Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition


Section 7.3 Seclusion and Restraint Reporting and Emergency Safety Response

7.3.1 Introduction
7.3.2 References
7.3.3 Scope
7.3.4 Did you know…?
7.3.5 Definitions
7.3.6 Objectives
7.3.7 Procedures
7.3.7-A. Reporting to the T/RBHA
7.3.7-B. Reporting to the Office of Human Rights
7.3.7-C. Reporting to the Human Rights Committee
7.3.7-D. Non-licensed Facility Reporting

NOTICE:  Contractors and Providers should follow all local, state and federal regulations and requirements related to both facility oversight and member care.  The information outlined below is in addition to local, state and federal regulations and requirements.

7.3.1 Introduction
The purpose of this policy is to establish requirements for reporting of the use of seclusion, restraint, and emergency safety response for all enrolled persons. Tribal/Regional Behavioral Health Authorities (T/RBHAs) shall receive reports concerning the use of seclusion and restraint with all enrolled persons, including persons determined to have a Serious Mental Illness (SMI) and children and shall monitor their subcontracted providers to ensure that use of these methods is consistent with all applicable requirements.

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7.3.2 References
The following citations can serve as additional resources for this content area:

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7.3.3 Scope
To whom does this apply?

To all Tribal and Regional Behavioral Health Authority (T/RBHA) contracted Office of Behavioral Health Licensure (OBHL) licensed Level I behavioral health inpatient treatment programs. The policy is applicable to all enrolled individuals.

7.3.4 Did you know…?

  • Trauma associated with seclusion and restraint can trigger Post Traumatic Stress Disorder
     
  • Each State has a designated protection and advocacy system. In Arizona, the Arizona Center for Disability Law serves as the designated protection and advocacy agency.

R9-20-602(Q) and R9-21-204 require that all staff members and medical professionals involved in ordering, providing, monitoring or evaluating seclusion or restraint complete and document education and training to include: understanding behavioral and environmental risk factors, nonphysical interventions, the safe use of seclusion or restraint and responding to emergency situations.

In 2003, the Substance Abuse and Mental Health Services Administration (SAMHSA) published the Roadmap to Seclusion and Restraint Free Mental Health Services. Developed by administrations, experts and behavioral health recipients, the training is a resource for mental health service direct care staff, administrators, and recipients on alternatives to the use of seclusion or restraint, as well as a tool for mental health system transformation.

A staff member employing any method that results in a person either being precluded from exiting an area in fact or left with the reasonable belief of being prohibited from being able to exit freely (for example – a staff member’s use of his/her body to block an individual’s exit from a specified area) constitutes seclusion.

A.R.S. 36-513 and A.R.S. 36-528 require that a person under emergency detention or court ordered evaluation may not be treated without consent, except that pharmacological restraint may be used to protect the safety of that person and others in an emergency.  Therefore, psychiatric medications given involuntarily to persons under emergency detention or court ordered evaluation must be considered chemical restraint and documented as such.

42 CFR 482.13 clarifies that a drug or medication used as a restraint is not a standard treatment or dosage for a behavioral health recipient’s condition.  Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN).
  • Each T/RBHA is also required to collect certain aggregate data that compiles total seclusion and restraints for the reporting period, and forward that data to to the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS).

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7.3.5 Definitions
Definitions for terms are located online at http://www.azdhs.gov/bhs/definitions/index.php. The following terms are referenced in this section:

ADHS/DBHS Office of Human Rights

Emergency Safety Response

Human Rights Committees

Personal Restraint - Behavioral Health Inpatient Psychiatric Acute Hospital Programs

Personal Restraint - Behavioral Health Inpatient Facility Providing Services to Persons under the Age of 21

Restraint

Seclusion - Individuals Determined to have a Serious Mental Illness

Seclusion - Behavioral Health Inpatient Programs

Serious Mental Illness (SMI)

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7.3.6 Objectives

  • To establish requirements for reporting the use of seclusion and restraint, and emergency safety response for all enrolled persons.
     

