PHYSICAL RESTRAINT, LEAST RESTRICTIVE & PLANNED INTERVENTIONS

PHYSICAL RESTRAINT, LEAST RESTRICTIVE & PLANNED INTERVENTIONS

POLICY     All direct care staff, contract staff, and administrative support staff shall be required to receive NCI-the NC Version approved by the Division. All staff shall be required to receive certification in NCI before being released to use any of the trained techniques of the NCI Program. Attendance in a structured training provided by a licensed or credentialed instructor is required. The Ship Group Community Services will not employ seclusion or isolation as a recognized restraint technique; there will be two restraint techniques recognized by the program – exclusionary time-out and NCI. However, the use of both techniques shall be preceded by communication techniques (where possible) that allow the client to maintain dignity and respect, and which designed to offer a least restrictive alternative to any restraint technique. Further, the program requires trainers to instruct staff in specifics regarding “when and why” interventions should take place, “how” they should document the least restrictive alternatives considered or used and/or restrictive interventions used and lastly, “how” to debrief the client after all interventions and communicate the events through Progress/Service Notes, Incident/Critical Incident & Death Reports and interviews with Administration, Qualified Professionals, etc. Last but not least, the NCI Trainer, Contract Nurse (if applicable for the program), and Program Manager respectively, shall add to the NCI training, in Medical Emergencies training, additional safety measures which include, continuous assessment and monitoring of the client’s physical and psychological well-being following a restrictive intervention, “who” to contact and “when” to call for professional medical assistance. Restrictive Interventions employed at the permissive will of staff shall not go unchallenged by the Program’s Administration, once it is known. Staff members are encouraged to report client abuse without fear of repercussion and with the understanding that the program will keep all such reports confidential. The Program is released from “confidentiality” if and when the report of abuse becomes a matter of law and/or medical necessity requires the revelation of source information.

ALTERNATIVES TO RESTRICTIVE INTERVENTIONS

10A NCAC 28D .0209 TRAINING: EMPHASIS ON ALTERNATIVES TO RESTRICTIVE INTERVENTIONS

1. The Ship Group Community Services has implemented policies and practices that emphasize the use of alternatives to seclusion, physical restraint and isolation time-out.

2. Prior to providing services to people with disabilities, staff including service providers, employees, students or volunteers, shall demonstrate competence by successfully completing training in communication skills and other strategies for creating an environment in which the likelihood of imminent danger of abuse or injury to a person with disabilities or others, or to property is prevented.

3. The Ship Group Community Services Care training has been established based on state competencies, and includes monitoring for internal compliance and demonstrate action based on data gathered through evidence-based research.

4. A pre-requisite for taking this training is demonstrating competence by completion of training in preventing, reducing, and eliminating the need for restrictive interventions.

5. The training shall be competency based, include measurable learning objectives, measurable testing (written and by observation of behavior) on those objectives and measurable methods to determine passing or failing the course.

6. Formal refresher training shall be completed at least annually by each service provider.

7. Content of the training that the service provider plans to use shall be approved by the Division of MH/DD/SAS pursuant to Paragraph (g) of this Rule.

8. Staff shall demonstrate competence in the following core areas:

1. knowledge and understanding of the people being served;

2. recognizing and interpreting human behavior;

3. recognizing the effect of internal and external stressors that may affect people with

disabilities;

4. strategies for building positive relationships with people with disabilities;

5. recognizing cultural, environmental and organizational factors that may affect people with disabilities;

6. recognizing the importance, and assisting people with disabilities in making decisions about their life;

7. skills in assessing individual risk for escalating behavior;

8. communication strategies for defusing and de-escalating potentially dangerous behavior; and

9. positive behavioral supports (providing means for people with disabilities to choose

activities that directly oppose or replace behaviors that are unsafe).

10. refresher information on alternatives to the use of restrictive interventions;

11. guidelines on when to intervene (understanding imminent danger to self and others);

12. emphasis on safety and respect for the rights and dignity of all persons involved (using concepts of least restrictive interventions and incremental steps in an intervention);

13. strategies for the safe implementation of restrictive interventions;

14. the use of emergency safety interventions which include continuous assessment and monitoring of the physical and psychological well-being of the client and the safe use of restraint throughout the duration of the restrictive intervention;

15. prohibited procedures;

16. debriefing strategies, including their importance and purpose; and

17. documentation methods/procedures.

(i) The Ship Group Community Services Care shall maintain documentation of initial and refresher training for at least three years.

1. Documentation shall include:

▪ who participated in the training and the outcomes (pass/fail);

▪ when and where they attended; and

▪ instructor's name.

    2. The Division of MH/DD/SAS may request and review this documentation at any time.

(j) Instructor Qualifications and Training Requirements:

1. Trainers shall demonstrate competence by scoring 100% on testing in a training program aimed at preventing, reducing, and eliminating the need for seclusion, physical restraint and isolation time-out.

