(a) Restraint includes physical, chemical, and mechanical restraints, as further defined in this Section.
(b) The entire plan of care team shall agree to the use of restraints, confirmed with a signature from the participant, legally authorized representative, and all providers involved, and be consistent with this Section.
(c) When the use of positive behavior supports is not effective in modifying or changing a participant's challenging behavior, the participant's plan of care team may implement a restraint protocol to supplement the positive behavior support plan, subject to the provisions of this Section.
(d) Providers shall not use aversive techniques to modify a person's behavior. Aversive techniques include any intervention that causes pain, harm, discomfort, or social humiliation for the purpose of modifying or reducing a behavior.
(e) A provider serving more than five (5) participants with restraints in their plans are required to have one (1) employee complete training on positive behavior supports through any program approved by the Division. An additional employee shall be certified for every ten (10) additional participants with restraints in their plan.
(f) The plan of care team shall review the participant's plan thoroughly to ensure the individualized plan of care is not so restrictive that it repeatedly provokes behaviors that lead to the use of restraints.
(g) When restraints are deemed necessary, the individualized plan of care shall include a restraint protocol that includes the following: - (i) If a person other than the participant authorizes the use of restraint, the legal document, court order, guardianship papers, or medical orders that demonstrate this authority shall be provided.
- (ii) For any restraint imposed, the standards outlined in Section 4(h)(ii) shall be met.
(h) The case manager shall reconvene the participant's plan of care team if any restraints are used in the previous calendar quarter. When convened under this section, the team shall review all restraints for the previous quarter and make plans for reducing the number of restraints performed. On a quarterly basis, the case manager shall report data received from the provider concerning the number of restraints performed on the participant.
(i) The provider shall notify the case manager within one (1) business day of any use of an emergency restraint that is not written in a participant's individualized plan of care. A case manager who receives notice of restraint under this provision shall call a team meeting within two (2) weeks to discuss the incident and decide if the individualized plan of care shall be modified to include a crisis intervention protocol and a revised positive behavior support plan.
(j) Restraints shall only be performed by an individual trained and certified in restraint usage.
(k) Providers employing restraints shall: - (i) Adopt policies and procedures that:
- (A) Identify the provider's chosen certifying entity consistent with subsection (l) of this Section;
- (B) Specify the types of restraints that may be used by provider staff; and
- (C) Establish provider-specific training requirements for staff.
- (ii) Adhere to all state and federal statutes, rules, and regulations regarding the use of restraints.
- (iii) Only utilize restraints approved by the provider's chosen certifying entity recognized in subsection (l) of this Section, unless the restraints are prohibited in subsection (d) of this Section.
(l) The provider and provider staff shall maintain certification, and provider shall require ongoing training for employees in de-escalation techniques, crisis prevention and intervention, and proper restraint usage from entities certified to conduct the training, such as Crisis Prevention Intervention (CPI), MANDT, or other entity approved by the Division.
(m) Restraints shall only be used in emergency circumstances to ensure the immediate physical safety of the participant, a provider staff member, or other persons, and when less restrictive positive behavior supports have been determined to be ineffective. Providers shall only use restraints when the risk of injury without restraint is greater than the risk associated with the restraint. Restraints may include, but are not limited to, the following: - (i) A chemical restraint is any drug that is administered to manage a participant's behavior in a way that reduces the safety risk to the participant or others, has the temporary effect of restricting the participant's freedom of movement, and is not a standard treatment for the participant's medical or psychiatric condition.
- (A) A chemical restraint shall not be used unless ordered by a licensed medical professional chosen by the participant or any legally authorized representative(s), and administered by a person licensed to administer the medication.
- (B) Standing orders for chemical restraints are prohibited, except when deemed necessary to prevent extreme reoccurring behavior by a participant's plan of care team and limited to one (1) month. A standing order shall include clarification on the circumstances of its usage by the licensed medical professional.
