REQUIREMENTS FOR USE OF THIS SAMPLE DOCUMENT: 245D license holders are responsible for modifying this sample for use in their program. At a minimum, you must fill in the blanks on this form. You may modify the format and content to meet standards used by your program. This sample meets compliance with current licensing requirements as of August 31, 2015. Providers remain responsible for reading, understanding and ensuring that this document conforms to current licensing requirements. DELETE THIS HIGHLIGHTED SECTION TO BEGIN MODIFYING THIS FORM.
Program Name: ________________________________________________________________I. Policy
It is the policy of this DHS licensed provider (program) to promote the rights of persons served by this program and to protect their health and safety during the emergency use of manual restraints.
“Emergency use of manual restraint” means using a manual restraint when a person poses an imminent risk of physical harm to self or others and it is the least restrictive intervention that would achieve safety. Property damage, verbal aggression, or a person’s refusal to receive or participate in treatment or programming on their own, do not constitute an emergency.
II. Positive support strategies and techniques required
The following positive support strategies and techniques must be used to attempt to de-escalate a person’s behavior before it poses an imminent risk of physical harm to self or others:
[Insert a description of the positive support strategies and techniques to be used by the program.]
Examples that a program could use include:
· Follow individualized strategies in a person’s coordinated service and support plan and coordinated service and support plan addendum;
· Shift the focus by verbally redirect the person to a desired alternative activity;
· Model desired behavior;
· Reinforce appropriate behavior
· Offer choices, including activities that are relaxing and enjoyable to the person;
· Use positive verbal guidance and feedback;
· Actively listen to a person and validate their feelings;
· Create a calm environment by reducing sound, lights, and other factors that may agitate a person;
· Speak calmly with reassuring words, consider volume, tone, and non-verbal communication;
· Simplify a task or routine or discontinue until the person is calm and agrees to participate; or
· Respect the person’s need for physical space and/or privacy.
III. Permitted actions and procedures
Use of the following instructional techniques and intervention procedures used on an intermittent or continuous basis are permitted by this program. When used on a continuous basis, it must be addressed in a person’s coordinated service and support plan addendum.
A. Physical contact or instructional techniques must be use the least restrictive alternative possible to meet the needs of the person and may be used to:
1. calm or comfort a person by holding that persons with no resistance from that person;
2. protect a person known to be at risk of injury due to frequent falls as a result of a medical condition;
3. facilitate the person’s completion of a task or response when the person does not resist or the person’s resistance is minimal in intensity and duration; or
4. block or redirect a person’s limbs or body without holding the person or limiting the person’s movement to interrupt the person’s behavior that may result in injury to self or others, with less than 60 seconds of physical contact by staff; or
5. to redirect a person’s behavior when the behavior does not pose a serious threat to the person or others and the behavior is effectively redirected with less than 60 seconds of physical contact by staff.
B. Restraint may be used as an intervention procedure to:
1. allow a licensed health care professional to safely conduct a medical examination or to provide medical treatment ordered by a licensed health care professional to a person necessary to promote healing or recovery from an acute, meaning short-term, medical condition; or
2. assist in the safe evacuation or redirection of a person in the event of an emergency and the person is at imminent risk of harm; or
3. position a person with physical disabilities in a manner specified in the person’s coordinated service and support plan addendum.
Any use of manual restraint as allowed in this paragraph [Section B] must comply with the restrictions identified in [Section A].
C. Use of adaptive aids or equipment, orthotic devices, or other medical equipment ordered by a licensed health professional to treat a diagnosed medical condition do not in and of themselves constitute the use of mechanical restraint.
IV. Prohibited Procedures
Use of the following procedures as a substitute for adequate staffing, for a behavioral or therapeutic program to reduce or eliminate behavior, as punishment, or for staff convenience, is prohibited by this program:
1. chemical restraint;
2. mechanical restraint;
3. manual restraint;
4. time out;
5. seclusion; or
6. any aversive or deprivation procedure.
V. Manual Restraints Allowed in Emergencies
A. This program allows the following manual restraint procedures to be used on an emergency basis when a person’s conduct poses an imminent risk of physical harm to self or others and less restrictive strategies have not achieved safety:
[Insert a list of the types of manual restraints trained staff are allowed to use AND a description of the manual restraint.]
Examples that a program could include:
· Physical escort [insert description];
· One staff person arm restraint in standing position [insert description]
B. The program will not allow the use of a manual restraint procedure with a person when it has been determined by the person’s physician or mental health provider to be medically or psychologically contraindicated. This program will complete an assessment of whether the allowed procedures are contraindicated for each person receiving services as part of the service planning required under section 245D.070, subdivision 2, for recipients of basic support services; or the assessment and initial service planning required under section 245D.071, subdivision 3, for recipients of intensive support services.