2. Trainers shall demonstrate competence by scoring a passing grade on testing in an Instructor training program.

3. The training shall be competency-based, include measurable learning objectives, measurable testing (written and by observation of behavior) on those objectives and measurable methods to determine passing or failing the course.

4. The content of the instructor training the service provider plans to employ shall be approved by the Division of MH/DD/SAS pursuant to Subparagraph (i)(5) of this Rule.

5. Acceptable instructor training programs shall include but not be limited to presentation of:

▪ understanding the adult learner;

▪ methods for teaching content of the course;

▪ methods for evaluating trainee performance; and

▪ documentation procedures.

6. Trainers shall have coached experience teaching a training program aimed at preventing, reducing and eliminating the need for physical restraint, seclusion and isolation time-out at least one time, with a positive review by the coach.

7. Trainers shall teach a training program aimed at preventing, reducing and eliminating the need for seclusion, physical restraint and isolation time-out at least once annually.

8. Trainers shall be currently trained in CPR. Trainers shall complete a refresher instructor training at least every two years.

(k) Service providers shall maintain documentation of initial and refresher instructor training for at least three years.

1. Documentation shall include:

• who participated in the training and the outcomes (pass/fail);
• when and where attended; and
• instructor's name; and

2. The Division of MH/DD/SAS may request and review this documentation at any time.

(l) Qualifications of Coaches:

1. Coaches shall meet all preparation requirements as a trainer.

2. Coaches shall teach the course which is being coached at least three times.

3. Coaches shall demonstrate competence by completion of coaching or train-the-trainer instruction.

(m) Documentation shall be the same preparation as for trainers.

CLIENT RIGHTS REGARDING RESTRICTIVE INTERVENTIONS

Restriction of Legal Rights: There are some situations when some legal rights may be properly denied, but there must be a good reason. This reason must be stated in the treatment record, and an explanation shall be given to the client. Once the reason or denial of a right no longer exists, the right shall be given back to the client.

Denial of Client Rights

• A client’s right to refuse treatment, restrictive interventions or medications can be overruled by the legally responsible person.

Denial of Client Rights

• A legally responsible person’s right to deny treatment, other than those requiring express written consents can be overruled by the clinical coordinator of the program, or the clinical coordinator’s designee if the client loses the opportunity for realistic improvement by refusing treatment and the significant possibility of harm to himself or others exist

• Rights cannot be denied routinely as part of the program’s procedure.

• Rights cannot be denied for the convenience of staff.

• Rights cannot be considered privileges to be earned by the client.

•  Rights cannot be denied as a form of punishment.

PHYSICAL RESTRAINT DEFINED

Physical Restraint means the application or use of any manual method of restraint that restricts freedom of movement; holding a client in a therapeutic hold that restricts his or her movement constitutes manual restraint for that client. Escorting means the temporary touching or holding of the hand, wrist, arm, shoulder or back for the purpose of inducing a client to walk to a safe location. Escorting or gentle physical prompting techniques are excluded from the definition of physical restraint.

RESTRICTIVE INTERVENTIONS

The Ship Group Community Services will provide NC-I Training.

NCI TRAINING CRITERIA

The definition above will be used by the Trainer of NC-I and will be taught to all agency, contract and key administrative support staff during the NC-I training and through Clinical Supervisions and In-Service Trainings.

Communication as outlined in Restrictive Intervention Procedures will be used along with other least restrictive alternatives to restraint. An additional element of NCI training will be:

1. Instruction in the definitions provided in APSM 95-2- Client Rights in Community- for physical restraint, dangerous to themselves or others, abuse, neglect, exploitation, physical restraint and confidential information;

2. Recognizing the need for early communication interventions;

3. How to communicate effectively to avoid escalating situations;

4. When to intervene to avoid incidents;

5. How to safely apply a restrictive intervention technique;

6. How to communicate with the client following a restrictive intervention, so the client retains dignity and receives the respect due;

7. The proper questions and checks necessary to check for injury and provide First Aid or professional medical attention;

8. Using the client’s Crisis Plan when and as appropriate;

9. How to debrief a client following a restrictive intervention;

10. How to monitor the client and how long to monitor following the incident;

11. How to properly document the incident;

12. When and who to contact for assistance or advice; and

13. The next shift’s responsibility following the restrictive intervention.

ILLEGAL RESTRAINT TECHNIQUES

Within The Ship Group Community Services program of services the following regarding Restraint Techniques are prohibited:

1. Isolation;

2. Seclusion;

3. Corporal Punishment;

4. Excessive noise designed to deprive a client of sleep;

5. Forcing bad tasting food or depriving clients of food;

6. Over-medicating designed to make a client sleep;

7. Chores above and beyond those permitted by the program;

8. Legal restraints at the permissive will of staff.

The use of any of the aforementioned techniques or any other technique that is not sanctioned by this program or through state recognized physical restraint techniques, sanctioned by this program will be grounds for immediate termination of employment and possible prosecution. Staff persons with substantiated charges following the use of an illegal restraint technique will also have their names added to the NC Health Care Personnel Registry, thereby prohibiting paraprofessional employment in any North Carolina health care agency.

