Homes for Children
Level I Policies and Procedures
Policy Number: 42.03
Subject:
Interventions
Restrictive
Effective Date of Policy:
10/01/2014
Covered Entities:
Barium Springs and Grandfather Home for Children
Policy Statement Physical restraints, specifically physical holding, are the only approved restrictive intervention utilized in the
residential programs. All residential programs shall strive to provide services in the least restrictive, most appropriate and most
effective manner possible. Therefore, restrictive interventions will only be utilized in emergency situations in which a client is in
imminent danger to self or others and alternative de-escalation techniques have either failed or are not appropriate for the
situation. These interventions may be part of a planned measure of therapeutic treatment as specified in the Planned Restrictive
Intervention Policy. Staff who utilizes physical restraints will have successfully completed competency-based, restrictive
intervention training that has been approved by the North Carolina Department of Health and Human Services (DHHS). These
staff will also be trained in de-escalation techniques and ways to minimize the use of physical restraints. At no time, will
seclusion, isolation, exclusionary time-out or chemical restraint interventions be utilized in residential settings.
Procedures
A. Definitions
 Chemical Restraint: any drug that is administered to manage a resident’s behavior in a way that reduces
safety risk to the resident or others; has the temporary effect of restricting the resident’s freedom of
movement and, is not standard treatment for the resident’s medical or psychiatric condition. Emergency
Safety Intervention: the use of restraint or seclusion as an immediate response to an emergency safety
situation (42 CFR 483.352).
 Exclusionary Time-Out: a procedure in which an individual served is excluded from the immediate
environment by staff to help the individual regain behavioral/emotional control. This procedure involves the
staff verbally directing the individual to remove himself from the immediate environment and verbally
restricting the individual to a quiet area or unlocked quiet room This definition of time-out does not include
instances in which an individual served is restricted to an unlocked room or area consistent with program
rules (such as a restriction to the individual’s sleeping area for quiet time before bedtime or a room or area
for homework time) nor does it include a self-calming strategy that an individual served may learn and use to
remove himself from an overly-stimulating environment (Joint Commission).
 Physical Holding of Youth: a method of restraint in which a youth’s freedom of movement or normal access
to his body is restricted by means of staff physically holding the youth for safety reasons (Joint
Commission).
 Restraint: any method of restricting an individual’s freedom of movement, including seclusion, physical
activity, or normal access to his body that (1) is not a usual and customary part of a medical diagnostic or
treatment procedure to which the individual or his legal representative has consented, (2) is not indicated to
treat the individual’s medical condition or symptoms, or (3) does not promote the individual’s independent
functioning (Joint Commission).
 Seclusion: the involuntary confinement of an individual in a room alone, for any period of time, from which
the individual is physically prevented from leaving. Seclusion does not include involuntary confinement for
legally mandated but nonclinical purposes, such as the confinement of a person who is facing criminal
charges or who is serving a criminal sentence (Joint Commission).
B.
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Training
1. Only NC State Division of Health and Human Services approved competency based curriculums for the
implementation of restrictive interventions will be trained within the residential programs. This will include
Homes for Children
Level I Policies and Procedures
2.
3.
4.
5.
6.
7.
C.
Therapeutic Crisis Intervention (TCI) or Crisis Prevention Institute (CPI) depending on residential program
as determined by Managing Director and Clinical Director.
Only certified instructors, as evidenced by passing instructor certification and completing mandatory
updates, can train staff in approved restraints and de-escalation techniques.
All agency staff providing care to residents are trained and certified in the approved curriculum for their
program, including de-escalation techniques, before providing direct care for any resident. This initial
training will be per the requirements of the curriculum. Staff working in the residential setting will
demonstrate their competency in skills on a semi-annual basis as required by the approved training
curriculum. All staff engaged in restrictive interventions with clients must be trained and maintain
certification; and be supervised by a qualified professional certified in the approved curriculum.
Staff are required to have ongoing education, training and demonstrated knowledge of the following:
 Techniques to identify staff and resident behaviors, events, and environmental factors that may
trigger emergency safety situations.
