues, ethnicity,
 and history of sexual or physical abuse may affect the way in which an
 individual reacts to physical contact.

(l)
 Recognizing the behavior criteria for the
 discontinuation of restraint or seclusion.

(m)
 Records of initial and ongoing staff
 training and competency testing shall be maintained in personnel records and
 training materials shall be available for review as needed.

(28)
 All direct care staff are
 competent to initiate first aid and cardiopulmonary resuscitation. Records of
 staff training shall be maintained in personnel records.

(29)
 There is a written plan for provision of
 emergency medical services. Consumer records demonstrate that appropriate
 medical services were provided in an emergency.

(30)
 Restraint and seclusion shall: 
 
(a)
 Be implemented in a manner that protects
 and preserves the rights, dignity, and well-being of the
 child/adolescent.

(b)
 Be
 implemented in the least restrictive manner possible in accordance with safe,
 appropriate restraining techniques.

(c)
 Not be used as punishment, coercion,
 discipline, retaliation, for the convenience of staff, or in a manner that
 causes undue physical discomfort, harm, or pain.

(31)
 Consumer records document that the use
 of restraint or seclusion is consistent with organization policy, and
 documentation focuses on the individual. Each episode of use is recorded.
 Documentation includes:
(a)
 The circumstances
 that led to their use.

(b)

 Consideration or failure of non-physical interventions.

(c)
 That consumers who are deaf or limited
 English proficient are provided effective communication in the language that
 they prefer (signed or spoken) during seclusion and restraint.

(d)
 The rationale for the type of physical
 intervention selected.

(e)

 Notification of the individual's family/legal guardian consistent with
 organizational policy and the agreement with the family/legal
 guardian.

(f)
 Specification of the
 behavioral criteria for discontinuation of restraint or seclusion, informing
 the consumer of the criteria, and assistance provided to the consumer to help
 him or her meet the behavioral criteria for discontinuation.

(g)
 Each verbal order received from a
 physician, certified registered nurse practitioner, or physician's assistant
 must be signed within 48 hours.

(h)

 Each in-person evaluation of the consumer signed by the staff person who
 provided the evaluation.

(i)

 Continuous monitoring to include 15-minute assessments of the consumer's
 status.

(j)
 Debriefing of the
 individual with staff.

(k)
 Any
 injuries that are sustained and treatment received for these
 injuries.

(l)
 Circumstances that
 led to death.

(32)

 Staffing numbers and assignments are adequate to minimize circumstances leading
 to seclusion and restraint and to maximize safety when restraint and seclusion
 are used. Staff qualification, the physical design of the facility, the
 diagnoses and acuity level of the residents, age, gender, and developmental
 level of the residents shall be the basis for the staffing plan.

(33)
 The provider must report the use of
 seclusion and restraint to DMH in accordance with published reporting
 guidelines. Additionally, the organization is required by applicable law and
 regulations to report injuries and deaths to external agencies.

(34)
 The provider must demonstrate that
 procedures are in place to properly investigate and take corrective action
 where indicated and where seclusion and restraint results in consumer injury or
 death.

(35)
 Time-out shall be
 implemented as follows:
(a)
 A consumer in
 time-out must never be physically prevented from leaving the time-out
 area.

(b)
 Time-out may take place
 away from the area of activity or from other consumers such as in the
 consumer's room (exclusionary) or in the area of activity of other consumers
 (inclusionary).

(c)
 Staff must
 monitor the consumer while he or she is in time-out.

(d)
 Documentation shall support that these
 procedures were followed and shall include the following: 
 
1.
 Circumstances that lead to the use of
 time-out regardless of whether the time-out was consumer requested, staff
 suggested, or staff directed.

2.

 Name and credentials of staff who monitored the consumer throughout the
 time-out.

3.
 Where on the
 provider's premises either an inclusionary or an exclusionary time-out was
 implemented.

4.
 The length of time
 for which time-out was implemented.

5.
 Behavioral or other criteria for release
 from time-out if applicable.

6.
 The
 status of the consumer when time-out ended.

Notes

Ala. Admin. Code
 r. 
580-2-9-.23

New Rule: Filed June 14,
 2010; effective July 19, 2010.

Author:
 Division of Mental Illness, DMH

Statutory Authority:

Code of Ala.
 1975
, §
 
22-50-11
.

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