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Title: Behavior Management and Use of Physical Interventions Policy Number:Approved By:Issuance Date: Division/Office:Contact Person(s):Number of Pages:Summary: This policy applies to foster children placed in congregate facilities, which include institutions, group residences, group homes, and agency-operated boarding homes certified by the New York State Office of Children and Family Services. This policy will serve as the agency restraint policy required by 18 NYCRR 441.17.AGENCY is committed to the implementation of strategies and practices that promote environments that are free of violence and coercion, and the utilization of skills that reduce the risk of harm to youth and staff. The use of physical interventions can lead to several negative outcomes. Among these are the risk of serious injury or death for the youth or staff involved; emotional harm and trauma to youth and staff; and the disruption of relationships between youth, peers, and staff. This policy requires the development of individualized crisis intervention plan (example: Individual Crisis Management Plans [ICMP]) for each youth and describes requirements for the use of proactive, non-physical interventions prior to the use of physical restraints. It specifies training requirements, safety precautions, and procedures that must be followed to the best of staff’s ability before and after any use of physical restraint, and the circumstances under which staff may use physical restraint on youth placed in a congregate setting with AGENCY.AGENCY does not tolerate behavior that results in any unnecessary, inappropriate, or excessive use of force.Supersedes: NAME PREVIOUS BEHAVIOR MANAGEMENT POLICYAttachments (List all additional documents): Supporting Regulations: 18 NYCRR 441.4 (a), 18 NYCRR 441.9 and 18 NYCRR 441.17Related Laws: ChildAbusePreventionAct of 1992; Protection of People with Special Needs Act (Laws of 2012, Ch. 501)Related Policies/Manuals: Related Forms: Local Operating Practice Required ? N/A ? AGENCY/ORGANIZATIONPolicy and Procedures ManualI. POLICYThe guiding principle behind the AGENCY Use of Physical Intervention Policy is that staff must be engaged and proactive in their interactions with youth. In order to reduce the likelihood that problems, conflicts, or behaviors will escalate to a level that requires physical intervention, staff must create and maintain appropriate and supportive relationships with the youth in their care. They must address maladaptive behaviors and crises in a proactive, non-physical manner by utilizing a continuum of interventions and strategies including those noted in the youth’s INDIVIDUALIZED CRISIS INTERVENTION PLAN. In the event the use of physical restraint is necessary and authorized by this policy and 18 NYCRR 441.17, staff must only use the amount of force necessary to stabilize the situation, after (where possible) attempting to use non-physical means to assist youth in managing their behavior and affect. AGENCY may not permit the use of physical force as a behavior management tool, but only as a means to contain acute physical behavior, which is behavior that clearly indicates the intent to inflict physical injury upon oneself or others or to otherwise jeopardize the safety of any person, and in accordance with the circumstances described below.The objectives of this policy are the following:Encourage staff to build strong relationships with youthMinimize the use of physical interventions (restraints)Eliminate the use of restraint outside of policy parametersMinimize the risk of serious injury or death from the use of physical interventionsReduce injuries and further trauma to youth and staff from the use of physical interventionsAuthorized Use of Physical RestraintAGENCY is committed to creating environments where youth are not subject to unnecessary or unauthorized restraint. AGENCY authorizes the use of physical restraint: to contain acute physical behavior, which clearly indicates the intent to inflict physical injury upon oneself or others, or otherwise jeopardizes the safety of any person. AGENCY staff must utilize the least amount of force necessary to maintain the safety of staff and youth, and that which poses the minimum risk of injury to youth. Physical restraint may only be employed for the minimum amount of time necessary to stabilize the youth or situation. Accordingly, all incidents involving the use of physical restraint must be reviewed. Staff may use physical restraint in the emergency circumstances noted above. Except where not possible, staff must attempt all other appropriate proactive, non-physical behavior management techniques.AGENCY staff must utilize a continuum of interventions in an effort to reduce the need for physical restraint. All designated staff must receive training in the use of proactive, non-physical interventions, de-escalation skills, conflict resolution skills, and physical restraint techniques authorized by AGENCY. AGENCY trains and authorizes the use of the following restraint techniques:B.ProhibitionsThe use of excessive or unauthorized force is strictly forbidden and will result in disciplinary and/or corrective action as determined by AGENCY.The use of physical restraint as punishment is prohibited.Any staff observing staff-on-youth abuse, maltreatment, or any other harmful practice must take steps to immediately stop the behavior and promptly notify the residential director or person in charge. As mandated by law, the staff must report suspected abuse or maltreatment to the Justice Center’s Vulnerable Persons Central Register (VPCR), in accordance with the Protection of People with Special Needs Act (Laws of 2012, Ch. 501), and adequately document the matter.The use of physical restraints to enforce compliance with rules or directives is strictly prohibited.II. DEFINITIONSCongregate Facility – Any institution, group residences, group homes, or agency operating boarding homes certified by the Office of Children and Family Services (OCFS)Debriefing – A formal process employed with youth and staff after the use of physical restraint, designed to assess the well-being of youth and staff, and to analyze the effectiveness of the interventions utilized in the youth’s INDIVIDUALIZED