RESTRICTIVE PROCEDURES IN RESIDENTIAL TREATMENT FACILITIES

All residents of residential treatment facilities (RTF's) have the right to be free from restraint or seclusion, of any form, used as a means of coercion, discipline, convenience, or retaliation. (See 42 CFR §483.356, and 55 PA Code §3800.32(b)(n) and 202.)

The only restrictive procedures ever permitted by participating Medical Assistance RTF providers are manual restraint(s), chemical restraint, and exclusion. A restrictive procedure may not be used in a punitive manner for the convenience of staff persons or as a program substitution. For each incident in which use of a restrictive procedure is considered, every attempt shall be made to anticipate and de-escalate the behavior using methodology intervention less intrusive than restrictive procedures. Mechanical restraints are not permitted. Seclusion is not permitted. Facilities shall adhere to the federal requirements at 42 CFR 483 Subpart G, Conditions of Participation for the Use of Restraint or Seclusion in Psychiatric Residential Treatment Facilities Providing Inpatient Psychiatric Services for Individuals Under Age 21 for those restrictive procedures permitted by State and Federal law.

The purpose of this document is to clarify what constitutes a permissible restrictive procedure and the resulting requirements if such a restraint is necessary within an accredited RTF paid for by either the MA fee-for-service plan or a managed care organization delivery system. Citations are given throughout this document referencing the 55 PA Code Chapter 3800 regulations and/or the applicable 42 CFR rule for further reference.

This document is not intended to be a comprehensive, in depth synopsis of the above referenced regulations. As licensed and enrolled providers, facilities are expected to thoroughly review and adhere to applicable regulations.

RESTRICTIVE PROCEDURES PERMITTED UNDER 55 PA CODE, CHAPTER 3800, STATE REGULATIONS IN LIMITED CIRCUMSTANCES.

A manual (Federal term: "personal") restraint is application of a physical force on a person's body without the use of any device for the purpose of restricting the free movement of a resident's body. The term personal restraint does not include briefly holding without undue force a resident in order to calm or comfort him or her, or holding a resident's hand to safely escort a resident from one area to another (See 42 CFR §483.352).

A chemical restraint (Federal term: "drug used as a restraint") is a drug used to control acute, episodic behavior that restricts the movement or function of a resident. A drug ordered by a licensed physician as part of an ongoing medical treatment or pretreatment prior to a medical or dental examination or procedure is not a chemical restraint. (See 42 CFR §483.352 and 55 Pa. Code §3800.209)

Exclusion (Federal term: "exclusionary time out") is the removal of a child from the child's immediate environment and restricting the child alone to a room or area. (See 55 Pa. Code §3800.212) Exclusion differs from seclusion (55 Pa Code §3800.206), which is not allowed by State law, in that the resident is not confined to the room by any form of locking the room. Exclusion is similar to the Federal "time-out" which is the restriction of a resident for a period of time to a designated area from which the resident is not physically prevented from leaving, for the purpose of providing the resident an opportunity to regain self control. (See 42 CFR §483.352 and .368).

STAFF TRAINING

Staff may not be involved in the application of a restrictive procedure unless they have completed training within the past year in the use of that procedure. Federal regulations further require that staff must demonstrate competency before participating in an emergency safety intervention. (See 42 CFR §483.376 and 55 Pa. Code §3800.205)

Facilities are required to provide ongoing education and training for staff including training in the safe and appropriate use of restrictive procedures as well as alternative non-intrusive behavior modification techniques. Staff must demonstrate their competencies of emergency safety interventions on a semi-annual basis. Cardiopulmonary resuscitation certification must be reviewed annually. (See 42 CFR §483.376, 55Pa. Code §§3800.58 (b)(4) and (e))

The facility must record training completion and demonstration of competency in the employee's personnel record. All training programs and materials used by the facility must be available for review by the Center for Medicare and Medicaid Services, CMS, (formerly known as the Health Care Finance Administration), the State Medicaid agency, and the State survey agency. (See 42 CFR §483.376 (g) and 55 Pa. Code §3800.58(h).

NOTIFICATION OF POLICY TO RESIDENTS AND RESPONSIBLE PARTIES

At admission each facility must inform both the resident and in the case of a minor, the resident's parent(s), legal guardian, or custodian of its policy regarding the use of manual or chemical restraint or exclusion during an emergency safety situation in a language understood by the parties notified. The facility must obtain, in writing from the resident or in the case of a minor, from the parent, legal guardian or custodian, that he/she has been informed of this policy. A copy of that policy must be provided to the recipient and the parents/guardian/custodian. Information on how to contact the State Protection and Advocacy Organization (PA Protection and Advocacy; telephone 1-800-692-7443) shall be included in the written material. (See 42 CRF §483.356(c))

IMPLEMENTATION OF RESTRICTIVE PROCEDURES

Orders for Manual and Chemical Restraint

An emergency safety situation is the unanticipated resident behavior that places the resident or others at serious threat of violence or injury if no intervention occurs and that calls for an emergency safety intervention. Emergency safety intervention means the use of restraint as an immediate response to an emergency safety situation. (See 42 CFR § 483.352 and 55 Pa. Code§ 3800.202 (b)). Standing orders may not be implemented without an order and the restriction is limited to the duration of the emergency safety situation only.

