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TEXAS |
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Standard or Definition |
Texas Department of Protective and Regulatory Services
MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES
As of July, 2003 |
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Restraint Definition |
Restraint: The use of physical force alone, the use of a device, or the use of emergency medication in order to assist a child in regaining control. This includes personal restraint, mechanical restraint, and emergency medication as defined in this section.
Personal Restraint: The application of physical force, including escorting, without the use of any device for the purpose of restricting the free movement of the whole or a portion of a child's body in order to control physical activity.
Mechanical Restraint: The application of a device for the purpose of restricting the free movement of the whole or a portion of a child's body in order to control physical activity. |
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Restraint Exclusions |
None. |
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Chemical Restraint Definition |
Chemical Restraint: The use of any chemical, including pharmaceuticals, through topical application, oral administration, injection, or other means, solely for the purpose of immobilizing a child or sedating a child as a mechanism of control.
Emergency Medication: The use of any chemical, including pharmaceuticals, through topical application, oral administration, injection, or other means, in an emergency situation solely for the purpose of modifying a child's behavior. |
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Seclusion Definition |
Seclusion: The placement of a child, for any period of time, in a room or other area where the child is alone and is physically prevented from leaving by a locked or barricaded entryway. |
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Seclusion Exclusions |
An intervention that restricts a child to a room which involves a caregiver placing his or her body between the child and the exit from that area (e.g. standing in the doorway of a room) is not a seclusion because the child is not alone. If a caregiver uses physical force or a physical barrier to restrain a child or prevent a child from leaving, the intervention becomes a personal restraint regulated under §720.1007 of [Appendix M] (relating to Personal Restraint) or seclusion regulated under §720.1011 of [Appendix M] (relating to Seclusion). |
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Criteria for Restraint and Seclusion |
Before the use of restraint or seclusion, a caregiver qualified in behavior intervention must make the determination that the situation is an emergency situation. The basis for this decision must be documented.
No type of restraint or seclusion may be used as:
- punishment;
- a convenience for caregivers; or
- a substitute for program treatment.
Restraint: Personal restraint may only be used in emergency situations as defined in [the Glossary], or to administer intra-muscular medication or other medical treatments prescribed by a physician. In situations where a child is significantly damaging property, but is not posing a risk of harm to himself or others, a short personal restraint may be used to intervene only to immediately prevent the damage and only if less restrictive techniques have been attempted and have failed. The child must be released from this restraint as soon as the damaging behavior has been de-escalated. A personal restraint used to intervene in significant property damage is regulated as a personal restraint under [the 24-Hour Child-Care Licensing Rules].
Before the use of personal restraint, other preventive, de-escalative, less restrictive techniques must be attempted and proven ineffective at defusing the situation.
When personal restraint is appropriate, it must be discontinued as soon as the child's behavior no longer constitutes an emergency situation.
Any personal restraint that employs a technique listed [below] is prohibited:
- restraints that place a child face-down and place pressure on the child's back;
- restraints that obstruct the airways of the child or impair the breathing of the child;
- restraints that obstruct the caregiver's view of the child's face; or
- restraints that restrict the child's ability to communicate.
For children and adolescents ages 9 to 17 years, maximum time in personal restraint must not exceed one hour. For children under age nine years, a personal restraint must not exceed 30 minutes.
Continuation of personal restraint(s) beyond the stated maximum is permitted only if an order from a licensed psychiatrist allowing for the continuation exists.Such an order must meet all of the criteria in [Standard F-2332 and Appendix M,§720.1007(b)] and must include a clinical justification for the amount of time it permits the child to be restrained.
Only a caregiver qualified in behavior intervention may apply personal restraint.When a child must be personally restrained, the caregiver must consider the characteristics of the immediate physical environment and the permitted forms of personal restraint and act to protect the child's safety. Caregivers must make every effort to act to protect the child's privacy, including shielding the child from onlookers. Caregivers must make every effort to act to protect the child's personal dignity and well-being, including ensuring that the child's body is appropriately covered.
If an emergency health situation occurs during personal restraint, the child must be released immediately and treatment obtained.
As soon as possible after personal restraint is started, appropriate caregiver(s) must explain to the child in restraint the behaviors the child must exhibit to be released from the restraint or have the restraint reduced, and permit the child to make suggestions about what actions the caregiver(s) can take to help the child de-escalate.If the child does not appear to understand what action he must take to be releasedfrom the restraint, the caregiver(s) must attempt to re-explain it every 15 minutes until understanding is reached or the child is released from restraint. Personal restraint may be simultaneously implemented in combination with emergency medication only if specifically allowed by written orders and only if the specified restraint(s) is allowed in the facility by the rules in this section.
These orders must include clinical justification for the combination. The clinical justification for the combination of emergency medication and personal restraint must be provided by the physician ordering the emergency medication.
