| |
|
|
ILLINOIS
|
|
Standard or
Definition
|
TITLE 89: SOCIAL SERVICES
CHAPTER III: DEPARTMENT OF CHILDREN AND
FAMILY SERVICES
SUBCHAPTER d: LICENSING ADMINISTRATION
PART 384
BEHAVIOR TREATMENT IN RESIDENTIAL CHILD
CARE FACILITIES
AUTHORITY: Implementing and authorized by the Child Care
Act of 1969 [225 ILCS 10].
SOURCE: Adopted and codified at 6 Ill. Reg. 13713,
effective November 15, 1982; emergency amendments at 18 Ill. Reg. 8474,
effective May 20, 1994, for a maximum of 150 days; emergency expired October
17, 1994; amended at 19 Ill. Reg. 8165, effective June 9, 1995; amended at 26
Ill. Reg. effective March 15, 2002.
This Part applies
only to the following types of facilities licensed by the Department of
Children and Family Services: secure child care facilities, child care
institutions, group homes, and youth emergency shelters (as restricted by 89
Ill. Adm. Code 410, Licensing Standards for Youth Emergency Shelters). No
other facility licensed by the Department is authorized to use manual
restraint or seclusion.
|
|
Web site
|
http://www.state.il.us.dcfs.384.pdf
|
|
Restraint
Definition
|
Manual restraint means a behavior management technique
involving the use of physical contact or force, characterized by measures
such as arm or body holds, subject to the provisions of Section 384.50.
|
|
Restraint
Exclusions
|
"Extended
restriction" means periods of touching or holding by direct
person-to-person contact for a period of less than five minutes. Physical
restriction shall not constitute manual restraint if it is accomplished with
minimum force and is used to prevent a child from completing an act that is
likely to result in harm to self or others or to escort a child to a quieter
environment. Extended restriction must be documented in the child's record,
i.e., progress notes.
Manual restraint shall not be used as discipline for rule
infractions or as a convenience for staff.
A child may not be restrained for more than 15 minutes
beyond the point at which the child ceases presenting the specific behavior
for which the restraint was ordered or any other behavior for which restraint
is an appropriate intervention, unless specific clinical justification to the
contrary is documented in the child's treatment plan.
Manual restraint shall not consist of, or be accompanied
by, the use of mechanical restraints, the use of excessive or unnecessary
force, or any other action that produces pain, covers the head or any part of
the face, or in any way restricts normal circulation and respiration of the
child. Manual restraints that include neck holds or a staff member lying
across the torso of a client are prohibited.
Manual restraint shall not be used until after other less
restrictive procedures or measures have been explored and found to be
inappropriate. Manual restraint shall not be used for a child whose medical
condition, mental illness, or developmental or psychological status
contraindicates the use of this technique, as documented in the child's
individual treatment plan.
When manual restraint is imposed upon any child whose primary mode of communication is sign
language, the child shall be permitted to have his or her hands free from
restraint for brief periods during the restraint, except when such freedom
may result in physical harm to the child or others.
|
|
Chemical Restraint
Definition/Exclusions
|
"Chemical restraint", a prohibited practice by this Part, means the use of any
psychoactive medication that is not a part of a medical diagnostic or
treatment procedure for the express purpose of restricting an individual’s
freedom of movement that is used during a behavioral crisis or behavioral
emergency and results in the sedation of the child.
|
|
Seclusion
Definition
|
Seclusion means the contingent withdrawal of reinforcing
stimuli by removing the child from an area to a specifically designated room
from which egress is restricted. This procedure is considered a behavior
management technique and as such must be used only as a therapeutic response
to dangerous behavior. There are two forms of seclusion:
Staff-assisted
seclusion means the room is secured by a locking mechanism that engages
only when a key, button, or handle is being held by a staff member. When that
staff member takes his or her hand off the device, the door unlocks and the
child is able to easily and readily open the door from the inside. The door
to such a room may not/does not remain locked when unattended.
Key-locked
seclusion means the seclusion room has a locking device that remains
engaged without staff presence. Key-locked
seclusion is prohibited under this Part.
|
|
Seclusion
Exclusions
|
Seclusion shall not be used until after other, less
restrictive procedures or measures have been explored and found to be
inappropriate. Seclusion shall not be used for a child whose medical
condition, mental illness or developmental or psychological status
contraindicates the use of the technique, as documented in the individual
treatment plan.
Seclusion may be used to prevent runaway only when the
child presents a threat of physical harm to self or others.