CRISIS INTERVENTION PLAN, including de-escalation techniques and physical restraint. Debriefing occurs at multiple levels and should include the youth, staff, and administration. (See Section III, J, Debriefing Process below.)Direct Care Staff – AGENCY staff who have routine contact with youth and are required to engage in direct supervision of youth. These staff are usually assigned to work in AGENCY residences and programsDirect Service Staff – AGENCY staff who have routine contact with youth, who may or may not be required to do direct supervision. Job titles include, but may not be limited to: Teacher, Recreation, Nurse, Clinician, Food Service Worker, etc.Documented Instruction (DI) – A process to teach and coach staff in the proper use of a physical and/or de-escalation technique, or the monitoring of a restraint incidentExcessive Force – Use of more force than is needed to stabilize the youth and/or situation or holding a youth in a physical restraint for more time than is necessary to stabilize the youth or situation701675-11747500Individualized Crisis Intervention Plan – A documented child specific plan for the use of preferred de-escalation strategies and interventions to address acute physical behavior and to reduce the risk of physical or psychological harm to the child. The plan must include physical restraint techniques that are tailored to a youth's individual needs and are developed by the youth and his/her treatment team. The plan is designed to help the youth from the earliest indications of distress and escalation in order to prevent a crisis from evolving, and also includes any limitations on physical restraint techniques authorized for the youth.Injury – Any physical damage to a person, including, but not limited to, scratches, abrasions, swelling, burns, fractures, results of toxic ingestion or toxic exposure, or internal damage regardless of cause and regardless of the extent or severity, as well as any complaint of such damage or pain by a youthIntervention – Verbal and physical de-escalation skills utilized prior to and throughout the course of a physical restraintMental Health Crisis – An acute disturbance of thinking, mood, behavior, or social relationships that requires an immediate intervention. Indicators of such a disturbance may include, but are not limited to suicidal threats, gestures or attempts; self-injurious or self-mutilating behavior; and behavioral or emotional manifestations of psychiatric disordersPhysical Restraint – The use of staff to hold a child in order to contain acute physical behaviorRestraint Monitor – A trained staff member assigned to respond and reduce the risk of harm to youth and staff during restraint situations. This includes observing the scene for dangerous environmental factors; observing the youth for signs of physical and emotional distress; and directing and coaching staff regarding the appropriate use of physical restraint.Self-Protection Skills – Any AGENCY technique that provides staff the ability to protect themselves from a physical attack by a youthSerious Injury – Includes any of the following injuries:DislocationLacerations requiring stitches, sealants, or other such procedures to close a woundConcussionFractured or broken bonesTorn ligaments, muscles, or tendonsInternal injuriesLoss of toothBroken or damaged toothPunctured eardrumAny hearing lossAny loss of visionAny loss of consciousnessBurnsAny injury to the face, head, or neck areaPoisoningToxic exposureAny other injury requiring treatment at a hospital, clinic, or other medical provider.Stabilized – For the purposes of this policy, a youth’s behavior has stabilized when their behavior(s) no longer pose a danger to the safety of the youth or others.Supportive Gestures – A technique taught by qualified instructors as part of the AGENCY continuum of interventions, which does not restrict movement and is employed to calm and/or de-escalate the youth. This may include a light touch on the hand, arm, shoulder or back. Unauthorized Restraint – Use of physical restraint under circumstances or for reasons not specified by this policy or authorized by OCFS regulationUnauthorized Technique – Any physical intervention not authorized by this policy Use of Force – Any physical contact initiated by a staff person that intentionally restricts the movement of a youth. This includes self-protection skills, protective holds, escorts, standing restraint, and prone/supine restraint.III.PROCEDUREA. Proactive Supervision of YouthAGENCY residences must create an environment that supports positive youth development. A safe environment supervised by caring and supportive staff is the foundation of positive youth development. Positive youth development focuses on a youth’s strengths to foster individual successes and the development of competencies that lead to youth becoming successful, contributing adults.The primary tools for staff in the prevention of crises are building positive, supportive relationships with youth and utilizing proactive, non-physical supervision of youth (Reference AGENCY Supervision of Youth Policy/Procedure). By using positioning (environmental awareness), restructuring, and other proactive supervision practices and techniques, staff must intervene and prevent potential crises from developing. All staff are expected to utilize proactive practices and techniques during interactions with youth. Staff reporting for duty are required to read logs, INDIVIDUALIZED CRISIS INTERVENTION PLANS, and reports relevant to current youth circumstances prior to working with youth. B.Continuum of Interventions1. Individualized Crisis Intervention Plan An Individualized crisis intervention plan must be developed within 72 hours of a child being placed in a congregate care program. The INDIVIDUALIZED CRISIS INTERVENTION PLAN must describe preferred de-escalation strategies and interventions that are identified as likely to work successfully for each youth. AGENCY places limitations on the use of restraints for youth at heightened risk of physical or psychological harm from restraints. Following admission, all youth are assessed by medical and mental health staff for physical and mental health needs that may require limitations on the use of physical restraints. Youth are also