10A ncac 70I .0613 DISCIPLINE and Behavior Management

(a) A residential child-care facility shall have written policies and procedures on discipline and behavior management, including the type and use of physical restraint holds, if utilized. A copy of the written policies and procedures shall be provided to and discussed with each child and the child's parents, guardian, or legal custodian prior to or at the time of admission. Policies and procedures shall include:

(1) a way of interacting with and teaching children that emphasize praise and encouragement for exhibiting self control and desired behavior; and

(2) methods for protecting children and others when a child is out of control.

(b) A residential child-care facility shall implement standards for behavior that are appropriate for the child's age, intelligence, emotional makeup, and past experiences.

(1) corporal and physical punishment;

(2) cruel or abusive punishment, as established in G.S. 7B-101(1) and (15);

(3) discipline of one child by another child;

(4) denial of food, sleep, clothing, or shelter;

(5) denial of family contact, including family time, telephone, or mail contacts with family;

(6) exercise or work to the point of physical exhaustion;

(7) verbal abuse, threats, or humiliating remarks about himself or herself or his or her family;

(8) mechanical restraints;

(9) a drug used as a restraint, except as set forth in Paragraph (e) of this Rule;

(10) seclusion or isolation time-out; except as outlined in Paragraph (d) of this Rule;

(11) physical restraints except as outlined in Paragraph (f) of this Rule.

(d) "Time-out" means the removal of a child to a separate unlocked room or area from which the child is not physically prevented from leaving. The residential child-care facility may use isolation time-out as a behavioral control measure when the facility provides it within hearing distance of a staff member. The length of the isolation time-out shall be appropriate for the child's age, intelligence, emotional makeup, and past experiences.

(e) "A drug used as a restraint" means a medication used to control behavior or to restrict a child's freedom of movement that is not a standard medication for the child's medical or psychiatric condition. A drug used as a restraint shall be employed only if required to treat a medical condition. It shall not be employed for the purpose of punishment, staff convenience, or as a substitute for adequate staffing.

(f) "Physical restraint" of a child means physically holding a child who is at imminent risk of harm to himself or herself or others until the child is calm. A residential child-care facility shall only use physical restraint holds approved by the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, pursuant to 10A NCAC 27E .0108, which is hereby incorporated by reference, including subsequent amendments and editions. Approved physical restraint holds can be found at the following website: https://www2.ncdhhs.gov/mhddsas/providers/trainingandconferences/restraints.htm.

(g) Physical restraints where a person ends up in a prone or face down position are prohibited.

(h) Physical restraint holds shall be administered only by staff trained in the use of physical restraint holds. No child or group of children shall be allowed to participate in the physical restraint of another child.

(i) The residential child-care facility shall not use physical restraints that will cause a child harm, given his or her medical condition or any medications that he or she is taking.

(j) No child shall be physically restrained utilizing a physical object.

(k) Physical restraint holds shall:

(1) not be used for purposes of discipline or convenience;

(2) only be used when there is imminent risk of harm to the child or others and less restrictive approaches have failed;

(3) be administered in the least restrictive manner possible to protect the child or others from imminent risk of harm; and

(4) end when there is no longer any risk of imminent harm to any party.

(l) A residential child-care facility shall:

(1) ensure that any physical restraint hold utilized on a child is administered by a trained staff member with a second trained staff member in attendance. An exception may occur when no other staff member is present or can be called for assistance. Concurrent with the administration of a physical restraint hold and for a minimum of 15 minutes after the termination of the hold, a staff member shall monitor the child's breathing, ascertain the child is verbally responsive and motorically in control, and ensure the child remains conscious without any complaints of pain. If at any time during the administration of a physical restraint hold the child complains of being unable to breathe or loses motor control, the staff member administering the physical restraint hold shall terminate the hold or adjust the position to ensure that the child's breathing and motor control are not restricted. If at any time it appears to be necessary, a staff member shall immediately seek medical attention for the child. Following the use of a physical restraint hold, a staff member shall conduct an interview with the child about the incident, and the staff administering the physical restraint hold shall be interviewed by a supervisor about the incident;