Seclusion shall not be used as discipline for rule
infractions or for the convenience of staff.
Key-locked seclusion means the seclusion room has a
locking device that remains engaged without staff presence. Key-locked seclusion is prohibited under
this Part.
|
|
Mechanical Restraint/
Exclusions
|
"Mechanical restraint", as used in this Part,
means any device (including but not limited to straight jacket, arm/leg
restraints, and four-point restraints), other than personal physical force,
used to directly restrict the limbs, head or body of a person. The term does
not include medical restraint.
Mechanical
restraint may not be used in facilities licensed by the Department of
Children and Family Services, except as allowable under 89 Ill. Adm. Code 411
(Licensing Standards for Secure Child Care Facilities).
"Medical
restraint" means a process used
for the partial or total immobilization of a person for the purpose of
performing or maintaining a medical/surgical procedure under the supervision
of a licensed physician or registered nurse or as a physician-ordered
treatment for self-injurious behavior.
|
|
Criteria for
Restraint and Seclusion
|
General criteria
for behavior management including restraint and seclusion
[Agency must have:]
·
A procedure for review of the child's medical
record that shall contain explicit documentation by the consulting physician
for the facility that there are no
medical contraindications to the use of specific behavior treatment
techniques. This assessment and documentation must be renewed following any
significant change in the child's medical condition.
·
A procedure for review of any determination
made by the treatment team at the child's initial case staffing as to whether
any of the established behavior treatment procedures would be contraindicated
due to psychological or developmental reasons and documentation by the team
in the child's permanent record. This review and documentation shall be
renewed following any significant change in the child's developmental or
psychological condition and at least once per quarter as part of a treatment
review.
With respect to all discipline:
·
Prior to the application of the discipline,
the child shall be informed of the rule, or infraction.
·
Prior to application of the discipline, the
reasons for, the nature of, and duration of the discipline shall be explained
to the child.
Restraint specific
criteria
Each application of manual restraint may be used only as a
therapeutic measure when a child presents a threat of physical harm to self
or others. Such threat shall include any dangerous behavior reasonably
expected to lead to physical harm to self or others.
Manual restraint may be used to prevent runaway only when
the child presents a threat of physical harm to self or others, or as
specified in the individual treatment
plan.
When manual restraint is imposed upon any child whose primary mode of communication is sign
language, the child shall be permitted to have his or her hands free from
restraint for brief periods during the restraint, except when such freedom
may result in physical harm to the child or others.
Seclusion specific
criteria
Seclusion is
limited to children age six and older who have been placed in a child
care facility and who pose a threat of physical harm to themselves or others.
Such threat may include any dangerous behavior reasonably expected to lead to
physical harm to self or others.
Seclusion room
critera:
Seclusion shall be in a room at least 40 square feet with
the shortest wall at least 6 feet with an 8 foot ceiling which is heated,
lighted, and ventilated as the other rooms of the facility.
Seclusion rooms are to be unfurnished and may have padding
that is designed specifically for use in psychiatric or similar settings and
approved by the local health and fire authorities. Light fixtures are to be
screened or recessed, and interior door knobs are to be removed.
Seclusion rooms shall be approved by the Department's
licensing unit prior to usage. The Department is authorized to waive certain
space requirements that represent a minimal variance from the requirements of
this subsection (a)(2). Seclusion rooms must be inspected and approved under
the regulations adopted by the Office of the State Fire Marshal;
Duration criteria:
A child may not be kept in seclusion more than 15 minutes
beyond the point at which the child ceases presenting the specific behavior
for which the seclusion was ordered or any other behavior for which seclusion
is an appropriate intervention.
No child may be
kept in seclusion longer than a total of four hours in any 24 hour period.
If continuous seclusion is necessary for more than two hours, a mental health
professional shall approve continuing the seclusion on an hourly basis with a
total episode of seclusion not to exceed four hours. The treatment team must
explore alternative treatment strategies, such as an emergency SASS or
transporting the child to a hospital or mental health facility.
Other criteria:
Belts, shoes, matches, weapons, or any other object that
can be used to inflict self-injury are to be taken from the child or removed
from the room prior to placement of the child in the seclusion room if there
are indications in the child's record or the child's current behavior that
such precautions are warranted.
Children placed in seclusion shall not be deprived of
clothing (other than belts or items that may be used to inflict self-injury),
food, toileting, medication, or other basic living functions.
|
Monitoring
Requirements
|
Restraint
For any child posing documented medical or clinical risk
factors that may be negatively impacted by the use of specific behavior
treatment techniques, a licensed physician or registered/licensed nurse must
conduct a physical exam of the child during each application of the
procedures, with documentation of the examination to be noted in the medical
record.