Staff that retaliates against clients physically or verbally because of something they said or did using illegal or legally permitted restraint techniques, will be disciplined up to and including termination and possible prosecution.

LEAST RESTRICTIVE ALTERNATIVES:

Least restrictive alternatives will be employed for all clients (especially those with physical disabilities or surgeries) before more restrictive alternatives are used. Least restrictive alternatives can include, but not be limited to:

1.      Inability to attend a special activity;

2.      Following the Out-of-School Suspension policy;

3.      Allowing the client to run, exercise or other vigorous activity;

4.      Allowing the use of punching balloons or stress balls;

5.      Walking outside and counseling with the clients.

All interventions used shall be documented in the client’s record and communicated to the client. Least restrictive alternatives are not to be “stacked” against the client to the degree that a negative behavior has indefinite consequences.

PLANNED INTERVENTIONS

The client’s Treatment Plan/PCP shall have outlined methods or reasons for Planned Interventions upon admission to The Ship Group Community Services The client must be made aware of these planned interventions and the reasons they are included in the treatment regimen. The client and/or legally responsible person must sign the appropriate consents to acknowledge their understanding of the Planned Interventions.

The client and/or the legally responsible person have the right to refuse the use of restrictive interventions, when it has been decided by the client’s Treatment Team that they will be a part of the client’s Treatment//PCP.

For clients with prior physical or psychological disabilities that would otherwise preempt the use of physical intervention techniques, a client’s service/treatment/PCP shall include written authorization by the treatment team and the client’s physician for the use of restrictive interventions.

When physical and/or psychological disabilities are known that preempt the use of restrictive interventions the treatment team will document the reasons in the client’s service/treatment/PCP at intake. Restrictive Intervention Procedures-Information Provided at Intake.

Further the treatment team shall renew the order for or against the continued use of; or will set limits for the continued use of restrictive interventions if a client is unable to regain control of his behavior following the initial restrictive intervention. Clear rationales must exist that show the interventions have a “positive effect” to continue using them. Positive effects defined will mean that the client regains control, is able to immediately cease, discontinue and refrain from the negative behaviors that prompted the restrictive intervention. The Program’s Qualified Professional with input from a physician when necessary, the Program Manager and legally responsible person will approve all new authorizations, for the continued use of restrictive interventions. The approved and planned interventions will be signed by the legally responsible person every six months.

DEFINITIONS

“Dangerous to himself” means that within the relevant past:

A. The individual has acted in such a way as to show:

1. That he would be unable, without care, supervision, and the continued assistance of others not otherwise available, to exercise self-control, judgment, and discretion in the conduct of his daily responsibilities and social relations, or to satisfy his need for nourishment, personal or medical care, shelter, or self-protection and safety; and

2. That there is a reasonable probability of his suffering serious physical debilitation within the near future unless adequate treatment is given. A showing of behavior that is grossly irrational, of actions that the individual is unable to control, of behavior that is grossly inappropriate to the situation, or of other evidence of severely impaired insight and judgment shall create a prima facie inference that the individual is unable to care for himself; or

B. The individual has attempted suicide or threatened suicide and that there is a reasonable probability of suicide unless adequate treatment is given; or

1. The individual has mutilated himself or attempted to mutilate himself and that there is a reasonable probability of serious self-mutilation unless adequate treatment is given.

2. Previous episodes of dangerousness to self, when applicable, may be considered when determining reasonable probability of physical debilitation, suicide, or self-mutilation.

"Dangerous to others" means that within the relevant past, the individual has inflicted or attempted to inflict or threatened to inflict serious bodily harm on another, or has acted in such a way as to create a substantial risk of serious bodily harm to another, or has engaged in extreme destruction of property; and that there is a reasonable probability that this conduct will be repeated. Previous episodes of dangerousness to others, when applicable, may be considered when determining reasonable probability of future dangerous conduct. Clear, cogent, and convincing evidence that an individual has committed a homicide in the relevant past is prima facie evidence of dangerousness to others.

“Abuse” means the infliction of mental or physical or mental pain or injury by other than accidental means, or unreasonable confinement, or the deprivation by an employee of services that are necessary to the mental or physical health of the client. Temporary discomfort that is a part of an approved treatment plan or use of an emergency procedure shall not be considered abuse.

“Exploitation” means the use of a client’s person or property for another’s profit or advantage or breech of a fiduciary relationship through improper use of a client’s person or property including situations where an individual obtains money, property or other services from a client from undue influence, harassment, deception or fraud.

