TITLE 25.HEALTH SERVICES

Part 1. DEPARTMENT OF STATE HEALTH SERVICES

Chapter 448. STANDARD OF CARE

The Executive Commissioner of the Health and Human Services Commission, on behalf of the Department of State Health Services (department), proposes amendments to §§448.603, 448.701 and 448.706, concerning the regulation of training, client bill of rights, and restraint and seclusion in chemical dependency treatment facilities.

BACKGROUND AND PURPOSE

The amendments are necessary to implement legislation by the 79th Legislature, Regular Session, 2005. Specifically, amendments to the Health and Safety Code added Chapter 322 (Senate Bill (SB) 325), and, in particular, Subchapter B, relating to the restraint and seclusion of residents in certain health care facilities. These amendments implement requirements relating to chemical dependency treatment facilities.

SECTION-BY-SECTION SUMMARY

Amendments to §448.603(d)(5) add requirements to the restraint and/or seclusion training program. Amendments to §448.701(a) clarify the responsibility of treatment facilities to implement and enforce client rights, and add to the rights for which the facility is responsible the right of the client and the client's legally authorized representative to be notified of the rules and policies related to restraints and seclusion. Amendments to §448.706 add to existing regulation of restraint and seclusion a definition of small residential facilities not subject to the new requirement for an observer when a prone or supine hold is used and define practices to promote the safe, limited, and appropriate use of restraint and seclusion in chemical dependency treatment facilities. Amendments were added specifically governing the use of a prone or supine hold; adding restrictions and safeguards relating to interventions and restraints to reduce their frequency and minimize the risk of harm; and requiring certain actions after an episode of restraint or seclusion to help reduce the frequency and increase the safety of any future use of restraint or seclusion. In addition, to avoid conflict with Health and Safety Code, §322.052(c), language requiring the authorization of personal restraint in certain facilities was removed from the rule. While removing the specific requirement that personal restraint be authorized, the amendment should not be read to prevent or discourage those facilities from retaining authorization for the use of personal restraint, if it could be necessary in certain circumstances to protect the safety of clients or others when less restrictive alternatives have been exhausted, and thus to fulfill the facility's duty to maintain a safe environment at all times and under all circumstances.

FISCAL NOTE

Kathy Perkins, Director, Healthcare Quality Section, Regulatory Division, has determined that for each year of the first five-year period that the sections will be in effect, there will be no fiscal implications to state or local governments as a result of enforcing and administering the sections as proposed in that costs and workload resulting from the rule amendments will be absorbed within the existing budget.

SMALL AND MICRO-BUSINESS IMPACT ANALYSIS

Ms. Perkins has also determined that there will be no effect on small businesses or micro-businesses required to comply with the sections as proposed. This was determined by interpretation of the rules that small businesses and micro-businesses will not be required to alter their business practices in order to comply with the sections. There are no anticipated economic costs to persons who are required to comply with the sections as proposed because additional training requirements are not expected to increase the cost of meeting existing training requirements. There is no anticipated negative impact on local employment.

PUBLIC BENEFIT

In addition, Ms. Perkins has also determined that for each year of the first five years the sections are in effect, the public will benefit from adoption of the sections. The public benefit anticipated as a result of enforcing or administering the sections is to ensure that chemical dependency treatment facilities make safe and limited use of restraint and seclusion interventions, appropriately train relevant staff for that purpose, and, in doing so, better protect the welfare of their clients.

REGULATORY ANALYSIS

The department has determined that this proposal is not a "major environmental rule" as defined by Government Code, §2001.0225. "Major environmental rule" is defined to mean a rule the specific intent of which is to protect the environment or reduce risk to human health from environmental exposure and that may adversely affect, in a material way, the economy, a sector of the economy, productivity, competition, jobs, the environment or the pubic health and safety of a state or a sector of the state. This proposal is not specially intended to protect the environment or reduce risks to human health from environmental exposure.

