POLICY TITLE:
Special Treatment and Safety Measures
Policy Number:
Owner: PI Department
Effective Date:
Previous
CEO & Director of Operations
Approved By: & Efficiencies
Revision:
Date Approved:
Replaced:
February 2015
July 2011
Place an "X" next to the department/program to which this policy applies
ALL
All Staff
x
INTK
Intake
ACCT Accounting
IT
Information Technology
BILL
Billing
MAINT
Maintenance
x
CLIN
All Clinical staff
MKT/DEV Marketing and/or Development
x CPST CPST
x
OFS
Outpatient Family Services
x DEAF Deaf Services
OPER
Operations
Compliance (Performance &
DIET
Dietary
P&I
Improvement)
ECMH ECMH
x
RES
Residential
x
EDPH Extended Day
x
TSA
Therapeutic School Age
x
FC
Foster Care
x
TPS
Therapeutic Preschool
x
H/L
Hispanic/Latino
x TRANS
Transportation
x
IHB
Intensive Home Based
OTH
Other (specify):
1.0
PURPOSE AND POLICY
PURPOSE
SVFC must develop, implement, and regularly review a documented program for the use of Special
Treatment/Safety Measures (ST/SM). The program includes a list of the interventions that are to be
used with clients by trained staff members. Staff will be trained on proper interventions, limitations,
appropriate documentation, and the quality improvement review of all interventions performed. All
SVFC staff members will be provided with sufficient training and supporting reference materials to
enable them to appropriately use ST/SM. All new staff members must receive appropriate training
prior to initiating ST/SM.
POLICY
SVFC is committed to providing a safe environment for clients and staff members through the
implementation of appropriate interventions.
2.0
KEY TERMS
TERM
DEFINITION
Special Treatment and Safety
Measures (ST/SM)
Interventions used in accordance with either a behavior
management plan/safety plan or in response to a crisis situation
where there exists an imminent risk of danger to the individual or
others and no other effective, safe, less restrictive intervention is
possible. OAC 5122.26.16.
Behavior Management Plan (BMP)
Functional analysis of a child’s high risk behavior that is conducted
Safety Plan
Manual Restraint/Physical Restraint
Contraindications
Therapeutic Crisis Intervention (TCI)
Minor Aversive Behavioral
Interventions
Major Aversive Behavioral
Interventions
Time-Out
Individual Service Plan (ISP)
Risk Management Committee
Performance Improvement Committee
Life Space Interview
Child’s Point Sheet
every 90 days. Should a client move to a lower level of care such
as Community Psychiatric Support Treatment, Foster Care, or
Outpatient Family Services the child’s BMP is no longer valid.
Functional analysis of a child’s high risk behavior used for children
receiving Community Psychiatric Support Treatment, Outpatient
Family Services, and Deaf Services. This is reviewed every 6
months.
Method of physically restricting a person’s freedom of movement by
the use of physical holds with the goal of assisting the person to
regain internal and behavioral control or stopping a dangerous
behavior. OAC 5122.26.16
Items that place a person at greater risk for the use of ST/SM.
Includes gender, age developmental issues, ethnicity, history of
physical abuse, history of sexual abuse, medical conditions and
physical disability. OAC. 5122.26.16. Also, includes psychological
factors such as psychosis or claustrophobia. Special attention will
be given to individuals who receive any asthma or cardiac
medications.
Verbal intervention and Manual restraint techniques developed by
Cornell University.
Interventions such as 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.
Interventions such as the contingent loss of the regular meal, the
contingent loss of bed and the contingent use of unpleasant
substances or stimuli such as bitter tastes, bad smells, splashing
with cold water and loud or annoying noises. OAC 5122.26.16.
When a child is required to remove themselves from positive
reinforcement to a specified place for a specified period of time or
until ready behavior occurs. OAC 5122.26.16. Time-out is further
defined by the Agency as an instance when a child leaves or is
asked to leave programming for a specified period of time and
requires a one-on-one intervention to regain control and return to
programming. Time-out can occur in the hallway outside of
programming or in the quiet rooms, which are further separated
from the groups.
a. Identifies symptoms, goals, and interventions for both the
client/youth and treatment team
b. Identifies clinical and/or rehabilitative services
c. Permanency planning
d. Available options that SVFC offers to achieve the
child/youth’s goals and desired outcomes with specific
timeframes for achieving each specific goal
The committee identifies and rectifies potential risk and safety
concerns affecting clients and personnel. Additionally, the
committee reviews critical incidents and identifies potential risks
relating to health, safety, and facility related issues. Annually, the
committee develops a risk assessment analysis, which is used to
assess SVFC’s highest risk impacts.