assessed throughout their stay when there is a change to their medical and/or mental health condition that may require limitations. Such assessments occur immediately, or as soon as practicable, upon notification of the change in medical or mental health condition that may require limitations, but no later than 24 hours upon change in their condition.? These assessments, along with information received from the youth and his/her family during intake interviews, are combined to form the initial INDIVIDUALIZED CRISIS INTERVENTION PLAN for the youth. Each plan must contain the following components:Alerts about the youth, to provide information on potential responses of the youth to stressors and to staff interventions.Background about the youth, to provide staff a framework to understand the current functioning of the youth and give indications of potential youth responses to stressors and staff interventions.Recommendations from mental health staff regarding strategies for intervention, which given the youth’s history and current presentation are most likely to prove effective in stressful situations.Physical restraint modifications and/or restrictions. NOTE: Modifications to an approved restraint technique to meet the specific needs of a youth must be reviewed and approved by the OCFS regional office, as defined in current practice and 18 NYCRR 441.17.Information regarding each youth’s INDIVIDUALIZED CRISIS INTERVENTION PLAN must be readily available to all staff. Each living unit must maintain a binder of up to date INDIVIDUALIZED CRISIS INTERVENTION PLANS for each youth assigned to that living unit. Each program area (school, food service, recreation) must maintain a binder of up to date INDIVIDUALIZED CRISIS INTERVENTION PLANS for each youth assigned to the residence. Staff working in these areas are required to familiarize themselves with these plans, refer to them when needed, and utilize the preferred interventions when feasible. Changes and modifications made to a youth’s INDIVIDUALIZED CRISIS INTERVENTION PLAN should be reviewed during pre-shift briefings and/or acknowledged by staff by signing for said review in unit/facility/agency log.Each facility/agency must maintain a master listing of all youth who have limitations on the use of physical interventions. This list must be distributed to all program areas. The list must contain the name of the youth and the specific limitation(s) on the use of physical interventions.The efficacy of the plans must be reviewed by the youth’s treatment team as soon as practical after each use of restraint and at each treatment team meeting. The treatment team, in conjunction with medical staff, the youth, and his/her family, must modify the plan as needed. 2. De-EscalationThere will be instances when proactive supervision alone does not prevent a crisis situation from developing. When this occurs, the appropriate use of de-escalation techniques, as guided by, but not limited to, a youth’s INDIVIDUALIZED CRISIS INTERVENTION PLAN may reduce the likelihood of the situation becoming dangerous for youth and staff. AGENCY staff must be trained to utilize intervention strategies that contribute to effective communication, successful problem solving and conflict resolution, prevention of power struggles, and proactive prevention and management of crises through behavioral de-escalation strategies and trauma informed interventions.Qualified AGENCY mental health professionals should be consulted and respond to assist with the de-escalation of potential mental health crisis situations if necessary.Whenever possible, nonverbal and verbal de-escalation skills must be utilized prior to and throughout the course of a physical restraint unless otherwise indicated in the youth’s INDIVIDUALIZED CRISIS INTERVENTION PLAN. Whenever practical, staff must give the youth the opportunity to self-regulate their behavior prior to utilizing physical intervention strategies.3. Continuum of Physical InterventionsAGENCY authorizes the use of a continuum of physical interventions ranging from least restrictive and least likely to cause harm to more restrictive physical restraint techniques (e.g., supine restraints). If the use of physical intervention is authorized per this policy, staff must use techniques appropriate to the level of risk presented by the youth and consistent with the youth’s INDIVIDUALIZED CRISIS INTERVENTION PLAN, using the least amount of force necessary to stabilize the youth or situation. C. Circumstances When Physical Restraint May Be UsedThe use of physical restraint is limited to circumstances where all AGENCY approved proactive, non-physical behavior management techniques have been tried and failed and a youth poses a danger to him/herself or others, or unless the circumstances of the incident render the use of non-physical behavioral management techniques impractical due to the imminent danger of serious injury. Accordingly, restraints may only be used in the following circumstances:1. Where the behavior clearly indicates the intent to inflict physical injury upon oneself or others or otherwise jeopardizes the safety of any person. This circumstance may be apparent when a youth is aggressive or assaultive toward others or is engaging in self-injurious behavior. However, physical intervention may also be necessary in situations where youth are not being overtly physically aggressive. Examples include, but are not limited to, the following:Youth’s actions are likely to cause or are causing the escalation of other youth, which is likely to jeopardize the safety of any person.Youth is inciting other youth verbally or by action to hurt self or others.Where a youth is physically attempting to AWOL the boundary of a residence AND the potential AWOL clearly indicates the intent to inflict physical injury to the child or others or to otherwise jeopardize the safety of any person.D. Actions to Be Taken When Faced With the Possible Need to Use PhysicalRestraint1.Staff must demonstrate emotional control via voice volume, pitch and tone, facial expressions, and gestures regardless of the physical or emotional state of the youth. Staff must preserve the youth’s personal space while conducting de-escalation techniques, provided the youth is maintaining safe behavior.2.While maintaining safety and responding to youth behavior, staff must be patient and must consider and employ alternatives to physical intervention. 