TAKINGS IMPACT ASSESSMENT

The department has determined that the proposed amendments do not restrict or limit an owner's right to his or her property that would otherwise exist in the absence of government action and, therefore, do not constitute a taking under Government Code, §2007.043.

PUBLIC COMMENT

Comments on the proposal may be submitted to Jane Guerrero, Facility Licensing Group, Regulatory Licensing Unit, Department of State Health Services, 1100 West 49th Street, Mail Code 1980, Austin, Texas 78756, 512/834-6639 or by email to jane.guerrero@dshs.state.tx.us. Comments will be accepted for 30 days following publication of the proposal in the Texas Register .

LEGAL CERTIFICATION

The Department of State Health Services General Counsel, Cathy Campbell, certifies that the proposed rules have been reviewed by legal counsel and found to be within the state agencies' authority to adopt.

Subchapter F. PERSONNEL PRACTICES AND DEVELOPMENT

25 TAC §448.603

STATUTORY AUTHORITY

The proposed amendments are authorized by Health and Safety Code, §464.009, which authorizes the Executive Commissioner of the Health and Human Services Commission (Executive Commissioner) to adopt rules governing chemical dependency treatment facilities, including their policies and procedures, minimum staffing requirements, protection of client rights, and requirements to ensure client safety, protection, health and comfort; Health and Safety Code, §§322.051, 322.052, and 322.053, which require rulemaking to implement Health and Safety Code, Chapter 322, added by the 79th Legislature, Regular Session, 2005 (SB 325); and Government Code, §531.0055, and Health and Safety Code, §1001.075, which authorize the Executive Commissioner to adopt rules and policies necessary for the operation and provision of health and human services by the department and for the administration of Health and Safety Code, Chapter 1001.

The proposed amendments affect the Health and Safety Code, Chapters 322, 464 and 1001, and Government Code, Chapter 531.

§448.603.Training.

(a) - (c) (No change.)

(d) The following initial training(s) must be received within the first 90 days of employment and must be completed before the employee can perform a function to which the specific training is applicable. Subsequent training must be completed as specified.

(1) - (4) (No change.)

(5) Restraint and/or Seclusion. All direct care staff in residential programs and programs accepting court commitments that use or authorize the use of restraint or seclusion shall have face-to-face training and demonstrate competency in the safe methods of the specific procedures before assuming job duties involving direct care responsibilities . This includes programs that accept adolescent residential and emergency detentions.

(A) - (C) (No change.)

(D) The training program shall include:

(i) identifying the underlying causes of threatening behaviors exhibited by the clients receiving services;

(ii) identifying aggressive or threatening behavior;

(iii) explaining how the behavior of personnel can affect the behaviors of clients;

(iv) using de-escalation, mediation, self-protection, and other techniques;

(v) recognizing and responding to signs of physical distress in clients who are being restrained;

(vi) identifying the risks associated with positional, compression, or restraint asphyxiation and with prone and supine holds;

(vii) the initiation of seclusion;

(viii) the application of personal restraint;

(ix) the application of approved restraint devices;

(x) monitoring cardiac and respiratory status and interpreting their relevance to the physical safety of the client in restraint or seclusion;

(xi) addressing physical and psychological status and comfort, including signs of distress;

(xii) assisting clients in meeting behavioral criteria for the discontinuation of restraint or seclusion;

(xiii) recognizing readiness for the discontinuation of restraint or seclusion; and

(xiv) recognizing when to contact emergency medical services to evaluate and/or treat a client for an emergency medical condition.

(6) - (7) (No change.)

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State on March 20, 2006.

