Library: Policy

317:30-5-95.39. Restraint, seclusion, and serious occurrence reporting requirements for members under the age of twenty-one (21)

Revised 9-14-18

(a) All PRTFs must comply with the condition of participation for restraint or seclusion, as is established by 42 C.F.R. '' 483.350 through 483.376, which is hereby incorporated by reference in its entirety. All general and psychiatric hospitals must comply with the standard for restraint or seclusion, as is established by 42 C.F.R. ' 482.13(e) B (g), which is hereby incorporated by reference in its entirety. In the case of any inconsistency or duplication between these federal regulations and OAC 317:30-5-95.39, the federal regulations shall prevail, except where OAC 317:30-5-95.39 and/or other Oklahoma law is more protective of a member's health, safety, or well-being.

(b) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the member, a staff member, or others from harm and may only be imposed to ensure the immediate physical safety of the member, a staff member, or others. The use of restraint or seclusion must be in accordance with a written modification to the member's individual plan of care. The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the member or others from harm. Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. Mechanical restraints will not be used on children under age eighteen (18).

(1) Each facility must have policies and procedure to describe the conditions in which restraint or seclusion would be utilized, the behavioral/management intervention program followed by the facility, and the documentation required. Restraint or seclusion may only be ordered by the following individuals trained in the use of emergency safety interventions: a Physician; a Physician Assistant (PA); or an Advanced Practice Registered Nurse (APRN) with prescriptive authority. If, however, the member's treatment team physician is available, then only he or she can order restraint or seclusion. Each order for restraint or seclusion may only be renewed in accordance with the following limits for up to a total of twenty-four (24) hours:

(A) four (4) hours for adults eighteen (18) to twenty-one (21) years of age;

(B) two (2) hours for children and adolescents nine (9) to seventeen (17) years of age; or

(2) An order for the use of restraint/seclusion must never be written as a standing order or on an as-needed basis.

(3) The documentation required to ensure that restraint or seclusion was appropriately implemented and monitored will include, at a minimum:

(A) documentation of events leading to intervention used to manage the violent or self-destructive behaviors that jeopardize the immediate physical safety of the member or others;

(B) documentation of alternatives or less restrictive interventions attempted;

(C) a signed order for restraint/seclusion that includes the name of the individual ordering the restraint/seclusion, the date and time the order was obtained, and the length of time for which the order was authorized;

(D) the time the restraint/seclusion actually began and ended;

(E) the name of staff involved in the restraint/seclusion;

(F) documentation sufficient to show the member was monitored in accordance with 42 C.F.R. ' 482.13(e) (for general and psychiatric hospitals) or 42 C.F.R. '' 483.362 and 483.364 (for PRTFs), as applicable;

(G) the time and results of a face-to-face assessment completed within one (1) hour after initiation of the restraint/seclusion by a Physician, PA, APRN with prescriptive authority, or Registered Nurse, who has been trained in the use of emergency safety interventions. The assessment must evaluate the member's well-being, including those criteria set forth in 42 C.F.R. ' 482.13(e) (for general and psychiatric hospitals) or 42 C.F.R. ' 483.358(f) (for PRTFs), as applicable;

(H) in the event the face-to-face assessment was completed by anyone other than the member's treatment team physician, documentation that he or she consulted the member's treatment team physician as soon as possible after completion of the face-to-face assessment;

(I) debriefing of the child and staff involved in the emergency safety intervention within twenty-four (24) hours, in accordance with 42 C.F.R. ' 483.370, as applicable;

(J) debriefing of all staff involved in the emergency safety intervention and appropriate supervisory and administrative staff within twenty-four (24) hours, in accordance with 42 C.F.R. ' 483.370, as applicable; and

(K) for minors, notification of the parent(s)/guardian(s).

(1) In accordance with 42 C.F.R. ' 483.374, PRTFs must notify the OHCA Behavioral Health Unit and Oklahoma Department of Human Services (DHS) by phone no later than 5:00 p.m. on the business day following a serious occurrence and disclose, at a minimum: the name of the member involved in the serious occurrence; a description of the occurrence; and the name, street address, and telephone number of the facility.

(A) Within three (3) days of the serious occurrence, a PRTF must also submit a written Facility Critical Incident Report to the OHCA Behavioral Health Unit containing: the information in OAC 317:30-5-95.39(c)(1), above; and any available follow-up information regarding the member's condition, debriefings, and programmatic changes implemented (if applicable). A copy of this report must be maintained in the member's record, along with the names of the persons at OHCA and DHS to whom the occurrence was reported. A copy of the report must also be maintained in the incident and accident report logs kept by the facility.

(B) In the case of a minor, the PRTF must also notify the member's parent(s) or legal guardian(s) as soon as possible, and in no case later than twenty-four (24) hours after the serious occurrence.

(2) In addition to the requirements in paragraph (1), above, the death of any member must be reported in accordance with 42 C.F.R. ' 482.13(g) (hospital reporting requirements for deaths associated with the use of seclusion or restraint) or 42 C.F.R. ' 483.374(c) (PRTF reporting requirements for deaths), as applicable.

(d) In accordance with 42 C.F.R. ' 483.374(a), OHCA requires all PRTFs that provide SoonerCare inpatient psychiatric services to members under age twenty-one (21) to attest in writing at the time of contracting, that the facility is in compliance with all federal standards governing the use of restraint and seclusion. The attestation letter must be signed by the facility director, and must include, at a minimum:

(1) the name, address, and telephone number of the facility, and its provider identification number;

(2) the name and signature of the facility director;

(3) the date the attestation is signed;

(4) a statement certifying that the facility currently meets all of the federal requirements governing the use of restraint and seclusion;

(5) a statement acknowledging the right of OHCA, CMS, and/or any other entity authorized by law, to conduct an on-site survey at any time to validate the facility's compliance with 42 C.F.R. '' 483.350 through 483.376, to investigate complaints lodged against the facility, and to investigate serious occurrences;

(6) a statement that the facility will notify the OHCA if it is out of compliance with 42 C.F.R. '' 483.350 through 483.376; and

(7) a statement that the facility will submit a new attestation of compliance in the event the facility director changes, for any reason.