3.Staff must use proactive, non-physical behavior management techniques, and the preferred interventions provided in the youth’s INDIVIDUALIZED CRISIS INTERVENTION PLAN to resolve conflicts and crises, unless the circumstances of the incident render their use impractical due to the imminent danger of serious injury.4.Staff are authorized to utilize self-protection skills in response to physical attacks by youth. 5.Staff must stop at the lowest level of intervention and use only the minimum amount of time in restraint necessary to stabilize the youth or situation and must reduce the level of intervention used as the youth and situation stabilize. Whenever practical, staff must give the youth the opportunity to self-regulate behavior prior to utilizing a greater degree of intervention.6.Staff must neither use physical restraint to compel a youth’s compliance with receiving medication nor may staff utilize physical restraint to compel a youth to comply with medication refusal protocols.7.When there is the potential for the use of physical restraint, staff must immediately call for assistance utilizing response procedures as required in AGENCY POLICY (Emergency Response Codes and Protocols). Staff must work to avoid the use of physical restraint until assistance arrives unless the circumstances of the incident require immediate response due to the imminent danger of serious injury.8.Staff must not enter a youth’s room to confront negative behavior except to prevent a youth from physically harming him/herself or another person. Staff is still required to take all appropriate actions as indicated on youth’s INDIVIDUALIZED CRISIS INTERVENTION PLAN and utilize emergency response procedures if needed. 9. If a youth is unclothed at any time during de-escalation or physical restraint, a staff of the same gender as the youth will be involved in the de-escalation and/or restraint, if feasible. Reasonable efforts must be made to safely cover the youth.10. Staff must be aware of the physical environment when addressing a youth’s behavior and be cognizant of impediments that may exist (e.g., furniture placement, walls, other youth).11.Staff must only utilize physical restraint techniques as taught in AGENCY training and consistent with the agency’s OCFS approved restraint policy.12. During off grounds programing, physical restraint may be used in a community setting if a youth meets any of the criteria outlined in Section III.C. Staff must be mindful of the circumstances and environment, and balance the safety needs of the community, the youth, and themselves.E.Safety Precautions1. Only staff who have successfully completed and are up to date in their training on the use of physical restraints are authorized to conduct physical restraints.2. Staff must be mindful of staff/youth size differentials when utilizing physical restraint.3. Whenever a youth complains of pain, staff must adjust their position to immediately remove pressure from the area of complaint.4. Medical emergencies as noted below always override the physical restraint and require staff to call for medical assistance.Throughout the use of physical restraint, staff must continually monitor whether a youth is breathing, is responsive, and can speak. Whenever a youth shows signs of difficulty in breathing, the restraint must stop.If breathing is absent or if staff are unsure, if a youth appears to have lost consciousness, or if signs of any other health emergencies are evident, staff must immediately stop the restraint. Staff must immediately contact medical professionals and initiate CPR if necessary.Whenever a youth vomits, staff must release the youth from the restraint and either sit the youth up or help the youth to his/her side.Whenever a youth becomes incontinent, staff must look for an indication of medical emergency, such as loss of consciousness. If present, staff must release the youth from the restraint.If a youth appears to be experiencing an active mental health crisis (e.g., actively psychotic or dissociated) during a restraint, physical safety remains the first consideration in continuing the restraint.Staff must call for a mental health consultation. Staff must release the youth from the restraint when the youth no longer poses an imminent danger to himself/herself or others and offer self-regulation skills and coaching to help the youth calm down.F.Role of the Restraint Monitor1. The restraint monitor can be any staff member trained to conduct restraints. Whenever practical, a restraint monitor should respond to situations with the potential need for use of physical restraints prior to them becoming a restraint situation. A restraint monitor must not be involved in the restraint, except as noted in paragraphs 4 and 5 below. A restraint monitor cannot monitor more than one restraint simultaneously. 2. When observing a restraint in progress, the restraint monitor must survey the scene for environmental factors (e.g., furniture and potential weapons) that may be dangerous, observe the youth for signs of physical and emotional distress, and direct and coach staff regarding the appropriate use of physical restraints, including the utilization of the youth’s INDIVIDUALIZED CRISIS INTERVENTION PLAN. Signs of physical and emotional distress may include, but are not limited to the following:Difficulty breathingYouth’s claim of difficulty breathingYouth’s complaint of painLack of or altered responsivenessVomitingIncontinenceInability to speakLoss of or altered consciousnessVerbalizations that are disconnected with the events of the restraint situation3.During incidents involving restraints, the highest ranking, most senior staff present must designate (or become) a restraint monitor for said restraint. In the event that a physical restraint occurs and all staff present are involved in the restraint(s), the staff in the primary position (controlling the youth’s arms/upper body) is responsible for monitoring the youth for signs of distress until a restraint monitor is present (or for the duration of the incident, if necessary).4. If the restraint monitor observes that the restraint is not safe for the staff or the youth, and there are no other trained staff on the scene who can assist, and the restraint monitor can’t correct or address the situation from an observer’s perspective, the restraint monitor must physically intervene to assist with the restraint.5.The restraint monitor is authorized to direct all activities related to a potential or actual physical restraint incident. Staff must comply with all instructions from the restraint monitor.6.The restraint monitor, including a primary staff acting as restraint monitor, must observe and evaluate the effectiveness of the interventions utilized and report such observations in writing AGENCY RESTRAINT MONITORING REPORT. 