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Seclusion & Restraint Crosswalk - constraint vs restraint army



|Seclusion & Restraint Crosswalk |
|DMHMRSAS Human Rights ∈ |HCFA Hospital ∉ |HCFA Res Tx ∠ |HCFA LTC ∇ |HCFA ICF-MR ® |JCAHO © |PL 016-310 ™ |
|B1 May not use S/R as punishment, reprisal|Sec. 482.13(e)(1) |Sec. 483.356(a)(1) |Sec.483.10: Client | |TX.7.1.4, TX.7.1.4.1 & | |
|or for staff convenience |Sec. 482.13(f)(1) | |behavior & Facility | |Intent of | |
| | | |Practices (b)(3) | |TX.7.1.4-TX.7.1.4.1 | |
|B2 Authorization for behavioral restraint |Sec. 482.13(f)(3)(ii)(D) |Sec. 483.358(e)(2) |Sec. 483.10(d)(2)(i) |Sec.483.450(d)(2)(i) |TX.7.1.7 | |
|limited to 4 hrs for adults; 2 hours for | | |Maximum is 12 hours |Maximum is 12 hours | | |
|children 9-17 and 1 hour for children | | | | | | |
|under 9 | | | | | | |
|B3 Monitoring of S&R required by |Sec. 482.13(f)(4)(i) |Sec.483.356(a)(4) Prohibits | | |Intent of TX.7.11 |Sec.595 - Limits - Required for use|
|continuous face-to-face observation, not | |simultaneous use of S&R & Sec.| | | |of seclusion in non-medical |
|by electronic surveillance device | |483.364 Prohibits use of any | | | |community-based facilities for |
| | |electronic surveillance | | | |children & adol. |
|B4 S/R only implemented, monitored, & |Sec. 482.13(e)(5) |Sec. 483.376(a-f) | Sec.483.10(d) |Sec.483.430(e)(3) |TX.7.1.2A-D |Sec.593 (b)(2)) and |
|discontinued by trained staff |Sec. 482.13(f)(6) | |(4) |Sec.483.450(d)(4) | |Sec.595(1)(a)(B) |
|B5a Justification documented in individual|Sec. 482.13(e)(3)(iii) |Sec.483.358(h) |Sec.483.10(b) |Sec.483.450(b)(4) |TX.7.1.14 & Intent of |Sec.591 - In General- (a)(2) |
|services plan |Sec. 482.13(f)(3)(iii) | |(4) Systematic use of |Systematic use of |TX.7.1.14 |Duration & rationale must be part |
| | | |restraint must be |restraint must be | |of order |
| | | |incorporated into |incorporated into client’s| | |
| | | |client’s treatment plan|treatment plan | | |
|B5b Must include behavioral criteria for |Interpretive Guidelines- | | | |TX.7.1.12 & intent of | |
|release |Sec. 482.13(e)(3)(B) | | | |TX.7.1.12 | |
| |(iii)3 - | | | | | |
| |medical/protective & | | | | | |
| |behavioral restraints | | | | | |
|B5c Time-limited. PRN orders for S/R |Sec. 482.13(e)(3)(ii)(A) |Sec.483.356(a)(2) |Sec.483.10(d)(3) |Sec.483.450(d)(3) |TX.7.1.7 | |
|prohibited |Sec. 482.13(f)(3)(ii)(A) |Sec.483.358(e)(2) | | | | |
|B5d Authorizing professional must |Interpretive Guidelines- |Sec.483.356(a)(4) | | |TX.7.1.14 & Intent of | |
|documented consideration of risk factors |Sec.482.13(e); | | | |TX.7.1.14 | |
| |Sec.482.13(f)(3(ii)(D)(iv)| | | | | |
|B6 Qualified professional regularly |Sec. 482.13(e)(5) |Sec.483.362(a) | | |TX.7.1.10 | |
|reviews every use of S/R |Sec. 482.13(f)(5) | | | | | |
|B6 Individual released when criteria for | | | | |TX.7.1.12 | |
|removal met | | | | | | |
|B7 May not use S/R solely because criminal| | | | | Intent of | |
|or delinquency charges pending | | | | |TX.7.1.4-TX.7.1.4.1 | |
| | | | | |addresses history of | |
| | | | | |dangerous behavior | |
|B8 Providers must develop written P&P that| |Sec.483.356(a) |Sec.483.10-Client |Sec.483.450 (b)(1) |TX.7.1.16 & Intent of | |
|comply with state & federal standards | |Sec.483.356(c) |Behavior & Facility | |TX.7.1.16 | |
| | | |Practices (b)(1) | | | |
|B8a Must submit proposed S/R P&P to LHRC | | | |Sec 483.440(f)(3)(iii) | | |
|for review | | | |Requires review by a | | |
| | | | |“specially constituted | | |
| | | | |committee” | | |
|B8b Individuals in S/R are given |Sec.482.13(f)(5)3 | |Sec.483.10 (d)(6) |Sec.483.450(d)(6) |TX.7.1.10 & Intent of | |
|opportunity for motion, exercise, normal | | | | |TX.7.1.10 | |
|meals, fluids, use of restroom & baths, as| | | | | | |
|needed | | | | | | |
|B8c Continuously monitor medical and |Sec. 482.13(e)4 |Sec.483.362(a) |Requires 30 minute |Requires 30 minute checks |TX.7.1.11 & Intent of |Sec.595 - Limits - Required for use|
|mental condition of each individual in S/R|Sec.482.13(f)(5) | |checks | |TX.7.1.11 |of seclusion in non-medical |
| | | | | | |community-based facilities for |
| | | | | | |children & adolescents |
|B8d S/R will end when release criteria are|Does not refer to criteria|Does not address criteria but | | |TX.7.1.12 | |
|met |but “released at the |released when “emergency | | | | |
| |earliest possible time” |safety situation has ceased | | | | |
| | |and the resident’s safety and | | | | |
| | |the safety of others can be | | | | |
| | |ensured, even if the restraint| | | | |
| | |or seclusion order has not | | | | |
| | |expired.” | | | | |
|B8e Rationale, type & duration of each | | | | |TX.7.1.15 requires data on|Sec.595(A)(2) |
|restrain incident will be reported to | | | | |type, rationale, and | |
|DMHMRSAS | | | | |duration of ea. episode | |
|B10 S/R may be used only after other less |Interpretive Guidelines- | |Sec.483.10(b)(1) |Sec.483.450(b)(1)(iii) |Intent of TX.7.1.4 - |Sec.595(1)(a)(A) |
