Summary of Select Regulations Regarding Behavioral Restraint and Seclusion

Disability Rights California

Investigations Unit

1330 Broadway, Suite 500

Oakland, CA 94612

Tel. (510) 267-1200

April 2008

Publication #5457

Readers are directed to review the specific language of the regulations and/or standards and not rely upon the summaries contained within this document as they are abbreviated and may have subsequently been revised.

Table of Contents

Table of Contents. 1

General Acute Care Hospitals. 1

Acute Psychiatric Hospitals. 1

Joint Commission on Accreditation of Healthcare Organizations. 1

Hospital Standards. 1

Joint Commission on Accreditation of Health Care Organizations. 1

Behavioral Health Care Standards. 1

Psychiatric Health Facility (PHF) 1

Skilled Nursing Facility (SNF) 1

Skilled Nursing Facility (SNF) with Special 1

Treatment Program Service Unit 1

Intermediate Care Facility (ICF) 1

Intermediate Care Facility (ICF) 1

Intermediate Care Facility for Developmentally Disabled (ICF/DD) 1

Intermediate Care Facility State/DD - Habilitative (ICF/DD-Hab) 1

Department of Corrections. 1

Correctional Treatment Centers. 1

Acute and Nonacute 24-hour Mental Health Care. 1

Schools – Special Education. 1

Psychiatric Residential Treatment Facility for Individuals. 1

under Twenty-one (21) Years of Age. 1

Community Treatment Facilities. 1

Mental Health Rehabilitation Centers. 1

Chemical Dependency Recovery Hospitals. 1

Juvenile Halls. 1

Facilities Limiting/Banning Seclusion and Restraint 1

Community Care Facilities. 1

Child Care Facilities. 1

Hospitals Federal
Primary regulation	42 CFR 482.13
Alternatives explored	“Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient a staff member or others from harm.” 42 CFR 482.13(e)(1)(ii)(2). “The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm.” 42 CFR 482.13(e)(1)(ii)(3).
Who can order it	“The use of a restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner… authorized to order seclusion or restraint by hospital policy in accordance with state law.” 42 CFR 482.13(e)(5). “The attending physician must be consulted as soon as possible, if the attending physician did not order the restraint or seclusion.” 42 CFR 482.13(e)(7).
When does an MD have to cosign
Is the presence of an MD required to apply	No. Patient must be seen face-to-face within 1hour after initiation of restraint or seclusion by physician or other licensed independent practitioner; or registered nurse or physician’s assistant who has received special training. 42 CFR 482.13(e)(12). See 42 CFR 482.13(f) for training requirements. If face-to-face by registered nurse or physician’s assistant, must consult the attending physician or other licensed independent practitioner responsible for care of patient as soon as possible after completing 1 hour assessment. 42 CFR 482.13(e)(14).
Duration of each order	“Each order for restraint or seclusion used for management of violent or self-destructive behavior that jeopardizes the immediate physical safety of patient, staff…, or others may only be renewed in accordance with following limits up to a total of 24 hours: (A) 4 hours for adults 18 years and older; (B) 2 hours for children and adolescents ages 9 to 17; or (C) 1 hour for patients under 9.” 42 CFR 482.13(e)(8)(i). “After 24 hours, before writing a new order…, physician or other licensed independent practitioner who is responsible for the care of the patient … must see and assess the patient.” 42 CFR 482.13(e)(8)(ii).
How often must they check on patients	Simultaneous restraint and seclusion use is only permitted if patient is continually monitored face-to-face by assigned, trained staff member; or by trained staff using both video and audio equipment and in close proximity to patient. 42 CFR 482.13(e)(15). Monitoring patient in restraint or seclusion… at interval determined by hospital policy. 42 CFR 482.13(e)(10).
Documentation	When restraint or seclusion is used, there must be documentation in patient’s medical record of: (i) 1 hours face-to-face evaluation; (ii) description of patient’s behavior and intervention used; (iii) alternatives or other less restrictive interventions attempted (as applicable); (iv) patient’s condition or symptom(s) that warranted use; and (v) patient’s response to intervention(s) used, including rationale for continued use. 42 CFR 482.13(e)(16).
Staff training required	“Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion before performing [restraint or seclusion], as part of orientation, and subsequently on a periodic basis consistent with hospital policy.” 42 CFR 482.13(f)(1)
Restraint	“Any manual, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely; or drug… (see below).” 42 CFR 482.13(e)(1)(i)(A). Does not include devices… that … hold patient during routine physical exam or to protect from falling out of bed… 42 CFR 482.13(e)(1)(i)(C).
Chemical Restraint	“A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.” 42 CFR 482.13(e)(1)(i)(B).
Seclusion	“Seclusion is the involuntary confinement of a person alone in a room or an area which the person is physically prevented from leaving.” May only be used for management of violent or self-destructive behavior. 42 CFR 482.13(e)(1)(ii).
Postural Supports	Expressly not included in definition of restraint. 42 CFR 482.13(e)(1)(ii)(C).

General Acute Care Hospitals State
Primary regulation	22 CCR 70577(j)
Alternatives explored	“Restraint shall be used only when alternative methods are not sufficient to protect the patient or others from injury.” 22 CCR 70577(j)(1).
Who can order it	“[O]nly on the written order of the physician. In a clear case of emergency, a patient may be placed in restraint at the discretion of a registered nurse and a verbal or written order obtained thereafter.” 22 CCR 70577(j)(2).
When does an MD have to cosign	Always. “If a verbal order is obtained it shall be recorded in the patient's medical record and be signed by the physician on his next visit.” 22 CCR 70577(j)(2).
Is the presence of an MD required to apply	No. “In a clear case of emergency, a patient may be placed in restraint at the discretion of a registered nurse and a verbal or written order obtained thereafter.” 22 CCR 70577(j)(2).
Duration of each order
How often must they check on patients	“Patients in restraint by seclusion or mechanical means shall be observed at intervals not greater than 15 minutes.” 22 CCR 70577(j)(3).
Documentation	“Record of type of restraint including time of application and removal shall be in the patient's medical record.” 22 CCR 70577(j)(5). “If a verbal order is obtained it shall be recorded in the patient's medical record.” 22 CCR 70577(j)(2).
Staff training required	“Psychiatric unit staff shall be involved in orientation and in-service training of hospital employees.” 22 CCR 70577(l).
Restraint[1]	“Restraint means controlling a patient's physical activity in order to protect the patient or others from injury by seclusion or mechanical devices.” 22 CCR 70059.
Chemical Restraint
Seclusion[2]	Same as restraint.
Postural Supports