This committee is a meeting between the chairs of all performance
improvement committees and the executive team members to
summarize the events of each committee and give suggestions for
improvement.
A therapeutic, verbal strategy for intervening with a young person.
A positive reinforcement method that helps monitor a child’s
behaviors and progress. It is a program to help promote a safe and
stable environment.
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3.0
PROCEDURES
Admission
1.
Upon admission to an Agency program, the least restrictive, safest, and most effective
interventions for a child will be determined through the assessment. The assessment
will include:
a. Documentation of special needs.
b. Input from the child and their parent/guardian to identify triggers and techniques
that would help the child control their behavior.
c. Potential risk of harm to self and others.
d. Antecedents to out of control behavior.
e. The effectiveness of previous uses of ST/SM.
f. Contraindications (psychological, social, medical factors, ext.).
i. These will be documented throughout the child’s receipt of services at the
Agency.
2.
3.
The assessment will be used to develop a behavior management plan.
Content the behavior management plan:
a.
b.
c.
d.
4.
5.
Results of initial assessment.
Specifics about interventions that may or may not be used.
Signature of parent guardian.
The behavior management plan will be reviewed and updated when appropriate.
When a child enters a lower level of care (Outpatient Family Services, Community
Psychiatric Supportive Treatment, Medication Management Clinic and Foster Care) the
child’s behavior management plan will be modified, as manual restraints are no longer
permitted at these lower levels of care.
Upon admission, annually thereafter, and when clinically warranted, the child and their
parent/guardian will receive a copy of this ST/SM Policy and will be informed of the
Agency’s philosophy on the use of ST/SM. Family members will be given the
opportunity to ask questions about this policy.
Note: This does not involve individuals within the Foster Care Program.
6.
7.
8.
9.
The parent/guardian will be asked to sign an acknowledgement of awareness of the use
of the ST/SM policy.
ST/SM will not be used as a form of discipline or for staff convenience.
ST/SM is not to be performed by SVFC clients, by foster caregivers, or by a non-TCI
trained staff member.
Should a child experience repeated or sustained use of these measures, a transfer to a
more structured treatment environment with the capacity to meet the child’s needs may
be considered.
Overview of ST/SM
1.
2.
ST/SM will be used only to ensure the safest possible control of clients’ dangerous
behaviors who are unable to respond to less restrictive interventions and are a clear
danger to themselves and/or others.
The approved methods of ST/SM are time-out and manual restraint. Time-out and
manual restraint are to immediately cease as soon as the child has re-established
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control or if the techniques produce any adverse side effects such as illness, injury,
severe emotional stress, and/or severe physical stress.
a. Time-out is to be used in response to escalating client behavior, such as the
antecedents to aggression.
b. A manual restraint will be used as a response to an emergency only with the goal
of assisting the child to re-establish internal and behavioral control and/or
stopping a dangerous behavior when verbal directions and/or non-verbal prompts
have been ineffective.
3.
4.
5.
6.
7.
The interventions used with a client will include attention to the preservation of the
person’s health, safety, rights, dignity, and well-being.
Respect for the child is to be maintained during initiation and application of such
measures.
Staff will ensure that body temperature and modesty are maintained.
The environment will be kept safe and clean.
Well-being will be preserved through adequate exercise, nourishment, and personal
care.
Prohibited Interventions
The below interventions are prohibited by the agency. Any use of these methods will lead to
disciplinary action up to and including termination.
