Ala. Admin. Code r. 660-5-49-.04

Current through Register Vol. 43, No. 1, October 31, 2024

Section 660-5-49-.04 - Restrictive Interventions

(1)Restrictive Interventions - The more restrictive interventions for managing existing and teaching new behaviors include isolation, medication, seclusion, and restraint.

(a)Isolation - Isolation, a less restrictive intervention than medication, seclusion or restraint, is designed to be used with less extreme or dangerous behaviors than those requiring seclusion or restraint. Isolation shall be used only when therapeutically indicated and as part of a behavior management plan to modify or eliminate targeted behaviors; used in conjunction with supportive and interactive treatment methods as the principle interventions; conducted in a manner that fosters the child's capacity for self-regulation; and time-limited as specified in the behavior management plan with the child being released as indicated by the plan.

1. When a child is isolated, provisions shall be made for humane and safe conditions including room space appropriate to the developmental level of the child, adequate ventilation and lighting, and a room temperature consistent with the rest of the home or facility. Meals, routine medication and water must be provided. Observation of a child in isolation shall occur at least every 30 minutes or more often as necessary. The behavior management plan will describe how frequently the child must be observed and will authorize any restrictions imposed while the child is in isolation.

2. The use of isolation must be authorized in advance by the child and family planning team in accordance with the ISP and behavior management plan. Appropriate members of the child and family planning team (e.g., mental health professional, DHR worker, residential provider) shall explain and assist the age-appropriate child and family to understand the need for this intervention. The individuals designated to implement and monitor isolation will review the intervention frequently (e.g., weekly, bimonthly, monthly depending upon the frequency of usage) to determine if it is having the desired effect on the child, and if the desired outcome is not being achieved, isolation must be modified or discontinued.

3. The use of isolation 3 times or more in a 24 hour period or for more than 2 hours in a 24 hour period will be reviewed by the provider's treatment team for the intervention's appropriateness and the need for alternative interventions.

(b)Medication, Seclusion and Restraint - Medication, seclusion, and restraint are the more restrictive interventions for managing children's behaviors and shall be used only when approved by the child and family planning team to do so and when more normalized, less restrictive interventions have been unsuccessful or would not be practicable.

1. Medication may only be administered to children when the informed consent of the parent, legal custodian/guardian, or the foster parent legally authorized to provide consent and the informed consent of the child (age 14 or older) has been obtained. The child's and parent's preferences and requests for alternative interventions should be considered; and consent may be withdrawn at any time; however, a child's refusal to consent may be overridden by a court of appropriate jurisdiction.

2. Prescriptions for medication must be made by a licensed physician who is trained in the use of medication with children and adolescents. Medication is to be carefully and closely monitored by the child's physician and the child and family planning team for both desired effects and potential side effects.

3. A qualified physician must complete a thorough assessment of the child before prescribing medication in order to determine the appropriateness of prescribing the medication and to establish baseline data for monitoring its effects.

4. In a crisis where the child will seriously harm self, harm others, or cause substantial property damage, medication may be administered without informed consent upon an order by the treating physician and in accordance with generally accepted medical standards. There must be documented evidence in the child's record that in the physician's professional judgment, the harm or substantial property damage will occur without the benefit of the medication and that less restrictive interventions are not therapeutically indicated.

5. If it appears that medication will be used to address crises in a periodic, on-going pattern with the child, a court order or informed consent must be obtained from the child (age 14 or older) and the parent(s), legal custodian, guardian or foster parent legally authorized to provide consent.

6. The dispensing of Prescribed as Needed (PRN) medication can only be allowed if in compliance with a physician's approved protocol and the order is documented in the child's medical file of the provider's record and the child's DHR case record. PRN medications administered to address a child's behavior two or more times a week for three consecutive weeks will result in a comprehensive review of the child's individualized service and behavior management plans and the incidents, factors, and rationales for such PRN medication use.

(c)Seclusion or Restraint - Seclusion and restraint are two of the most restrictive interventions and shall be used only by those providers who meet the following criteria and who have been approved by DHR to utilize the interventions. Seclusion or restraint may be used only as part of a behavior management plan approved by the child and family planning team and when more normalized, less restrictive interventions have been unsuccessful or would not be practicable.

1. Seclusion or restraint may be used only when needed to protect a child from seriously harming self or others (including other children, family members, and provider staff), or to prevent substantial property damage. Mechanical restraint may be used only when needed to protect the child from engaging in behavior that has a likelihood of resulting in serious self-injury.

2. The criteria for use of seclusion or restraint by residential treatment providers are when the provider has an on-site or on-staff QCCP at the time of the seclusion or restraint; the staff member(s) who will implement seclusion or restraint has received training from a qualified source to safely use the intervention(s); the provider's behavior management policy provides for adequate documentation of the use of seclusion or restraint; the provider has internal reporting and review procedures that include reporting all use of seclusion or restraint to the program's director and documenting all use of seclusion or restraint in a central file; a periodic review of seclusion or restraint practices will be done by a committee convened by the provider that includes outside persons; and the rooms or spaces used to seclude or restrain the child meet generally accepted professional standards.

3. If seclusion or restraint is authorized, there must be evidence in the provider's record for the child and the child's case record that the intervention is the most effective and least restrictive for managing behavior. The use of seclusion or restraint must be discontinued as soon as the child is no longer a danger and in accordance with the release criteria outlined in the QCCP's authorization/order.