Any order for restraint must be the least restrictive intervention that is likely to be effective and may only be imposed at the time of an emergency safety situation and limited to the duration of the emergency safety situation. Restaint must not be applied without an order based upon the presenting situation (Standing orders do not meet this requirement). Only a licensed physician may order chemical restraint. Manual restraint is preferably ordered by a physician. However, if a physician is not available, a certified registered nurse practitioner (CRNP) or physician assistant (PA) may order a manual restraint . A licensed psychologist or a licensed social worker (LSW) or licensed clinical social worker (LCSW) may also order manual restraint if the other practitioners are not available. The resident's treatment team physician must be contacted and informed about the use of restraint, unless the ordering licensed professional is also the resident's treatment team physician.

If the practitioner is not at the facility, a registered nurse (RN) or practical nurse (LPN) obtains the verbal order while the emergency safety intervention is being initiated by staff or immediately after the safety intervention ends. If an RN or LPN is not available, a licensed occupational therapist (OT), or physical therapist (PT) may obtain the verbal order.

Within one hour of the emergency safety intervention and when the restraint is removed, a face-to-face assessment of the physical and psychological well being of the resident must be conducted. The face-to-face assessment is preferably conducted by a physician. However, if a physician is not available a certified registered nurse practitioner (CRNP), physician assistant (PA), or a registered nurse (RN) may also conduct the assessment. If the aforementioned practitioners are not available, the facility may request an exception which if approved would allow other licensed practitioners to complete the assessment. The facility must notify the Office of Mental Health and Substance Abuse (OMHSAS) field office in writing to request approval of any proposed alternative method. The request must include a description of why an exception is being requested and an explanation of how the proposed arrangement meets the Federal requirement that a licensed practitioner evaluate both the physical and psychological well being of the resident and indicate any additional training which qualifies the practitioner to perform the assessment.

Each party involved in restrictive procedures may only perform as permitted by their training and scope of practice.

Manual restraints must be discontinued when the child demonstrates they have gained self-control (55 Pa. Code §3800.202(c)(3)). Maximum duration an order for restraint (42 CFR §483.358):
Residents ages 18- 21 No more than 4 hours
Residents ages 9 - 17 No more than 2 hours
Residents under age 9 No more than 1 hour

Should the emergency situation extend beyond the time of the order, licensed staff must contact the ordering licensed practitioner for guidance.

At a minimum the ordering practitioner must be available to staff at least by phone during the duration of the emergency situation. Documentation of all orders must be made in the resident's record and signed. In the case of a verbal order for manual restraint, the ordering practitioner must countersign the verbal order. (42 CFR §483.358) In the event of chemical restraint, a physician must complete a written order for the administration of the drug based upon the physician's examination of the individual before the order is written (See 55 Pa. Code §3800.209).

Since manual or chemical restraint may only be implemented as the result of an emergency situation where the child or others are a risk, the responsible physician determines if the residential treatment facility continues to be the appropriate level of care, or whether the resident should be hospitalized. If hospitalization is appropriate and the child over 14 years of age refuses voluntary hospitalization, involuntary commitment under 302 criteria of the Pennsylvania Mental Health Procedures Act may be followed.

Notification of restrictive procedure application.

In the case of a minor, the family, guardian or custodian must be notified as soon as possible after the initiation of any emergency safety intervention. If the child is in the custody of Children and Youth the custodial County Children and Youth Agency is notified. The facility must document in the resident's record who has been notified of the emergency safety intervention, including the date and time of the notification and the name of the staff person providing the notification. (See 42 CFR §483.366)

POST INTERVENTION DEBRIEFING

Within 24 hours after a resident has been restrained, staff involved in the emergency safety intervention and the resident shall participate in a face-to-face discussion. An exception may be granted if the physical presence of a particular staff person jeopardizes the well-being of a resident. Other staff and family member(s), guardian(s) or custodian may participate when deemed appropriate by the facility. The purpose is to identify the circumstances resulting in the restraint and to identify alternate treatment strategies. (See 42 CFR §§483.360 and .370(a)).

Within 24 hours after a resident has been restrained a staff debriefing and review of the situation that required the restraint by all staff involved in the incident as well as appropriate treatment team members, supervisory and administrative staff shall occur to identify areas requiring modification to administrative policy and procedures and if injuries were present, to prevent future injuries. (See 42 CFR §483.370 (b)).

Documentation of the above meetings shall be recorded in the resident's record (See 42 CFR §483.370(c)).

FACILITY REPORTING

No later than 24 hours following the occurrence, the facility must report to the State Protection and Advocacy (P&A) system, and Medicaid agency any serious occurrence involving the resident such as death, serious injuries or a suicide attempt. The facility shall indicate whether a manual or chemical restraint or exclusion was used during or immediately prior to death or injury (See 42 CFR §483.374(b)).

Deaths must be reported to the Center for Medicare and Medicaid Services Regional Office (See 42 CFR §483.374(c)). Contact Stuart Cogan at telephone (215) 861-4734, or Joseph Hopko at telephone (215) 861-4192 of the Philadelphia Regional Office no later than close of business the next business day after the resident's death.

Parents Involved Network (PIN), a project of
Mental Health Association of SE PA
1211 Chestnut Street, 11th Floor
Philadelphia, PA 19107
215-751-1800 or 800-688-4226
Email: law@pinofpa.org