(a) The facilities to which this subchapter applies
shall ensure that staff members are informed of their roles and responsibilities
under this subchapter and are trained and demonstrate competence accordingly.
(b) The training program shall be consistent with the
requirements of this subchapter and shall:
(1) target the specific needs of each patient population
being served;
(2) be tailored to the competency levels of the staff
members being trained;
(3) emphasize the importance of reducing and preventing
the use of restraint and seclusion;
(4) be evaluated annually, which shall include evaluation
to ensure that the training program, as planned and as implemented,
complies with the requirement of this section;
(5) incorporate evidence-based best practices;
(6) provide information about declarations for mental
health treatment, including:
(A) the right of individuals to execute declarations
for mental health treatment; and
(B) the duty of staff members and other health care
providers to act in accordance with declarations for mental health
treatment to the fullest extent possible.
(c) Before assuming job duties involving direct care
responsibilities, and at least annually thereafter, staff members
other than physicians must receive training and demonstrate competence
in at least the following knowledge and applied skills that shall
be specific and appropriate to the population(s) the facility serves:
(1) using team work, including team roles and techniques
for facilitating team communication and cohesion;
(2) identifying the causes of aggressive or threatening
behaviors of individuals who need mental health services, including
behavior that may be related to an individual's non-psychiatric medical
condition;
(3) identifying underlying cognitive functioning and
medical, physical, and emotional conditions;
(4) identifying medications and their potential effects;
(5) identifying how age, weight, cognitive functioning,
developmental level or functioning, gender, culture, ethnicity, and
elements of trauma-informed care, including history of abuse or trauma
and prior experience with restraint or seclusion, may influence behavioral
emergencies and affect the individual's response to physical contact
and behavioral interventions;
(6) explaining how the psychological consequences of
restraint or seclusion and the behavior of staff members can affect
an individual's behavior, and how the behavior of individuals can
affect a staff member;
(7) applying knowledge and effective use of communication
strategies and a range of early intervention, de-escalation, mediation,
problem-solving, and other non-physical interventions, such as clinical
timeout and quiet time; and
(8) recognizing and appropriately responding to signs
of physical distress in individuals who are restrained or secluded,
including the risks of asphyxiation, aspiration, and trauma.
(d) Before any staff member may initiate any restraint
or seclusion the staff member shall receive training and demonstrate
competence in:
(1) safe and appropriate initiation and use of seclusion
as a last resort in a behavioral emergency;
(2) safe and appropriate initiation and application,
and use of personal restraint as a last resort in a behavioral emergency;
(3) safe and appropriate initiation and application,
and use of mechanical restraint devices as a last resort in a behavioral
emergency or as a protective or supportive device, and knowledge of
the mechanical restraint devices permitted under §415.256 of
this title (relating to Mechanical Restraint Devices) and approved
by the facility; and
(4) management of emergency medical conditions in accordance
with the facility's policies and procedures and other applicable requirements
for:
(A) obtaining emergency medical assistance; and
(B) obtaining training in and using techniques for
cardiopulmonary respiration and removal of airway obstructions.
(e) Before assuming job duties, and at least annually
thereafter, a registered nurse or a physician assistant who is authorized
to:
(1) perform assessments of individuals who are in restraint
or seclusion shall receive training, which shall include a demonstration
of competence in:
(A) monitoring cardiac and respiratory status and interpreting
their relevance to the physical safety of the individual in restraint
or seclusion;
(B) recognizing and responding to nutritional and hydration
needs;
(C) checking circulation in, and range of motion of,
the extremities;
(D) providing for hygiene and elimination;
(E) identifying and responding to physical and psychological
status and comfort, including signs of distress;
(F) assisting individuals in de-escalating, including
through identification and removal of stimuli, that meet the criteria
for a behavioral emergency if known;
(G) recognizing when continuation of restraint or seclusion
is no longer justified by a behavioral emergency; and
(H) recognizing when to contact emergency medical services
to evaluate and/or treat an individual for an emergency medical condition.
(2) conduct evaluations of individuals, including face-to-face
evaluations pursuant to §415.260(c) of this title (relating to
Initiation of Restraint or Seclusion in a Behavioral Emergency) of
individuals who are in restraint or seclusion, shall receive training,
which shall include a demonstration of competence in:
(A) identifying restraints that are permitted by the
facility, by this subchapter, and by other applicable law;
(B) identifying stimuli that trigger behaviors;
(C) identifying medical contraindications to restraint
and seclusion;
(D) recognizing psychological factors to be considered
when using restraint and seclusion, such as sexual abuse, physical
abuse, neglect, and trauma.
(f) Before assuming job duties, and at least annually
thereafter, staff members who are authorized to monitor, under the
supervision of a registered nurse, individuals during restraint or
seclusion shall receive training, which shall include a demonstration
of competence in:
(1) monitoring respiratory status;
(2) recognizing nutritional and hydration needs;
(3) checking circulation in, and range of motion of,
the extremities;
(4) providing for hygiene and elimination;
(5) addressing physical and psychological status and
comfort, including signs of distress;
(6) assisting individuals in de-escalating, including
through identification and removal of stimuli, if known.
(7) recognizing when continuation of restraint or seclusion
is no longer justified by a behavioral emergency; and
(8) recognizing when to contact a registered nurse.
(g) For physicians who may order restraint or seclusion,
the facility's credentialing and privileging processes must require
that such physicians:
(1) demonstrate competency in ordering restraint or
seclusion; and
(2) receive training and refresher training in:
(A) the use of alternatives to restraint or seclusion;
and
(B) how to reduce the physical and emotional harm caused
by restraint or seclusion.
(h) When a staff member's duties change, the facility
shall reassess the staff member's training and competence and require
and ensure the staff member's retraining, as required under this subchapter,
based upon the facility's reassessment and the staff member's new
duties.
(i) The facility shall maintain documentation of training
for each staff member. Documentation shall include the date that training
was completed, the name of the instructor, a list of successfully
demonstrated competencies, the date competencies were assessed, and
the name of the person who assessed competence.
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