Acute Psychiatric Hospitals State
Primary regulation	22 CCR 71545
Alternatives explored	“Restraint shall be used only when alternative methods are not sufficient to protect the patient or others from injury.” 22 CCR 71545(a).
Who can order it	“[O]nly on the written order of the physician. In a clear case of emergency, a patient may be placed in restraint at the discretion of a registered nurse and a verbal or written order obtained thereafter.” 22 CCR 71545(b).
When does an MD have to cosign	“If a verbal order is obtained it shall be recorded in the patient's medical record and be signed by the physician on his next visit.” 22 CCR 71545(b).
Is the presence of an MD required to apply	No. “In a clear case of emergency, a patient may be placed in restraint at the discretion of a registered nurse and a verbal or written order obtained thereafter.” 22 CCR 71545(b).
Duration of each order
How often must they check on patients	“Patients in restraint by seclusion or mechanical means shall be observed at intervals not greater than 15 minutes.” 22 CCR 71545(c).
Documentation	“This order shall include the reason for restraint and the type of restraint being used…. If a verbal order is obtained it shall be recorded in the patient's medical record.” 22 CCR 71545(b).
Staff training required
Restraint[3]	“Restraint means controlling a patient's physical activity in order to protect the patient or others from injury by seclusion, medication or mechanical devices.” 22 CCR 71055.
Chemical Restraint	Same as restraint.
Seclusion[4]	Same as restraint.
Postural Supports

Joint Commission on Accreditation of Healthcare Organizations Hospital Standards[5]
Primary regulation	Hospital Accreditation Standards (HAS) (2008) PC.12[6]
Alternatives explored	Limited to emergencies in which there is an imminent risk of a patient physically harming him/herself, staff, or others, and nonphysical interventions would not be effective. PC.12.60.
Who can order it	A licensed independent practitioner[7] (LIP) orders the use of restraint or seclusion. Organization may authorize qualified, trained staff members (who are not LIPs) to initiate before an order is obtained in an emergency when LIP is not immediately available. Must obtain order from LIP as soon as possible, no longer than one hour. PC.12.70.
When does an MD have to cosign
Is the presence of an MD required to apply	No. LIP evaluates in-person within: - 4 hours of initiation for adults; - 2 hours of initiation for child 17 and under. PC.12.90. Thereafter, LIP conducts in-person reevaluation: - every 8 hours for adults; - every 4 hours for children under 17 years. PC.12.110. LIP evaluates in person a patient released from restraint or seclusion within 24 hours of the initiation of the restraint or seclusion, if patient released before original order expires (4 hours for adults; 2 hours for children). PC.12.90.
Duration of each order	Orders for restraint or seclusion are limited to: - 4 hours for adults; - 2 hours for children 9 -17 years; - 1 hour for children under 9 years. PC.12.100.
Extended duration restraint/seclusion	Clinical leaders notified of restraint/seclusion: - extending beyond 12 hours; - occurring two or more separate episodes within 12 hours; - thereafter, every 24 hours. PC.12.120.
How often must they check on patients	- Continuous in-person observation; - After first hour of seclusion only, may continuously monitor by video and audio equipment; - Second staff member required to observe during physical holds. PC.12.140. - Patient assessed every 15 minutes. PC.12.130.
Documentation	Medical records document that the use of restraint or seclusion is consistent with hospital policy. Includes specific requirements. PC.12.170.
Staff training required	Staff is trained and competent to minimize the use of restraint and seclusion and, when use is indicated, to use restraint or seclusion safely. PC.12.30.
Restraint	Any method (chemical or physical) of restricting a patient’s freedom of movement, including seclusion, physical activity, or normal access to his/her body that: - is not a usual and customary part of a medical diagnostic or treatment procedure to which the patient or his/her legal representative has consented; - is not indicated to treat the patient’s medical condition or symptoms; or - does not promote the patient’s independent functioning. HAS glossary. Excludes when a staff member(s) physically redirects or holds a child, without the child’s permission, for 30 minutes or less (but must meet training standards), OR restraint with patients who receive treatment for formal behavior mgmt programs (other standards apply).
Chemical Restraint	“The inappropriate use of a sedating psychotropic drug to manage or control behavior.” HAS glossary.
Seclusion	Included in definition of restraint. Excludes time-out when a patient is restricted for 30 minutes or less from leaving an unlocked room & when its use is consistent with patient’s treatment plan; OR restriction to unlocked room or area consistent with unit’s rules or regulations and organization policy(ies) and procedure(s)
Postural Supports	Adaptive support in response to patient’s assessed physical needs (e.g. postural support, orthopedic appliances) are exceptions to restraint standards.

Joint Commission on Accreditation of Health Care Organizations Behavioral Health Care Standards[8]
Primary regulation	Standards for Behavioral Health Care (SBHC) (2008) PC12[9]
Alternatives explored	Limited to emergencies in which there is an imminent risk of a client physically harming him/herself, staff, or others, and nonphysical interventions would not be effective. PC.12.60.
Who can order it	A licensed independent practitioner[10] (LIP) orders the use of restraint or seclusion. PC.12.70. Organization may authorize qualified, trained staff members (who are not LIPs) to initiate before an order is obtained in an emergency when LIP is not immediately available. Must obtain order from LIP as soon as possible, no longer than one hour. PC.12.70.
When does an MD have to cosign
Is the presence of an MD required to apply	No. LIP evaluates in-person within: - 4 hours of initiation for adults; - 2 hours of initiation for child 17 and under. PC.12.90. Thereafter, LIP conducts in-person reevaluation: - every 8 hours for adults; - every 4 hours for children under 17 years. PC.12.110. LIP evaluates in-person a client released from restraint or seclusion within 24 hours of the initiation of the restraint or seclusion. PC.12.90.
Duration of each order	Orders for restraint or seclusion are limited to: - every 4 hours for adults; - every 2 hours for children 9 -17 years; - every 1 hour for children under 9 year. PC.12.100.
Extended duration restraint/seclusion	Clinical leaders notified of restraint/seclusion: - extending beyond 12 hours; - occurring two or more times within 12 hours; - thereafter, every 24 hours. PC.12.120.
How often must they check on patients	- Continuous in-person observation. - After first hour of seclusion only, may continuously monitor by video & audio equipment. - Second staff member required to observe during physical holds. PC.12.140. Client assessed every 15 minutes. PC.12.130.
Documentation	Clinical/case records document that the use of restraint or seclusion is consistent with organization policy. Includes specific requirements. PC.12.170.
Staff training required	Staff is trained and competent to minimize the use of restraint and seclusion and, when use is indicated, to use restraint or seclusion safely. PC.12.30.
Restraint	Any method (chemical or physical) of restricting a client’s freedom of movement, including seclusion, physical activity, or normal access to his/her body that: - is not a usual and customary part of a medical diagnostic or treatment procedure to which the client or his/her legal representative has consented, - is not indicated to treat the resident’s medical condition or symptoms, or - does not promote the client’s independent functioning SBHC glossary Excludes when a staff member(s) physically redirects or holds a child, without the child’s permission, for 30 minutes or less (but must meet training & monitoring standards); OR restraint as intervention through formal behavior mgmt and treatment programs (other standards apply).
Chemical Restraint	“The inappropriate use of a sedating psychotropic drug to manage or control behavior.” SBHC glossary.
Seclusion	Included in definition of restraint. Excludes time-out when a client is restricted for 30 minutes or less from leaving an unlocked room & when its use is consistent with client’s plan for care, treatment, and services; OR restriction to unlocked room or area consistent with program rules or regulations and organization policy(ies) and procedure(s)
Postural Supports	Adaptive support in response to client’s assessed physical needs (e.g. postural support, orthopedic appliances) are exceptions to restraint standards.