Chemical restraint
Corporal punishment
Excessive use of ST/SM
Face down holds
Forced exercise
Group punishment for
individual behavior
Handcuffs or any type of
mechanical restraint
Interventions that involve
withholding hydration
and nutrition or forced
exercise
Major aversive
interventions
Pepper spray
Punishment by peers
Techniques that impede
breathing
Techniques that restrict the
child’s ability to
communicate
Techniques that obstruct
vision
Use of restraints in noncrisis, non-emergency
situation, or any non-TCI
methods
Training
1. TCI training is broken down into two sections, verbal techniques and proper physical
holds. Staff are required to attend the following trainings:
a. Verbal Techniques
i. Direct care staff (Adaptive Behavior Specialist)
ii. Licensed providers (Clinicians “Therapeutic Pre-school , Therapeutic
School Age, Therapeutic After School, Residential, Parent Child
Interaction Therapy, Intake”)
iii. Community Psychiatric Support Therapy (includes Deaf Services)
iv. Program Directors
v. Nursing Staff
vi. Performance Improvement Staff
b. Physical Hold
i. Direct care staff (Adaptive Behavior Specialist)
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ii. Licensed providers (Clinicians “Therapeutic Pre-school , Therapeutic
School Age, Therapeutic After School, Residential, Parent Child
Interaction Therapy, Intake”)
iii. Program Directors
iv. Nursing Staff
v. Performance Improvement Staff
2. The HR Department is responsible for ensuring completion of ST/SM training and for
tracking training and eligibility requirements. Any staff ineligible to perform ST/SM will
receive a cease and desist order from HR that is provided to the staff member’s
supervisor.
3. For new staff, training will occur during orientation, which occurs within 30 days of hiring.
4. New staff receive 24 hours of initial training on the following:
a.
b.
c.
d.
Recognizing situations, including medical conditions that can lead to a crisis.
Understanding staff influence on client behavior.
Identifying the earliest precipitant to aggression in order to prevent escalation.
Non-physical techniques for the de-escalation of disruptive and/or aggressive
acts, persons and/or situations, including the use of time-out.
e. Approved Manual/Physical Restraint techniques.
f. Assessment of physical and mental status.
g. Assessment of physical need (hydration, nutrition, readiness to discontinue
manual restraint, etc.)
h. Understanding when emergency medical personnel are needed.
i. Identification and assessment of contraindications.
j. Experiencing a physical restraint.
5.
6.
7.
8.
Training will include post-testing in order to ensure competency in the above areas.
The curriculum used to train staff will be documented and be made available on request.
Annually, staff must attend a refresher course to remain certified.
All staff utilizing ST/SM will be required to be CPR and First Aid certified.
a. New staff certification will occur during orientation, unless the staff member is
already certified.
b. CPR and First Aid certifications must be renewed every two years, unless
specified otherwise.
9. All administrative and support staff are trained on procedures for witnessing clients in
crisis. Administrative and support staff are not permitted to use any ST/SM with the
exception of Program Directors and the Agency’s Clinical Director.
10. Staff that have successfully completed the verbal technique and physical hold TCI
training and hold current CPR and First Aid certificates are authorized to use ST/SM.
Performance Improvement (PI)
1. Interventions are to be documented on appropriate forms and are reviewed by the staff
member’s supervisor. Completed forms become part of the clinical record and are
forwarded to the PI department.
2. Quality reviews and data analysis are performed by the PI Department.
3. The PI Department will review forms and the supervisors input and will update the
Restraint Log accordingly.
a. Content of the Restraint Log:
i. Client name.
ii. Account number.
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iii. Age, gender and ethnicity of the child.
iv. Date, start and end time, and duration of special treatment and safety
measure used.
v. Type of intervention (time-out, manual restraint).
vi. Program intervention occurred in.
vii. Names of staff involved in the intervention.
b. The log will be maintained electronically, in a spreadsheet format to allow for data
analysis.
c. As required by the State and pursuant to OAC 5122.26.16, a log will be
maintained for each incident of manual restraint and each incident of time-out
that lasts longer than 15 minutes. The log will be maintained by the PI
Department.
4. Monthly data are created, aggregated, and reviewed.
a. Such information will include descriptive statistics that examine demographics,
program characteristics, staff, and client thresholds.
b. The Performance Improvement Specialist will identify clients and staff that have
exceeded the restraint threshold to Program Directors on a monthly basis.
c. The PI Committee reviews areas including, but not limited to, number of children
restrained, number of minutes of restraint, restraints by demographic
characteristics, and total number of restraints performed.
d. The Performance Improvement Specialist aggregates data for each relevant
Agency program.
5. Annually, the Agency will research current best practices related to behavior
management and compare those practices to the current processes.
Use of Time-Out
1. Time-out is to be used as a de-escalation technique that is part of the child’s ISP.
Note: Children may ask for a time-out in order to manage their feelings and
behavior.
2. Time-out is also to be used in response to sensory issues (over or under stimulation) and
in response to safety issues, such as the antecedents to aggressive behavior.
3. Prior to initiating a time-out, staff should offer a less restrictive alternative such as
moving to a quiet place within the room that programming is occurring.