- (C) If a provider uses three (3) or more instances of a chemical restraint on a participant within a consecutive six (6) month period, the participant's team shall arrange for the participant to see his or her treating medical professional for a formal medical review in case the treatment plan needs to change. The participant's plan of care team shall meet to determine if the positive behavior support plan or crisis intervention protocol needs to change. The formal medical review shall be documented in the participant's file with the restraining provider and the case manager. If it is determined that the treatment plan or individualized plan of care will not be changed, then the case manager shall document the reasons it is not being changed in the individualized plan of care.
- (D) Chemical restraints shall not be used on persons under the age of 18.
- (ii) A mechanical restraint is any device attached or adjacent to a participant's body that he or she cannot easily move or remove that restricts freedom of movement or normal access to the body.
- (A) Mechanical restraints shall only be used under the direct supervision of a licensed medical professional for the purpose of medical treatment procedures when compliance is deemed necessary to protect the health of the participant.
- (B) Mechanical restraints shall not be used on persons under the age of 18.
- (iii) A physical restraint is the application of physical force without the use of any device, for the purposes of limiting the free movement of a participant's body. Physical restraint does not include briefly holding a participant, without undue force, in order to calm or comfort him or her, or holding a participant's hand to safely escort him or her from one area to another.
(n) Seclusion is the involuntary confinement of a participant alone in a room or an area from which the participant is physically prevented from leaving. Seclusion is prohibited, and may result in repayment of funds for waiver services and other sanctions.
(o) A provider using restraints shall: - (i) Maintain internal documentation to track and analyze: each use of a restraint, its antecedents, reason(s) for the restraint, the participant's reaction to the restraint, and actions that may make future restraints unnecessary;
- (ii) Implement additional supports with the participant in an effort to minimize restraints;
- (iii) Use appropriate de-escalation techniques to redirect or mitigate a behavior before restraints occur;
- (iv) Address and correct staff using restraints incorrectly;
- (v) Hold a debriefing meeting with the participant, legally authorized representative, and case manager as soon as practicable after an incident to discuss the use of the restraint. Legally authorized representatives may be part of the participant's debrief discussion either by phone or in person;
- (vi) Within five (5) business days of the event, provide case managers with a copy of the provider's completed internal tracking form, or notify the case manager that the electronic form is available for viewing;
- (vii) Send a copy of the completed internal tracking form to the legally authorized representative within five (5) business days or notify the legally authorized representative that the electronic form is available for viewing;
- (viii) Submit a critical incident report to the Division for each instance when a restraint is used; and
- (ix) Regularly collect and review all available data regarding the use of restraints and work to reduce their duration and frequency, and eliminate their occurrence.
- (x) The case manager shall follow-up on each incident within two (2) business days of notification of the incident to ensure the participant is safe, uninjured, and to ensure the restraint protocol, and participant's positive behavior support plan was implemented appropriately and documentation demonstrates that less restrictive intervention techniques were used prior to the use of restraint. The case manager shall also review whether the items in this section were completed and report any suspected non-compliance to the Division.
- (xi) The Division may request an interdisciplinary team meeting with the provider, case manager, and legally authorized representative to review any incident of restraint performed by a provider or provider staff.
(p) Restraints shall not be used for the following purposes. Violation of this provision may result in immediate sanctions of the provider: - (i) For the convenience of the provider;
- (ii) To coerce, discipline, force compliance, or retaliate against a participant;
- (iii) As a substitute for a habilitation program or in quantities that interfere with services, treatment, or habilitation;
- (iv) Restraint that is contraindicated by the person's medical or psychological condition;
- (v) Restraint procedures or devices that obstruct a person's airway or constrict the person's ability to breathe;
- (vi) The use of any supine or prone restraint including, but not limited to, restraining a person on the floor, in a bed, in any form of reclined chair, or using any other horizontal flat surface; and
- (vii) Any use of physical, mechanical, or chemical restraint not provided for in this section.
(q) Any restraint shall be time-limited and removed immediately when the participant no longer presents a risk of immediate harm to self or others.
048-45 Wyo. Code R. § 45-18