Psychiatric Health Facility (PHF) State
Primary regulation	22 CCR 77103
Alternatives explored
Who can order it	“[S]hall only be used upon a physician's or clinical psychologist's written or verbal order, except under emergency circumstances. Under emergency circumstances behavioral restraint may be applied and then an order obtained as soon as possible, but at least within one hour of application.” 22 CCR 77103(b).
When does an MD have to cosign	“Telephone orders shall be… within twenty-four (24) hours, weekends and holidays excepted, signed by the prescriber.” 22 CCR 77103(b).
Is the presence of an MD required	No.
Duration of each order	“Orders for behavioral restraint and seclusion shall be in force for not longer than 24 hours.” 22 CCR 77103(d).
How often must they check on patients	“Patients in restraint shall remain in staffs' line of vision….” 22 CCR 77103(f). “[P]atient… in behavioral restraint or seclusion shall be checked at least every 15 minutes by professional staff….” 22 CCR 77103(g).
Documentation	“Telephone orders… shall be recorded immediately in the patient's health record….” 22 CCR 77103(b). “A written record shall be kept of [required] checks and maintained in the individual patient's health record.” 22 CCR 77103(g).
Staff training required
Restraint[11]	Not defined. Seclusion and exclusionary timeout are considered to be a physical restraint. 22 CCR 77101(b) & (c). No physical restraints with locking devices shall be used or available for use unless approved by State Fire Marshal. 22 CCR 77101.
Chemical Restraint
Seclusion[12]	“[I]solation… in a locked area, for the purpose of modifying behavior.” 22 CCR 77029.
Exclusionary timeout	Exclusionary timeout means removing a patient from an activity to another area in the same room or vicinity for a period of time contingent on a specific maladaptive behavior. 22 CCR 77010.
Postural Supports	“[A] method other than orthopedic braces used to assist patients to achieve proper body position and balance.” 22 CCR 77021. “Treatment restraint means the use of a restraining device during medically prescribed treatment or diagnostic procedures….” 22 CCR 77033.
Other	“Behavioral and treatment restraints shall be utilized only with patients being treated pursuant to Sections 5150 et seq. of the Welfare and Institutions Code or who are judicially committed.” 22 CCR 77103(i).

Skilled Nursing Facility (SNF) State
Primary regulation	22 CCR 72319
Alternatives explored
Who can order it	“Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care except in an emergency which threatens to bring immediate injury to patient or others. In an emergency an order may be received by telephone.” 22 CCR 72319(i)(2). “Physical restraints for behavior control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately to the elimination of, the behavior for which the restraint is applied.” 22 CCR 72319(i)(2)(A).
When does an MD have to cosign	[I]n an emergency [which threatens to bring immediate injury to the patient or others] an order may be received by telephone, and shall be signed within 5 days.” 22 CCR 72319(i)(2).
Is the presence of an MD required	No.
Duration of each order	“Each patient care plan which includes the use of physical restraint for behavioral control shall specify… the time limit for the use of the method.” 22 CCR 72319(i)(2)(B).
How often must they check on patients	“Patients shall be restrained only in an area that is under supervision of staff and shall be afforded protection from other patients who may be in the area.” 22 CCR 72319(i)(2)(C).
Documentation	“Full documentation of the episode leading to the use of physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record.” 22 CCR 72319(i)(2). “Each patient care plan…[for] physical restraint for behavioral control shall specify the behavior to be eliminated, the method to be used and the time limit for the use of the method.” 22 CCR 72319(i)(2)(B).
Staff training required
Restraint[13]	“[O]nly acceptable forms of physical restraint shall be cloth vests, soft ties, soft cloth mittens, seat belts and trays with spring release devices.” 22 CCR 72319(c). “No restraint with locking devices shall be used or available for use in skilled nursing facility.” 22 CCR 72319(e).
Chemical Restraint vs. Psychotherapeutic Drug	“A drug used to control behavior and used in a manner not required to treat the patient’s medical symptoms.” 22 CCR 72018. “Psychotherapeutic drug means a medication to control behavior or to treat thought disorder processes.” 22 CCR 72092. “When drugs [including PRNs] are used to restrain or control behavior or to treat a thought disorder, the following shall apply: - The specific behavior or manifestation of disordered thought process to be treated with the drug is identified in the patient's health record. 22 CCR 72319(j)(1). - The plan of care for each patient specifies data to be collected for use in evaluating the effectiveness of the drugs and the occurrence of adverse reactions. 22 CCR 72319(j)(2). - The data collected shall be made available to the prescriber in a consolidated manner at least monthly. 22 CCR 72319(j)(3).
Seclusion[14]	“Seclusion, which is defined as the placement of a patient alone in a room, shall not be employed.” 22 CCR 72319(f).
Postural Supports & Treatment Restraints	“Postural support means a method other than orthopedic braces used to assist patients to achieve proper body position and balance. Postural supports may only include soft ties, seat belts, spring release trays, or cloth vests and shall only be used to improve a patient's mobility and independent functioning, to prevent the patient from falling out of a bed or chair, or for positioning, rather than to restrict movement. These methods shall not be considered restraints.” 22 CCR 72319(k). “Treatment restraints may be use for the protection of the patient during treatment and diagnostic procedures…. Treatment restraints shall be applied for no loner than the time required to complete the treatment.” 22 CCR 72319(i)(1).

Skilled Nursing Facility (SNF) with Special Treatment Program Service Unit State
Primary regulation	22 CCR 72461 (Must also comply with 22 CCR 72319 in applying physical restraints)
Alternatives explored
Who can order it	“Restraint and seclusion shall only be used on the signed order of a physician.… In a documented case of emergency, which threatens to bring immediate injury to the patient or others, a restraint may be applied, and a physician shall give an order for application of the restraint within one hour. A physician may give the order by telephone.” 22 CCR 72461(a).
When does an MD have to cosign	In [documented case of emergency], the physician shall sign the [telephone] order “within 5 days.” 22 CCR 72461(a).
Is the presence of an MD required	No.
Duration of each order	Orders “shall be renewed every 24 hours.” 22 CCR 72461(a).
How often must they check on patients	Patients placed in restraint or seclusion shall be observed by qualified treatment personnel at least every half hour.” 22 CCR 72463(a)(2) and (b)(1).
Documentation	“A daily log shall be maintained… indicating the name of the patient for whom behavior restraint or seclusion is ordered….” 22 CCR 72461(b). “Full documentation of the episode leading to the behavior restraint or seclusion, the type of behavior restraint or seclusion used, the length of time that the restraint or seclusion was applied or utilized, and the name of the individual applying such measures shall be entered in the patient's health record.” 22 CCR 72461(c). Observation [in restraint or seclusion] shall be noted and initialed in the patient's health record. 22 CCR 72463(a)(2). Individual program plan authorizing restraint shall specific behavior to be modified, method to be used, schedule for use, person responsible for program and effectiveness. 22 CCR 72463(a)(3).
Staff training required
Restraints[15]	Mechanical or behavior restraints are… any apparatus that interferes with the free movement of a patient. 22 CCR 72459(a). Physical restraint means restraint to control an acutely disturbed person to prevent the person from causing harm to self or others. 22 CCR 72459(a)(1). Only the following types of physical restraint may be used: - Soft tie consisting of cloth… - Mittens without thumbs…securely fastened around wrist with a tie - Cloth vests… - Belts and cuffs, well padded, used to control a seriously disturbed, assaultive patient 22 CCR 72459(a)(1).
Chemical Restraint
Seclusion[16]
Postural Supports	“A physical restraint shall not be confused with a postural support as defined in Section 72319(k).” 22 CCR 72459(a)(1). “Postural support means a method other than orthopedic braces used to assist patients to achieve proper body position and balance. Postural supports may only include soft ties, seat belts, spring release trays or cloth vests and shall only be used to improve a patient's mobility and independent functioning, to prevent the patient from falling out of a bed or chair, or for positioning, rather than to restrict movement. These methods shall not be considered restraints.” 22 CCR 72319(k).

