R432-152-15. Client Behavior and Facility Practices

(1) The facility shall develop and implement written policies and procedures for the management of conduct between staff and clients.

(2) The policies and procedures shall:

(a) promote the growth, development and independence of the client;

(b) address the extent to which client choice will be accommodated in daily decision-making, emphasizing self-determination and self-management to the extent possible;

(c) specify client conduct to be allowed or not allowed; and

(d) be available to all staff, clients, parents of minor children, and legal guardians.

(3) To the extent possible, clients shall participate in the formulation of these policies and procedures.

(4) Clients shall not discipline other clients, except as part of an organized system of self-government, as set forth in facility policy.

(5) The facility shall develop and implement written policies and procedures that govern the management of inappropriate client behavior.

(a) The policies and procedures shall be consistent with the provisions of R432-152-15(2).

(b) The policies and procedures shall:

(i) specify all facility-approved interventions to manage inappropriate client behavior;

(ii) designate these interventions on a hierarchy to be implemented, ranging from most positive or least intrusive, to least positive or most intrusive; and

(iii) ensure, prior to the use of more restrictive techniques, that less restrictive measures have been implemented with the results documented in the client's record.

(c) The policies and procedures shall address the following:

(i) the use of time-out rooms;

(ii) the use of physical restraints;

(iii) the use of chemical restraints to manage inappropriate behavior;

(iv) the application of painful or noxious stimuli;

(v) the staff members who may authorize the use of specified interventions; and

(vi) a mechanism for monitoring and controlling the use of such interventions.

(d) Interventions to manage inappropriate client behavior shall be employed with safeguards and supervision to ensure that the safety, welfare and civil and human rights of clients are adequately protected.

(e) A facility may not utilize p.r.n. or as needed programs to control inappropriate behavior.

(6) A client may be placed in a time-out room from which egress is prevented only if the following conditions are met:

(a) The placement is part of an approved systematic time-out program as required by R432-152-15(5).

(b) The client is under the direct constant visual supervision of designated staff.

(c) The door to the room is held shut by staff or by a mechanism requiring constant physical pressure from a staff member to keep the mechanism engaged.

(d) Placement of a client in a time-out room shall not exceed one hour per incident of maladapted behavior.

(e) Clients placed in time-out rooms shall be protected from hazardous conditions including sharp corners and objects, uncovered light fixtures, and unprotected electrical outlets.

(f) The facility must maintain a log for each time-out room.

(7) A facility may employ physical restraints only:

(a) as an integral part of an individual program plan that is intended to lead to less restrictive means of managing and eliminating the behavior for which the restraint is applied;

(b) as an emergency measure, but only if absolutely necessary to protect the client or others from injury; or

(c) as a health-related protection prescribed by a physician, but only if absolutely necessary during the conduct of a specific medical or surgical procedure, or only if absolutely necessary for client protection during the time that a medical condition exists.

(8) A facility may apply emergency restraints for initial or extended use for no longer than 12 consecutive hours for the combined initial and extended use time period provided that authorization is obtained as soon as the client is restrained or stable.

(9) A facility may not issue orders for restraint on a standing or as needed basis.

(10) Facility staff must check clients placed in restraints at least every 30 minutes and maintain documentation of these checks.

(a) Restraints must be applied to cause the least possible discomfort and may not cause physical injury to the client.

(b) Facility staff must provide and document opportunity for motion and exercise for a period of not less than 10 minutes during each two hour period in which a restraint is employed.

(c) Barred enclosures shall not be more than three feet in height and shall not have tops.

(11) The facility shall not administer drugs at a dose that interferes with a client's daily living activities.

(a) Drugs used for control of inappropriate behavior must be approved by the interdisciplinary team and be used only as an integral part of the client's individual program plan that is directed specifically towards the reduction of and eventual elimination of the behaviors for which the drugs are employed.

(b) Drugs used for control of inappropriate behavior shall be:

(i) monitored closely, in conjunction with the physician and the drug review requirement; and

(ii) gradually withdrawn at least annually in a carefully monitored program conducted in conjunction with the interdisciplinary team, unless clinical evidence justifies that this is contraindicated.