Section 85161 - Emergency Intervention Documentation and Reporting Requirements(a) Each use of manual restraint or seclusion shall be reported to the client's authorized representative, if any, by telephone, no later than the next calendar day. This report shall include the type of emergency intervention used, the duration of the manual restraint or seclusion, the time the event was reported to the authorized representative, and the time and response of the authorized representative and shall be documented in the client's file.(b) Each use of manual restraint or seclusion shall be reported to the Department in writing no later than the next business day. This time frame shall supersede the reporting time frame required by Section 80061(b). (1) An incident report of the use of the manual restraint or seclusion shall be reviewed, for accuracy and completeness, and signed by the licensee or licensee's designee prior to submission to the Department.(2) If a manual restraint or seclusion technique that was not part of the facility Emergency Intervention Plan or the Individual Emergency Intervention Plan was used during the emergency intervention, the plan for corrective action, at minimum, shall require staff to repeat or obtain emergency intervention training. Within 24 hours of the licensee's discovery of non-compliance of the Plan, the licensee shall also submit a plan for corrective action to the Department to describe how he or she will ensure that there is no recurrence of a violation of the Plan. This shall not impede upon the Department's authority to enforce applicable statutes and regulations or initiate administrative action.(c) The report in Section 85161(b) above must include the following: (1) A description of the client's behavior that required the use of manual restraint or seclusion, and description of the precipitating factors, including behaviors of others, which led to the intervention.(2) Description of what manual restraints were used, how long the client was restrained or secluded, and if the restraint resulted in the use of seclusion.(3) Description of what non-physical interventions were utilized prior to the use of the manual restraint or seclusion; explanation of why more restrictive interventions were necessary.(4) The client's verbal response and physical appearance, including a description of any injuries at the completion of the manual restraint or seclusion, whether they are related to the manual restraint or seclusion, and how the licensee became aware of the injury.(5) Description of injuries sustained by the client or facility personnel, what type of medical treatment was sought and where was client taken or an explanation if medical treatment was not sought for injuries.(6) Name(s) of facility personnel who participated in or witnessed the manual restraint or seclusion.(7) Name of the certified administrator who approved the continuation of the manual restraint or seclusion for more than 15 minutes.(8) If it is determined in the debriefing, as required in Section 85168.3, that facility personnel did not adequately attempt to prevent the manual restraint or seclusion, a description of what action should have been taken by facility personnel to prevent the manual restraint or seclusion incident shall be documented. This documentation shall also include what corrective action will be taken or not taken and why.(9) If law enforcement was involved, a description of the precipitating factors, including behaviors of others, which led to the police intervention.(10) Date and time of other manual restraint or seclusion involving the same client in the past 24 hours.(d) If it is necessary to continue the use of manual restraint or seclusion for more than 15 minutes it shall be documented in accordance with Section 85122(e)(6)(A)1.(e) A copy of the incident report shall be made available for review, inspection, audit or copy, upon request, by the Department as specified in Section 80070.(f) The information required in subdivision (b), shall be documented following the use of manual restraint or seclusion no later than the end of the working shift(s) of the staff(s) who participated in the manual restraint or seclusion, or both.(g) The licensee shall maintain a monthly log of information related to each use of manual restraint or seclusion, which includes: (1) The name of each client for which a manual restraint or seclusion was used.(2) The date and time of the manual restraint or seclusion.(3) The duration of time of the manual restraint or seclusion.(4) The behaviors of others connected to the incident and factors that contributed to the incident.(5) The name(s) and job title(s) of staff that participated in the manual restraint or seclusion.(6) The name of the certified administrator that approved the continuation of the manual restraint or seclusion for more than 15 minutes, if applicable.(7) A description of the manual restraint or seclusion and type used, including: (A) The outcome to the client, including injury or death.(B) The outcome to the staff, including injury or death.(C) Whether the injury in Section 85161(g)(7)(A) and (B) above was serious as defined in Health and Safety Code section 1180.1(g)(8) The total number of incidents of manual restraint and the total number of incidents of seclusion per month.(9) The total number of serious injuries to clients as a result of manual restraint or seclusion per month.(10) The total number of non-serious injuries to clients as a result of manual restraint or seclusion per month.(11) The total number of serious injuries to staff as a result of manual restraint or seclusion per month.(12) The number of deaths per month that occur to a client while in a manual restraint or seclusion, or where it is reasonable to assume that a death was related to the use of manual restraint or seclusion.(h) The monthly log specified in (g) shall be available for review, inspection, audit and copy, upon request, by the Department.Cal. Code Regs. Tit. 22, § 85161
1. Change without regulatory effect renumbering former section 85361 to new section 85161, including amendment of subsections (c), (c)(8), (d) and (g)(7)(C), filed 1-2-2019 pursuant to section 100, title 1, California Code of Regulations (Register 2019, No. 1). Note: Authority cited: Section 1530, Health and Safety Code. Reference: Sections 1180.2, 1180.3, 1180.5, 1501 and 1531, Health and Safety Code.
1. Change without regulatory effect renumbering former section 85361 to new section 85161, including amendment of subsections (c), (c)(8), (d) and (g)(7)(C), filed 1-2-2019 pursuant to section 100, title 1, California Code of Regulations (Register 2019, No. 1).