Intermediate Care Facility (ICF) Federal
Primary regulation	42 CFR 483.450
Alternatives explored
Who can order it	“The facility may employ physical restraint only: (i) as an integral part of an individual program plan; (ii) as an emergency measure; or (iii) as a health related protection prescribed by a physician.” 42 CFR 483.450(d)(i) to (iii).
When does an MD have to cosign
Is the presence of an MD required	“Authorizations to use or extend restraints as an emergency must be obtained as soon as the client is restrained or is stable.” 42 CFR 483.450(d)(2)(ii).
Duration of each order	“Authorizations to use or extend restraints… must be in effect no longer than 12 consecutive hours.” 42 CFR 483.450(d)(2)(i). “Placement of a client in a time-out room must not exceed one hour.” 42 CFR 483.450(c)(2).
How often must they check on patients	“[A]t least every 30 minutes by staff trained in the use of restraints.” 42 CFR 483.450(d)(4). A client placed in time-out (seclusion) must be “under the direct constant visual supervision of designated staff.” 42 CFR 483.450(c)(ii).
Staff training required	“The facility must develop and implement written policies and procedures that govern the management of inappropriate client behavior.” 42 CFR 483.450(b)(1).
Chemical Restraint	“The facility must not use drugs in doses that interfere with the individual client's daily living activities. Drugs used for control of inappropriate behavior must be approved by the interdisciplinary team and used only as an integral part of the client's individual program plan…. Drugs used for control of inappropriate behavior must not be used until it can be justified that the harmful behavior clearly outweighs the potentially harmful effects of the drugs. Drugs... must be monitored closely... and gradually withdrawn at least annually.” 42 CFR 483.450(e)(1-4).
Seclusion	“A client may be placed in a room from which egress is prevented only if… the placement is a part of an approved systematic time-out program… the client is under the direct constant visual supervision of designated staff… the door to the room is held shut by staff or by a mechanism requiring constant physical pressure from a staff member.” 42 CFR 483.450(c)(1). Placement in time out room must not exceed 1 hour. 42 CFR 483.450(c)(1).
Postural Supports
Documentation	“[A] record of checks and usage must be kept.” 42 CFR 483.450(d)(4). “A record of time-out activities must be kept.” 42 CFR 483.450(c)(4).

Intermediate Care Facility (ICF) State
Primary regulation	22 CCR 73403-73409
Alternatives explored
Who can order it	“[S]hall only be used on the signed order of a physician…. In a clear case of medical emergency, a physician may give the order by telephone.” 22 CCR 73409(a).
When does an MD have to cosign	In case of medical emergency, the physician shall sign the telephone order within 48 hours.” 22 CCR 73409(a).
Is the presence of an MD required	No.
Duration of each order	“[O]rder… shall be renewed every 24 hours.” 22 CCR 73409(a).
How often must they check on patients	Patients placed in restraint or seclusion shall be observed by qualified treatment personnel at least every hour.” 22 CCR 73407(a)(3) & (4).
Documentation	“A daily log shall be maintained in each facility… indicating the name of the patient…, full documentation of the episode leading to the behavior restraint or seclusion, the type of the behavior restraint or seclusion used, the length of time and the name of the individual applying such measures.” 22 CCR 73409(b). Thirty minute observation of patients in restraint or seclusion shall be noted and initialed in patient record. 22 CCR 73407(a)(3) & (4).
Staff training required
Restraint[17]	Physical restraint means any physical or mechanical device or material, attached or adjacent to a patient’s body, that the patient cannot remove easily, which has the effect of restricting patient’s freedom of movement. Does not include least restrictive immobilization necessary to administer treatment, non-continuous in nature… 22 CCR 73080. Restraint means controlling a patient’s physical activity in order to protect the patient or others from injury. 22 CCR 73095. Mechanical or behavior restraint consists of any apparatus that interferes with the free movement of a patient. Only the following types of restraint may be used: - soft tie consisting of cloth; - mittens without thumbs securely fastened around the wrist with a small tie; - tie jackets of sleeveless cloth; - restraining sheet of a wide piece of muslin over body of patient; - belts and cuffs to control seriously disturbed, assaultive patient. 22 CCR 73405.
Chemical Restraint vs. Psychotherapeutic Drug	Means a drug used to control behavior and used in a manner not required to treat the patient’s medical symptoms. 22 CCR 73012.2. Psychotherapeutic drug means a medication to control behavior or to treat thought disorder processes. 22 CCR 73090.
Seclusion[18]	“Except in rooms approved by the [Department of Public Health] for seclusion, patient's rooms shall not be locked when occupied.” 22 CCR 73407(a)(2).
Postural Supports

Intermediate Care Facility for Developmentally Disabled (ICF/DD) State
Primary regulation	22 CCR 76325-76331
Alternatives explored
Who can order it	“[O]nly upon a physician's or clinical psychologist's written or telephone order.” 22 CCR 76327(a). “There shall be no P.R.N. orders….” 22 CCR 76327(d).
When does an MD have to cosign	“ Telephone orders… shall be signed by the prescriber within 48 hours.” 22 CCR 76327(a).
Is the presence of an MD required	No.
Duration of each order	“Orders for physical restraints shall be in force for not longer than 12 hours.” 22 CCR 76327(b).
Extended duration restraint/seclusion	“Orders for treatment restraints shall be in force for not longer than seven days.” 22 CCR 76327(c).
How often must they check on patients	“[S]hall be checked every 30 minutes….” 22 CCR 76329(a)(4). “Clients shall be restrained only in an area that is under direct observation of staff....” 22 CCR 76329(a)(6).
Documentation	“The client's record shall include a recording with justification and authorization of all periods of restraint.” 22 CCR 76327(e). A record shall be kept of [30 minute observation] checks. 22 CCR 76329(a)(4). Physical restraint shall be used only as an integral part of an individual program plan ….. 22 CCR 76329(a)(1).
Staff training required
Restraint	Physical restraint means restraint to control an acutely disturbed person to prevent the person from causing harm to self or others. Types: - wide piece of muslin over body; - mittens; - soft ties; - jacket of sleeveless cloth. Includes restraint of hands, body or feet separately or in combination and totally enclosed cribs. 22 CCR 76325(a)(1). No restraint with locking devices shall be used or available. 22 CCR 76327(h).
Chemical Restraint	Means the use of psychotropic or behavior-modifying drugs use to prevent a client from exhibiting an identified maladaptive behavior. 22 CCR 76325(a)(2). Psychotropic or behavior-modifying drugs (including PRNs) shall be used only as an integral part of an individual program plan ….” “Each program plan utilizing a psychotropic drug... [s]hall... [b]e a time-limited (no more than 30 days) prescription by a physician.... [S]hall include written justification for the continued use of the drug.” 22 CCR 76329(b)(2)(A) & (b)(3).
Seclusion	“Seclusion, which is defined as placement of a client alone in a locked room, shall not be employed.” 22 CCR 76327(f).
Postural Supports	“Postural supports mean devices other than orthopedic braces used to assist clients to achieve proper body position and balance. Postural supports may only include soft ties, seat belts, spring release trays or cloth sheeting and shall only be used to improve a client's mobility and independent functioning, rather than restrict movement. These devices shall not be considered restraints.” 22 CCR 76335. Treatment restraint means restraint during medically prescribed treatment or diagnostic procedure. This may be accomplished by soft ties only. 22 CR 76325(a)(3).
Documentation	“Telephone orders… shall be recorded immediately.” 22 CCR 76327(a). “The client's record shall include a recording with justification and authorization of all periods of restraint.” 22 CCR 76327(e).