7.If the restraint monitor observes staff-on-youth abuse or maltreatment or other harmful practice, they must take steps to immediately stop the behavior and notify the residential director or person in charge. As required, the restraint monitor must report suspected abuse or maltreatment to the Justice Center’s Vulnerable Persons Central Register (VPCR), in accordance with the Protection of People with Special Needs Act (Laws of 2012, Ch. 501), and adequately document the matter.G.Post-Physical Restraint Medical Response1. First Aid, if required, must be administered immediately by trained staff following an incident of physical restraint. If a youth, staff member or visitor appears or claims to be injured, medical assistance must be obtained.2.If it appears that a youth may have sustained an injury immediately prior or during the use of restraint, the child must be examined by a physician or nurse immediately following the period of restraint. Youth must be seen immediately following an incident of physical restraint by medical staff in these circumstances:The youth requests medical attention.The youth complains of injury or pain.The youth is visibly injured.The youth claims difficulty breathing.The youth demonstrates lack of or altered responsiveness.The youth vomits.The youth displays incontinence.The youth demonstrates an inability to speak.The youth indicates that the youth lost consciousness or was observed by staff to have lost or had altered consciousness during the restraint.Activity such as head banging, colliding with furniture, falling or other potentially injurious behavior occurs before, during, or after the restraint.The youth exhibits behavior suggesting the need for a mental health evaluation and/or treatment. This may include, but is not limited to, the report or observation by others of emotional or behavioral distress; disorientation to person, place, time, or situation; incoherence; demonstration of bizarre behavior; continued mood or behavioral dysregulation.3.When medical attention is indicated, the residential director/person in charge must, without delay, arrange for medical examination by a licensed medical professional, which may include community providers if no health staff is on duty.4.All youth in an institution licensed by OCFS must receive a post-physical restraint health review.In a residence with health staff on duty, the youth must receive a post-restraint health review by the responsible health professional within one hour of the conclusion of the restraint, unless extenuating circumstances prevent assessment within one hour. Such circumstances must be documented in the restraint packet.When no facility health staff is on duty, the health staff must see the youth as soon as practicable during the first tour of duty upon the health staff’s return.The post-physical restraint health review must occur in the medical clinic area. The clinic is equipped to conduct a thorough health assessment and designed to allow for confidential/private interviews. The health staff on duty may attend to injuries on the unit and may observe a youth who refuses to go to the clinic on the unit for obvious injuries, but that will not be considered the post-physical restraint health review. If a youth refuses post-restraint health review, the youth and staff must complete a medical refusal form5.The staff accompanying the youth for medical review or treatment must not be a staff who was involved in the physical restraint incident. Witnesses to the incident may not be used to accompany the youth unless no other uninvolved staff is available.6.The accompanying staff must afford medical staff privacy during this encounter and remain outside of the examination area and out of earshot so that a confidential/private interview may occur.7.When facility/agency health staff is not present to examine the youth following the use of physical restraint, the residential director or person in charge must observe the youth for injuries within one hour of the incident. The youth must be asked the following questions:Do you have any injuries or pain?How did you receive this injury?The youth’s answers and the reason for the residential director or person in charge conducting the inquiry must be documented on AGENCY FORM.8.When conducting a post-physical restraint medical review, facility/agency health staff must, outside the hearing of other staff or youth, ask the following questions of the youth and record his/her responses on AGENCY POST RESTRAINT MEDICAL EXAMINATION FORM:What happened?Do you have any injuries or pain?How did you get this injury? (Concentrate on the actual cause of the injury, not simply the restraint.)If health staff observes an injury that is not reported by the youth, health staff must inquire as to the source of the injury.9. If health staff observes injuries that appear to be inconsistent with the report of the incident, if the use of physical restraint appears to have been unauthorized, or if a youth alleges inappropriate staff conduct, the health staff must immediately take all appropriate steps to document evidence, including: take photographs (see section H “Photographs”) of the injury, notify the residential director or person in charge and adequately document the matter in the youth's medical record, report the matter to the Justice Center’s Vulnerable Persons Central Register (VPCR), in accordance with the Protection of People with Special Needs Act (Laws of 2012, Ch. 501).H.PhotographsPhotographs must be taken of any youth who was physically restrained to document youth injuries, or