Rule 290-2-6-.18 - Behavior Management and Emergency Safety Interventions(1)Behavior Management.(a) Every center shall develop and implement policies and procedures on behavior management. Such policies and procedures shall set forth the types of children served and the center's capacities in accordance with its program purpose, the anticipated behavioral problems of the children, and acceptable methods of managing such problems.(b) Such behavior management policies and procedures shall incorporate the following minimum requirements: 1. Behavior management principles and techniques shall be used in accordance with the individual comprehensive service plan and written policies and procedures governing service expectations, service plan goals, safety, security, and these rules and regulations.2. Acceptable behavior management methods shall be limited to the least restrictive appropriate method, as described in the child's comprehensive service plan pursuant to Rule .12(2) and in accordance with the prohibitions as specified in these rules and regulations.(c) The following forms of behavior management shall not be used: 1. Assignment of excessive or unreasonable work tasks beyond that which is identified as a learning need in the comprehensive service plan;2. Denial of meals and hydration;4. Denial of shelter, clothing, or essential personal needs;5. Denial of essential program services;6. Verbal abuse, ridicule, or humiliation;7. Chemical or mechanical restraint, manual holds, and seclusion used as a means of coercion, discipline, convenience, or retaliation;8. Denial of communication and visits unless restricted in accordance with Rule .12(2);(d) When there is a need for a chemical restraint, there shall be a verbal doctor's order authorizing the chemical restraint followed by a written doctor's order within one (1) business day thereafter. 1. The child's care must be monitored by a doctor for as long as the chemical restraint is ongoing.2. There shall be no standing orders for chemical restraints.(e) Restraints for positioning during physical therapy shall not be used as a form of behavior management.(f) Time out. A child may be placed in a separate room or area, from which egress is prevented only if the following conditions are met: 1. If the room in which the child is to be placed has a door, the door must remain open at all times; and2. The child is under the direct constant supervision of a designated staff member.(g) Residents shall not be permitted to participate in the behavior management of other residents or to discipline other residents, except as part of an organized therapeutic self-governing program in accordance with accepted standards of practice that is conducted in accordance with written policy and is supervised directly by designated staff.(h) Centers shall submit to the Department electronically or by facsimile a report within 24 hours whenever an unusual incident occurs regarding behavior management, including any injury requiring medical treatment beyond first aid that is received by a child as a result of any behavior management.(i) All forms of behavior management used by direct care staff shall also be documented in case records in order to ensure that such records reflect behavior management problems.(j) A positioning or securing device used to maintain the position, limit mobility, or temporarily immobilize a child during medical, dental, diagnostic, or surgical procedures is permissible if ordered by a physician and removed upon the completion of the procedure.(2)Emergency Safety Interventions.(a) Emergency safety interventions may be used only by staff trained in the proper use of such interventions when a child exhibits a dangerous behavior reasonably expected to lead to immediate physical harm to the child or others and less restrictive means of dealing with the injurious behavior have not proven successful or may subject the child or others to greater risk of injury.(b) Emergency safety interventions shall not include the use of any mechanical or chemical restraint or manual hold that would potentially impair the child's ability to breathe or has been determined to be inappropriate for use on a particular child due to a documented medical or behavioral condition. All emergency safety interventions which employ the use of chemical restraints shall be implemented in accordance with the requirements set forth in Rule .18(1)(d).(c) The center 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 child and the child's parents and/or legal guardians prior to or at the time of admission. Emergency safety interventions policies and procedures shall include: 1. Provisions for the documentation of a physician's assessment that states there are no medical issues that would be incompatible with the appropriate use of emergency safety interventions on that child. Such assessments and documentation must be re-evaluated following any significant change in the child's medical condition; and2. Provisions for the documentation of each use of an emergency safety intervention including: (i) Date and description of the precipitating incident;(ii) Description of the de-escalation techniques used prior to the emergency safety intervention, if applicable;(iii) Environmental considerations;(iv) Names of staff participating in the emergency safety intervention;(v) Any witnesses to the precipitating incident and subsequent intervention;(vi) Exact emergency safety intervention used;(vii) Beginning and ending time of the intervention;(viii) Outcome of the intervention;(ix) Detailed description of any injury arising from the incident or intervention; and(x) Summary of any medical care provided.3. Provisions for prohibiting manual hold use by any employee not trained in prevention and use of emergency safety interventions.(d) Emergency safety interventions or the use of physical or chemical restraints may be used to prevent runaways only when the child presents an imminent threat of physical harm to self or others, or as specified in the individual comprehensive service plan.(e) Center staff shall be aware of each child's medical and behavioral conditions, 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 health and well-being of the child.