“Neglect” means the failure to provide the care or services necessary to maintain the mental or physical health and well-being of the client.

“Confidential Information” means any information, whether recorded or not, relating to an individual served by a agency that was received in connection with the performance of any function of the agency.

"Confidential information" does not include statistical information from reports and records or information regarding treatment or services which are shared for training, treatment, habilitation, or monitoring purposes that does not identify clients either directly or by reference to publicly known or available information.

PROHIBITED PROCEDURES

The Ship Group Community Services prohibits the following procedures:

• Any intervention which would be considered corporal punishment under GS 122C-59

• The contingent use of painful body contact

• Substances administered to induce painful bodily reactions, exclusive of Antabuse

• Electric shock (excluding medically administered electro convulsive therapy);

• Insulin shock

• Unpleasant tasting food items

• Contingent application of any noxious substances which include but are not limited to noise, bad smells, or splashing with water; and

• Any potentially physically painful procedure, excluding prescribed injections, or stimulus which is administered to the client for the purpose of reducing the frequency or intensity of a behavior

• Isolation time out

• Physical restraint in excess of one continuous hour

• Seclusion

• Protective devices used for behavioral control

    • Mechanical restraints

• Chemical restraint

• Voluntary use of physical restraint

• Any combination thereof

The governing body may determine to prohibit use of any interventions deemed unacceptable.

GENERAL POLICIES REGARDING INTERVENTION PROCEDURES

Restrictive interventions will not be used unless The Ship Group Community Services can make provisions for humane, secure, and safe conditions.

The following procedures will be followed when physical restraint is utilized 3 or more times during a calendar month or for more than 40 hours in 30 consecutive days or as a measure of therapeutic treatment designed to reduce dangerous, aggressive, self-injurious, or undesirable behaviors to a level which will allow the use of less restrictive treatment or habilitation procedures:

1. The Treatment / Person Centered Plan will be revised to include:

• Indication of need
• Specific description of problem behavior
• Specific goal to be achieved and estimated duration of procedure
• Specific early intervention when precursor behaviors are exhibited
• Specific procedure to be employed
• Specific methodology for the intervention
• Methods for measuring treatment efficiency
• Guidelines for discontinuation of the procedure

2. The accompanying positive Treatment Methods which are intended to be as strong as the negative aspects of the plan

3. The specific limitations on approved uses of the intervention per episode and per day and requirements for on-sight assessments by the responsible Professional.

4. The following procedures will only be employed when clinically or medically indicated as method of therapeutic treatment:

• Planned non-attention to specific undesirable behaviors when those behaviors are health threatening;

• Contingent deprivation of any basic necessity; or

• Other professionally acceptable behavior modification procedures that are not prohibited by Rule .0102 of this Section or covered by Rule .0104 of this Section

The determination that a procedure is clinically or medically indicated, and the authorization for the use of such treatment for a specific client, will

• only be made by either a physician or a licensed practicing psychologist who has been formally trained and privileged in the use of the procedure.

• Before implementation of the planned intervention [27E.0104 (g)], the Treatment Team (including the consumer/guardian) must approve the Treatment, Service or Program Plan.

• The Treatment Team must review the use of the approved intervention at least monthly. (Client, client’s legal responsible persons or employees may request a review of any decisions made under the rules in this Subchapter by the area or state agency, or director, or if elsewhere with in the Division, by the Division direct)

• Restrictive interventions will never be the sole treatment modality designed to eliminate the target behavior.

• The Ship Group Community Services Care employees who are authorized and implement interventions will be privileged to do so and will be trained in the intervention technique. They must have demonstrated competency in the use of the intervention.

• Only trained and currently certified staff will be privileged to implement physical restraint.

• The use of restrictive interventions shall be limited to:

• Emergency situations in order to terminate a behavior or action in which a client is in imminent danger of abuse or injury to self or other person(s) or when property damage is occurring that puts the client and others in danger.

• As a planned measure of therapeutic treatment as specified in paragraph (G) of this Rule.

Restrictive interventions will not be employed as retaliation or for the convenience of the agencies and/or staff members. Nor will they be used due to inadequate staffing of the clinical sites. Restrictive interventions will not be used in a manner that causes harm or abuse.

The Ship Group Community Services will ensure:

• Timely notice and explanations to the person who is legally responsible by the Qualified Professional;

• Valid opportunities to consent to or to refuse planned interventions;

• The intervention is justified, properly time-limited, and that appropriate positive and less restrictive alternative are thoroughly, systematically and continuously considered and used;

• When the restrictive is used on a recurring or planned basis, it will be incorporated into a Treatment/Person Centered Plan;

• Implementation by trained staff, closely supervised by a Qualified Professional;

• Manner, conditions, and location of the intervention are safe and humane;

• Implementation is monitored and the monitoring results are disseminated to assure follow through, continuing justification and timely adjustment to meet changing circumstances; and

     • That the safeguards in this Rule are documented

The duties and responsibilities of QP or responsible Professionals regarding the use of restrictive interventions include review of all uses for appropriateness and continual analysis of less restrictive interventions that may prove effective. The qualified professional will also be responsible for notifying the legally responsible person after the use of restrictive interventions, if such notification has been requested and for notifying the contract agency, the Director (designee of the governing body) and the treatment team.

