Rule 111-8-2-.16. Behavior Management and Emergency Safety Interventions

1. (1) Behavior Management

   1. (a) The program shall develop and implement policies and procedures on behavior management.
   2. (b) Program staff shall be made aware of each client's known or apparent medical and psychological conditions and family history to ensure that the staff have adequate knowledge to deliver safe and healthy care to the client.

   3. (c) Behavior management policies and procedures shall incorporate the following minimum requirements:

      1. 1. Behavior management principles and techniques shall be used in accordance with the client treatment plan and written policies and procedures governing service expectations, treatment goals, safety, security, and these rules and regulations.
      2. 2. Behavior management shall be limited to the least restrictive appropriate method, as described in the client's treatment plan and in accordance with the prohibitions as specified in these rules and regulations.

   4. (d) Behavior management techniques shall be administered by trained staff and shall be appropriate for the client's age, intelligence, emotional makeup and past experience. The following forms of behavior management shall not be used by program staff with clients receiving services through the program:

      1. 1. Assignment of excessive or unreasonable work tasks;
      2. 2. Denial of meals and hydration;
      3. 3. Denial of sleep;
      4. 4. Denial of shelter, clothing, or essential personal needs;
      5. 5. Denial of essential program services;
      6. 6. Verbal abuse, ridicule, or humiliation;
      7. 7. Manual holds, chemical restraints, or mechanical restraints not used appropriately as emergency safety interventions;
      8. 8. Denial of communication and visits, except when a temporary peer restriction is implemented based on a clinical assessment as part of the treatment plan;
      9. 9. Corporal punishment; and
      10. 10. Seclusion or confinement of a client.
   5. (e) Clients shall not be permitted to participate in the behavior management of other clients or to discipline other clients, except as part of an organized therapeutic self-governing program in accordance with accepted standards of clinical practice that is conducted in accordance with written policy and is supervised directly by designated staff.
   6. (f) All forms of behavior management or emergency safety interventions used by staff shall also be documented in case records in order to ensure that such records reflect behavior management problems.
   7. (g) The program shall take appropriate corrective action when the program staff become aware of or observe the use of prohibited forms of behavior management. Documentation of the incident and the corrective action taken by the program shall be maintained in the case records of the client.

2. (2) Emergency Safety Interventions.

   1. (a) Emergency safety interventions may be used only by staff trained in the proper use of such interventions when it can be reasonably anticipated from a client's behavioral history, that a client may require the use of emergency safety interventions to keep either the client or others safe from immediate physical harm, and less restrictive means of dealing with the injurious behavior have not proven successful or may subject the client or others to greater risk of injury.
   2. (b) Program staff working with such client shall be trained in emergency safety interventions utilizing a nationally recognized training program in emergency safety interventions which has been approved by the department.
   3. (c) Emergency safety interventions shall not include the use of any restraint or manual hold that would potentially impair the client's ability to breathe or has been determined to be inappropriate for use on a particular client due to a documented medical or psychological condition.

   4. (d) The program shall have written policies and procedures for the use of emergency safety interventions, a copy of which shall be provided to and discussed with each client or legal guardian, if applicable, prior to or at the time of admission. Emergency safety interventions policies and procedures shall include:

      1. 1. Provisions for the documentation of an assessment at admission and at each annual exam by the client's physician, a physician's assistant, or a registered nurse with advanced training working under the direction of a physician, or a public health clinic which states that there are no medical issues that would be incompatible with the appropriate use of emergency safety interventions on that client. Such assessment and documentation must be re-evaluated following any significant change in the client's medical condition; and

      2. 2. Provisions for the documentation of each use of an emergency safety intervention including:

         1. (i) Date and description of the precipitating incident;
         2. (ii) Description of the de-escalation techniques used prior to the emergency safety intervention, if applicable;
         3. (iii) Environmental considerations;
         4. (iv) Names of staff participating in the emergency safety intervention;
         5. (v) Any witnesses to the precipitating incident and subsequent intervention;
         6. (vi) Exact emergency safety intervention used;
         7. (vii) Beginning and ending time of the intervention;
         8. (viii) Outcome of the intervention;
         9. (ix) Detailed description of any injury arising from the incident or intervention; and
         10. (x) Summary of any medical care provided.
      3. 3. Provisions for prohibiting manual hold use by any employee not trained in prevention and use of emergency safety interventions.
   5. (e) Emergency safety interventions may be used to prevent runaways only when the client presents an imminent threat of physical harm to self or others, or as specified in the client treatment plan.
   6. (f) Program staff shall be aware of each client's medical and psychological conditions (e.g. obvious health issues, list of medications, history of physical abuse, etc.), as evidenced by written acknowledgement of such awareness, to ensure that the emergency safety intervention that is utilized does not pose any undue danger to the physical or mental health of the client.
   7. (g) Clients shall not be allowed to participate in the emergency safety intervention of other clients.
   8. (h) Immediately following the conclusion of the emergency safety intervention and hourly thereafter for a period of at least four hours where the client is with a staff member, the client's behavior will be assessed, monitored, and documented to ensure that the client does not appear to be exhibiting symptoms that would be associated with an injury.