(f) Residents shall not be allowed to participate in the emergency safety intervention of another resident.(g) Immediately following the conclusion of the emergency safety intervention and hourly thereafter for a period of at least four hours where the child is with a staff member, the child's behavior will be assessed, monitored, and documented to ensure that the child does not appear to be exhibiting symptoms that would be associated with an injury.(h) At a minimum, the emergency safety intervention program that is utilized shall include the following:1. Techniques for de-escalating problem behavior including child and staff debriefings;2. Appropriate use of emergency safety interventions;3. Recognizing aggressive behavior that may be related to a medical condition;4. Awareness of physiological impact of a restraint on the child;5. Recognizing signs and symptoms of positional and compression asphyxia and restraint associated cardiac arrest;6. Instructions as to how to monitor the breathing, verbal responsiveness, and motor control of a child who is the subject of an emergency safety intervention;7. Appropriate self-protection techniques;8. Policies and procedures relating to using manual holds, including the prohibition of any technique that would potentially impair a child's ability to breathe;9. Center policies and reporting requirements;10. Alternatives to restraint;11. Avoiding power struggles;12. Escape and evasion techniques;13. Time limits for the use of restraint and seclusion;14. Process for obtaining approval for continual restraints and seclusion;15. Procedures to address problematic restraints;17. Investigation of injuries and complaints;18. Monitoring physical signs of distress and obtaining medical assistance; and(i) Emergency safety intervention training shall be in addition to the annual training required in Rule .08(6)(d)2. and shall be documented in the staff member's personnel record.(j) All actions taken that involve utilizing an emergency safety intervention shall be recorded in the child's case record showing the cause for the emergency safety intervention, the emergency safety intervention used, and, if needed, approval by the director, the staff member in charge of casework services, and the external physician who has responsibility for the diagnosis and treatment of the child's behavior.(k) Centers shall submit to the Department electronically or by facsimile a report, in a format acceptable to the Department, within 24 hours whenever an unusual incident occurs regarding emergency safety interventions, including: 1. Any injury requiring medical treatment beyond first aid that is received by a child as a result of any e mergency safety intervention;2. Whenever a center utilizes emergency safety interventions three or more times in one month with the same child and/or whenever the center utilizes more than 10 emergency safety interventions for all children in care within a 30-day period.(l) Centers shall submit a written report to the program's director on the use of any emergency safety intervention immediately after the conclusion of the intervention and shall further notify the child's parents or legal guardians regarding the use of the intervention. A copy of such report shall be maintained in the child's file.(m) At least once per quarter, the center, utilizing a master restraint log and the child's case record, shall review the use of all emergency safety interventions for each child and staff member, including the type of intervention used and the length of time of each use, to determine whether there was an appropriate 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 center identifies opportunities for improvement as a result of such reviews or otherwise, the center shall implement these changes through an effective quality improvement plan.(n) All direct care staff who may be involved in the use of emergency safety interventions, shall have evidence of having satisfactorily completed a training program for emergency safety interventions to protect residents and others from injury, which has been approved by the Department and taught by an appropriately certified trainer in such program. Centers shall check the Department's website for a list of approved training programs.(o) Manual Holds. 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. Emergency safety interventions shall not include the use of any chemical or mechanical restraint or manual hold that would potentially impair the child's ability to breathe or has been determined to be inappropriate for use on a particular child due to a documented medical or behavioral condition.3. When a manual hold is used upon any child whose primary mode of communication is sign language, the child 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 child or others.4. If the use of a manual hold exceeds 15 consecutive minutes, the center director or his or her designee, who possesses at least the qualifications of the director and has been fully trained in the center's emergency safety intervention plan, shall be contacted by a two-way communications device or in person and determine that 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 child's health given the child's physical or mental condition.5. A manual hold may not continue for more than 30 minutes at any one time without the consultation as specified in subparagraph (2) 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. If the use of a manual hold on a child reaches a total of one hour within a 24-hour period, the staff shall reconsider alternative strategies, document same, and consider notifying the authorities or transporting the child to a hospital or other appropriate facility for evaluation.7. The child'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.8. A positioning or securing device used to maintain the position, limit mobility, or temporarily immobilize a child during medical, dental, diagnostic, or surgical procedures is not considered a manual hold.Ga. Comp. R. & Regs. R. 290-2-6-.18
O.C.G.A. Secs. 49-5-3, 49-5-8, 49-5-12.
Original Rule entitled "Behavior Management and Emergency Safety Interventions" adopted. F. Jan. 27, 2009; eff. Feb. 16, 2009.