PURPOSE: This rule establishes requirements for the use of restraint, seclusion, and time out in Substance Use Disorder Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Opioid Treatment Programs, Gambling Disorder Treatment Programs, Substance Awareness Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPR), and Outpatient Mental Health Treatment Programs.

1. (1) General Principles and Practices. The organization shall implement written policies and procedures to prevent and respond to disruptive behaviors, behavioral crises, and psychiatric crises that may occur with individuals served, staff, visitors, and others. All efforts shall be made to minimize re-traumatization of persons served or others involved in a disruptive situation, including consideration as to whether the program is suitable to meet the individual’s needs.

   1. (A) Policies and procedures shall indicate whether time-out, seclusion, and restraint are used in the organization, by whom, and under what circumstances, including protocols for their use with children/youth, adults, and individuals with special needs.
   2. (B) Organizations may prohibit by policy and practice the use of time-out, seclusion, and restraint and must have policies and procedures for addressing disruptive behaviors, behavioral crises, and psychiatric crises.

   3. (C) All policies and procedures must be—

      1. 1. Approved by the organization’s board

of directors;

1. 2. Available to all program staff and ser-

vice providers;

1. 3. Available to individuals served and

parents/guardians, family members, and other natural supports, as appropriate;

1. 4. Developed with input from individu-

als served and, whenever possible, parents/guardians, family members, and other natural supports; and

1. 5. Consistent with department regula-

tions regarding individual rights.

1. (D) As applicable to the population served, all staff and volunteers having direct contact with individuals served shall receive documented initial and ongoing competency-based 9 CSR 10-7

training on evidence-based and best practice interventions to prevent disruptive behaviors and behavioral crises and to address them in the least restrictive manner if they occur.

1. (E) All organizations shall prohibit by policy and practice—

   1. 1. Aversive conditioning of any kind—

the application of startling, unpleasant, or painful stimulus or stimuli that have a potentially harmful effect on an individual in an effort to decrease maladaptive behavior;

1. 2. Withholding of food, water, or bath-

room privileges;

1. 3. Painful stimuli;
2. 4. Corporal punishment (such as use of

pepper spray, mace, Taser, stun gun);

1. 5. Techniques that obstruct the individu-

al’s airways or impairs breathing;

1. 6. Techniques that restrict the individu-

al’s ability to communicate;

1. 7. Use of time-out or other disciplinary

action for staff convenience; and

1. 8. Chemical restraints—use of a medica-

tion to sedate or limit an individual’s ability to participate in treatment rather than treat the symptoms of a behavioral health disorder as prescribed and specified in the individual treatment plan. Medication used as prescribed and as indicated in the individual’s treatment plan to treat symptoms of a behavioral disorder, including aggressive behavior, is not considered chemical restraint.

1. (2) Seclusion and Restraint. Recognizing there are times when other interventions such as de-escalation or a change in the physical environment are not successful and there is imminent danger of serious harm to the individual or others, seclusion or restraint may be necessary to ensure safety. Any emergency safety interventions used by the organization must promote the rights, dignity, and safety of individuals being served. Organizations utilizing seclusion and restraint must obtain a separate written authorization from the department, in addition to complying with all other requirements of this rule. The department may issue such authorization on a timelimited basis subject to renewal.

   1. (A) Staff of the organization shall assure seclusion and restraint are only used when an individual’s behavior presents an immediate risk of danger to themselves or others and no other safe or effective treatment intervention is possible. These measures shall only be implemented when alternative, less restrictive interventions have failed or cannot be safely implemented. Crisis prevention techniques shall be used to de-escalate such occurrences, when possible. Seclusion and restraint are never used as treatment interventions. They are emergency/security measures to maintain safety when all other less restrictive interventions are inadequate.
   2. (B) The use of seclusion or restraint shall be in accordance with the order of the organization’s attending physician or clinical director. Staff shall notify the attending physician or clinical director at the earliest possible time when a situation has a significant likelihood of leading to seclusion or restraint. If seclusion or restraint is initiated prior to obtaining an order, staff must obtain an order immediately.
   3. (C) Standing or Pro re nata (PRN) orders for seclusion or restraint are not allowed.
   4. (D) Orders for seclusion or restraint shall be individualized to each event, define specific time limits, and be ended at the earliest possible time. Orders shall not exceed four

2. (4) hours for adults, two (2) hours for children/youth age nine (9) to seventeen (17), and one (1) hour for children under age nine (9). If there is a need for continuing seclusion or restraint beyond the time limits specified herein, the attending physician or clinical director must write a new order for seclusion or restraint.