TRD-200601710

Cathy Campbell

General Counsel

Department of State Health Services

Earliest possible date of adoption: April 30, 2006

For further information, please call: (512) 458-7111 x6972


Subchapter G. CLIENT RIGHTS

25 TAC §448.701, §448.706

STATUTORY AUTHORITY

The proposed amendments are authorized by Health and Safety Code, §464.009, which authorizes the Executive Commissioner of the Health and Human Services Commission (Executive Commissioner) to adopt rules governing chemical dependency treatment facilities, including their policies and procedures, minimum staffing requirements, protection of client rights, and requirements to ensure client safety, protection, health and comfort; Health and Safety Code, §§322.051, 322.052, and 322.053, which require rulemaking to implement Health and Safety Code, Chapter 322, added by the 79th Legislature, Regular Session, 2005 (SB 325); and Government Code, §531.0055, and Health and Safety Code, §1001.075, which authorize the Executive Commissioner to adopt rules and policies necessary for the operation and provision of health and human services by the department and for the administration of Health and Safety Code, Chapter 1001.

The proposed amendments affect the Health and Safety Code, Chapters 322, 464 and 1001, and Government Code, Chapter 531.

§448.701.Client Bill of Rights.

(a) The facility shall respect , [ and ] protect , implement and enforce each client right required to be contained in the facility's Client Bill of Rights [ clients' rights ]. The Client Bill of Rights for all facilities shall include:

(1) - (6) (No change.)

(7) You have the right to be told about the program's rules and regulations before you are admitted , including, without limitation, the rules and policies related to restraints and seclusion. Your legally authorized representative, if any, also has the right to be and shall be notified of the rules and policies related to restraints and seclusion .

(8) - (19) (No change.)

(b) - (c) (No change.)

§448.706.Restraint and Seclusion.

(a) A small residential facility is defined as a treatment facility with less than eight licensed beds.

(b) [ (a) ] The governing body shall adopt a policy to either authorize or prohibit the use of personal restraint, mechanical restraint, and seclusion. [ All adolescent residential programs and programs accepting emergency detentions shall authorize use of personal restraint. ] Any facility authorizing use of restraint or seclusion shall comply with and have a written procedure that ensures compliance with Health and Safety Code, Chapter 322, including its definition of seclusion; the rules adopted under that chapter; and this section. Outpatient programs shall prohibit the use of restraint or seclusion, except as it relates to court commitment clients.

(c) [ (b) ] In programs authorizing use of restraint or seclusion, direct care staff shall be trained as described in the applicable provisions of §448.603 [ §148.603 ] of this title (relating to Training). Staff sufficient in number and who have the training required by §448.603 of this title to safely implement any permitted restraint or seclusion shall be on duty at all times.

(d) [ (c) ] Staff shall not use restraint or seclusion unless it is necessary to intervene to prevent imminent probable death or substantial bodily harm to the client or imminent physical harm to another [ a client's behavior endangers the client or others ] and less restrictive methods have been tried and failed.

(e) [ (d) ] Staff shall not use more force than is necessary to prevent imminent harm and shall ensure the safety, well-being, and dignity of clients who are restrained or secluded, including attention for personal needs. Staff shall not deny bathroom privileges, water, sleep, or regularly scheduled meals and snacks.

(f) [ (e) ] Staff shall obtain authorization from the supervising Qualified Credentialed Counselor (QCC) before starting restraint or seclusion or as soon as possible after initiation or implementation.

(1) The facility shall not use standing authorizations for restraint or seclusion.

(2) Authorization for mechanical restraint or seclusion shall be based on a face-to-face evaluation by the direct care staff initiating or implementing the procedure .

(3) Each authorization shall include a specific time limit, not to exceed 12 hours.

(4) The QCC must take into consideration information that could contraindicate or otherwise affect the use of restraint or seclusion, including information obtained during the initial assessment of each client at the time of admission or intake. This information includes, but is not limited to:

(A) techniques, methods, or tools that would help the client effectively cope with his or her environment;

(B) pre-existing medical conditions or any physical disabilities and limitations, including substance use disorders, that would place the client at greater risk during restraint or seclusion;

(C) any history of sexual or physical abuse that would place the client at greater psychological risk during restraint or seclusion; and

(D) any history that would contraindicate seclusion, the type of restraint (personal or mechanical), or a particular type of restraint devise.

(g) [ (f) ] When the client has been safely restrained or secluded, staff shall tell the client what behavior and timeframes are required for release and shall release the client as soon as the criteria are met.