|restrictive techniques have been |Sec.482.13(e)(2); | |(3) | |TX.7.1.4.1 | |
|considered and documented in service plan |Sec.482.13(f)(3)(i) | | | |Intent of TX.7.1.14 | |
|B11 Seclusion is allowed only in inpatient| | | |Sec.483.450 Specifies | | |
|hospital settings | | | |conditions under which | | |
| | | | |client may be placed in | | |
| | | | |room where egress is | | |
| | | | |prevented. | | |
|B12 Must comply with highest standard of | | | | | | |
|state & federal laws & regulations & 3rd | | | | | | |
|party payor requirements, | | | | | | |
|B13 Notify DMHMRSAS of non-compliance with| | | | | | |
|regulatory/accreditation body or 3rd party| | | | | | |
|payor requirements | | | | | | |
|B14 Time-out is limited to 30 minutes per | | | | |Standards do not apply if | |
|episode | | | | |time out is used for 30 | |
| | | | | |minutes or less | |
|B15 Only ICF-MR certified facilities may | |Definition of time-out | |Sec.483.450(c) Time-out | |Sec.591 & 595- Definition of |
|use isolated time-out and only in | |consistent with HR reg | |rooms | |Time-Out - may only be used as part|
|compliance with those regulations | |definitions and do not include| | | |of approved program |
| | |“isolated time-out” provision | | | | |
|C1 May impose Seclusion & behavioral |Sec.482.13(f)(2) |Sec.483.356(3)(i) | |Sec. 483.450(c)(1)(i) May |Introduction to the |Sec.591 (a)(2) Sec.595(2)(A) |
|Restraint only in emergency | | | |not use time-out in an |Behavioral Health Care R/S|Sec.595(3)(B) - Mechanical |
| | | | |emergency |Standards |restraint prohibited in non-medical|
| | | | | | |community-based facilities for |
| | | | | | |children and adol |
|C1a Must first exhaust less restrictive |Sec.482.13(f)(3)(i) | | |Sec.480.450(1)(ii) and |TX.7.1.4, TX.7.1.4.1 & | |
|measures or | | | |(iii) |Intent of | |
| | | | | |TX.7.1.4-TX.7.1.4.1 | |
|C1b Emergency so sudden that less | | | | |TX.7.1.4, TX.7.1.4.1 & | |
|restrictive measures impossible | | | | |Intent of | |
| | | | | |TX.7.1.4-TX.7.1.4.1 | |
|C2a Prior assessment & documentation of |Interpretive Guidelines- | | |Sec.483.450(b)(1)(iv) |TX.7.1.6 & TX7.1.14 | |
|rationale by qualified professional |Sec.482.13(e)(3)(B)(iii); | | |(E) Facility must specify | | |
| |Sec.482.13(f)(3)(ii)(C) | | |who may authorize | | |
| | | | |intervention. No | | |
| | | | |assessment required | | |
|C2b Qualified professional determines S/R |Sec.482.13(e)(3)(ii) |Sec.483.358(b-d) | |Sec.483.450(b)(1)(iv) |TX.7.1.6 |Sec.591 - In General- (a)(2) May be|
|necessary for effective treatment or |Sec.482.13(f)(3)(i) | | |(E) Facility must specify | |imposed only upon written order of |
|protection of individual or others | | | |who may authorize | |physician or other licensed |
| | | | |intervention. | |practitioner |
|C2c Rationale documented in service record|Interpretive Guidelines- |Sec.483.358(f)(3) but this is | |Sec.483.450(b)(1)(iii) |TX.7.1.14 & Intent of |Sec.591- In General - (a)(2) |
| |Sec.482.13(e)(2)(3)(i) & |not required until the 1 hour | | |TX7.1.14 |Rationale must be part of order |
| |Sec.482.13(f)(2) |evaluation | | | | |
|C2d Reason for S/R & criteria for removal | | | | |TX.7.1.12 & intent of | |
|explained to individual | | | | |TX.7.1.12 | |
|C3 Provider must have P&P for S/R in | | | |Sec.483.440(f)(3)(iii) | | |
|behavioral treatment plans that are | | | | | | |
|reviewed by LHRC | | | | | | |
|C3a Beh tx plans initiated, developed, | | | |Sec.483.430(b)(1) | | |
|carried out, and monitored by | | | | | | |
|professionals | | | | | | |
|C3b Plans approved by independent review | | | |Sec.483.440(f)(3)(i) | | |
|committee | | | | | | |
|C3b Plans reviewed by LHRC | | | | HCFA guidance approved | | |
| | | | |use of LHRC as “specially | | |
| | | | |constituted committee” | | |
|C3c Info about individual plans & | | | | | | |
|aggregate data about all plans available | | | | | | |
|to LHRC | | | | | | |
|C3d1 S/R may only be included in plans to| | | | | |Sec.591- In general - (a)(1) May |
|address behaviors that present immediate | | | | | |use but only to ensure physical |
|danger to individual or others | | | | | |safety and only upon order of MD or|
| | | | | | |licensed professional |
|C3d2 S/R may only be included in plans | | | |Sec.483.440(f)(3)(i) | | |
|after their review by LHRC | | | |requires approval by | | |
| | | | |“specially constituted | | |
| | | | |committee” HCFA guidance | | |
| | | | |approved use of LHRC as | | |
| | | | |“specially constituted | | |
| | | | |committee” | | |
|C3d3 S/R may only be included in plans if | | | | | | |
|plans include non-restrictive procedures | | | | | | |
|and environmental modifications to address| | | | | | |
|behavior | | | | | | |
|C4 May only use time-out in compliance | | | |Sec.483.450(a)(1)(i) P&P | | |
|with P&P that comply with sound | | | |must promote growth, | | |
|therapeutic practice | | | |development, & | | |
| | | | |independence of client | | |