Intermediate Care Facility State/DD - Habilitative (ICF/DD-Hab) State
Primary regulation	22 CCR 76866-76869
Alternatives explored
Who can order it	“[O]nly upon a written or telephone order of a physician or clinical psychologist.” 22 CCR 76867(a). “There shall be no P.R.N. (as needed) orders for physical restraints.” 22 CCR 76867(c).
When does an MD have to cosign	“Telephone orders… shall be signed by prescriber within five days.” 22 CCR 76867(a).
Is the presence of an MD required	No. “Telephone orders… shall be signed by the prescriber within five days.” 22 CCR 76867(a).
Duration of each order	“[S]hall be in force for not longer than 12 hours.” 22 CCR 76867(b).
How often must they check on patients	“[S]hall be checked every 15 minutes….” 22 CCR 76868(a)(2). “Clients in restraint shall remain in staff's constant line of vision....” 22 CCR 76868(a)(4).
Documentation	“Telephone orders shall be recorded immediately….” 22 CCR 76867(a). “The client's record shall include an entry noting the time of application and removal of restraints, justification for and authorization of all periods of restraints and signature of the person applying the restraints.” 22 CCR 76867(d). Written documentation of [15 minutes] checks identifying staff responsible for performing the check shall be kept in … client record. 22 CCR 76868(a)(4).
Staff training required	“Behavior management programs shall be approved by the [Department of Developmental Services] prior to implementation....” 22 CCR 76869(a).
Restraint	Devices used to control a client’s physical activity in order to prevent the client from causing harm to self or others. 22 CCR 76827. See also 22 CCR 76827. Only the following types shall be used: - mittens and/or soft ties; - jackets consisting of sleeveless cloth webbing. 22 CCR 76866(a). Totally enclosed cribs and bared enclosures shall not be used. 22 CCR 76866(b). No restraint with locking devices shall be used. 22 CCR 76867(f).
Chemical Restraint	Means the use of psychotherapeutic or behavior modifying drugs used to prevent a client from exhibiting an identified maladaptive behavior. 22 CCR 76803. “Chemical restraints shall not be used as a substitute for active treatment.” 22 CCR 76866(c). “Psychotherapeutic or behavior-altering drugs shall be used only as an integral part of an individual service plan …..” 22 CCR 76868(b)(2). “Each individual service plan utilizing a psychotropic drug... [s]hall... be a time-limited prescription of no more than 30 days, ordered by a physician…” 22 CCR 76868(b)(2)(A). “P.R.N. prescriptions shall be subject to Section 22 CCR 76896.” 22 CCR 76868 (b)(3).
Seclusion	“Clients shall not be placed in a room that is locked or where the door is held closed by any means.” 22 CCR 76867(e). Exclusionary time out means removing a client from an activity to another area in the same room or vicinity for a period of time contingent on a specific maladaptive behavior. 22 CCR 76816.
Postural Supports	“Postural supports are devices other than orthopedic braces used to assist clients to achieve proper body position and balance.” 22 CCR 76828 & 76871(a). Shall not be considered restraints. 22 CCR 76828.

Department of Corrections State
Primary regulation	15 CCR 3268
Alternatives explored	“The choices [available to an employee when selecting a reasonable force option]… include, but are not necessarily limited to…physical strength and holds; chemical agents and/or other immobilization devices; handheld batons.” 15 CCR 3268(a)(6)(B). “Employees may use reasonable force as required in the performance of their duties.…” 15 CCR 3268(b). Reasonable force is “[t]he force that an objective, trained and competent correctional employee, faced with similar facts and circumstances, would consider necessary and reasonable to subdue an attacker, overcome resistance, effect custody, or gain compliance with a lawful order.” 15 CCR 3268(a)(1).
Who can order it	“Authority to order... administrative segregation, before such action is considered and ordered by a classification hearing, may not be delegated below the staff level of correctional lieutenant except when a lower level staff member is the highest ranking official on duty.” 15 CCR 3336.
When does an MD have to cosign
Is the presence of an MD required	No.
Duration of each order	Administrative segregation is reviewed within 10 days, and every 30 days thereafter. 15 CCR 3335(c).
How often must they check on patients
Documentation	“Use of restraint equipment by direction of medical staff shall be fully documented in the institution medical file of the restrained inmate.” 15 CCR 3268.2(e). “An Administrative Segregation Log… will be maintained in each administrative segregation unit….” 15 CCR 3344(a).
Staff training required
Restraint	“Mechanical restraints shall not be… (1) used as punishment… (2) placed around a person's neck… (3) applied in a way likely to cause undue physical discomfort or restrict blood flow or breathing. e.g., hog-tying.” 15 CCR 3268.2(b).
Chemical Restraint	“The choices [available to an employee when selecting a reasonable force option]… include, but are not necessarily limited to… chemical agents and/or other immobilization devices.…” 15 CCR 3268(a)(6)(B).
Seclusion	“Administrative segregation may be accomplished by confinement… to any single cell unit capable of providing secure segregation.” 15 CCR 3335(a).
Postural Supports