   1. (E) Seclusion and restraint shall only be implemented by staff who are trained and competent in the proper techniques for administering/applying the form of seclusion or restraint ordered and for providing ongoing monitoring and assessment of individuals for their safety and well-being. At a minimum, initial and periodic training shall include:

      1. 1. Techniques to identify individual

behaviors, events, and environmental factors that may trigger circumstances requiring the use of seclusion or restraint;

1. 2. The use of nonphysical intervention

skills;

1. 3. Use of the least restrictive interven-

tion based on an individualized assessment of the individual’s medical and/or behavioral status or condition;

1. 4. The safe application and use of all

types of seclusion or restraint used by the organization, including how to recognize and respond to signs of physical and psychological distress;

1. 5. Clinical identification of specific

behavioral changes that indicate restraint or seclusion is no longer necessary;

1. 6. Monitoring the physical and psycho-

logical well-being of the individual who is secluded or restrained, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified in the organization’s policies and procedures associated with faceto-face evaluations; and

1. 7. The use of First Aid techniques and

certification in CPR, including required periodic recertification.

1. (F) When an individual is being secluded or restrained, trained staff shall continually observe and assess him or her to assure appropriate care and treatment including, but not limited to:

   1. 1. Attention to vital signs;
   2. 2. Need for meals and liquids;
   3. 3. Need for bathing and use of the

restroom; and

1. 4. Need for seclusion or restraint to con-

tinue.

1. (G) Staff observing the individual shall immediately notify the attending physician or clinical director if his or her behavior has improved such that seclusion or restraint can be ended. Use of seclusion or restraint shall be discontinued when the attending physician or clinical director determines the need for the intervention is no longer present or the individual’s needs can be addressed using less restrictive methods.

2. (H) All orders for seclusion or restraint must be documented in the individual record as soon as possible and shall include, but is not limited to:

   1. 1. Reason for the intervention;
   2. 2. Staff who ordered the intervention;
   3. 3. Type of intervention used;
   4. 4. Starting and ending time;
   5. 5. Regular observations of the individu-

al, including any resulting injuries or other issues as a result of the intervention;

1. 6. Notification of parent/guardian, as

applicable;

1. 7. Notification of healthcare provider, as

applicable; and

1. 8. Modifications to the treatment plan as

a result of the intervention.

1. (I) The organization’s clinical director and/or performance improvement coordinator shall review every episode of seclusion or restraint within seventy-two (72) hours of the occurrence to ensure policies and procedures were followed and identify any areas needing improvement. A written report on the organization’s overall use of emergency safety interventions, including progress made in reducing their use, shall be prepared at least annually and reviewed by organizational leadership.

1. (3) Behavior Modification Plans. Behavior modification plans are designed to assist individuals in being successful while engaged in services and minimize inappropriate behaviors. Behavioral expectations, procedures, and consequences shall be clearly defined and explained to the individual served.

   1. (A) The need for a behavior modification plan shall be evaluated upon—

      1. 1. Any incident of seclusion or restraint;
      2. 2. The use of time-out two (2) or more

times per day; or

1. 3. The use of time-out three (3) or more

times per week.

1. (B) The behavior modification plan shall be developed with the individual served and his or her parents/guardian and family members/natural supports, as appropriate.
2. (C) The plan shall identify what the individual is attempting to communicate or achieve through his or her behavior before identifying interventions to change it.
3. (D) The plan shall be reevaluated within the first seven (7) days after it is developed, and every seven (7) days thereafter, to determine whether inappropriate behavior is being reduced and more functional alternatives achieved by the individual.

AUTHORITY: sections 630.050 and 630.055, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed April 15, 2002, effective Nov. 30, 2002. Amended: Filed Aug. 12, 2019, effective Feb. 29, 2020. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980.