   9. (i) At a minimum, the emergency safety intervention program that is utilized shall include the following:

      1. 1. Techniques for de-escalating problem behavior including client and staff debriefings;
      2. 2. Appropriate use of emergency safety interventions;
      3. 3. Recognizing aggressive behavior that may be related to a medical condition;
      4. 4. Awareness of physiological impact of a restraint on the client;
      5. 5. Recognizing signs and symptoms of positional and compression asphyxia and restraint associated cardiac arrest;
      6. 6. Instructions on how to monitor the breathing, verbal responsiveness, and motor control of a client who is the subject of an emergency safety intervention;
      7. 7. Appropriate self-protection techniques;
      8. 8. Policies and procedures relating to using manual holds, including the prohibition of any technique that would potentially impair a client's ability to breathe;
      9. 9. Agency policies and reporting requirements;
      10. 10. Alternatives to restraint;
      11. 11. Avoiding power struggles;
      12. 12. Escape and evasion techniques;
      13. 13. Time limits for the use of restraint;
      14. 14. Process for obtaining approval for continual restraints;
      15. 15. Procedures to address problematic restraints;
      16. 16. Documentation;
      17. 17. Investigation of injuries and complaints;
      18. 18. Monitoring physical signs of distress and obtaining medical assistance; and
      19. 19. Legal issues.
   10. (j) Emergency safety intervention training shall be in addition to the annual training required under these rules and shall be documented in the staff member's personnel record.
   11. (k) All actions taken that involve utilizing an emergency safety intervention shall be recorded in the client's case record showing the cause for the emergency safety intervention, the emergency safety intervention used, and, if restraints are needed, approval by the medical director or other physician with responsibility for the diagnosis and treatment of the client's behavior.

   12. (l) Programs shall submit to the department electronically in a format acceptable to the department, within 24 hours whenever the program becomes aware of an incident which results in injury to a client requiring medical treatment beyond first aid that is received by a client as a result of or in connection with any emergency safety intervention.

       1. 1. For any program with a licensed capacity of 20 clients or more, any 30-day period in which three or more instances of emergency safety interventions of a specific client occurred and/or whenever the program has had a total of 10 emergency safety interventions for all clients in care within the 30-day period; and
       2. 2. For any program with a licensed capacity of less than 20 clients, any 30-day period in which three or more instances of emergency safety interventions of a specific client occurred and/or whenever the program has had a total of five instances for all clients in care within the 30-day period.

   13. (m) Programs shall submit a written report to the program's medical director on the use of any emergency safety intervention immediately after the conclusion of the intervention and, if the client has an assigned legal guardian, shall further notify the client's legal guardian regarding the use of the intervention. A copy of such report shall be maintained in the client's file.

       1. (a) At least once per quarter, the program, utilizing a master agency restraint log and the client's case record, shall review the use of all emergency safety interventions for each client and staff member, including the type of intervention used and the length of time of each use, to determine whether there was a clinical basis for the intervention, whether the use of the emergency safety intervention was warranted, whether any alternatives were considered or employed, the effectiveness of the intervention or alternative, and the need for additional training. Written documentation of all such reviews shall be maintained. Where the program identifies opportunities for improvement as a result of such reviews or otherwise, the program shall implement these changes through an effective quality improvement plan.
   14. (o) All program staff who may be involved in the use of emergency safety interventions shall have evidence of having satisfactorily completed a nationally recognized training program for emergency safety interventions to protect clients and others from injury, which has been approved by the department and taught by an appropriately certified trainer in such program.

   15. (p) Manual Holds.

       1. 1. Emergency safety interventions utilizing manual holds require at least one trained staff member to carry out the hold. Emergency safety interventions utilizing prone restraints require at least two trained staff members to carry out the hold.
       2. 2. Emergency safety interventions shall not include the use of any restraint or manual hold that would potentially impair the client's ability to breathe or has been determined to be inappropriate for use on a particular client due to a documented medical or psychological condition.
       3. 3. When a manual hold is used upon any client whose primary mode of communication is sign language, the client shall be permitted to have his or her hands free from restraint for brief periods during the intervention, except when such freedom may result in physical harm to the client or others.
       4. 4. If the use of a manual hold exceeds 15 consecutive minutes, the medical director or his or her designee who has been fully trained in the program's emergency safety intervention plan, shall be contacted for an evaluation of whether the continuation of the manual hold is appropriate under the circumstances. Documentation of any consultations and outcomes shall be maintained for each application of a manual hold that exceeds 15 minutes. Manual holds shall not be permitted to continue if the restraint is determined to pose an undue risk to the client's health given the client's physical or mental condition.
       5. 5. A manual hold may not continue for more than 30 minutes at any one time without the consultation as specified in subparagraph (4) of this subparagraph, and under no circumstances may a manual hold be used for more than one hour total within a 24-hour period.
       6. 6. If the use of a manual hold on a client reaches a total of one hour within a 24-hour period, the staff shall reconsider alternative treatment strategies, document same, and consider notifying the authorities or transporting the client to a hospital for evaluation.
       7. 7. The client's breathing, verbal responsiveness, and motor control shall be continuously monitored during any manual hold. Written summaries of the monitoring by a trained staff member not currently directly involved in the manual hold shall be recorded every 15 minutes during the duration of the restraint. If only one trained staff member is involved in the restraint and no other staff member is available, written summaries of the monitoring of the manual hold shall be recorded as soon as is practicable, but no later than one hour after the conclusion of the restraint.

Authority: O.C.G.A. §§ 37-3-204, 37-3-205, 37-3-212, 31-2-4, 31-2-7, 31-2-8, 31-7-2.1.

History. Original Rule entitled "Behavior Management and Emergency Safety Interventions" adopted. F. Dec. 10, 2024; eff. Dec. 30, 2024.