4. If a child is unable to maintain their behavior, staff will direct the child to the hallway
outside of the programming they are participating in.
5. If the child continues to be unable to maintain their behavior, staff will direct them to a
separate quiet room.
6. The quiet room will not be locked and children should not be prevented from leaving the
room.
7. Only one child at a time should be present in the quiet room.
8. Staff must continuously monitor the child through the period of time-out.
9. Every 15 minutes the client will be assessed to determine if time out should continue.
10. The child will have access to nutrition, hydration, and use of the lavatory (if requested)
during the period of time-out.
11. After the child has de-escalated, staff must:
a. Complete the Life Space Interview.
b. Return the child to programming.
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12. A Time-Out/Restraint form must be completed by the end of the work day. The
completed form is to be given to the supervisor for review, which is forwarded to the PI
Department upon the supervisor’s approval.
Use of Manual Restraint
1. Manual restraint can only be used if it is indicated in the child’s Behavior
Management/Safety Plan.
2. Manual restraint is to be used only as a response to an emergency situation where
the child poses a safety risk to themselves or others.
a. The goal is to assist the child with re-establishing internal and behavioral
control and/or stopping a dangerous behavior.
b. Manual restraint is to be used only when all less restrictive means (verbal
directions and/or non-verbal prompts) have been ineffective and the child
poses a risk to themselves and/or others.
c. If the child is unable to de-escalate or continues to escalate, manual restraint
should be applied according to TCI procedures.
d. A TCI restraint should be completed by two trained staff members.
Note: One staff member can perform the proper physical hold while the other staff
member acts as a support witness, so long as both are TCI trained staff.
3. An AIR must be completed if only one staff member is involved and/or the second staff
person is not TCI trained.
4. For children under the age of five, the child’s age has to be listed as a contraindicator
on the Time-Out/Restraint form.
5. Restraints should not last longer than 15 minutes for children nine or under.
6. Restraints should not last longer than 30 minutes for children 10 and older.
7. In the case of chronic, high-risk or self-harming behaviors, extended time frames may
be authorized by a physician, nurse, or qualified clinician.
8. Every 15 minutes, a client will be assessed by a physician, nurse, or qualified clinician
for harmful health or psychological reactions. Vital signs, circulation, range of motion,
nutrition, hydration, hygiene, toileting, and need for continued restraint should be
reviewed.
9. After the child has de-escalated, staff must:
a. Complete the Life Space Interview.
b. Return the child to programming.
c. Staff must also complete a Time-Out/Restraint immediately following the use of
ST/SM. The completed form is to be given to staff’s supervisor for review and
forwarded to the PI Department.
d. A child’s parent/guardian is notified that the child had to be restrained via
point sheet and phone call.
Documentation
1.
Each incident of time-out or manual restraint is to be documented on the TimeOut/Restraint form and maintained in the child’s clinical record.
a. Content of the form includes:
i.
Demographic information.
ii.
Medications.
iii.
Contraindicators.
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iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
xii.
xiii.
2.
3.
4.
ST/SM type.
Description of precipitating behavior.
Less restrictive interventions that were attempted.
Explanation to the child regarding the reason for implementation of the
intervention and the required behaviors of the child that would indicate
sufficient behavioral control.
Description of child’s response to the intervention.
Description of post-intervention processing with the child.
Review of child’s plan to maintain control and return to programming.
Notation that relevant contraindications were reviewed if a manual
restraint was utilized.
Assessment for the need for ambulating, fluid intake, toileting, and
other needs if a manual restraint was utilized.
Documentation of any injury if a manual restraint was utilized.
Debriefing will be documented on the Restraint Form when a manual restraint occurs
and becomes part of the child’s clinical record.
An AIR will be completed whenever there is an incident that poses a risk to a staff
member or client, when an abnormal incident occurs, and when a one person restraint
is conducted.
Each program director will have the appropriate forms available for staff. Forms will
also be available to staff through the Agency Intranet.
4.0
SVFC POLICY INTERACTIONS
5.0
FORMS AND STORAGE LOCATION


6.0
Time-Out/Restraint form
Adverse Incident form
REGULATORY STANDARDS/INTERFACES, RESOURCES & REFERENCES (TO INCLUDE
COA, ADAMH, ODJFS, ODAMH etc.)



OAC: 5122.26.16
OAC: 5122.30
COA: BSM Standard
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