lack thereof, and to visually identify the youth.Photographs must be taken of each youth involved in a use of physical restraint incident during the post-physical restraint health review, regardless of whether the youth has or claims any injuries.Photographs must be taken by medical staff when they are on duty. Photographs must be taken with a digital camera in order to facilitate production of duplicates.In all instances, two full body photos (one front and one back), fully clothed, must be taken that clearly identify the youth.Where there are injuries or reports of injuries, two photographs must be taken of each view of a youth’s injury or purported injury.All photographs must clearly depict the actual injuries or purported injury sites and should include an object that provides a perspective for the scale/size of the injury.Two copies of each photograph must be printed, and each photograph must be labeled with the following information:The name of the youth photographedThe date, time, and location of the photographsThe date and time of the incidentThe name, title, and signature of person taking the photographsThe signature of the youth photographedOne full set of photographs must be attached to AGENCY POST RESTRAINT MEDICAL EXAMINATION FORM to be included in the physical restraint packet, and the second set filed in the youth’s medical record.If a youth refuses to be photographed, such refusal must be documented on AGENCY MEDICAL REFUSAL FORM.I.Notification and DocumentationEach use of physical restraint must be reported to the residential director or person in charge immediately after the situation is under control. If the incident results in a reportable incident, a record of this reporting must be documented on AGENCY FORM.The initial report to the residential director or person in charge may be an oral report, followed by a written report on AGENCY FORM. Each staff involved in or witnessing the incident must complete a written report on AGENCY FORM as soon as practical following the incident, but prior to the end of his or her shift. This report must be completed independently, without collaborating with other staff.Information required on AGENCY FORM, includes, but is not limited to, the following:Precipitating factors and youth’s behavior prior to the restraintThe de-escalation techniques employed and the youth’s responseIf, when, and what type of assistance was requested The justification for the use of physical restraintType(s) of physical restraint usedWhether exigent circumstances were present. If exigent circumstances were present, they must be specifically described. Who responded to the scene?The identity of staff and youth witnessesThe youth’s behavior during the restraint, and reaction(s) to the restraintAny injuries and/or complaints of injuries by youthAny injuries and/or complaints of injuries by staff or visitorsAny observations of the youth’s well-beingThe restraint monitor must complete form AGENCY RESTRAINT MONITOR REPORT and submit it for inclusion with the completed restraint documentation packet. Only one AGENCY RESTRAINT MONITOR REPORT must be completed for each restraint incident. If more than one staff member functions in the role of restraint monitor for a restraint, AGENCY RESTRAINT MONITOR REPORT must be completed jointly by the staff, and it must indicate the time period each staff was the restraint monitor. If no restraint monitor is present for the entire duration of a restraint, the administrator doing the post-restraint review must note the reason on AGENCY ADMINISTRATIVE REVIEW FORM. The staff involved in the restraint that monitored the youth for signs of distress must document that on his/her activity report (AGENCY FORM) and must complete appropriate sections of AGENCY RESTRAINT MONITOR FORM. Any incident of suspected child abuse or maltreatment must be reported to the Justice Center’s Vulnerable Persons Central Register (VPCR), in accordance with the Protection of People with Special Needs Act (Laws of 2012, Ch. 501; SSL §491).When there is an allegation of staff misconduct, the residential director or person in charge must preserve any physical evidence in accordance with procedures for preservation of evidence noted in AGENCY POLICY.Where surveillance video exists of the area in which the physical restraint incident and/or the incident leading up to the use of physical restraint occurred, the residential director or designee must download and preserve the recorded events as evidence.Any incident involving the use of physical restraint must be recorded in the Physical Restraint Log. Entries must include only the following: Date of incidentTime of incidentName of youthJustification for use of physical restraintType of physical restraint usedName of primary staffName of secondary staffYouth injured: Y/NStaff injured: Y/NVPCR notified: Y/NName of restraint monitorNotification must be made to the youth’s parent, legal guardian, or other person legally responsible; the youth’s attorney for the child; and the agency with legal custody of the child, if different, regarding the use of physical restraint, information on any injuries sustained, and any contacts with the VPCR; and this notification shall be documented on the AGENCY ADMINISTRATIVE REVIEW FORM.A completed restraint packet (photographs, AGENCY FORMS X, Y, and Z) must be filed in the youth’s case record and a copy maintained in a separate facility file in chronological order. The restraint packet must contain, at a minimum:Administrative Review Form Video Review Form Post-Physical Restraint Health Report All incident-related Activity Reports Restraint Monitor Report Staff Debriefing A copy of the youth’s most recent Individualized Crisis Intervention Plan A copy of the video footage of the event (where cameras are installed)The separately filed restraint packet must be preserved as required by AGENCY policy.On at least a weekly basis, the residential director or designee must report to OCFS and provide an accurate and complete account of incidents involving the use of physical restraint by entering data into the Automated Restraint Tracking System (ARTS).J.Debriefing ProcessDebriefing after the use of physical restraint is an essential tool to learn about the well-being of youth and staff, to