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7.3.1 Introduction
Seclusion and restraint are high-risk interventions that must be
used to address “emergency safety situations” only when less
restrictive interventions have been determined to be ineffective, in
order to protect behavioral health recipients, staff members or
others from harm. All persons have the right to be free from
seclusion and restraint, in any form, imposed as a means of
coercion, discipline, convenience or retaliation by staff. Seclusion
or restraint may only be imposed to ensure the immediate physical
safety of the person, a staff member or others and must involve the
least restrictive intervention, and be discontinued at the earliest
possible time (42
CFR § 482.13).
This section
includes seclusion and restraint reporting requirements for licensed
Level I psychiatric acute hospital programs (42
CFR § 482.13) residential treatment centers serving persons
under the age of 21 (42
CFR § 483 Subpart G) and sub-acute agencies (9
A.A.C. 20).
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7.3.2 References
The following citations can serve as additional resources for this
content area:
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7.3.3 Scope
To whom does this apply?
To all Tribal
and Regional Behavioral Health Authority (T/RBHA) contracted Office
of Behavioral Health Licensure (OBHL) licensed Level I behavioral
health inpatient treatment programs. The policy is applicable to all
enrolled individuals.
7.3.4 Did you know…?
- Trauma
associated with seclusion and restraint can trigger Post
Traumatic Stress Disorder
- Each
State has a designated protection and advocacy system. In
Arizona, the Arizona Center for Disability Law serves as the
designated protection and advocacy agency.
R9-20-602(Q) and
R9-21-204 require that all staff members and medical
professionals involved in ordering, providing, monitoring or
evaluating seclusion or restraint complete and document
education and training to include: understanding behavioral
and environmental risk factors, nonphysical interventions,
the safe use of seclusion or restraint and responding to
emergency situations.
In 2003, the Substance Abuse and Mental Health Services
Administration (SAMHSA) published the
Roadmap to Seclusion and
Restraint Free Mental Health Services.
Developed by administrations, experts and behavioral health
recipients, the training is a resource for mental health
service direct care staff, administrators, and recipients on
alternatives to the use of seclusion or restraint, as well
as a tool for mental health system transformation.
A staff member employing any method that results in a person
either being precluded from exiting an area in fact or left
with the reasonable belief of being prohibited from being
able to exit freely (for example – a staff member’s use of
his/her body to block an individual’s exit from a specified
area) constitutes seclusion.
A.R.S. § 36-513
and
A.R.S. § 36-528
require that a person under emergency detention or court
ordered evaluation may not be treated without consent,
except that pharmacological restraint may be used to protect
the safety of that person and others in an emergency.
Therefore, psychiatric medications given involuntarily to
persons under emergency detention or court ordered
evaluation must be considered chemical restraint and
documented as such.
42 CFR 482.13
clarifies that a drug or medication used as a restraint is
not a standard treatment or dosage for a behavioral health
recipient’s condition. Orders for the use of restraint
or seclusion must never be written as a standing order or on
an as needed basis (PRN).
- Each
T/RBHA is also required to collect certain aggregate data that
compiles total seclusion and restraints for the reporting
period, and forward that data to to the Arizona Department of
Health Services/Division of Behavioral Health Services (ADHS/DBHS).
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7.3.5 Definitions
ADHS/DBHS Office of Human Rights
Drug used as a Restraint, Sub Acute Agency
Emergency Safety Situation
Human Rights Committee
Level I Inpatient Treatment Program
Mechanical Restraint
Personal Restraint - Level I Psychiatric Acute Hospital Programs
Personal Restraint - Residential Treatment Centers Providing Services to Persons under the Age of 21
Personal Restraint, Sub-Acute Agency
Residential Treatment Center (RTC)
Restraint
Seclusion - Individuals Determined to have a Serious Mental Illness
Seclusion - Level I Programs
Seclusion, Sub-Acute Agency
Serious Occurrence
Serious Mental Illness (SMI)
Sub-Acute Agency
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7.3.6 Objectives
To establish reporting requirements regarding the use of seclusion and restraint, for all enrolled
persons, including persons determined to have a Serious Mental Illness (SMI) and children.
7.3.7 Procedures
7.3.7-A. Reporting to the T/RBHA
Licensed Level I behavioral health programs authorized to use seclusion
and restraint must report each occurrence of seclusion and restraint and information on the
debriefing subsequent to the occurrence of seclusion or restraint
to the T/RBHA within five days of the end of the occurrence. The
individual reports must be submitted on PM Form 7.3.1, Seclusion and Restraint
Reporting-Level I Facilities.
