5122-26-16 Special treatment and safety measures.

(A) Philosophy

The provision of a physically and psychologically safe environment is a basic foundation and requirement for effective mental health treatment. Creating calm surroundings and establishing positive, trusting relationships are essential to facilitating a person’s treatment and recovery.

We share a goal of reducing and minimizing the use of special treatment and safety measures. We must recall that these measures are very intrusive techniques to be used by trained, qualified staff as a last resort in order to control dangerous and potentially harmful behaviors and to preserve safety.

Best practices include careful early assessment of a person’s history, experiences and preferences and the effectiveness or ineffectiveness of past exposure to these methods.

When individuals in less restrictive settings experience repeated or sustained use of these measures, providers in such settings should consider possible transfer/placement to a more structured treatment environment with the capacity to meet individual needs with reduced exposure to these intrusive interventions.

Use of special treatment and safety measures must be subject to quality improvement processes in order to identify ways in which the use of these measures can be decreased/avoided and more positive, relevant and less potentially dangerous techniques used in their place.

(B) The purpose of this rule is to state the general requirements applicable to special treatment and safety measures. These measures include the following:

(1) Mechanical restraint;

(2) Seclusion;

(3) Physical restraint; and

(4) Major aversive behavioral interventions.

(C) The following definitions shall apply to rules 5122-26-16 to 5122-26-16.3 of the Administrative Code and supercede those contained in rule 5122-24-01 of the Administrative Code:

(1) “Aversive behavioral intervention” means any behavior management intervention that employs any unpleasant or aversive stimuli. The two levels of such an intervention are:

(a) “Minor aversive behavioral interventions”, which include: time-out, loss of tokens, the contingent removal of items that are reinforcing to the person that are not listed as major aversive behavioral interventions, and the contingent loss of access to the person’s room; and

(b) “Major aversive interventions”, which include: the contingent loss of the regular meal, the contingent loss of bed (mattress must be provided at regularly scheduled hours of sleep), and the contingent use of unpleasant substances or stimuli such as bitter tastes, bad smells, splashing with cold water, and loud or annoying noises.

(2) “Behavior management” means the utilization of interventions in which positive reinforcers or aversive stimuli are applied in a systematic and contingent manner in the context of individual or group programs to change or manage behavior or facilitate improved self-control. The goal of behavior management is not to curtail or circumvent an individual’s rights or human dignity, but rather to assist the individual in increasing his/her ability to exercise those rights.

(3) “Behavior management plan” means an agreement negotiated with the person served, and as appropriate, parent or guardian, in which mutually agreeable behavioral goals and interventions are specified.

(4) “Clear treatment reasons” means that a person would present an imminent, substantial risk of physical harm to him/herself or others.

(5) “Mechanical restraint” means any method of restricting a person’s freedom of movement, physical activity, or normal use of his or her body, using an appliance or device manufactured for this purpose.

(6) “Physical restraint” means any method of physically restricting a person’s freedom of movement, physical activity or normal use of his or her body, without the use of mechanical restraint devices. These methods include the utilization of physical holds by one or more qualified persons with the goal of either assisting the person to reestablish internal and behavioral control, or of stopping a dangerous behavior when verbal directions and/or non-verbal prompts have been ineffective.

(7) “Qualified person” means an individual or staff member who is qualified to participate in one or all of the mechanisms identified in rules 5122-26-16 to 5122-26-16.3 of the Administrative Code by virtue of the following: education, training, experience, competence, registration, certification, or applicable licensure, law or regulation.

(8) “Ready behavior” means the behavior that the person needs to demonstrate to signal that an intervention can be terminated. Ready behavior shall be explained to the person and shall include a specific description and length of time. Ready behavior should be displayed for as short a time as possible.

(9) “Seclusion” means the involuntary confinement of a person alone in a room where the person is physically prevented from leaving.

(10) “Targeted behavior” means the behavior that is addressed in the behavior management plan as the behavior in need of changing/enhancing. The behavior should be observable/measurable and so stated in the plan.

(11) “Time-out” means an intervention in which a person is required to remove him/herself from positive reinforcement to a specified place for a specified period of time or until ready behavior occurs.

(D) General requirements

(1) The use of special treatment and safety measures shall be in accordance with either a behavior management plan or in response to a crisis situation (i.e., where there exists an immediate risk of danger to the individual or others and no other safe and effective intervention is possible).

(2) The following shall not be used under any circumstances:

(a) Face down restraint with back pressure;

(b) Any technique that obstructs the airways or impairs breathing;

(d) Any technique that restricts the recipient’s ability to communicate;

(e) Pepper spray, mace, handcuffs or electronic restraint devices such as stun guns, and

(f) A drug or medication that is used as a restraint to control behavior or restrict the individual’s freedom of movement that is not a standard treatment for the individual’s medical or psychiatric condition.

(3) The agency shall ensure that the use of special treatment and safety measures is routinely reviewed for safety, effectiveness and appropriateness and that the competency of staff in the use and documentation of these measures is routinely evaluated.

(a) Quality improvement processes shall identify opportunities, when appropriate, to reduce the use of special treatment and safety measures;

(b) The agency shall continuously review the reason(s) for the use of such measures and determine whether desired results might be achieved by some other less restrictive means; and

(c) The agency shall establish policies and procedures which shall reflect how special treatment and safety measures are reviewed, evaluated and approved for use.

(4) The choice of the least restrictive, safe and effective special treatment and safety measure for an individual is determined by the person’s assessed needs, the effective or ineffective measures previously used with the person, and, when possible, upon the person’s preference.