VI. Conditions for Emergency Use of Manual Restraint
A. Emergency use of manual restraint must meet the following conditions:
1. immediate intervention must be needed to protect the person or others from imminent risk of physical harm;
2. the type of manual restraint used must be the least restrictive intervention to eliminate the immediate risk of harm and effectively achieve safety; and
3. the manual restraint must end when the threat of harm ends.
B. The following conditions, on their own, are not conditions for emergency use of manual restraint:
1. the person is engaging in property destruction that does not cause imminent risk of physical harm;
2. the person is engaging in verbal aggression with staff or others; or
3. a person’s refusal to receive or participate in treatment or programming.
VII. Restrictions When Implementing Emergency Use of Manual Restraint
Emergency use of manual restraint must not:
1. be implemented with a child in a manner that constitutes sexual abuse, neglect, physical abuse, or mental injury;
2. be implemented with an adult in a manner that constitutes abuse or neglect;
3. be implemented in a manner that violates a person’s rights and protection;
4. be implemented in a manner that is medically or psychologically contraindicated for a person;
5. restrict a person’s normal access to a nutritious diet, drinking water, adequate ventilation, necessary medical care, ordinary hygiene facilities, normal sleeping conditions, or necessary clothing;
6. restrict a person’s normal access to any protection required by state licensing standards and federal regulations governing this program;
7. deny a person visitation or ordinary contact with legal counsel, a legal representative, or next of kin;
8. be used as a substitute for adequate staffing, for the convenience of staff, as punishment, or as a consequence if the person refuses to participate in the treatment or services provided by this program;
9. use prone restraint. “Prone restraint” means use of manual restraint that places a person in a face-down position. It does not include brief physical holding of a person who, during an emergency use of manual restraint, rolls into a prone position, and the person is restored to a standing, sitting, or side-lying position as quickly as possible; or
10. apply back or chest pressure while a person is in a prone position, supine (meaning a face-up) position, or side-lying position,
11. be implemented in a manner that is contraindicated for any of the person’s known medical or psychological limitations.
VIII. Monitoring Emergency Use of Manual Restraint
A. The program must monitor a person’s health and safety during an emergency use of a manual restraint. The purpose of the monitoring is to ensure the following:
1. only manual restraints allowed in this policy are implemented;
2. manual restraints that have been determined to be contraindicated for a person are not implemented with that person;
3. allowed manual restraints are implemented only by staff trained in their use;
4. the restraint is being implemented properly as required; and
5. the mental, physical, and emotional condition of the person who is being manually restrained is being assessed and intervention is provided when necessary to maintain the person’s health and safety and prevent injury to the person, staff involved, or others involved.
A. When possible, a staff person who is not implementing the emergency use of a manual restraint must monitor the procedure.
C. A monitoring form, as approved by the Department of Human Services, must be completed for each incident involving the emergency use of a manual restraint.
IX. Reporting Emergency Use of Manual Restraint
A. Within 24 hours of an emergency use of manual restraint, the legal representative and the case manager must receive verbal notification of the occurrence as required under the incident response and reporting requirements in the 245D HCBS Standards, section 245D.06, subdivision 1.
When the emergency use of manual restraint involves more than one person receiving services, the incident report made to the legal representative and the case manager must not disclose personally identifiable information about any other person unless the program has the consent of the person.
B. Within 3 calendar days after an emergency use of a manual restraint, the staff person who implemented the emergency use must report in writing to the program’s designated coordinator the following information about the emergency use:
1. who was involved in the incident leading up to the emergency use of a manual restraint; including the names of staff and persons receiving services who were involved;
2. a description of the physical and social environment, including who was present before and during the incident leading up to the emergency use of a manual restraint;
3. a description of what less restrictive alternative measures were attempted to de-escalate the incident and maintain safety before the emergency use of a manual restraint was implement. This description must identify when, how, and how long the alternative measures were attempted before the manual restraint was implemented;
4. a description of the mental, physical, and emotional condition of the person who was manually restrained, leading up to, during, and following the manual restraint;
5. a description of the mental, physical, and emotional condition of the other persons involved leading up to, during, and following the manual restraint;
6. whether there was any injury to the person who was restrained before or as a result of the use of a manual restraint;
7. whether there was any injury to other persons, including staff, before or as a result of the use of a manual restraint; and
8. whether there was a debriefing with the staff and, if not contraindicated, with the person who was restrained and other persons who were involved in or who witnessed the restraint, following the incident. Include the outcome of the debriefing. If the debriefing was not conducted at the time the incident report was made, the report should identify whether a debriefing is planned.
