10A ncac 28D .0203       GENERAL POLICIES REGARDING INTERVENTIVE PROCEDURES

(a)  This Rule governs the policies and requirements regarding the use of the following interventions:

(1)           seclusion;

(2)           physical restraint including:

(A)          mechanical restraint; or

(B)          manual restraint;

(3)           isolation time-out;

(4)           exclusionary time-out for more than 15 minutes;

(5)           time-out for more than one hour;

(6)           protective devices when used for behavioral control;

(7)           contingent withdrawal or delay of access to personal possessions or goods to which the client would ordinarily be entitled;

(8)           consistent deprivation of items or cessation of an activity which the client is scheduled to receive (other than basic necessities); and

(9)           overcorrection which the client resists.

(b)  The  state facility director shall develop policies and procedures for those interventions determined to be acceptable for use in the state facility.  Such policies and procedures shall include that:

(1)           positive alternatives and less restrictive alternatives are considered and used whenever possible prior to the use of seclusion, physical restraint or isolation time-out; and

(2)           consideration is given to the client's physical and psychological well-being before, during and after utilization of a restrictive intervention, including:

(A)          review of the client's health history or the comprehensive health assessment conducted upon admission to a facility. 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;

(B)          continuous assessment and monitoring of the physical and psychological well-being of the client and the safe use of physical restraint throughout the duration of the restrictive intervention by staff who are physically present and trained in the use of emergency safety interventions;

(C)          continuous monitoring of the client’s physical and psychological well-being by an individual trained in the use of cardiopulmonary resuscitation during the use of manual restraint; and

(D)          continued monitoring of the client’s physical and psychological well-being by an individual trained in the use of cardiopulmonary resuscitation for a minimum of 30 minutes subsequent to the termination of a restrictive intervention;

(3)           procedures for ensuring that the competent adult client or legally responsible person of a minor client or incompetent adult client is informed in a manner he or she can understand:

(A)          of the general types of intrusive interventions that are authorized for use by the state facility; and

(B)          that the legally responsible person can request notification of each use of an intervention as specified in this Rule, in addition to those situations required by G.S. 122C‑62;

(4)           provisions for humane, secure and safe conditions in areas used for the intervention, such as ventilation,  light and a room temperature consistent with the rest of the state facility;

(5)           attention paid to the need for fluid intake and the provision of regular meals,  bathing and the use of the toilet.  Such attention shall be documented in the client record; and

(6)           procedures for assuring that when an intervention as specified in this Rule has been used with a client three or more times in a calendar month, the following requirements are met:

(A)          A treatment/habilitation plan shall be developed within 10 working days of the third intervention. The treatment/habilitation plan shall include, but not be limited to:

(i)            indication of need;

(ii)           specific description of problem behavior;

(iii)          specific goals to be achieved and estimated duration of procedures;

(iv)          specific early interventions to prevent tension from escalating to the point of loss of control whenever possible;

(v)           consideration, whenever possible, for client's preference for the type of physical restraint to be used;

(vi)          specific procedure(s) to be employed;

(vii)         specific methodology of the intervention;

(viii)        methods for measuring treatment efficacy;

(ix)          guidelines for discontinuation of the procedure;

(x)           the accompanying positive treatment or habilitation methods which shall be at least as strong as the negative aspects of the plan;

(xi)          description and frequency of debriefing, if determined to be clinically necessary;

(xii)         specific limitations on approved uses of the intervention per episode, per day and requirements for on‑site assessments by the responsible professional; and

(xiii)        description of any requirements in Rule .0206 of this Section to be incorporated into the plan;

(B)          In emergency situations, with the approval of the state facility director, the treatment/habilitation team may continue to use the intervention until the planned intervention is addressed in the treatment/habilitation plan;

(C)          The treatment/habilitation team shall explain the intervention and the reason for the intervention to the client and the legally responsible person, if applicable, and document such explanation in the client record;

(D)          Before implementation of the planned intervention, the treatment/habilitation team, with the participation of the client and legally responsible person if applicable, shall approve the treatment/habilitation plan and consent shall be obtained as specified in Rule .0210(e) in this Section;

(E)           The use of the intervention shall be reviewed at least monthly by the treatment/habilitation team and at least quarterly, if still in effect, by a designee of the state facility director.  The designee of the state facility director may not be a member of the client's treatment/habilitation team.  Reviews shall be documented in the client record;

(F)           Treatment/habilitation plans which include these interventions shall be subject to review by the Human Rights Committee in compliance with confidentiality rules as specified in 10A NCAC 28A;

(G)          Each treatment/habilitation team shall maintain a record of the use of the intervention.  Such records or reports shall be available to the Human Rights Committee and internal client advocate within the constraints of 10A NCAC 26B .0209 and G.S. 122C‑53(g);

(H)          The state facility director shall follow the Right to Refuse Treatment Procedures as specified in Section .0300 of this Subchapter; and

(I)            The interventions specified in this Rule shall never be the sole treatment modality designed to eliminate the target behavior.  The interventions are to be used consistently and shall always be accompanied by positive treatment or habilitation methods.

(c)  Whenever the interventions specified in this Subchapter other than seclusion, physical restraint or isolation time-out result in the restriction of a right specified in G.S. 122C‑62(b) and (d), the procedures specified in G.S. 122C‑62(e) shall be followed.  The requirements for restriction of rights associated with the use of seclusion, physical restraint or isolation time-out are specified in Paragraph (f) of Rule .0206 of this Section.

(d)  The state facility director shall assure by documentation in the personnel records that state facility employees who authorize interventions shall be qualified professionals and state facility employees who implement interventions shall be trained and shall demonstrate competence in the area of such interventions, as well as in the use of alternative approaches.

(e)  The state facility director shall maintain a statistical record that reflects the frequency and duration of the individual uses of interventions specified in this Rule.  This statistical record shall be made available to the Human Rights Committee and the Division at least quarterly.

 

History Note:        Authority G.S. 122C‑51; 122C‑53; 122C‑60; 122C‑62; 131E-67; 143B‑147;

Eff. October 1, 1984;

Amended Eff. November 1, 1993; July 1, 1989;

Temporary Amendment Eff. January 1, 2001;

Temporary Amendment Expired October 13, 2001;

Amended Eff. April 1, 2003.