PURPOSE: This rule establishes requirements for the use of restraint, seclusion and time out in Alcohol and Drug Abuse Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Compulsive Gambling Treatment Programs, Substance Abuse Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Psychiatric Outpatient Programs.

1. (1) General Policy. Any behavior management methods used by an organization shall promote the rights, dignity and safety of individuals being served. An organization may prohibit by policy and practice the use of behavior management, including physical, mechanical and chemical restraint; seclusion; time out; and the use of behavior management plans for selected individuals. If any of these methods of behavior management are to be used within the organization, it shall develop policies and procedures which define, describe and limit the conditions and circumstances of their use.

   1. (A) Organizations utilizing seclusion and restraint must obtain a separate written authorization from the appropriate division of the Department of Mental Health, in addition to other requirements of this rule. The department may issue such authorization on a timelimited basis subject to renewal.

   2. (B) The organization must prohibit by policy and practice:

      1. 1. Aversive conditioning of any kind.

Aversive conditioning is defined as the application of startling, unpleasant or painful stimulus or stimuli that have a potentially noxious 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; and
3. 5. Use of seclusion, restraint, time out,

discipline or coercion for staff convenience.

1. (C) Behavior management policies and procedures shall be:

   1. 1. Approved by the organization’s board

of directors;

1. 2. Made available to all program

employees and providers;

1. 3. Made available to the individuals

served, their families and others upon request;

1. 4. Developed with the participation of

the individuals and, whenever possible, their family members or advocates, or both; and

1. 5. Consistent with department rules

regarding individual rights.

1. (2) Seclusion and Restraint.

   1. (A) The organization shall assure that 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. They shall only be implemented when alternative, less restrictive interventions have failed or cannot be safely implemented. Seclusion and restraint are never used as a treatment intervention. They are emergency/security measures to maintain safety when all other less restrictive interventions are inadequate.
   2. (B) Seclusion and restraint shall only be implemented by competent, trained staff.

   3. (C) The organization shall assure that seclusion or restraint is used only when ordered by a licensed practitioner trained in the use of emergency safety interventions or a certified substance abuse counselor trained in the use of emergency safety interventions. Orders for seclusion or restraint must define specific time limits. Seclusion and restraint shall be ended at the earliest possible time.

      1. 1. If seclusion or restraint is initiated

prior to obtaining an order, staff must obtain an order immediately.

1. 2. Within one (1) hour of the initiation

of the seclusion or restraint a certified substance abuse counselor or licensed practitioner trained in the use of emergency safety interventions and assessment of the physical and psychological well being of residents, must conduct a face-to-face assessment of the physical and psychological well-being of the resident, including but not limited to:

1. A. The resident’s physical and psy-

chological status;

1. B. The resident’s behavior;
2. C. The appropriateness of the inter-

vention measures; and

1. D. Any complications resulting from

the intervention.

1. 3. Standing or pro re nata (PRN) orders

for seclusion or restraint are not allowed.

1. 4. An order cannot exceed four (4)

hours for adults, two (2) hours for children and adolescents ages nine to seventeen (9– 17), or one (1) hour for children under age nine (9). When nonlicensed staff initiate seclusion or restraint, an order based on a face-to-face evaluation must be obtained from a licensed practitioner trained in the use of emergency safety interventions or a certified substance abuse counselor trained in the use of emergency safety interventions within one (1) hour.

1. 5. Individuals in restraint shall be mon-

itored continuously. Monitoring may be faceto-face by assigned staff or by audiovisual equipment.

1. 6. Individuals in seclusion shall be visu-

ally monitored at least every fifteen (15) minutes.

1. 7. Individuals in seclusion or restraint

are offered regular food, fluid and an opportunity to meet their personal hygiene needs no less than every two (2) hours.

1. 8. The need for continuing seclusion or

restraint shall be evaluated by and, where necessary, re-ordered by a licensed practitioner trained in the use of emergency safety interventions or certified substance abuse counselor trained in the use of emergency safety interventions at least every four (4) hours for adults, two (2) hours for children and adolescents ages nine through seventeen inclusively (9–17), or one (1) hour for children under age nine (9).

1. 9. The evaluation for the first renewal

following an order based on a face-to-face evaluation by a licensed practitioner trained in the use of emergency safety interventions or certified substance abuse counselor trained in the use of emergency safety interventions may be based on a telephone consultation between a licensed practitioner trained in the use of emergency safety interventions or a certified substance abuse counselor trained in the use of emergency safety intervention and on-site staff who have done a face-to-face evaluation with the person in seclusion or restraint. The evaluation for every alternate renewal period shall be based on face-to-face observation and/or interview with the individual by the licensed practitioner or certified substance abuse counselor trained in the use of emergency safety interventions.

1. 10. The organization’s clinical director

or quality improvement coordinator shall review every episode of seclusion or restraint within seventy-two (72) hours.

1. 11. Any incident of restraint or seclu-

sion shall be promptly reported to the person’s parent or legal guardian, when applicable.

1. (3) Individualized Behavioral Management Plan.

   1. (A) Definitions. The following terms shall mean:

      1. 1. Behavioral management plan, array of

positive and negative reinforcement to reduce unacceptable or maladaptive interactions and behaviors;

1. 2. Time out, an individual’s voluntary

compliance with the request to remove himself or herself from a service area to a separate location.

1. (B) The need for a behavioral management 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. (C) Behavioral plan shall include the input of the individual being served and family, if appropriate.
2. (D) The plan shall identify what the individual is attempting to communicate or achieve through the maladaptive behavior before identifying interventions to change it.
3. (E) The plan shall be reevaluated within the first seven (7) calendar days and every seven (7) days thereafter to determine whether maladaptive and unacceptable behaviors are being reduced and more functional alternatives acquired.

AUTHORITY: sections 630.050 and 630.055, RSMo 2000.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed April 15, 2002, effective Nov. 30, 2002. *Original authority: 630.050, RSMo 1980, amended 1993, 1995 and 630.055, RSMo 1980.