Correctional Treatment Centers State
Primary regulation	22 CCR 79801
Alternatives explored	“[S]hall only be used when less restrictive alternative methods are not sufficient to protect the inmate-patient or others from injury, and shall not be used as punishment or as a substitute for more effective programming or for the convenience of staff.” 22 CCR 79801(d).
Who can order it	“[S]hall only be used on a written or verbal order of a psychiatrist or clinical psychologist. Clinical restraint shall additionally require a physician's or physician's assistant's or a nurse practitioner's (operating under the supervision of a physician) written or verbal approval…. Under emergency circumstances clinical restraint or clinical seclusion may be applied, and then an approval and/or order must be obtained….” 22 CCR 79801(b).
When does an MD have to cosign	Always. “Under emergency circumstances clinical restraint or clinical seclusion may be applied, and then an approval and/or order must be obtained... at least within one hour of application.” 22 CCR 79801(b). Telephone orders… must be signed within 24 hours. 22 CCR 79801(b).
Is the presence of an MD required	No.
Duration of each order	“[S]hall be in force for no longer than twenty-four (24) hours.” 22 CCR 79801(e).
How often must they check on patients	“A physician shall complete a medical assessment of an inmate-patient at the earliest opportunity but no later than within twenty-four (24) hours.…” 22 CCR 79801(c). “[S]hall be physically checked at least every fifteen (15) minutes by nursing staff.…22 CCR 79801(g). “[S]hall be placed… only in an area that is under direct observation of staff.” 22 CCR 79801(j).
Documentation	“The inmate-patient's record shall include written justification for the application of clinical restraints, note the times of application and removal of restraints and document the inmate-patient's status and the judgment of the physician or clinical psychologist on the necessity for continuation of clinical restraints at a minimum of once every twenty-four (24) hours.” 22 CCR 79801(h).
Staff training required	“Each correctional treatment center shall have an ongoing educational program planned and conducted for the development of the necessary skills and knowledge for all facility personnel.” 22 CCR 79797(a).
Restraint	“Clinical restraint means the use of a physical restraining device during the period of mental health treatment, as a measure to protect the inmate-patient from injury to self or others when alternative methods are not sufficient.” 22 CCR 79511. “Treatment restraint means the use of a restraining device during medically prescribed treatment….” 22 CCR 79577.
Chemical Restraint
Seclusion	“Clinical seclusion means isolation during the period of mental health treatment of an inmate-patient in a separate, locked area… for the purpose of preventing injury to self or others.” 22 CCR 79513. Not considered clinical seclusion: removing an inmate-patient… to another unlocked area. 22 CCR 79801(d).
Postural Supports

Acute and Nonacute 24-hour Mental Health Care State
Primary regulation	9 CCR 1115
Alternatives explored	“[S]hall only be used when less restrictive alternative methods are not sufficient to protect the inmate-patient or others from injury, and shall not be used as punishment or as a substitute for more effective programming or for the convenience of the staff.” 9 CCR 1115(d).
Who can order it	“[S]hall be based on a written or verbal order of a psychiatrist or clinical psychologist. Clinical restraint shall additionally require a physician's or physician's assistant's, or nurse practitioner's written or verbal approval operating under the supervision of a physician.... Under emergency circumstances clinical restraint or clinical seclusion may be applied and then approval and/or an order shall be obtained... at least within one hour of application.” 9 CCR 1115(b).
When does an MD have to cosign	Always. “Under emergency circumstances clinical restraint or clinical seclusion may be applied and then approval and/or an order shall be obtained... at least within one hour of application.” 9 CCR 1115(b).
Is the presence of an MD required	No. “Under emergency circumstances clinical restraint or clinical seclusion may be applied and then approval and/or an order shall be obtained... at least within one hour of application.” 9 CCR 1115(b). “Telephone orders… shall be signed within twenty-four (24) hours.” 9 CCR 1115(b).
Duration of each order	“[S]hall be in force no longer than twenty-four hours.” 22 CCR 79801(e).
How often must they check on patients	“A physician shall complete a medical assessment of an inmate-patient at the earliest opportunity but no later than within twenty-four (24) hours.” 22 CCR 79801(c). “[S]hall be physically checked at least every fifteen (15) minutes by nursing staff… Fluids and nourishment shall be provided every two hours, except during sleep…An inmate-patient placed in clinical seclusion shall be checked by nursing staff at least every fifteen (15) minutes. Routine range of motion exercises shall be done for at least ten (10) minutes every two (2) hours.” 9 CCR 1115(g). “[S]hall be placed… only in an area that is under direct observation of staff.” 9 CCR 1115(j).
Documentation	“The inmate-patient's record shall include written justification for the application of clinical restraints, note the times of application and removal of clinical restraints and document the inmate-patient's status and the judgment of the physician or clinical psychologist on the necessity of continuing the order [at] the approval of a physician on the medical safety of the continuation of restraints at a minimum of once every twenty-four (24) hours.” 9 CCR 1115(h).
Staff training required
Restraint
Chemical Restraint
Seclusion	Same as restraint. 9 CCR 1115(a). “Removing an inmate-patient… to another unlocked area… shall not be considered clinical seclusion.” 9 CCR 1115(d).
Postural Supports

Schools – Special Education State
Primary regulation	Ed. Code 56523; 5 CCR 3052
Alternatives explored	“Emergency interventions may only be used to control unpredictable spontaneous behavior… which cannot be immediately prevented by a response less restrictive than the temporary application of a technique used to contain the behavior.” 5 CCR 3052(i).
Who can order it	No order required.
When does an MD have to cosign	N/A
Is the presence of an MD required	N/A
Duration of each order	“No emergency intervention shall be employed for longer than is necessary to contain the behavior.” 5 CCR 3052(i)(3).
Extended duration restraint	“Any situation which requires prolonged use of an emergency intervention shall require staff to seek assistance of the school site administrator or law enforcement agency, as applicable to the situation.” 5 CCR 3052(i)(3).
How often must they check on patients
Documentation	“A 'Behavioral Emergency Report' shall immediately be completed and maintained in the individual's file. “ 5 CCR 3052(i)(5).
Staff training required	“[T]echniques such as prone containment may be used as an emergency intervention by staff trained in such procedures.” 5 CCR 3052(i)(4)(B).
Restraint	“Emergency interventions shall not include… [e]mployment of a device or material or objects which simultaneously immobilize all four extremities, except that techniques such as prone containment may be used as an emergency intervention by staff trained in such procedures.” 5 CCR 3052(i)(4)(B).
Chemical Restraint
Seclusion	“Emergency interventions may not include… locked seclusion, unless it is in a facility otherwise licensed or permitted by state law to use a locked room.” 5 CCR 3052(i)(4)(A).
Postural Supports