C. A copy of this report must be maintained in the person’s service recipient record. The record must be uniform and legible.
D. Each single incident of emergency use of manual restraint must be reported separately. A single incident is when the following conditions have been met:
1. after implementing the manual restraint, staff attempt to release the person at the moment staff believe the person’s conduct no longer poses an imminent risk of physical harm to self or others and less restrictive strategies can be implemented to maintain safety;
2. upon the attempt to release the restraint, the person’s behavior immediately re-escalates; and
3 staff must immediately re-implement the manual restraint in order to maintain safety.
Internal Review of Emergency Use of Manual Restraint
A. Within 5 business days after the date of the emergency use of a manual restraint, the program must complete and document an internal review of the report prepared by the staff member who implemented the emergency procedure.
B. The internal review must include an evaluation of whether:
1. the person’s service and support strategies need to be revised;
2. related policies and procedures were followed;
3. the policies and procedures were adequate;
4. there is need for additional staff training;
5. the reported event is similar to past events with the persons, staff, or the services involved; and
6. there is a need for corrective action by the program to protect the health and safety of persons.
C. Based on the results of the internal review, the program must develop, document, and implement a corrective action plan for the program designed to correct current lapses and prevent future lapses in performance by individuals or the program.
D. The corrective action plan, if any, must be implemented within 30 days of the internal review being completed.
E. The program has identified the following person or position responsible for conducting the internal review and for ensuring that corrective action is taken, when determined necessary:
[Insert the name and/or position title of the responsible person. Typically this is done by staff responsible for program coordination, evaluation and oversight under the 245D HCBS Standards in section 245D.081].
Expanded Support Team Review of Emergency Use of Manual Restraint
A. Within 5 working days after the completion of the internal review, the program must consult with the expanded support team to:
1. Discuss the incident to:
a. define the antecedent or event that gave rise to the behavior resulting in the manual restraint; and
b. identify the perceived function the behavior served.
2. Determine whether the person’s coordinated service and support plan addendum needs to be revised to:
a. positively and effectively help the person maintain stability; and
b. reduce or eliminate future occurrences of manual restraint.
B. The program must maintain a written summary of the expanded support team’s discussion and decisions in the person’s service recipient record.
C. The program has identified the following person or position responsible for conducting the expanded support team review and for ensuring that the person’s coordinated service and support plan addendum is revised, when determined necessary.
[Insert the name and/or position title of the responsible person. Typically this is done by staff responsible for program coordination, evaluation and oversight under the 245D HCBS Standards in section 245D.081 ].
External Review and Reporting of Emergency Use of Manual Restraint
Within 5 working days after the completion of the expanded support team review, the program must submit the following to the Department of Human Services and the Office of the Ombudsman for Mental Health and Developmental Disabities using the online behavior intervention reporting form (BIRF DHS-5148):
1. report of the emergency use of a manual restraint;
2. the internal review and corrective action plan; and
3. the expanded support team review written summary.
Before staff may implement manual restraints on an emergency basis the program must provide the training required in this section.
A. The program must provide staff with orientation and annual training as required in Minnesota Statutes, section 245D.09.
1. Before having unsupervised direct contact with persons served by the program, the program must provide instruction on prohibited procedures that address the following:
a. what constitutes the use of restraint, time out, seclusion, and chemical restraint;
b. staff responsibilities related to ensuring prohibited procedures are not used;
c. why such prohibited procedures are not effective for reducing or eliminating symptoms or undesired behavior;
d. why prohibited procedures are not safe; and
e. the safe and correct use of manual restraint on an emergency basis according to the requirements in the 245D HCBS Standards, section 245D.061 and this policy.
2. Within 60 days of hire the program must provide instruction on the following topics:
a. alternatives to manual restraint procedures, including techniques to identify events and environmental factors that may escalate conduct that poses an imminent risk of physical harm to self or others;
b. de-escalation methods, positive support strategies, and how to avoid power struggles;
c. simulated experiences of administering and receiving manual restraint procedures allowed by the program on an emergency basis;
d. how to properly identify thresholds for implementing and ceasing restrictive procedures;
e. how to recognize, monitor, and respond to the person’s physical signs of distress, including positional asphyxia;
f. the physiological and psychological impact on the person and the staff when restrictive procedures are used;
g. the communicative intent of behaviors; and
h. relationship building.
B. Training on these topics received from other sources may count toward these requirements if received in the 12-month period before the staff person's date of hire.
C. The program must maintain documentation of the training received and of each staff person's competency in each staff person’s personnel record.
Policy reviewed and authorized by:
Print name & title Signature
Date of last policy review: Date of last policy revision:Report/Rate this page