The individual initiating the use of the restrictive intervention is responsible for documentation when restrictive interventions are used. Documentation is required on the incident report and in the consumer record. The incident report is used for quality assurance purposes and should not be referenced nor filed in the consumer record.

The primary physician will be responsible for the identification of a client with a reasonably foreseeable physical consequence to the use of physical restraint and in such cases there will be procedures regarding:

• Documentation of a client with physical disability or past surgical procedures that would make affected nerves and bones sensitive to injury; and

• The identification and documentation of alternative emergency procedures, if needed.

Whenever The Ship Group Community Services utilizes a restrictive intervention, it will be documented in the client’s record to include, at a minimum:

• A notation of the frequency, intensity and duration of the behavior which led to the intervention, and any precipitating circumstance contributing to the onset of the behavior;

• Notification of client’s physical and psychological well-being

• The rationale for the use of the intervention, the positive or less restrictive interventions considered and used which also addresses the inadequacy of less restrictive intervention techniques that were used;

• A description of the intervention and the date, time, and duration of its use;

• A description of accompanying positive methods of intervention;

• A signature and title of the agencies’ employee who initiated the restrictive intervention, and of the employee who further authorized the use of the intervention.

• A description of the debriefing and planning with the client and the legally responsible person if applicable, for the emergency use of seclusion, physical restraint or isolation time-out to eliminate or reduce the probability of the future use of restrictive interventions;

• A description of the debriefing and planning with the client and the legally responsible person if applicable, for the planned use of seclusion, physical restraint or isolation time-out, it determining to be clinically necessary; and

The emergency use of restrictive interventions will be limited, as follows:

• An agency employee trained to administer emergency interventions may employ such procedures for up to 15 minutes without further authorization.

• Continued use of such interventions will be authorized only by the responsible Professional or another Qualified Professional who is approved to use and to authorize to use the restrictive intervention based on experience and training.

The responsible professional must meet with and conduct an assessment that includes the physical and psychological well-being of the client and write a continuation authorization as soon as possible after the time of initial employment of the intervention.

• If the responsible professional or a qualified professional is not immediately available to conduct an assessment of the client, but concurs that the intervention is justified after discussion with the agency employee, continuation of the intervention may be verbally authorized until an on-site assessment of the client can be made.

• Verbal authorization will not exceed 3 hours after the time of initial employment.

• an agency employee must remain present with the client continuously.

• The use of a restrictive intervention must be discontinued immediately at any indication of risk to the client’s health or safety or immediately after the client gains behavioral control. If the client is unable to gain behavioral control within the time frame specified in the authorization of the intervention, a new authorization must be obtained. The written approval of the designee of the governing body is required when the original order for a restrictive intervention is renewed for up to a total of 24 hours in accordance with the limits specified in Item (E) of Subparagraph (e)(10) of this rule. Standing orders or PRN orders shall not be used to authorize the use of seclusion, physical restraint or isolation timeout. The use of restrictive intervention shall be considered a restriction of the client’s rights as well specified in G.S. 122C-62(b) or (d). The documentation requirements in this rule shall satisfy the requirements specified in G.S. 122C-62(e) for rights restrictions. When any restrictive intervention is utilized for a client, notification of others shall occur as follows:

• Those to be notified as soon as possible but within 24 hours of the next working day, to include:

• The treatment or clinical team or its designee, after each use of the intervention;

• A designee of the governing body; and the legally responsible person of a minor or incompetent adult client shall be notified immediately unless she/he has requested to be notified.

Whenever a consumer is being physically restrained, continuous observation of the client will occur and will be documented in the consumer’s record such observation and attention shall be documented in the client’s record. The use of restrictive intervention will be discontinued as soon as therapeutically appropriate but in no case longer than 30 minutes after the client gains behavioral control. If the client is unable to gain behavioral control within the time frame specified in the authorization of the intervention, a new authorization must be obtained.

When any restrictive intervention is utilized for a client, notification of others shall occur as follows:

• Person to be notified, no more than 72 hours after the behavior has been controlled include the following:

• The Treatment Team or it’s representative, after each use of the intervention; and

• The Director/or a designee of the governing body of The Ship Group Community Services , LLC.;

• In a timely fashion the legally responsible person of the client, when such notification has been requested.

The Ship Group Community Services will conduct reviews and reports on any and all use of restrictive interventions, including:

1. A regular review by the Program Director, the Qualified Professional and the quality assurance/quality improvement committee of The Ship Group Community Services , LLC.