Emergency medication:
The use of emergency medication is only permitted in emergency situations and only when ordered by a licensed physician.
The use of chemical restraint is prohibited.
The use of chemical sprays, drops, ointments, or any form of topically administered substance, including tear gas and pepper sprays, for emergency medication is prohibited.
Medications that have a secondary effect of immobilizing or sedating a child or modifying the behavior of a child, but are administered solely for medical reasonsother than immobilizing or sedating a child or modifying the behavior of the child(e.g. Benadryl for an allergic reaction or medication to control seizures) are notemergency medications or chemical restraints and are not regulated as such under[the 24-Hour Child-Care Licensing Rules.]
Mechanical Restraint:
The use of mechanical restraints is prohibited in all child-care facilities except residential treatment centers and institutions serving mentally retarded children.
Seclusion:
The use of seclusion is prohibited in all child-care facilities except residential treatment centers, child-care facilities serving children with autistic-like behavior, and emergency shelters.
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Monitoring Requirements |
See "In-Person Assessment" |
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Ordering and Initiation |
Restraint:
- A licensed psychiatrist or licensed psychologist may write orders for the use of personal restraint for a specific child. A child's treatment team may write recommendations for the use of personal restraint for a specific child. Orders and treatment team recommendations must state that personal restraint may only be used in emergency situations.
- The psychiatrist or psychologist ordering personal restraint or the treatment team recommending personal restraint must first take into consideration any potential medical (including psychiatric) contraindications, including a child's history of physical or sexual abuse. This consideration must be documented in the child's records.
- The psychiatrist or psychologist ordering personal restraint may use PRN [see Glossary] orders. PRN orders for personal restraint must be reviewed by the psychiatrist or psychologist at least every three months. The review must be documented in the child's record.
- Orders and treatment team recommendations for personal restraint must designate the specific procedure authorized, including any specific measures for ensuring the child's health, safety, and well-being, and the protected, private nature of the setting.
- Orders and treatment team recommendations must include the circumstances under which the intervention may be used, instructions for observation of the child while in restraint, the behaviors that indicate the child is ready to be released from restraint, the number of times a child may be restrained in a seven day period, and the amount of time the child may be restrained regardless of behaviors exhibited.
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In-person Assessment |
Personal restraint must be initiated in a way that minimizes the risk of physical discomfort, harm, or pain to the child. Only the minimal amount of reasonable and necessary physical force may be used to implement personal restraint. During any personal restraint, a caregiver qualified in behavior intervention must monitor the child's breathing and other signs of physical distress and take appropriate action to ensure adequate respiration, circulation, and overall well-being. The caregiver monitoring the child should not be the same caregiver that is restraining the child. Appropriate action includes responding when a child indicates he cannot breathe.
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Debriefing |
When a child is released from personal restraint, the caregiver(s) must take appropriate actions to help the child return to normal activities. A child does not have to return to the activities he was engaged in prior to the restraint or the activities in which the group is participating at the time the child is released from restraint. The actions of the caregiver(s) must include:
- providing the child with an appropriate transition and offering the child an opportunity to return to regular activities;
- observing the child for at least 15 minutes; and
- providing the child with an opportunity to discuss the situation which led to the need for personal restraint and the caregiver's reaction to that situation privately as soon as possible and no later than 48 hours after the release from restraint. The goal of the discussion is to allow the child to discuss his behavior and the precipitating circumstances that constituted the emergency situation; the strategies attempted before the use of the restraint and the child's reaction to those strategies; and the restraint itself and the child's reaction to the restraint.
Staff involved in the personal restraint must make every attempt to debrief concerning the incident.
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Family & Guardian Notification |
No information provided. |
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Notification of Rights and Restraint and Seclusion Policies and Procedures at admission |
Prior to or at admission, a caregiver must explain to children, based on their levelof functioning and comprehension, the child-care facility's policies and practiceson the use of restraint. The explanation must include who can use a restraint, theactions caregivers must first attempt to defuse the situation and avoid the use ofrestraint, the kinds of situations in which restraint may be used, the types ofrestraints authorized by the agency under which the home operates, when the use of a restraint must cease, what action the child must exhibit to be released from the restraint, and the way to report an inappropriate restraint. This explanation must be documented in the child's record. |
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Training |
- The training must be direct delivery training provided by a qualified instructor.The use of video instruction as part of a training curriculum is considered direct delivery training as long as the instructor is available for questions during the training. Training on the implementation of restraints or seclusion must be delivered directly by the instructor and cannot be delivered by a video.
- A qualified instructor is an instructor certified in a recognized method of therapeutic behavior intervention or is an instructor who is able to document knowledge of the subject material, training delivery methods and techniques, and training evaluation or assessment methods and techniques.
- The training must be competency-based and the trainer must require participants to demonstrate skill competency at the end of the training.