For every restraint episode that exceeds 30 consecutive
minutes, a registered nurse or a licensed physician must be notified and
consulted by telephone or in person concerning the restraint. The licensed
physician or registered nurse must confirm, in writing, the content of the
consultation and document that the
restraint does not pose an undue risk to the child's health given the child's
physical or medical condition. At the same time, the treatment team must
explore alternative treatment strategies, such as an emergency SASS
assessment or transporting the child to a hospital or mental health facility.
No child may be restrained for more than two hours within
a 24 hour period. However, within the two hours of restraint, there may be no
period of continuous restraint that exceeds one hour.
If a child has been in and out of manual restraint for a
total of two hours, the treatment team must explore alternative treatment
strategies, such as an emergency SASS assessment or transporting the child to
a hospital or mental health facility.
Seclusion
The use of seclusion is under the direct management and
supervision of a mental health professional specifically trained in behavior
management who has demonstrated both written and applied competency in the
use of this procedure.
Supervision of a seclusion episode does not require in
person supervision provided that the “mental health professional” has viewed
the seclusion in person and is confident that the seclusion is being applied
according to the agency’s selected model.
The “mental health professional” must review the seclusion
episode immediately upon conclusion of the seclusion to ensure that the
seclusion continued and concluded in a manner that is consistent with the
model and the child’s interest.).
|
|
Ordering and
Initiation
|
Restraint
Application of manual restraint requires direct
authorization, supervision and management by the mental health professional,
as defined in Section 384.20, designated as responsible for making clinical
decisions at the time restraint is applied.
Seclusion
[There is no
specific language about the authorization of seclusion]
|
|
In-person
Assessment
|
Restraint
If this person [a
qualified mental health professional as defined in previous sections]is
not present when restraint is first applied, he or she must be summoned
immediately and maintain supervision and management of the restraint until
the restraint episode is concluded or he or she is relieved by a similarly
qualified and clinically responsible person.
Supervision of a restraint episode does not require in
person supervision throughout the duration of the restraint provided that the
mental health professional has viewed the restraint in person, has confirmed
that the restraint is being applied according to the agency’s selected model
and is confident that the restraint will continue to be so applied.
Seclusion
A staff member trained in the use of the seclusion shall
monitor the child by direct, in-person, visual observation on a continuous
basis.
A staff member assigned to monitor a child in a seclusion
room shall have this monitoring as his or her sole job duty throughout the
period of seclusion in order to ensure the child's safety while in the room,
and will maintain a written record of the observations.
Such observation may be through an uncovered one way
mirror or regular window that provides for observation of the entire room at
all times, if the staff person has unimpeded access to the seclusion room and
normal daily sounds are audible. (There shall be sufficient staff to insure
appropriate supervision of all other children while the staff member is
monitoring the child in seclusion).
|
|
Debriefing
|
Restraint
The administrator of the facility or designee shall review
all written records of manual restraint the next business day. The
administrator or designee shall approve or disapprove of the use of restraint
under the circumstances described and shall indicate review and
approval/disapproval by signing and dating the report of behavior treatment.
If the administrator or designee disapproves of this instance of manual
restraint, the administrator or designee shall state the reasons for
disapproval and shall correct the improper use of manual restraint.
The decision concerning the need for further action, if
any, should be documented whenever any of the following occurs:
1) restraint is used repeatedly and excessively by any
staff person;
2) restraint is used repeatedly and excessively on any
child;
3) the duration of the restraint exceeds 30 minutes;
4) any provision in this Part is violated; or
5) The restraint results in an injury requiring emergency
medical treatment by medical personnel.
Seclusion
Each use of seclusion shall be reported as soon as
practicable and a written record forwarded within 24 hours to the
administrator of the facility or designee, the assigned caseworker in the
facility, and the social work supervisor. The administrator of the facility
or designee shall approve or disapprove the use of seclusion under the
circumstances described and shall indicate review and approval/disapproval by
signing and dating the report. If the administrator or designee disapproves
the use of seclusion in this instance, the administrator or designee shall
state the reasons for disapproval and shall correct the improper use of
seclusion. If the use of seclusion results in an injury requiring emergency
medical treatment by a physician, the senior facility administrator shall be
notified immediately.