2. An investigation of any unusual or possibly unwarranted patterns of utilization

3. Documentation of the following shall be maintained on a log:

a. Name of client

b. Name of Responsible Professional

c. Date of each intervention

d. Time of each intervention

e. Type of intervention

f. Duration of each intervention

g. Reason for use of the intervention

When a restrictive intervention is used as a planned intervention, The Ship Group Community Services will ensure the following:

• Positive and less restrictive alternatives that were used or that were considered but not used and why those alternatives were not used;

• Debriefing and planning conducted with the client, legally responsible person, if applicable, and staff, as specified in parts (e)(9)(F) and (G) of this rule, to eliminate or reduce probability of the restriction intervention, if any, on the physical and psychological well being of the client. The agency shall collect data on the use of seclusion and physical restraint. The data collected and analyzed shall reflect for each incident:

• The type of procedure used and the length of time employed

• Alternatives considered or employed;

• The effectiveness of the procedure or alternative employed

The Ship Group Community Services analyzes the data on at least a quarterly basis to monitor effectiveness, determine trends and take corrective action where necessary. The agency will make the data available to the secretary upon request. Nothing in this rule will be interpreted to prohibit the use of voluntary restrictive interventions at client’s request; however, the procedures in this rule apply with the exception of subparagraph (f)(3) of this rule. The restrictive intervention is considered a planned intervention and may be included in the client’s treatment/Person Centered Plan however it is used: more than four times, or for more than 40 hours, in a calendar month; in a single episode in which the original order is renewed for up to a total of 24 hours in accordance with the limits specified in item (E) of subparagraph (e)(10)of this rule; or as a measure of therapeutic treatment designed to reduce dangerous, aggressive, self-injurious or undesirable behaviors to a level which will allow the use of less restrictive treatment procedures.

When a restrictive intervention is used as a planned intervention, The Ship Group Community Services policy specifies that:

• a consent or approval is considered valid for no more than six months and that the decision to continue the specific intervention shall be based on clear and recent behavioral evidence that the intervention is having a positive impact and continues to be needed;

prior to the initiation or continued use of any planned intervention, the following written notifications, consents and approvals shall be obtained and documented in the client record:

• approval of the plan by the responsible professional and the treatment team, if applicable, will be based on an assessment of the client and a review of the documentation required by Subparagraph (e)(9) and (e)(14) of this rule if applicable;

• consent of the client legally responsible person, after participation in treatment planning and after the specified intervention and the reason for it have been explained in accordance with 10A NCAC 27D .0201 notification of an advocate/client rights representative that the specific intervention has been planned for the client and the rationale for utilization of the intervention; and physician approval,

• after an initial medical examination, when the plan includes a specific intervention with reasonably foreseeable physical consequences. In such cases, periodic planned monitoring by a physician shall be incorporated into the plan.

• Within 30 days initiation of a planned intervention, the Intervention Advisory Committee established in accordance with rule .0106 of this section by majority vote, may recommend approval or disapproval of the plan or may abstain from making a recommendation; within any time during the use of a planned intervention, if requested, the Intervention Advisory Committee shall be given the opportunity to review the Treatment/Person Centered Plan if any of the persons or committees specified in Subparagraphs (h)(2) or (h)(3) of this Rule do not approve the initial use or continued use of a planned intervention, the intervention shall not be initiated or continued. Appeals regarding the resolution of any disagreement over the use of the planned intervention shall be handled in accordance with governing body policy; and description and frequency of debriefing with the client, legally responsible person, if applicable, and staff if determined to be clinically necessary. Debriefing shall be conducted as to the level of cognitive functioning of the client; bi-monthly evaluation of the planned by the responsible professional who approved the planned intervention; and review, at least monthly, by the treatment team that approved the panned intervention.

Seclusion, Restraints and Isolation time-out will not be employed retaliation or for the convenience of staff or used in a manner that causes harm or undue physical or mental discomfort or pain to the client.

PROTECTIVE DEVICES

The Ship Group Community Services governing body prohibits the use of protective devices. In accordance with rule .0101 of subchapter 27D, the governing body has established a policy that delineates the permissible use of restrictive intervention within the agency. Within The Ship Group Community Services , LLC., where restrictive interventions may be used, the policy and procedures are in accordance with the following provisions; the positive and less restrictive alternatives are considered and attempted whenever possible prior to the use of more restrictive interventions; consideration is given to the client’s physical and psychological well-being before, during and after utilization of a restrictive intervention, including: review of the client's health history or the client's comprehensive health assessment conducted upon admission to the agency. The health history or comprehensive health assessment shall include the identification of pre-existing medical conditions or any disabilities and limitations that would place the client at greater risk during the use of restrictive interventions.