- Facilities whose policies do not allow for the use of any type of restraint or seclusion, including personal restraint, must require a pre-service training that meets the curriculum requirements [in items a through g, below]. Facilities whose policies allow for the use of any one type of restraint or seclusion must require pre-service training that meets all of the curriculum requirements listed in this paragraph and require that at least three quarters of the pre-service training focus on early identification of potential problem behaviors and strategies and techniques of less restrictive interventions.
Staff training components include:
- developing and maintaining an environment or milieu that supports positive constructive behaviors;
- assessing causes of behaviors potentially harmful to self or others in childrenand adolescents including aspects of the environment or milieu;
- determining early signs of behaviors that may become dangerous to a childor others;
- understanding strategies and techniques the child can use to avoid harmful behaviors;
- teaching children to use the strategies and techniques to avoid harmful behavior and supporting the children's efforts;
- learning less-restrictive intervention strategies for preventing potentially harmful behaviors;
- learning less-restrictive intervention strategies for use with oppositional children; and
- determining strategies for the re-integration of children into the milieu after restraint or seclusion.
- The remainder of the pre-service behavior intervention training for caregiverswho are providing care in a home or facility whose policies allow for the use ofany one type of restraint or seclusion must focus on the:
- different roles and responsibilities of caregivers qualified in behavior intervention and caregivers who are not qualified in behavior intervention; and
- safe implementation of the restraints and/or seclusion permitted by the rules in this chapter and by the child-care facility and/or child-placing agency's policies and procedures.
- If a child-care facility and/or child-placing agency's behavior intervention policies do not allow for a certain type of restraint, the child-care facility and/or child-placing agency does not have to offer training in the use of that restraint or seclusion.
All caregivers having contact with children must complete at least four clock hours annually of behavior intervention training specific to the behavior interventions allowed by the facility's policies.
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Documentation |
The use of personal restraint must be documented as soon as possible and no later than 24 hours after the initiation of the restraint. Documentation must include:
- the child's name;
- a description and assessment of the precipitating circumstances and the specificbehaviors which constituted the emergency situation, and if applicable, thespecific behaviors which continued to constitute an emergency situation;
- the use of alternative strategies attempted before the use of personal restraint andthe child's reaction to those strategies;
- the time the restraint began;
- the name of the caregiver(s) participating in the restraint;
- the specific restraint techniques used;
- the de-escalating strategies employed during the restraint;
- the total length of time the child was restrained;
- all attempts to explain to the child what behaviors were necessary for release from the restraint;
- any injury the child sustained as a result of the incident or the use of restraint, andthe care or treatment provided;
- the actions the caregiver(s) took to facilitate the child's return to normal activitiesfollowing release from restraint; and
- the child's reaction to the opportunity [to discuss the situation leading up to theneed for personal restraint] offered in [Standard F-2334.1.c and Appendix M,§720.1007(d)(1)(C)], the date and time the discussion was offered, the date and time the discussion took place (if applicable), and the actual discussion itself (if applicable).
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Reporting |
All reports to Licensing of child death, suicide attempts, and incidents in which a child experiences substantial bodily harm must include the complete documentation of any emergency medications, restraints, and/or seclusions which were implemented within 48 hours prior to the incident.
Any serious incident report of an injury resulting from a short personal restraint that is made to Licensing must include documentation of the restraint and the precipitating circumstances and specific behaviors which led to the restraint.[Note: The interventions listed below are not subject to the requirements in Standard F-1210.7 and Appendix M, §§720.1007(a)(4), which address more than three personal restraints of the same child within a seven-day period.]
- Short personal restraints that last no longer than one minute.
- A short personal restraint used to intervene in a situation of imminent significant risk when a child's behavior is being restrained because of an external hazard and caregivers must protect the child, particularly a young child, from immediate danger- for example, preventing a toddler from running into the street or coming in contact with a hot stove. The restraint must end immediately after the danger is averted.
- A short personal restraint used as a physical response to intervene when a child under the age of five (chronological or developmental age) demonstrates disruptive behavior, such as a tantrum in a public place. The physical response must be an appropriate response to the disruptive behavior and efforts to deescalate the behavior must have failed. The restraint must end as soon as the disruptive behavior has been de-escalated.
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Quality Improvement |
- The child-care facility and/or child-placing agency must develop an overallevaluation program with the following objectives:
- development and maintenance of an environment or milieu that supports positive and constructive behaviors on the part of children in care;
- safe, appropriate, and effective use of any form of restraint or seclusion; and
- elimination or reduction of physical injuries and any other negative impact of necessary restraints or seclusions on the child's behaviors or emotional development.
- The child-care facility and/or child-placing agency evaluation must include an evaluation of the facility's policies and procedures, including the facility's training policy and curriculum.
- The results of the regular evaluation must be made available to the TexasDepartment of Protective and Regulatory Services. In regards to agency homes, the child-placing agency, not its agency homes, is responsible for these evaluations.
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