(h) [ (g) ] Clinical staff shall review and document alternative strategies for dealing with behaviors necessitating the use of restraint or seclusion for an individual client two or more times in any 30-day period.

(i) [ (h) ] The chief executive officer of the facility or designee shall review all incident reports involving restraint or seclusion and take action to address unwarranted use of these measures.

(j) [ (i) ] A client held in restraint shall be under continuous direct observation. The facility shall ensure adequate breathing and circulation during restraint and shall only use devices designed for therapeutic restraint. An acceptable hold is one that engages one or more limbs close to the body to limit or prevent movement and is performed in a manner consistent with the requirements set forth in this section.

(k) [ (j) ] Seclusion rooms shall be constructed to prevent clients from harming themselves and shall allow staff to observe clients easily in all parts of the room. When a client is in seclusion, staff shall conduct a visual check at least every 15 minutes.

(l) [ (k) ] Staff shall record the following information in the client record within 24 hours:

(1) the circumstances leading to the use of restraint or seclusion;

(2) the specific behavior necessitating the restraint or seclusion and the behavior required for release;

(3) less restrictive interventions that were tried before restraint or seclusion began;

(4) the signed authorization of the supervising QCC;

(5) the names of the staff members who implemented the restraint or seclusion;

(6) the date and time the procedure began and ended;

(7) the behavior and timeframes required for release;

(8) the client's response;

(9) observations made, including the 15 minute checks; and

(10) attention given for personal needs.

(m) A prone or supine hold shall not be used except as a last resort when other less restrictive interventions have proven to be ineffective. The hold shall be used only to transition a client into another position, and shall not exceed one minute in duration. Except in small residential facilities, when the prone or supine hold is used, an observer, who is trained to identify the risks associated with positional, compression, or restraint asphyxiation and with prone and supine holds, and who is not involved in the restraint, shall ensure the client's breathing is not impaired.

(n) No intervention, voluntary or involuntary, shall be used:

(1) as a means of discipline, retaliation, punishment, or coercion;

(2) for the purpose of convenience of staff members or other individuals; or

(3) as a substitute for effective treatment.

(o) A restraint shall not be used that:

(1) secures a client to a stationary object while the client is in a standing position;

(2) causes pain to restrict a client's movement (pressure points or joint locks);

(3) restricts circulation;

(4) obstructs a client's airway, including a procedure that places anything in, on, or over a client's mouth or nose or puts pressure on the torso;

(5) impairs a client's breathing;

(6) interferes with a client's ability to communicate; or

(7) is inconsistent with training received in compliance with §448.603 of this title (relating to Training).

(p) Use of chemical restraint is prohibited.

(q) Use of restraint or seclusion solely as a behavior therapy program or as part of a behavior therapy program is prohibited.

(r) Immediately following the release of a client from restraint or seclusion, a direct care staff must:

(1) take appropriate action to facilitate the client's reentry into the facility environment by providing the client with transition activities and an opportunity to return to ongoing activities;

(2) observe the client for at least 15 minutes; and

(3) document observations of the client's behavior during this transition period in the client's record.

(s) As soon as possible after an episode of restraint or seclusion, available staff members involved in the episode, supervisory staff, the client, the legally authorized representative, if any, and, with the consent of the client, family members must meet to discuss the episode. The purpose of the debriefing is to:

(1) identify what led to the episode and what could have been handled differently;

(2) identify strategies to prevent future restraint or seclusion, taking into consideration suggestions from the client;

(3) ascertain whether the client's physical well-being, psychological comfort, and right to privacy were addressed;

(4) counsel the client in relation to any trauma that may have resulted from the episode;

(5) when indicated, identify appropriate modifications to the client's treatment plan; and

(6) when clinically indicated or upon request of individuals who witnessed the restraint debrief persons who witnessed the restraint.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State on March 20, 2006.

TRD-200601711

Cathy Campbell

General Counsel

Department of State Health Services

Earliest possible date of adoption: April 30, 2006

For further information, please call: (512) 458-7111 x6972