The duties and responsibilities of responsible professionals regarding the use of restrictive interventions have been established as follows:

Continuous assessment and monitoring of the physical and psychological well- being of the client and the safe use of restraint throughout the duration of the restrictive intervention, by staff who are physically present and trained in the use of emergency safety interventions, will be maintained at any and all times requiring the use of restrictive interventions.

The use of restrictive interventions requires continuous monitoring by an individual trained in the use of cardiopulmonary resuscitation of the client's physical and psychological well-being during the use of manual restraint; and further requires continued monitoring by an individual trained in the use of cardiopulmonary resuscitation of the client's physical and psychological well-being for a minimum of 30 minutes subsequent to the termination of a restrictive intervention.

All The Ship Group Community Services employees must successfully complete both an interview and background check, along with satisfactory completion of all training aspects of NCI in order to help streamline the process of identifying, training, assessing competence of agency employees who may authorize and implement restrictive interventions. Employees that have not successfully completed or maintained current NCI status will not participate in restrictive interventions until all training requirements have been met.

All episodes resulting in the use of restrictive interventions will be documented by the staff that initiated the use of the restrictive intervention, during the shift in which the event occurred, and further reported to the Qualified Professional and/or Clinical Director.

Each direct care employee is responsible, at the beginning of each shift, for checking the client's physical and psychological well-being and assessing the possible consequences of the use of a restrictive intervention and, in such cases, there shall be documentation in the client record if the client has a physical disability or has had surgery that would make affected nerves and bones sensitive to injury; and

In the event where the need for additional medical or psychiatric treatment is identified, documentation of alternative emergency procedures, if needed, and a signature and title of the agency employee who initiated, and of the employee who further authorized, the use of the intervention must be included in the incident report.

Whenever restrictive intervention is utilized, documentation must be made in the client record to include, at a minimum:

• notation of the client's physical and psychological well-being;

• notation of the frequency, intensity and duration of the behavior which led to the intervention, and any precipitating circumstance contributing to the onset of the behavior

• the rationale for the use of the intervention, the positive or less restrictive interventions considered and used and the inadequacy of less restrictive intervention techniques that were used;

• a description of the intervention and the date, time and duration of its use;

• a description of accompanying positive methods of intervention;

• a signature and title of the facility employee who initiated, and of the employee who further authorized the use of the intervention.

The emergency use of restrictive interventions has established limitations, as follows:

a. a The Ship Group Community Services Care employee approved to administer emergency interventions may employ such procedures for up to 15 minutes without further authorization;

b. the continued use of such interventions must be authorized only by the responsible professional or another qualified professional who is approved to use and to authorize the use of the restrictive intervention based on experience and training;

c. the responsible professional will meet with and conduct an assessment that includes the physical and psychological well-being of the client and write a continuation authorization as soon as possible after the time of initial employment of the intervention. If the responsible professional or a qualified professional is not immediately available to conduct an assessment of the client, but concurs that the intervention is justified after discussion with the agency employee, continuation of the intervention may be verbally authorized until an on-site assessment of the client can be made;

d. a verbal authorization shall not exceed three hours after the time of initial employment of the intervention; and

The following precautions and actions are employed whenever a client is in physical restraint and may be subject to injury: a The Ship Group Community Services employee must remain present with the client continuously.

When any restrictive intervention is utilized for a client, notification of others will occur as follows:

Those to be notified as soon as possible but within 24 hours of the next working day, to include,

• the treatment team, or its designee, after each use of the intervention; and

• a designee of the governing body; and

• the legally responsible person of a minor client or an incompetent adult client shall be notified immediately unless she/he has requested not to be notified.

The Ship Group Community Services Care will conduct reviews and reports on any and all use of restrictive interventions, including:

A regular review by a designee of the governing body, and review by the Client Rights Committee, in compliance with confidentiality rules as specified in 10A NCAC 28A; an investigation of any unusual or possibly unwarranted patterns of utilization; and documentation of the following shall be maintained on a log:

• name of the client;

• name of the responsible professional;

• date of each intervention;

• time of each intervention;

• type of intervention;

• duration of each intervention;

• reason for use of the intervention;

• positive and less restrictive alternatives that were used or that were considered but not used and why those alternatives were not used;

• debriefing and planning conducted with the client, legally responsible person, if applicable, and staff, as specified in Parts (e)(9)(F) and (G) of this Rule, to eliminate or reduce the probability of the future use of restrictive interventions; and

• negative effects of the restrictive intervention, if any, on the physical and psychological well-being of the client.

• the type of procedure used and the length of time employed;

• alternatives considered or employed; and the effectiveness of the procedure or alternative employed.

• The Ship Group Community Services Care analyzes the data on at least a quarterly basis to monitor effectiveness, determine trends and take corrective action where necessary. The agency shall make the data available to the Secretary upon request. Nothing in this Rule shall be interpreted to prohibit the use of voluntary restrictive interventions at the client's request; however, the procedures in this Rule may apply with the exception of Subparagraph (f)(3) of this Rule.