determine what caused the event, to become aware of critical events that may upset the youth, to evaluate the effectiveness of interventions utilized, and to proactively mitigate future events. Debriefing is an integral part of a program’s efforts to reduce or eliminate the use of restraints.Each facility must conduct a series of debriefings as soon as practical after each use of physical restraint.1.Youth debriefing includes an interview of the youth, which is conducted by an uninvolved staff member, UNIT MANAGER OR HIGHER (see also Administrative Review). This interview/debriefing is documented on AGENCY DEBRIEFING FORM. The purpose of this debriefing is the following:Identify if the youth had any injuries resulting from the restraint.Identify precipitating factors that may be internal or external to the youth, which contributed to the emotional and behavioral escalation that led to physical intervention.Explore alternate, pro-social behaviors/skills that could have reduced/eliminated the need for staff to utilize the restraint.Explore the manner in which the youth was restrained, the staff involved, and any/all witnesses present.2.The staff debriefing process must be conducted by a trained administrator as soon as practical after the event. The purpose of this debriefing is the following:Assess staff members’ immediate needs (physical and mental well-being).Assess the need for emotional support and treatment for trauma for involved youth, staff, and witnesses as necessary (e.g., mental health referral for youth, health referral for staff).Discuss the efficacy of staff responses to the incident and the youth’sINDIVIDUALIZED CRISIS INTERVENTION PLAN.Identify steps needed to return to pre-crisis stability (e.g., physical plant remediation, conducting group meetings, and counseling individual youth).Facilitate communication between key staff involved in the incident, support staff and administration as applicable.Discuss and identify any need for further resolution between staff and youth or between youth and youth.The administrator conducting the debriefing review is responsible to complete form AGENCY STAFF DEBRIEFING FORM. This form must be included in the restraint documentation packet.3.As soon as practical, the youth’s treatment team, in conjunction with the youth, must debrief the incident to determine the need to modify or to review modifications made to the youth’s INDIVIDUALIZED CRISIS INTERVENTION PLAN.4.Each facility/agency’s multidisciplinary RISK REDUCTION COMMITTEE must conduct monthly reviews of physical restraint incidents. The committee must examine systemic factors that may have had an impact on the incidents, such as agency policy, facility procedures and practices, environmental issues, treatment approaches, and staff education and training. Minutes must serve to document these meetings.K.Administrative ReviewThe administrative review after each use of physical restraint is a two-part process consisting of a review by an assigned administrator (UNIT MANAGER OR ABOVE) and a review by the residential director, or designee. NOTE: If the residential director was physically involved in the restraint, the review must be conducted by an AGENCY EXECUTIVE OR DESIGNEE.1. Assigned Administrator Reviewa.As soon as possible, but no later than 24 hours from the conclusion of the incident involving the use of physical restraint, an administrative review must be conducted by a facility administrator (UNIT MANAGER OR ABOVE). The administrator conducting the review must not have been involved in the incident. An administrator involved solely as a witness may conduct the administrative review if no other administrator is available. Subordinates must not conduct administrative reviews of incidents involving supervisors.b.The assigned facility administrator must do the following:Review the following reports for completeness, as applicable to the situation:AGENCY Activity - Incident ReportAGENCY Post-Restraint Medical Report, photographs, and other medical reports, if applicableAGENCY Staff Debriefing ReportAGENCY Restraint Monitor ReportVideo evidence when presentDebrief/Interview the youth involved in the physical restraint incident and record the youth’s responses on the AGENCY ADMINISTRATIVE REVIEW FORM.Inquire about injuries and purported injuries and compare youth’s response to information documented on the AGENCY POST RESTRAINT MEDICAL REPORT.Complete their section of the AGENCY ADMINISTRATIVE REVIEW FORM and make a written recommendation to the residential director (or designee) on whether further action is recommended. Recommendations may include, but are not limited to, the following areas:Further investigation of incidentEnhanced supervision of staffDocumented instructionDisciplinary action for staff or youthConflict resolution for staff and youthStaff training2.Residential Director ReviewNOTE: In cases where the residential director was physically involved in a restraint incident, all steps below shall be done by AGENCY EXECUTIVE OR DESIGNEE.a.As soon as practical, but no more than two business days after the incident, the residential director or designee (designee must be higher than a UNIT MANAGER) must review the AGENCY ADMINISTRATIVE REVIEW FORM, all supporting documentation, the recommendation of the administrator who conducted the review, and available video recordings. b.The residential director or designee must preserve all recorded video coverage of the physical restraint incident including, if possible, the actions leading up to the use of physical restraint. All video footage from every camera with a recording of the incident must be copied onto a secure digital format. The digital version must be titled with the date, time, and name of the youth involved. The digital version must be filed with the agency’s copy of the completed restraint packet. Copies of completed restraint packets must be retained at the residence in files in chronological order. When saving the incident, consider the following:Is there sufficient video of events leading up to the incident being reviewed?Does the video provided show that the incident has concluded?If there is more than one camera with a view of the incident, have multiple views been preserved?c. The residential director/designee