In the event that a use of seclusion or restraint requires face-to-face monitoring, a report
detailing face-to-face monitoring must be attached to Form 7.3.1, Seclusion and Restraint
Reporting, Level I Programs. The face-to-face monitoring form must include the requirements as
per 42 CFR 482.13, 42 CFR § 483 Subpart G, R9-20-602 and R9-21-204, outlined in Attachment 7.3.1
Face-to-Face Monitoring Requirements.
Licensed Level
I behavioral health programs must submit a report of the total number of occurrences
of the use of seclusion and restraint that occurred in the prior
month to the T/RBHA by the 5th calendar day of the month. If there
were no occurrences of seclusion and/or restraint during the
reporting period, the report should so indicate. Monthly summary
data is to be submitted to the Gila River RBHA Manager of Quality
Management/Utilization Management utilizing PM Form 7.3-GR.
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7.3.7-B. Reporting to the Office of
Human Rights
The T/RBHA must submit individual reports received from providers involving enrolled children
and individuals determined to have a Serious Mental Illness to the Office of Human Rights. This
must be done on a weekly or monthly basis, as arranged with the Office of Human Rights.
The Arizona State Hospital (AzSH) must
submit individual reports involving individuals determined to have a Serious Mental Illness and
children to the Office of Human Rights. This must be done on a weekly or monthly basis, as
arranged with the Office of Human Rights.
The T/RBHA and AzSH must also submit
monthly summary reports, as required by
Policy and Procedure Manual Section QM 2.4, F.
Procedures, to the Office of Human Rights by the 10th day of each month.
7.3.7-C. Reporting to Human Rights Committees
The RBHAs and AzSH must submit redacted individual reports received from providers involving
all enrolled persons to the appropriate Human Rights Committee for the region. The reports must
be submitted on a weekly or monthly basis, as arranged with the appropriate Human Rights
Committee.
The RBHAs and AzSH must also submit monthly
summary reports to the appropriate Human Rights Committee by the 10th day of each month. Monthly
summary reports must be redacted.
7.3.7-D. Reporting a Serious Occurrence or Death
Because of the high-risk nature of seclusion and restraint interventions, it is possible that a person may be injured or that a serious occurrence may occur during a seclusion and restraint event. For more information regarding this subject, follow the guidelines in
Section 7.4,
Reporting of Incidents, Accidents and Deaths.
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7.3.7-E. Reporting to the Office of Behavioral Health Licensure
An OBHL licensed Level I behavioral health program must notify OBHL within one working day of
discovering a serious occurrence that requires medical services, or death that occurs as a
result of a seclusion and/or restraint. This notification must be followed up by a written
incident report within five days of initial notification. For more information regarding this
subject, follow the guidelines in
Section 7.4, Reporting of Incidents, Accidents and Deaths.
Reporting to Arizona Health Care Cost Containment System (AHCCCS) and Arizona Center for Disability Law (ACDL)
OBHL licensed Level I behavioral health facilities are required to report a serious occurrence, including a death or occurrence following a seclusion and/or restraint event, to AHCCCS and The ACDL no later than one working day following the serious occurrence. Staff must document in the person’s record and in the incident/accident report log that the serious occurrence was reported to AHCCCS and ACDL, and include the names of the individuals who received the report.
For reporting of serious occurrences:
AHCCCS
FAX Number (602) 417-4162-Attention DHCM Senior Clinical and Quality Consultant
The Arizona Center for Disability Law
FAX Number (602) 274-6779-Attention Mental Health Team
7.3.7-F. Reporting a Death to Centers for Medicare and Medicaid
Services (CMS)
In the case of a person’s death, the information must be reported to the Center for Medicare and Medicaid Services (CMS) Regional Office. The program must report:
- Each death that occurs while a resident is in restraint or seclusion;
- Each death that occurs within 24 hours after the resident
has been removed from restraint or seclusion; and
- Each death known to the facility that occurs within one week after the restraint or seclusion where it is reasonable to assume that the use of restraint or seclusion contributed directly or indirectly to a resident’s death. “Reasonable to assume” in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or deaths related to chest compression, restriction of breathing or asphyxiation.
Each death must be reported to CMS by telephone within one working day following knowledge of the resident’s death. Staff must document the death in the program’s incident/accident log. Staff must document in the patient’s medical record the date and time the death was reported to CMS, and the names of the individuals who received the report.
- CMS Regional Office (to report a death only)
Division of Survey & Certification phone: (415) 744-3679
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7.3 Seclusion and Restraint Reporting
Last Revised: 09/15/2009
Effective Date: 09/15/2009 |