When a restrictive intervention is used as a planned intervention, The Ship Group Community Services Care policy specifies:

• the requirement that a consent or approval be considered valid for no more than six months and that the decision to continue the specific intervention be based on clear and recent behavioral evidence that the intervention is having a positive impact and continues to be needed;

Prior to the initiation or continued use of any planned intervention, the following written notifications, consents and approvals must be obtained and documented in the client record:

• approval of the plan by the responsible professional and the treatment team, if applicable, will be based on an assessment of the client and a review of the documentation required by Subparagraph (e)(9) and (e)(14) of this Rule if applicable; consent of the client or legally responsible person, after participation in treatment planning and after the specific intervention and the reason for it have been explained in accordance with 10A NCAC 27D .0201;

• notification of an advocate/client rights representative that the specific intervention has been planned for the client and the rationale for utilization of the intervention; and

• physician approval, after an initial medical examination, when the plan includes a specific intervention with reasonably foreseeable physical consequences. In such cases, periodic planned monitoring by a physician will be incorporated into the plan.

• 
  

According to The Ship Group Community Services policy, within 30 days of initiation of the use of a planned intervention, the Intervention Advisory Committee established in accordance with Rule .0106 of this Section, by majority vote, may recommend approval or disapproval of the plan or may abstain from making a recommendation; within any time during the use of a planned intervention, if requested, the Intervention Advisory Committee will be given the opportunity to review the treatment plan; if any of the persons or committees specified in Subparagraphs (h)(2) or (h)(3) of this Rule do not approve the initial use or continued use of a planned intervention, the intervention may not be initiated or continued. Appeals regarding the resolution of any disagreement over the use of the planned intervention shall be handled in accordance with governing body policy; and description and frequency of debriefing with the client, legally responsible person, if applicable, and staff if determined to be clinically necessary. Debriefing will be conducted as to the level of cognitive functioning of the client; bi-monthly evaluation of the planned by the responsible professional who approved the planned intervention; and review, at least monthly, by the treatment team that approved the planned intervention.

INTERVENTION ADVISORY COMMITTEES

An Intervention Advisory Committee has been established to provide additional safeguards in agencies of The Ship Group Community Services that utilize restrictive interventions as planned interventions. The membership of the Intervention Advisory Committee will include at least one person who is or has been a consumer of direct services provided by the agency or who is a close relative of a consumer. At least three citizens who are not employees of or members of the governing body will serve as committee members. Additionally, the Intervention Advisory Committee will have a member or a regular independent consultant who is a Professional with training and expertise in the use of the type of interventions being utilized, and who is not directly involved in the treatment or habilitation of a client served by the agencies.

Access to client information will only be given to committee members when necessary for them to perform their duties and upon written consent of the consumer/legally responsible person. Committee members will receive specific training and orientation as to the charge of the committee, will be given copies of appropriate statutes and rules governing client rights and related issues, and be provided, when available, with copies of literature about the use of a proposed intervention and any alternatives.

The intervention advisory committee will make an annual written report to the governing body on the activities of the committee. An Intervention Advisory Committee shall be established to provide additional safeguards in a agency that utilizes restrictive interventions as planned interventions as specified in Rule .0104(g) of this Section.

The membership of the Intervention Advisory Committee shall include at least one person who is or has been a consumer of direct services provided by the governing body or who is a close relative of a consumer and:

for an agency operated by an area program, the Intervention Advisory Committee shall be the Client Rights Committee or a subcommittee of it, which may include other members;

for an agency that is not operated by an area program, but for which a voluntary client rights or human rights committee has been appointed by the governing body, the Intervention Advisory Committee shall be that committee or a subcommittee of it, which may include other members; or

for an agency that does not meet the conditions of Subparagraph (b)(1) or (2), the committee shall include at least three citizens who are not employees of, or members of the governing body.

The Intervention Advisory Committee specified in Subparagraphs (b)(2) or (3) shall have a member or a regular independent consultant who is a professional with training and expertise in the use of the type of interventions being utilized, and who is not directly involved in the treatment or habilitation of the client.

The Intervention Advisory Committee implements policy that governs its operation and requirements that:

a. access to client information may be given only when necessary for committee members to perform their duties;

b. committee members may have access to client records on a need to know basis only upon the written consent of the client or his legally responsible person as specified in G.S. 122C-53(a); and

c. information in the client record shall be treated as confidential information in accordance with G.S. 122C-52 through 122C-56;

d. receive specific training and orientation as to the charge of the committee;

e. be provided with copies of appropriate statutes and rules governing client rights and related issues;

f. be provided, when available, with copies of literature about the use of a proposed intervention and any alternatives;

g. maintain minutes of each meeting; and

h. make an annual written report to the governing body on the activities of the committee.