Psychiatric Residential Treatment Facility for Individuals under Twenty-one (21) Years of Age Federal
Primary regulation	42 CFR 483.358
Alternatives explored	The physician must order the least restrictive emergency safety intervention… likely to be effective in resolving the emergency…. 42 CFR 483.358(c). Restraint and seclusion must not be used simultaneously. 42 CFR 483.356(a)(4).
Who can order it	“Only a board-certified psychiatrist, or a physician licensed to practice medicine with specialized training and experience in … treatment of mental diseases may order…restraint or seclusion.” If the resident's treatment team physician is available, only he or she can order….” 42 CFR 483.358(a) & (b). “If physician is not available…, the physician’s verbal order must be obtained by a registered nurse at the time emergency safety intervention is initiated ….
When does an MD have to cosign	“The physician’s verbal order must be followed with the physician’s signature verifying the verbal order. 42 CFR 483.358(d).
Is the presence of an MD required	“Within 1 hour of initiation…a physician or clinically qualified registered nurse [with training] … must conduct a face-to-face assessment….” 42 CFR 483.358(f). “[In case of a verbal order], the ordering physician must be available to staff for consultation, at least by telephone, throughout the period of the emergency safety intervention." 42 CFR 483.358(d).
Duration of each order	“[N]o more than 4 hours for residents ages 18-21, 2 hours for residents ages 9 to 17, and 1 hour for residents under age 9.” 42 CFR 483.358(e)(2). “If the emergency safety situation continues beyond the time limits of the order, a registered nurse or other licensed staff must immediately contact the ordering physician in order to receive further instructions.” 42 CFR 483.362(b).
How often must they check on patients	Clinical staff trained in the use of emergency safety interventions must be physically present [in or immediately outside the seclusion room], continually assessing and monitoring… the resident [in restraint or seclusion] throughout the duration of the emergency safety intervention. 42 CFR 483.362(a) and 483.364(a). Video monitoring does not meet this requirement. 42 CFR 483.364(a).
Documentation	Each order for restraint or seclusion must include: - the name of the order physician; - the date & time the order was obtained; - the emergency safety intervention ordered, including length of time.... 42 CFR 483.358(g). Must document the intervention in the resident’s record… by the end of the shift in which intervention occurs… [or, if continuing across shifts], during which it ends. 42 CFR 483.358(h). Must include (1) order; (2) time began and ended; (3) time and results of 1 hr. assessment; (4) emergency safety situation that required restraint or seclusion; (5) name of staff involved. 42 CFR 483.358(h).
Staff training required	The facility must require staff to have ongoing education, training and demonstrated knowledge of: - techniques to identify staff and resident behaviors, events, and environmental factors that may trigger emergency safety situations; - the use of nonphysical intervention skills, such as de-escalation, medication conflict resolution, active listening, … - the safe use of restraint and… seclusion…. 42 CFR 483.376(a).
Restraint	Means a “personal restraint,” “mechanical restraint,” or “drug used as a restraint.” 42 CFR 483.352. Mechanical restraint means any device attached or adjacent to the resident’s body that he or she cannot easily remove that restricts freedom of movement or normal access to his or her body. 42 CFR 483.352. Personal restraint means the application of physical force without the use of any device for the purposes of restraining the free movement of a resident’s body. 42 CFR 483.352.
Chemical Restraint	“Drug used as a restraint means any drug that: - is administered to manage a resident’s behavior in a way that reduces the safety risk to the resident or others; - has the temporary effect of restricting the resident’s freedom of movement; and - is not a standard treatment for the resident’s medical or psychiatric condition.” 42 CFR 483.352.
Seclusion	Seclusion means the involuntary confinement of a resident alone in a room or an area from which the resident is physically prevented from leaving. 42 CFR 483.352. Time out means the restriction of a resident for a period of time to a designated area from which the resident is not physically prevented from leaving for the purpose of providing the resident an opportunity to regain self-control. 42 CFR 483.352. Simultaneous use of seclusion and restraint is prohibited. 42 CFR 483.356(a)(4).
Postural Supports

Community Treatment Facilities State
Primary regulation	9 CCR 1929
Alternatives explored	“Physical restraint and seclusion shall be used only when alternative methods are not sufficient to protect the child or others from immediate injury.” 9 CCR 1929(a).
Who can order it	May be used “only with a signed order of a physician or licensed psychologist, except in an emergency.… In such an emergency a child may be placed in physical restraint at the discretion of a registered nurse.” 9 CCR 1929(d)(2).
When does an MD have to cosign	Always. “In [an emergency] a child may be placed in physical restraint at the discretion of a registered nurse. An order shall be received by telephone within sixty (60) minutes of the application… and shall be signed by the prescriber within twenty-four (24) hours.” 9 CCR 1929(d)(2).
Is the presence of an MD required
Duration of each order	“All orders for physical restraint shall become invalid two (2) hours after the restraint or seclusion is initiated for children ages 9 to 17, one (1) hour for children under age 9, and four (4) hours for any special education pupils ages 18 through 21…. If continued physical restraint or seclusion is needed a new order shall be required.” 9 CCR 1929(d)(2)(D).
Time frame on longer duration orders	“[P]hysical restraint shall not be allowed for longer than twenty-four (24) hours.” 9 CCR 1929(d)(3). P.R.N. orders are prohibited. 9 CCR 1929(d)(4).
How often must they check on patients	“[A] child placed in physical restraint shall be checked at a minimum of every fifteen (15) minutes by the licensed nursing staff.” 9 CCR 1929(d)(11). “Vital signs shall be measured at least every half hour, unless otherwise indicated by the prescribing professional.” 9 CCR 1929(d)(11)(A).
Documentation	“Full documentation of the episode leading to the use of physical restraint… shall be entered in the child's facility record.” 9 CCR 1929(d)(2)(B). “At the time physical restraint is initiated, or as soon as practical, but in every case within one (1) hour, information regarding the child's medical condition... shall be reviewed... and noted in the child's facility record.” 9 CCR 1929(d)(2)(C). “A written record of each check shall be placed in the child's record.” 9 CCR 1929(d)(11).
Staff training required	“Staff participating in the physical restraint or seclusion of a child shall also participate in a required four (4) hours of bi-annual review.” 9 CCR 1922(b).
Restraint
Chemical Restraint
Seclusion	“Seclusion in either a designated seclusion room with a door which may be held shut to prevent a child's egress by a staff member or by a mechanism which releases upon removal of a staff person's foot and/or hand or in any other room or part of the facility where the child is prevented from physically leaving for any period of time, thus limiting their movement, activities and contact with the other children.” 9 CCR 1929(d)(5)(A).
Postural Supports

Mental Health Rehabilitation Centers State
Primary regulation	9 CCR 784.35
Alternatives Required	“Restraint and seclusion shall… only [be used] when there is no less restrictive method to prevent injurious behavior.” 9 CCR 784.35(a).
Who can order it	“[S]hall only be used as authorized by the order of a physician or psychologist within the scope of their license.” 9 CCR 784.36(a). “In a clear case of emergency, when a physician or psychologist is not available… [seclusion or restraint may be ordered] at the discretion of a licensed nursing staff. A confirming telephone order from a physician or psychologist must be obtained within one (1) hour of the time of the occurrence.” 9 CCR 784.36(d).
When does an MD have to cosign	Always. “Telephone orders… must be signed and dated within no longer than five days following the date of issue of the order.” 9 CCR 784.36(f).
Is the presence of an MD required	No. “Every four (4) hours, when a person is secluded or retrained the medical directory, a physician, a psychologist, a member of the licensed mental health professional… shall in person assess the client’s clinical condition face-to-face.” 9 CCR 78437(a).
Duration of each order	“Orders for seclusion or restraint shall not exceed 24-hours in duration.” 9 CCR 784.36(a)(2).
How often must they check on patients	“At the time restraint or seclusion is initiated, or as soon as practical, but in every case within one (1) hour, information regarding the client's medical condition... shall be reviewed by an on-duty member of the licensed nursing staff, or the documentation of the reason(s) it was not safe to conduct this evaluation.” 9 CCR 784.36(c). “Clients... shall be provided... timely and appropriate nursing and medical care... at least once per shift, not to exceed eight (8) hours, or more often if indicated by the client's condition.” 9 CCR 784.37(c)(1). “Regular observation and assessment… [must occur] at least every 15 minutes.” 9 CCR 784.37(c)(2). “Every four (4) hours… the medical director, a physician, a psychologist, a member of the licensed nursing staff or a licensed mental health professional designated by the mental health rehabilitation center director, shall in person ass the client's clinical condition face to face.” 9 CCR 784.37(a).
Documentation	“Restraint or seclusion shall not be initiated absent the documentation of a separate justification for each intervention.” 9 CCR 784.35(b). “Care provided to a client in restraint or seclusion shall be documented in the client record.” 9 CCR 784.38(a).
Staff training required
Restraint
Chemical Restraint
Seclusion	Same as restraint. 9 CCR 784.35 to 784.38.
Postural Supports