The supervisor on duty at the time of the incident and
seclusion shall review the report submitted by the child care staff, inquire
into any irregularities, and sign and date the written report indicating the
date it was reviewed.
[There is no
language in the code about debriefing with the child or youth, and none about
the staff except if the intervention is deemed inappropriate by an
administrator as described above.]
|
|
Family &
Guardian Notification
|
[The agency must
have:]
Restraint
·
A policy providing that the child's parents
(unless parental rights have been terminated), guardian, and attorney shall
be advised of their right to be notified of each instance of manual restraint
or seclusion.
·
Upon request, the administrator of the
facility or designee shall notify the child's parents (unless parental rights
have been terminated), guardian and attorney, in writing, within two business
days, when a child is subjected to manual restraint, and shall provide such
notice for any manual restraint that results in injury to the child within 12
hours. Communication to the child's parent or guardian shall be conducted in
the parent's or guardian's primary language or preferred mode of
communication.
Seclusion
·
A policy providing that the child's parents
(unless parental rights have been terminated), guardian, and attorney shall
be advised of their right to be notified of each instance of manual restraint
or seclusion.
·
Upon request, the child's parents (unless
parental rights have been terminated), guardian and attorney shall be
notified in writing within two business days when a child remains in
seclusion for two hours and within 12 hours when seclusion results in injury.
Communication to the child’s parent or guardian shall be conducted in the
parent’s or guardian’s primary language or preferred mode of communication.
|
|
Notification of
Rights and Restraint and Seclusion Policies and Procedures at admission
|
[The agency must
have:]
·
A policy for informing the child, referring
agencies, parents, and guardians prior to admission concerning the behavior
treatment techniques employed by the facility and the procedures for their
administration.
·
A procedure for obtaining the informed consent
of clients/parents/guardians at intake of the behavior treatment techniques
that will be used as indicated by the client's treatment plan, except in
cases of an unanticipated behavioral emergency.
In order to help a child know the rules of a child care
facility, each facility shall have simple, understandable rules for both
children and staff. The rules shall set the limits of behavior required for
the protection of the group. The rules shall be explained orally in the
child's primary language or preferred mode of communication and a written
copy in the child's primary language or preferred mode of communication shall
be given to each child at the time the child is admitted to the facility.
|
|
Training
|
The mental health
professional responsible for making clinical decisions regarding the use of
manual restraint, seclusion, or other restrictive behavior management
techniques shall have completed at least 15 clock hours of training in the
application of the specific behavior management techniques used by the
facility.
[The agency must
have:]
·
A description of the credentials of the
personnel involved in designing, approving, implementing, monitoring and
overseeing the implementation of the behavior treatment procedures.
·
A system for required training and assuring
the competency (both written and practical) of individuals involved in all
facets of behavior treatment, including a plan for ensuring that all nursing
staff associated with the agency receive annual training on the potential
consequences, complications, and/or physical side. effects associated with
being physically restrained while taking any medications;
·
Each staff member shall receive training in
the rules of the child care facility and shall be given a written copy of the
rules prior to starting active service.
·
Manual restraint shall be employed only by
persons who are certified as having successfully completed a competency based
training program presenting the specific procedures to be used. This
certification must be renewed through a competency based assessment at least
every 12 months. Current certification of competency shall be documented in
the individual's permanent personnel record. If an organized self-governance
program, as defined in Section 384.20, approved by the governing body and the
Department allows for peer participation, only peers having completed such
training may assist with the technique. This training shall include
demonstrated competency in the humane and efficient implementation of the
restraint program as demonstrated in applications of the procedures on
participants in the training.
|
|
Documentation
|
Extended restriction must be documented in the child's
record, i.e., progress notes.
The case record shall contain documentation of the
discipline applied, specifying the conduct of the child leading to the
discipline and the nature and duration of the discipline.
Restraint
The written record of manual restraint shall include: the
date of the occurrence, the precipitating incidents; the age, height, weight,
sex and race of the restrained child; the persons who participated in
restraining the child; any witnesses to the precipitating incident and
subsequent restraint; the exact methods of restraint used; the beginning and
ending time of the restraint; a detailed description of any injury arising
from the incident or restraint; and a summary of any medical care provided.
The supervisor in charge at the time of the incident and restraint shall
review the report submitted by staff, inquire into any irregularities, and
sign and date the written report indicating the date it was reviewed and
approved or disapproved.