 Use of non-physical skills, such as de-escalation, meditation, conflict resolution, active listening, and
verbal and observational methods to prevent emergency safety situations.
 Safe use of restraint, including the ability to recognize and respond to signs of physical distress in
residents who are restrained.
 Current CPR certification is required for at least on staff member on each shift.
 Staff training will include exercises in which staff successfully demonstrates in practice the
techniques that they have learned to manage emergency situations.
 Staff must be trained and demonstrate competency before participating in an emergency safety
intervention.
Documentation of initial and refresher trainings will be maintained throughout the employee’s tenure and for
at least 3 years thereafter.
All training materials will be made available to CMS, State Medicaid Agency and State Surveyors upon
request.
All staff who are involved in providing, authorizing and reviewing restrictive interventions will demonstrate
the competency to do so through the standard training and evaluation process utilized by the organization.
Operational Guidelines
1. At no time will a behavior that may threaten the health of a resident ever be ignored or receive “planned
non-attention”. Some active intervention will always be developed and implemented. Basic necessity will
never, under any circumstances, be deprived.
2. Physical holding is only permitted and conducted according to the guidelines established in approved
curriculum for the program only after appropriate verbal intervention and other approved intervention
attempts to induce self-regulation within the resident have failed.
3. Physical holding is permissible by staff only under the following conditions:
 To ensure the physical safety of the resident—when a resident’s behavior is so self-destructive as
to be dangerous, external limits must be set to maintain a positive and safe environment. To avoid
injury, intervention must be immediate, and may require physical holding.
 To promote the physical safety of other residents—a resident who places other residents in physical
danger may require physical holding if other alternatives have failed.
 To protect the physical safety of staff—when staff is in danger of possible serious injury, immediate
physical intervention and physical holding may be the only safe recourse for the resident and staff.
4. The use of restraint using a protective or mechanical device is prohibited.
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Homes for Children
Level I Policies and Procedures
5. Physical holding may not be utilized to attempt to control cursing, screaming, or refusal to participate in
group activities.
6. The use of chemical restraint is prohibited.
7. Staff shall only use the degree of force necessary to repel or secure a violent or aggressive resident. The
degree of force that is necessary depends upon the individual characteristics of the resident (such as age,
size, gender, physical, medical and psychiatric condition, and personal history-including any history of
physical or sexual abuse) and the degree of aggressiveness displayed by the resident. Staff will make
adjustments, as needed and appropriate in response to resident complaints of pain. The restraint will be
discontinued should the client complain of difficulty breathing.
8. As any physical intervention involves the risk of injury to the resident and/or staff, staff must weigh this risk
against the risks involved in failing to intervene physically when it may be warranted.
9. Before instituting a physical hold, the staff shall take into consideration the resident’s medical condition and
any relevant effects that the medications the resident is taking could potentially have on the intervention. As
a part of the resident’s Initial Assessment, all residents are screened for any pre-existing medical conditions,
disabilities, or limitations that present a higher risk during a physical hold. This includes assessment of
limitations related to resident’s medication regime at the time of admission and throughout their treatment.
Identification and documentation of alternative emergency procedures will be developed and implemented
as soon as these contraindications are identified.
10. Staff must ensure that the manner, conditions, and location of the physical hold are safe and humane.
11. Immediately prior to the initiation of a physical hold, a health status check is conducted, including
observation of the resident’s breathing.
12. Upon initiation of the physical hold, a health status check is conducted to assess the resident’s circulation,
range of motion in extremities, vital signs and physical/psychological status and comfort.
13. During a restrictive intervention, residents will be monitored continuously and assessed at least every fifteen
minutes for any harmful health and psychological reactions. The client must be assessed for breathing,
verbal responsiveness, motor control, consciousness, and complaints of pain.
14. Staff members who are privileged to administer restrictive interventions may employ such procedures for up
to 15 minutes without further authorization. If a restrictive intervention continues for more than 15 minutes, a
responsible or qualified professional trained and competent in the use of restrictive interventions may give
verbal authorization to continue with the intervention for up to one hour from the time the hold was initiated.