Chemical Dependency Recovery Hospitals State
Primary regulation	22 CCR 79315
Alternatives explored
Who can order it	“[S]hall only be used upon a physician's written or verbal order.… Telephone orders shall be received only by authorized personnel.” 22 CCR 79315(c).
When does an MD have to cosign	“Telephone orders… shall be signed by the prescriber within five days.” 22 CCR 79315(c).
Is the presence of an MD required	No.
Duration of each order	“Orders for physical restraints shall be in force for not longer than 24 hours.” 22 CCR 79315(e). “There shall be no PRN orders… for physical or treatment restraints.” 22 CCR 79315(f).
How often must they check on patients	“[S]hall be checked at least every 15 minutes.” 22 CCR 79315(h). “Patients shall be restrained only in an area that is under direct observation of staff ….” 22 CCR 79315(g).
Documentation	“Telephone orders… shall be recorded immediately in the patient's health record.” 22 CCR 79315(c). “A written record shall be kept of [required checks] and maintained in the individual patient's health record.” 22 CCR 79315(h).
Staff training required
Restraint	Physical restraints [not defined] shall be used to protect patient from injury to self or others. 22 CFR 79315(a) Treatment restraints shall only be used during medically prescribed treatment or diagnostic procedures. 22 CFR 79315(b).
Chemical Restraint
Seclusion
Postural Supports	“Postural supports are devices used to assist the patient in achieving proper body position and balance and… shall include only the following: soft ties; seat belts; spring release trays; cloth vests. Postural supports are not considered to be restraints and shall only be used to improve the patient's mobility and independent functioning rather than to restrict the patient's movement.” 22 CCR 79317.

Juvenile Halls
Primary regulation	15 CCR 1358, 1359. Minimum standards for juvenile facilities set by the Board of Corrections. Welf. & Inst. Code § 210.
Alternatives explored	“Physical restraints should be utilized only when it appears less restrictive alternatives would be ineffective in controlling the disordered behavior.” 15 CCR 1358(b).
Who can order it	“Minors shall be placed in restraints only with the approval of the facility manager or designee. The facility manager may delegate authority to place a minor in restraints to a physician.” 15 CCR 1358(c).
When does an MD have to cosign	“A medical opinion on the safety of placement and retention shall be secured as soon as possible, but no later than two hours from the time of placement. The minor shall be medically cleared for continued retention at least every three hours thereafter.” 15 CCR 1358(c).
Is the presence of an MD required to apply	No. “A medical opinion on the safety of placement and retention shall be secured as soon as possible, but no later than two hours from the time of placement. The minor shall be medically cleared for continued retention at least every three hours thereafter. A mental health consultation shall be secured as soon as possible, but in no case longer than four hours from the time of placement, to assess the need for mental health treatment.” 15 CCR 1358(c).
Duration of each order	“Continued retention in restraints shall be reviewed a minimum of every hour.” 15 CCR 1358(c).
How often must they check on patients	“Continuous direct visual supervision shall be conducted to ensure that the restraints are properly employed, and to ensure the safety and well-being of the minor.” 15 CCR 1358(d).
Documentation	“Circumstances leading to the application of restraints must be documented.” 15 CCR 1358(b). “Continuous direct visual supervision shall be conducted to ensure that the restraints are properly employed, and to ensure the safety and well-being of the minor. Such observation shall be documented at least every 15 minutes.” 15 CCR 1358(d).
Staff training required
Restraint
Chemical Restraint	“Minors found by a physician to be a danger to themselves or others by reason of a mental disorder may be involuntarily given psychotropic medication immediately necessary for the preservation of life or the prevention of serious bodily harm, and when there is insufficient time to obtain consent from the parent, guardian, or court before the threatened harm would occur. It is not necessary for harm to take place or become unavoidable prior to initiating treatment.” 15 CCR 1439(c).
Seclusion	“Safety Room Procedures.” “The room shall be used to hold only those minors who present an immediate danger to themselves or others, who exhibit behavior which results in the destruction of property, or reveals the intent to cause self-inflicted physical harm. A safety room shall not be used for punishment or discipline, or as a substitute for treatment.” 15 CCR 1359.
Postural Supports

Group Homes
Primary regulation	22 CCR 84300
Alternatives explored	“The licensee must use a continuum of interventions, starting with the least restrictive intervention. More restrictive interventions may be justified when less restrictive techniques have been attempted and were not effective and the child continues to present an imminent danger for injuring or endangering himself, herself, or others.” 22 CCR 84300(c).
Who can order it	Manual restraint may be a component of group home’s emergency intervention plan: 22 CCR 84322(e) & (f). - Written approval must be obtained from administrator or designee, facility social work staff, and child’s representative for restraint exceeding 15 minutes, 30 minutes, and 60 minutes respectively. See “Duration of each order” below. - The individual who approves continuation must be a person other than the individual who restrained child. 22 CCR 84322(f)(2)(A)(1).
When does an MD have to cosign	N/A
Is the presence of an MD required	No
Duration of each order	Pursuant to an emergency intervention plan: - Child will not remain in manual restraint for more than 15 consecutive minutes unless written approved to continue …after initial 15 minutes is obtained from administrator or designee. 22 CCR 84322(f)(2)(A). - Child does not remain in a manual restraint for more than 30 consecutive minutes in a 24 hour period unless…written approval to continue restraint after initial 30 minutes is obtained from administrator or designee and [verbal/written approval from] facility social work staff. 22 CCR 84322(f)(2)(B). - Manual restraint in excess of 60 consecutive minutes must be approved, every 30 minutes, in writing by administrator or designee and facility social work staff and [verbal/written approval from] the child’s authorized representative. 22 CCR 84322 (f)(2)(E). - Manual restraint may not exceed 4 cumulative hours in a 24-hour period. 22 CCR 84322(f)(2)(G)
How often must they check on patients	Pursuant to an emergency intervention plan: - Visual check is required after 15 minutes by person other than person restraining child. 22 CCR 84322(f)(2)(A)(2). - Visual check is required every 15 minutes after the initial 30 minutes by person other than person restraining child. 22 CCR 84322(f)(2)(C).
Documentation	“The manual restraint plan is to be included as a component of the emergency intervention plan.” 22 CCR 84322(f). Written approval to continue a manual restraint beyond 15 consecutive minutes must be documented in the child’s record. 22 CCR 84322(f)(2)(A). Visual checks must be documented in child’s record. 22 CCR 84322(f)(2)(C)(1).
Staff training required