Seclusion
[The agency must
have:]
·
A written log is to be kept of each seclusion
episode. The staff member monitoring the seclusion shall make an entry in the
log at least once every 15 minutes, clearly describing the behavior of the
child at that time and a clinical impression of whether the behavior requires
continuation of the seclusion.
A written report shall be created and maintained for each
episode of seclusion. This report shall state the events and behavior leading
to the initiation of seclusion; any additional behavior presented by the
child during the seclusion period that required continuation of seclusion;
the date of the occurrence; the age, height, weight, sex and race of the
secluded child; the precipitating incidents; the persons (including other
peers) who participated in secluding the child; any witnesses to the
precipitating incident and subsequent seclusion; the exact methods of
seclusion used; the beginning and ending time of the seclusion; and a
detailed description of any injury occurring as a result of the incident and
seclusion.
The supervisor on duty at the time of the incident and
seclusion shall review the report submitted by the child care staff, inquire
into any irregularities, and sign and date the written report indicating the
date it was reviewed.
|
|
Reporting
|
[Agency must have:]
·
A detailed description of the agency's ongoing
system for collecting and reviewing monthly aggregate data that reflect the
use of restrictive treatment elements, including the number of applications
of seclusion and/or manual restraint, the number of individuals whose
behavior resulted in seclusion and/or manual restraint, the names of staff
members who participated in each instance of seclusion or restraint, the
range and average length of seclusion and/or manual restraint, and unusual
incidents and injuries.
·
A procedure for handling and reporting
behavior emergencies.
The mental health professional must review the restraint
episode immediately upon conclusion of the restraint to ensure that the
restraint continued and concluded in a manner that is consistent with the
model and the child’s interest. Each use of manual restraint shall be
reported as soon as practicable and a written record forwarded within 24
hours to the administrator of the facility or designee, the assigned
caseworker in the facility, and the social work supervisor. If the use of
manual restraint results in an injury requiring emergency medical treatment
by medical personnel or exceeds 60 consecutive minutes, the senior agency
administrator shall be contacted immediately.
Section 384.90 Reports
·
Child care facilities shall report to the
Department licensing authority unusual incidents regarding discipline and
behavior management of children placed in the facility.
·
The facility shall report as an unusual
incident:
·
any injury received by a child as a result of
discipline or behavior management;
·
any 30-day period in which five or more
instances of restraint and/or confinement of a specific child occurred;
·
any violation of this Part.
·
Reports shall be made in writing and
postmarked within two business days after the unusual incident.
|
|
Quality Improvement
|
"Behavior Treatment Committee" means a
professional review or behavior treatment review committee formed by one or
more child care facilities and composed of persons with technical expertise
in the use of crisis prevention, and behavior management techniques. At least
one member of the committee must be a person who is not an owner, employee,
principal shareholder owning at least 5% of the stock of the corporation or
member of the governing body of any of the participating child care
facilities.
This committee fulfills a
quality assurance function and reviews
for technical acceptability the use of a facility’s applicable behavior
treatment procedures that have been outlined in the facility’s Behavior
Treatment Plan. This would include a retrospective examination of at least
13% of all interventions, or 25% of all interventions in the case of programs
with fewer than 25 total residents, and all grievances submitted concerning
the use of restrictive intervention to determine whether there is a clinical
basis for the use of the procedure, whether a procedure of this level is
warranted, and what is the standard of best clinical practice. The committee
shall meet at least once per quarter, and written documentation (i.e.,
minutes) of all meetings shall be maintained. A quality assurance/quality
improvement committee may function as the Behavior Treatment Committee when
the committee membership meets the requirements of this definition.
“Human Rights Committee" means a group of three or
more persons that includes an attorney, or access to an attorney, who
understands mental health law. At least one member of the Human Rights
Committee shall not be an owner, employee, principal shareholder owning at
least 5% of the stock of the corporation, or member of the governing body of
any of the participating child care facilities.
Human
Rights Committees are charged with assuring that children's rights are
protected. The Committee is responsible for reviewing procedures and
practices for intrusive or restrictive behavior interventions that are
expressed in the child care facility’s Behavior Management Plan. The
committee assures that the facility’s procedures assure, among other things,
that processes and practices address informed consent, due process and
grievances, least restrictive practices, and appropriateness of fit to the
population served and that they broadly reflect community standards for
conduct. The Committee also recommends acceptance of the facility’s practices
to the Chief Executive Officer for referral to the governing body for
approval. The Human Rights Committee must meet at least annually.
|
 Back to Top  Printer-friendly Page  Contact Us
|
|