(a) The presence of advance directives addressing the use of special treatment and safety measures shall be determined and considered. Documentation of such shall be entered in the clinical record.

(b) When appropriate, and as part of a documented initial clinical assessment, the person and/or his/her custodian or guardian, shall assist in the identification of techniques that would help the person control his or her behavior; and where appropriate, the person’s need for methods or tools to manage his or her own aggressive behavior shall be identified. As clinically warranted, this information shall be incorporated in the ISP/ITP.

(c) Upon admission/intake and when clinically warranted, the person and/or his/her custodian or guardian, as appropriate, shall be informed of the agency’s philosophy on the use of special treatment and safety measures. the role of the family, custodian or guardian and their notification of the use of such measures shall also be discussed.

(d) Requirements for the initial and ongoing identification and documentation of individual-specific contraindications for the use of special treatment and safety measures shall be documented.

(i) Consideration of the use of such measures shall take into account the following which may place the person at greater risk for their use:

(a) Gender;

(b) Age;

(d) Ethnicity;

(e) History of physical or sexual abuse;

(f) Medical conditions; and

(g) Physical disabilities.

(5) The agency shall identify, educate and approve staff members to use special treatment and safety measures.

(a) Staff shall have appropriate training prior to commencing use of special treatment and safety measures and annually thereafter.

(i) Staff shall be trained in non-physical techniques for intervention and de-escalation of disruptive or aggressive acts, persons and/or situations.

(ii) Training will address the identification and assessment of those items noted in paragraph (D)(4)(d) of this rule.

(b) The curriculum used to train staff shall be documented and shall be made available to ODMH upon request.

(c) The number of appropriately trained staff available to apply or initiate special treatment and safety measures shall be adequate to ensure safety.

(6) Policies and procedures governing the use of special treatment and safety measures shall include attention to preservation of the person’s health, safety, rights, dignity, and well-being during use. Further, policies and procedures shall reflect how:

(a) Respect for the person is maintained during the application or initiation of such measures;

(b) The person is able to continue his or her care and participate in care processes;

(d) Physical well-being is preserved through adequate exercise, nourishment, and personal care; and

(e) Modesty, visibility to others, and comfortable body temperature are maintained.

(7) When special treatment and safety measures are used in crisis situations, policies and procedures shall include:

(a) Development of staff orientation and education that creates a culture emphasizing prevention, appropriate use of the measures, and encourages alternatives such as de-escalation techniques; and

(b) Assurance that such measures will not be utilized to compensate for the lack of sufficient staff, as a substitute for treatment, or as retaliation.

(8) When special treatment and safety measures are used in a behavior management program, policies and procedures shall include:

(a) The requirement of a positive approach to behavior management and the progressive use of the least restrictive alternatives;

(b) The requirement that behavior management programs identify and teach the individual appropriate expression of the target behavior or alternative adaptive behaviors;

(d) Prohibition of seclusion, mechanical and/or physical restraint;

(e) Prohibition of corporal punishment; and

(f) Prohibition of other patients/clients from carrying out a person’s behavior management plan.

(9) The agency shall notify ODMH of each death that occurs while a person is restrained or in seclusion, of each death occurring within twenty four hours after the person has been removed from restraints and seclusion, or where it is reasonable to assume that a person’s death is a result of such seclusion or restraint. Such notification shall include the name of the person and shall be provided not later than twenty four hours after the time of the person’s death.

(10) A log shall be maintained for department review of each incident of mechanical restraint, seclusion, physical restraint, major aversive behavioral interventions, and for time-out exceeding fifteen minutes per episode. The log shall include at minimum the following information:

(a) The person’s name or other identifier;

(b) The date, time and type of special safety and treatment measure; and

(11) Internal review for clinical appropriateness and documentation of such review(s) shall be made:

(a) For all instances of repeated or continual use of mechanical restraint and/or seclusion consisting of more than:

(i) Eight continuous hours for adults; or

(ii) Four continuous hours for children and adolescents ages nine to eighteen; or

(iii) Two continuous hours for children under age nine.

(b) For any physical restraint, major aversive behavioral intervention, and time-out that exceeds fifteen minutes per episode; and

(c) To ascertain overall patterns and trends of the agency’s use of special treatment and safety measures. Such utilization review shall occur at least monthly.

(12) Reviews as prescribed in paragraph (D)(11) of this rule shall consist of one of the following:

(a) An ITP/ISP review by appropriate members of the treatment team which shall be included in the person’s medical/clinical record; or

(b) A review by the service’s clinical/medical director or his/her designee; or

(d) Documentation of such reviews shall include, at minimum:

(i) Identification of data used, both internal and external;

(ii) A summary of clinical conclusions reached regarding the data; and

(iii) As warranted, specific steps taken to improve clinical practice including an identification of ways to reduce the use of special treatment and safety measures, if possible.

(13) Instances of special treatment and safety measures resulting in staff or patient/client injury shall also be reviewed via quality improvement processes to ascertain if appropriate policies and procedures were followed, and if so, whether a need to revise such policies and procedures currently exists.

HISTORY: Eff 1-1-91; 4-16-01

Rule promulgated under: RC Chapter 119.

Rule authorized by: RC 5119.01(G), 5119.01(I), 5119.22, 5119.61(M)

Rule amplifies: RC 5119.01(G), 5119.01(I), 5119.22, 5119.61(M) Replaces: 5122-26-16 RC 119.032 review dates: April 15, 2006