Key to Crosswalk Categories

∈ DMHMRSAS, Rules and Regulations to Assure the Rights of Individuals Receiving Services from Providers of Mental Health, Mental Retardation and Substance Abuse Services, November 2001
∉ HCFA Regulations: 42 CFR, Part 482.13 -- Conditions of Participation: Patients’ rights. Applies to all HCFA hospitals
∠ HCFA Regulations: 42 CFR , Parts 441 and 483 -- Use of Restraint and Seclusion in Psychiatric Residential Treatment Facilities Providing Inpatient Psychiatric Services to Individuals Under Age 21,
∇ HCFA Regulations: 42 CFR, 483, Subpart B – Requirements for Long Term Care Facilities.
® HCFA Regulations: 42 CFR, 483, Subpart I – Conditions of Participation for Intermediate Care Facilities for the Mentally Retarded.
© Joint Commission for the Accreditation of Health Care Facilities. Applies to behavioral and non-behavioral health care settings in which restraint or seclusion is used for behavioral health reasons.
™ Public Law 106-310 - Applies to all public or private general hospitals, nursing facilities, intermediate care facilities, or other health care facilities & programs funded in whole or part by any program receiving federal funds.



How to Read the Crosswalk

Χ The provisions of the Rules and Regulations to Assure the Rights of Individuals Receiving Services from Providers of Mental Health, Mental Retardation and Substance Abuse Services are listed in the far right hand column of the matrix. Other regulations, laws, and standards are listed to the right.

Χ Whenever there is full congruence between a law, regulation, or accreditation requirement and the provision of the new human rights regulations, the regulation, provision of the law, or standard is cited in the appropriate column to the right of the DMHMRSAS human rights regulatory provision.

Χ If there is partial congruence between a law, regulation, or accreditation requirement and the provision of the new human rights regulations, a brief explanation of how the regulation, provision of the law, or standard differs is noted in the appropriate column to the right of the DMHMRSAS human rights regulatory provision.

Χ When there is no congruence between a law, regulation, or accreditation requirement and the provision of the new human rights regulations, the box to the right of the DMHMRSAS human rights regulatory provision is left blank.

What is the policy on the use of restraint? This policy recognises that the use of physical restraint can cause injury or harm to both children and young people, and to those performing the restraint, and it can seriously impact on the relationship between children and their carers.