(2) document each incident of a child being subjected to a physical restraint hold on an incident report. This report shall include the following:

(A) the child's name, age, height, and weight;

(B) the type of hold utilized;

(D) the staff member administering the hold;

(E) the staff member witnessing the hold;

(F) the supervisory staff who reviewed the incident report;

(G) less restrictive alternatives that were attempted prior to utilizing physical restraint;

(H) the child's behavior that necessitated the use of physical restraint;

(I) whether the child's condition necessitated medical attention;

(J) planning and debriefing conducted with the child and staff to eliminate or reduce the probability of reoccurrence; and

(K) the total number of restraints of the child since admission.

Within 72 hours, supervisory staff shall review the incident report to ensure that correct steps were followed and shall forward the report to the parents, guardian, or legal custodian and the licensing authority on a report developed by the licensing authority. If a child dies as a result of a physical restraint hold, the residential child-care facility shall report the death of the child to the parents, guardian or legal custodian and to the licensing authority within 72 hours;

(3) submit a report to the licensing authority by the 10^th day of each month stating the number of physical restraint holds used during the previous month on each child and any injuries that resulted;

(4) ensure that any physical restraint hold utilized on a child is administered by a trained staff member who has completed at least 16 hours of training in behavior management, including techniques for de-escalating problem behavior, the appropriate use of physical restraint holds, monitoring of the child's breathing, verbal responsiveness, and motor control. Training shall also include debriefing children and staff involved in physical restraint holds. Thereafter, staff authorized to use physical restraint holds shall annually complete at least eight hours of behavior management training, including techniques for de-escalating problem behavior. Instructor qualifications and training requirements include:

(A) instructors shall demonstrate competence by scoring 100 percent on testing in a training program aimed at preventing, reducing and eliminating the need for restrictive interventions;

(B) instructors shall demonstrate competence by scoring 100 percent on testing in a training program teaching the use of physical restraint;

(C) instructors shall demonstrate competence by scoring a passing grade on testing in an instructor training program as determined by the North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services;

(D) the training shall be competency-based, and shall include measurable learning objectives, measurable testing (written and by observation of behavior) on those objectives and measurable methods to determine passing or failing the course;

(E) the content of the instructor training shall be approved by the Division of Mental Health, Developmental Disabilities and Substance Abuse Services;

(F) instructors shall be retrained annually and demonstrate competence in the use of physical restraints;

(G) instructors shall be trained in CPR, such as those provided by the American Red Cross, American Heart Association, or substantially equivalent organizations. Division staff shall determine that an organization is substantially equivalent if the organization is already approved by the Department or meets the same standard of care as the American Heart Association or American Red Cross. The Division shall not accept web-based trainings for certification in CPR;

(H) instructors shall have been coached in teaching the use of restrictive interventions two times with a positive review by the coach; and instructors shall teach a program on the use of physical restraints at least once annually; and

(I) instructors shall complete a refresher instructor training at least every two years;

(5) complete an annual review of the discipline and behavior management policies and techniques to verify that the physical restraint holds being utilized are being applied properly and safely. This review shall be documented and submitted to the licensing authority as part of the biennial licensing renewal application; and

(6) maintain reports of physical restraint holds in a manner consistent with the facility's risk management policies (clinical decisions and activities undertaken to identify, evaluate, and reduce the risk of injury to clients, staff, and visitors and reduce the risk of loss to the facility) and make them available to the licensing authority upon request.

History Note: Authority G.S. 131D-10.5; 143B-153;

Eff. July 1, 1999;

Temporary Amendment Eff. July 20, 1999;

Temporary Amendment Eff. May 15, 2000;

Amended Eff. November 1, 2009; October 1, 2008; April 19, 2001;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. April 5, 2016;

Amended Eff. October 1, 2017.