  • Tribal/Regional Behavioral Health Authorities (T/RBHAs) shall receive reports concerning the use of seclusion and restraint with all enrolled persons, including persons determined to have a Serious Mental Illness (SMI) and children and shall monitor their subcontracted providers to ensure that use of these methods is consistent with all applicable requirements.

7.3.7 Procedures

7.3.7-A. Reporting to the T/RBHA
All ADHS or state licensed Behavioral Health facilities and programs, including out-of state facilities, authorized to use seclusion, restraint and emergency safety response submit individual reports of incidents of seclusion, restraint and emergency safety response within five (5) days of the occurrence to the T/RBHA utilizing Policy Form 1702.1, Seclusion, Restraint, and Emergency Safety Response Reporting Form or submitting the necessary required fields as specified in Policy Attachment 1702A Seclusion, Restraint and Emergency Safety Response Reporting Requirements.

In the event that a use of seclusion or restraint requires face-to-face monitoring, a report detailing face-to-face monitoring is submitted to the T/RBHA along with Policy Form 1702.1, Seclusion, Restraint, and Emergency Safety Response Reporting Form (see Face-to-Face Monitoring Requirements).

Each subcontracted ADHS licensed Behavioral Health Inpatient Facility reports the total number of occurrences of the use of seclusion, restraint, and emergency safety response that occurred in the prior month to the T/RBHA by the 5th calendar day of the month. If there were no occurrences of seclusion, restraint, and/or emergency safety response during the reporting period, the report should so indicate. Monthly summary data is to be submitted to the Gila River RBHA Manager of Quality Management/Utilization Management utilizing PM Form 7.3-GR.

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7.3.7-B. Reporting to the Office of Human Rights
Each T/RBHA and the Arizona State Hospital (AZSH) shall:

  • Forward individual reports concerning the use of seclusion and restraint with member’s designated as SMI and children to the ADHS/DBHS Office of Human Rights (OHR) on a weekly or monthly basis, as arranged with OHR. The AzSH or T/RBHA should redact any information on substance abuse or HIV/AIDS/ communicable disease from the reports. Individual reports must be submitted, via a secure and encrypted e-mail delivery system or portal, to the following address: OHRts@azdhs.gov
     
  • Submit monthly reports of seclusion and restraint information involving member’s designated as SMIs to the OHR using the Seclusion and Restraint Monthly Report for DBHS/OHR. Reports are to be forwarded by the 10th day of each month.
     
  • Submit summary seclusion and restraint reports to the ADHS/DBHS Bureau of Quality and Integration (BQ&I) as required by ADHS/RBHA contracts and ADHS/TRBHA Intergovernmental Agreements (IGAs).

7.3.7-C. Reporting to Human Rights Committees
The RBHAs and Arizona State Hospital (AzSH) shall forward individual reports of the use of seclusion, restraint, or emergency safety response for all enrolled persons to the appropriate Human Rights Committee (HRC) for the region on a weekly or monthly basis, as arranged with the individual HRC. The Arizona State Hospital or RBHA must ensure that the disclosure of protected health information is in accordance with Policy 1806, Disclosure of Confidential Information to Human Rights Committees.

The RBHAs and AzSH shall also submit monthly summary reports of seclusion, restraint, and emergency safety response information for all enrolled persons to the appropriate Human Rights Committee for the region using the Seclusion and Restraint Monthly Report for the Human Rights Committees included in the ADHS/DBHS Performance Improvement Specifications Manual. The reports must be submitted by the 10th day of each month. Monthly summary reports must be redacted.

7.3.7-D. Non-licensed Facility Reporting
Non-licensed facilities shall submit monthly summary seclusion, restraint, and emergency safety response reports to the ADHS/DBHS BQ&I. Each organization shall report the total number of occurrences of the use of seclusion, restraint, and emergency safety response that occurred in the prior month to ADHS/DBHS BQ&I by the 10th calendar day of the month. If there were no occurrences of seclusion, restraint, and/or emergency safety response during the reporting period, the report should so indicate. Individual reports must be submitted, via a secure and encrypted e-mail delivery system or portal, to the following address: BHSQMO@azdhs.gov.

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7.3 Seclusion and Restraint Reporting
Last Revised: 2/28/2016
Effective Date: 2/28/2016

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