a) The facility shall develop and implement a written plan to create coercion-free environments as defined in the Mental Health and Developmental Disabilities Code in recognition of the prevalence of trauma histories in the populations to be treated in all levels of service in the facility. The plan shall address how the facility will:

1. 1) Use leadership to create organizational change;
2. 2) Use data to inform practice;
3. 3) Train the workforce in policies and practices;
4. 4) Use restraint and therapeutic separation prevention tools;
5. 5) Use debriefing techniques following the use of restraints or therapeutic separations; and
6. 6) Create appropriate spaces (e.g., comfort rooms) for therapeutic separations.

b) Restraints

1. 1) A physical restraint, or momentary physical restriction by direct person-to-person contact, without the aid of material or mechanical devices, shall be applied only by staff trained in the safe and humane application of the particular type of restraint. Training shall be in a program administered or approved by DHS-DMH.
2. 2) A restraint shall be used only in an emergency and when alternative interventions cannot ensure safety.

3. 3) Informed consent shall be required for restraints consistent with the requirements contained in Section 2-106(c) of the Nursing Home Care Act. (Section 3-115 of the Act)

   1. A) Written informed consent for the short-term emergency use of a restraint may be obtained from a consumer when he or she is admitted or after admission. Before obtaining informed consent, the facility shall inform the consumer that, in a behavioral emergency, when necessary to protect the consumer or other people from immediate physical harm, the staff may use the temporary holding, and, if informed consent has been given, may use short-term restraint until the consumer can be transported to a hospital.
   2. B) Whenever use of a physical restraint is initiated, the consumer shall be advised of his or her right to have a person or organization of his or her choosing, including the Guardianship and Advocacy Commission, notified of the use of the physical restraint. A period of use is initiated when a physical restraint is applied to a consumer for the first time under a new or renewed informed consent for the use of physical restraints. A recipient who is under guardianship may request that a person or organization of his or her choosing be notified of the physical restraint, whether or not the guardian approves the notice. The person or organization shall be notified whenever a consumer is restrained.

   3. C) The facility shall provide the following information in writing to the person or organization named by the consumer. If the consumer requests that the Guardianship and Advocacy Commission be contacted, the facility shall also provide the following information in writing to the Guardianship and Advocacy Commission:

      1. i) The reason the physical restraint was needed;
      2. ii) The type of physical restraint that was used;
      3. iii) The interventions used or considered prior to physical restraint and the impact of these interventions;
      4. iv) The length of time the physical restraint was applied; and
      5. v) The name and title of the facility employee to be contacted for further information.
   4. D) Whenever a physical restraint is used on a consumer whose primary mode of communication is sign language, the consumer shall be permitted to have his or her hands free from restraint for brief periods each hour, except when this freedom may result in physical harm to the consumer or others.

4. 4) The use of a restraint is not permitted unless a consumer presents a behavioral emergency. In these circumstances, restraints may be used for a brief period until emergency care and physical transportation to a hospital can be accomplished. In situations that are successfully resolved through manual holding lasting less than five minutes, without physical hold to the ground or undue force, and without injury, transport to an emergency room or hospital is not required.

   1. A) The use of restraints in a behavioral emergency shall comply with the provisions of Sections 380.150(a) and 380.610(d).
   2. B) Restraint use shall be limited to the least amount of physical restriction and the briefest possible duration necessary to resolve the immediate danger.
   3. C) The limitation on allowable restraint use applies to any physical restraint, including physical hold and prolonged restriction of movement by staff, as well as the use of any mechanical restraint device. Gentle physical guidance, prompting, and escorting a consumer are not considered restraints. Momentary periods of physical restriction by direct person-to-person contact, without the aid of material or mechanical devices, accomplished with limited force, and that are designed to prevent a consumer from completing an act that would result in potential physical harm to himself or herself or another shall not constitute restraint, but shall be documented in the consumer's clinical record, and may be used only by a person trained pursuant to subsection (b)(1).
   4. D) Any consumer being restrained shall be continuously monitored by a staff member, who shall be present throughout the period of restraint use to ensure safety, to avoid injury, and to minimize discomfort. The consumer's position shall be monitored to ensure that breathing is unrestricted. Consumer hydration or toileting needs shall be addressed unless precluded by immediate safety concerns.
   5. E) Nursing staff shall examine the consumer as soon as possible, but no later than 10 minutes, after the start of the restraint use.
   6. F) The consumer's psychiatrist shall be contacted immediately for medical direction. If the consumer's psychiatrist is unavailable, the psychiatric medical director shall be contacted.
   7. G) The QMHP, pursuant to the facility's written policy, shall debrief the staff involved in the restraint use regarding the events leading up to the restraint, physical hold, or application, and the consumer's condition during the duration of the restraint use. A consumer who was transported to a hospital shall be debriefed upon return to the facility.

   8. H) The use of physical restraints shall be documented in the consumer's record, including:

      1. i) The behavior emergency that prompted the use of restraints, including preceding events, staff efforts to de-escalate the situation, and reasons for the use of restraint;
      2. ii) The date and time that restraints were applied to the consumer, the methods used in restraining the consumer, the duration of restraint use, the time of release, and events surrounding release;
      3. iii) The names and titles of the staff responsible for applying the restraint and for monitoring the consumer, and the names and titles of any other staff involved in the incident;
      4. iv) Orders by the psychiatrist or psychiatric medical director who was notified of the restraint;
      5. v) The emergency transportation that was used and the hospital to which the consumer was taken;
      6. vi) Any injury or other negative impact sustained by the consumer; and
      7. vii) The date of the scheduled care planning conference and the results of the care plan review in light of the use of emergency restraints.
   9. I) Facility staff, including safety personnel, shall receive a basic orientation in crisis prevention and in safe physical hold and restraint methods. No facility staff may use any physical hold or other restraint method unless trained pursuant to subsection (b)(1).
   10. J) The facility shall maintain written records of training related to the use of restraints and to de-escalation practices provided to staff.

c) Therapeutic Separation

1. 1) The facility shall develop policies and procedures for the use of therapeutic separation as a strategy for creating a coercion-free environment.

2. 2) The facility shall designate specific space (e.g., a comfort room) for therapeutic separation that is designed in a way that calms the senses and provides a temporary sanctuary from stress. The comfort room shall be:

   1. A) Used as a tool to teach individuals calming techniques to decrease agitation and aggressive behavior;
   2. B) Used to prevent the use of emergency restraints;
   3. C) Used at the consumer's will, and shall remain unlocked;
   4. D) Located in an area that is easily accessible to those who will be using it and close to a staffed area for adequate line of sight and supervision;
   5. E) Used before the onset of aggressive/uncontrolled behavior, and after as necessary; and
   6. F) Developed and furnished with input from staff and consumers.
3. 3) Therapeutic separation shall not be forced upon consumers and shall not be used as punishment.

4. 4) Supervised therapeutic separation may be used for de-escalation of a potentially harmful situation, provided that:

   1. A) The supervised separation lasts for no more than 30 minutes without the facility contacting the psychiatric medical director in accordance with Section 380.610(d);
   2. B) The consumer is attended by an MHP or CRSS at all times in therapeutic separation until the consumer can reasonably discuss the situation or event;
   3. C) An MHP or licensed nurse personally reviews the therapeutic separation situation at least every 15 minutes while a consumer is in therapeutic separation; and
   4. D) The situation is entered into the consumer's record for review by the Interdisciplinary Team.