As soon as possible, after the time of the initial employment of the intervention, a responsible or qualified
professional shall meet with and conduct an assessment of the client and write a continuation authorization
for the continued use of the restrictive intervention. The authorization shall only be by a responsible or
qualified professional who is privileged to use restrictive intervention based upon training and experience.
The administrative on-call individual is notified any time a restrictive intervention exceeds 30 minutes.
15. A continuum of less restrictive alternatives and verbal de-escalation techniques must be thoroughly,
systematically, and continuously considered prior to utilizing a physical restraint. These less restrictive
interventions are dictated by the curriculum of the clinical models utilized in the program.
16. The focus of the staff during a physical hold shall be to aid the resident in working through the crisis until the
resident is able to remain calm and in control.
17. Physical holding is never used as a punishment, consequence, for convenience of staff, to exercise staff
authority or because of a shortage of staff (refer to Behavior Management and Discipline Policy and
Procedure.)
18. If a staff member witnesses a physical hold that is being implemented improperly or against
policy/procedure, it is the responsibility of the staff member to intervene to protect the safety of the resident
and to report the incident to the proper administrative staff.
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Homes for Children
Level I Policies and Procedures
19. If other residents are in the vicinity of a resident whose behavior has escalated to the consideration of a
physical hold the other residents shall be removed from the situation.
20. Residents are not permitted to assist or participate in any restrictive intervention of another resident.
21. Physical holding must only be employed for the minimum time necessary and the resident must be released
when able to follow basic instructions, exhibit relaxed breathing and use appropriate voice tones during
verbal responses.
22. Physical restraints will be utilized following the mandatory ratios dictated by the approved curriculum and
with at least two staff members present.
23. The restrictive intervention will be discontinued as soon as therapeutically appropriate after the resident
gains behavioral control and is safe to release from the hold.
24. If required by the LME/MCO, written permission will be obtained from the LME/MCO prior to utilizing prone
restraints.
D.
Post Restrictive Intervention
1. A staff member trained in First Aid/CPR shall evaluate and document the resident’s breathing and ensure
that the resident is not experiencing any type of physical distress that would require immediate medical
follow-up. The resident will be visually monitored for at least 30 minutes following the utilization of a
restrictive intervention. This evaluation and monitoring will be documented in the resident’s medical record.
2. Within 24 hours after the restrictive intervention, staff and the resident involved in the restrictive intervention
will have a face to face discussion of the incident. All staff must be involved, unless it is documented that
the participation of a particular staff person may jeopardize the well-being of the resident. Other staff and
the legally responsible person may be included in the discussion should it be deemed appropriate. The
discussion will be conducted in a language that is understood by the resident/legally responsible person.
There must be an opportunity for both resident and staff to discuss circumstances that resulted in the use of
the restrictive intervention and strategies to be used by staff, resident or others that could prevent future
restrictive intervention use.
3. Within 24 hours after the restrictive intervention, all staff involved and appropriate supervisory staff must
conduct a debriefing session that includes (at a minimum), review and discussion of the following:
 Emergency safety situation that required restrictive intervention, including precipitating factors that
led up to the intervention.
 Alternative techniques that might have been used to prevent the use of the restrictive intervention
 Procedures, if any, that are to be implemented to prevent any recurrence of the use of the restrictive
intervention.
 Outcome of intervention, including any injuries that may have resulted from the use of the restrictive
intervention.
4. If a resident is injured during the restrictive intervention, medical attention will be sought immediately. The
administrator on-call will be notified of the injury and conduct and interview with the resident within one hour
of the intervention or as soon as possible pending treatment for the injury.
5. If staff suspects that the injury was due to a lack of following established training protocols, the staff member
will report this incident to the appropriate administrator (See reporting abuse and neglect policy and
procedure).
6. The documentation of Restrictive Interventions is detailed in the Critical Incident Reporting Policy.
Approved by Senior Management Team: 10/1/2014
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