4. The provider using seclusion or restraint and the child and family planning team shall monitor use of the intervention to determine if it is having a positive effect on the child and whether more normalized, less restrictive interventions could be used. The use of seclusion or restraint 3 times or more in a 24 hour period or for more than 2 hours in a 24 hour period will be reviewed by the provider's treatment team and the program director for the intervention's appropriateness and the need for alternative interventions.

(d)Physical Environment And Care Of The Child - The room or space used for seclusion or restraint is to be constructed to protect the health, safety and well being of children placed there. The floor space will be appropriate to the developmental level of the child, the purpose of the seclusion or restraint and the maximum time a child might spend in the room. The design, construction and operation of any room or space used for seclusion or restraint are to conform to all applicable provisions of the Life Safety Code prescribed by the National Fire Prevention Association.

1. When a child is being restrained or secluded periodic observation of the child shall occur at least every 15 minutes, or more often as necessary, as well as verbal interaction with the child when appropriate; the child's physical and psychological condition shall be documented every 15 minutes or more frequently if indicated or ordered and vital signs must be taken as clinically indicated; the child shall not be deprived of food, fluids, toilet and bathing opportunities, and appropriate exercise; the child shall be protected from other children and environmental hazards; the child shall be protected from potential risks of self-injury; and care must be taken so that mechanical restraint does not restrict the flow of blood to the limbs, and protective devices are kept clean at all times.

(e)Notification Of Parent, Legal Guardian/Custodian, DHR - A child's parent, legal guardian/custodian, and the DHR worker shall routinely receive information about any use of seclusion or restraint with the child. The parent or legal guardian/custodian and the DHR worker shall be notified, within the next 24 hours, if the child is placed in seclusion or restraint 3 times or more in a 24 hour period or for more than 2 hours in a 24 hour period.

(f)Procedural Requirements - Providers must follow the procedures below when authorizing and implementing seclusion or restraint.

1.Authorization/Orders.

(i) Prior to authorization and implementation, children shall receive a physical evaluation to identify any medical restrictions or prohibitions associated with the use of restraints or seclusion.

(ii) Each use of seclusion or restraint must be authorized by a written order from a QCCP who is physically present and has assessed the child's physical and psychological condition.

(I)Exceptions - AQCCP's authorization/order is not required for the brief use of seclusion (i.e., fifteen minutes or less) or the brief use of restraint (i.e., five minutes or less) for the purpose of interrupting aggressive or assaultive behaviors or disruption to the therapeutic environment.

(II) In a crisis situation seclusion or restraint may be authorized and implemented for up to 2 hours by a staff member who has experience and training in the proper use of the procedure. The staff member must be physically present and evaluate, to the extent feasible, the child's physical and psychological condition. The staff member must consult with the QCCP as soon as possible to obtain verbal authorization to use the intervention. The QCCP must provide a written authorization/order including any related documentation within 24 hours after implementation of the verbal authorization. The intervention may be used no longer than two (2) hours unless the QCCP is physically present to personally assess the child and write a new authorization/order to continue use of the intervention.

(iii) Authorizations/orders for seclusion or restraint are valid for no more than 8 hours. All written authorizations/orders (including crisis situations) shall include a clinical assessment of the child, a description of precipitating events and alternative interventions attempted, and the criteria for the child's release.

(iv) Children must be released from seclusion or restraint when the criteria for release have been met or at the end of the time frame set out in the authorization/order, whichever occurs first. If additional time in seclusion or restraint appears to be needed, a QCCP must examine the child and write a new authorization/order. Prescribed as Needed (PRN) orders are not to be used to authorize seclusion or restraint.

(v) Restraint may be authorized when a child is transported from one location to another only because of threat of harm to self or others and only if there has been a documented dangerous incident within the past 14 days that clearly indicates restraint is necessary to prevent injury to the child or others.

2.Release - A child must be released from seclusion or restraint when the child is no longer a danger and in accordance with the release criteria outlined in the authorization/order. A child who falls asleep in seclusion or restraint shall be released immediately. The person supervising the child must be aware of the steps necessary for the child to be released from restraint or to leave seclusion and the intervals when these steps should be attempted or repeated. If the child needs to remain in seclusion or restraint for a longer period than initially specified, a new authorization/order must be obtained. It must describe the basis for the belief that the child needs extended time in seclusion or restraint. The use of extended periods is to be reviewed at the child and family planning team meetings.

(g)Documentation - The use of seclusion or restraint must be documented in both the provider's and DHR's case records for the child. In addition, the provider's record for the child must maintain adequate documentation of a clinical assessment of the child including a description of precipitating events, any medical restrictions or prohibitions associated with the intervention, and alternative interventions attempted; the QCCP's written order identifying the intervention authorized, time frames for periodic observation, and criteria for termination, including the date, time, and duration the intervention was used, and presence or absence of contraindications; the periodic observation of the child's physical and psychological condition; the provision of meals, toilet opportunities, fluids on a regular basis, bathing and exercise, as needed; an assessment of the child's physical and emotional condition upon release; a medical evaluation of any injury suspected to be related to the use of seclusion or restraint; orders and related documentation issued during a crisis situation; evidence of timely reassessment of the intervention's use and its effects on the child; and evidence that decisions indicated by the reassessments and evaluations have been made.

Author: Jerome Webb

Ala. Admin. Code r. 660-5-49-.04

New Rule: Filed August 6, 2003; effective September 10, 2003.

Statutory Authority:R.C. v. Fuller case (R.C. v. Hornsby, No. 88-H-1170-N, Consent Decree) (M.D. Ala. Approved December 18, 1991).