must review the recorded events for consistency with the reported version(s) of the incident and evaluate the staff’s competency in the use of physical restraint techniques. The residential director or designee must initiate any further necessary action, as warranted. Circumstances (e.g., allegations of abuse or maltreatment, hospitalization of youth or staff due to injuries, law enforcement involvement) may require an immediate review.d. If the use of restraint is unauthorized as defined in this policy or OCFS regulation, or if untrained techniques were used, follow-up action is required (i.e., Documented Instruction, safety plan, disciplinary action) and must be documented. Consideration should be given to whether there were exigent circumstances. Consideration shall also be given to whether the staff used reasonable efforts to apply an approved technique but was not successful in doing so. e.The residential director or designee must confirm that all allegations of abuse or neglect or significant incidents have been reported to the Justice Center’s Vulnerable Persons Central Register (VPCR), in accordance with the law.f.After an allegation of staff misconduct is made or an incident has occurred, the residential director or designee must promptly make a determination regarding the appropriate level of contact between the employee and the youth, in light of the nature of the allegation and a preliminary assessment of the credibility of the allegation. The determination must be consistent with the safety needs of all youth and may not be based on staff shortages.g.Each residence is responsible for tracking employees who have limited or no contact with youth, so that safety plans are followed.k.In cases where staff exhibit deficiencies in technique (de-escalation skills, physical technique, or restraint monitoring), the residential director shall refer the staff member for documented instruction (DI), using the form AGENCY DOCUMENTED INSTRUCTION FORM. DI is not a disciplinary procedure, and it is not employee counseling. The DI is meant to be instructive, and it is not to be considered as punitive or disciplinary action.Staff who exhibit deficiencies in physical skills techniques shall be prohibited from using physical restraint until they receive the instruction on the proper techniques. (Staff who exhibit deficiencies in de-escalation or monitoring techniques are not prohibited from using physical restraint.)The DI must be provided by a certified trainer to address the observed technique deficiency(ies). If a certified trainer is not available, DI may be provided by a MANAGER (must be current in training requirements) to provide for staff returning to coverage. However, the DI must be reviewed and ultimately approved, and documented by a certified trainer during the trainers next tour of duty. 3.RISK MANAGEMENT/QI REVIEWSa.Designated AGENCY TEAM MEMBERS must review A SAMPLE of incidents that involve the use of physical restraint and the corresponding video, during REGULARLY SCHEDULED MEETINGS.b.This review must be documented on the AGENCY RISK MANAGEMENT FORM and must include recommendations for further action(s) if applicable.c.AGENCY TEAM MEMBERS must also review data from ARTS to improve supervision and training of staff, guide staff discipline, and make policy or programmatic changes. IV.Training RequirementsA.Qualified Instructors and Field TrainersAll AGENCY APPROVED RESTRAINT TECHNIQUE training and refreshers must be taught by instructors or field trainers qualified through the AGENCY. Each instructor and field trainer must be re-qualified as the models prescribe, and training files must be maintained for every staff member in a central location for ease of review.B. Restraint Monitor TrainingAll staff who are required to take AGENCY APPROVED RESTRAINT TECHNIQUE training (except agency nursing staff) are required to satisfactorily complete the Restraint Monitor training course.C.Training1.All staff involved in the use of restraint are required to complete the initial AGENCY APPROVED RESTRAINT trainings. All staff involved in the use of restraint must complete restraint training prior to the use of restraint, except as otherwise authorized by OCFS regulations. All staff are also required to complete refresher trainings every six months thereafter, in the same content areas as dictated by the curriculum. Each refresher must consist of de-escalation skills and physical restraint techniques.2.In order for staff to achieve satisfactory completion, they must be able to demonstrate competency in all portions of the training required for their job title. Staff that have not satisfactorily completed required trainings are not authorized to engage in physical restraints.D.Failure to Pass and/or Attend Training1.Any staff that does not attend training or does not demonstrate competency in all portions of the training required for their job title must be marked incomplete on the Training Roster. The trainer must make specific comments in the Instructor Remarks section of the Training Roster indicating the specific de-escalation skills, self-protection skills, and/or physical restraint techniques that were not satisfactorily performed. Employees who have not satisfactorily completed training must not be authorized to use physical restraint. 2.Failure to attend training as assigned may result in disciplinary action.3.Each AGENCY is responsible for tracking the training status of its employees and to comply with the restrictions and provisions of this section.E.Remedial Instruction and Training1.Ongoing opportunities exist (direct observation, Restraint Monitor reports, mandatory camera reviews, and post-restraint administrative reviews) for supervisors to evaluate staff competency in the use of de-escalation skills and physical restraint techniques. Training, coaching, and supervision, as appropriate, must be utilized to address deficiencies.2.During TCI and CPM training, staff must be evaluated by qualified trainers to determine competency in the use of de-escalation and physical restraint techniques. Staff that demonstrate deficiency or lack of competency must receive remedial training to assist them in meeting the standards of competency.

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