1180. (a) The California Health and Human Services Agency, in
accordance with their mission, shall provide the leadership and
coordination necessary to reduce the use of seclusion and behavioral
restraints in facilities that are licensed, certified, or monitored
by departments that fall within its jurisdiction.
(b) The agency may make recommendations to the Legislature for
additional facilities, or for additional units or departments within
facilities, that should be included within the requirements of this
division in the future, including, but not limited to, emergency
rooms.
(c) At the request of the secretary, the involved state
departments shall provide information regarding existing training
protocols and requirements related to the utilization of seclusion
and behavioral restraints by direct care staff who work in facilities
within their jurisdiction. All involved state departments shall
cooperate in implementing any training protocols established pursuant
to this division. It is the intent of the Legislature that training
protocols developed pursuant to this division be incorporated into
existing training requirements and opportunities. It is further the
intent of the Legislature that, to the extent feasible, the training
protocols developed pursuant to Section 1180.2 be utilized in the
development of training protocols developed pursuant to Section
1180.3.
(d) The secretary, or his or her designee, is encouraged to pursue
federal and private funding to support the development of a training
protocol that can be incorporated into the existing training
activities for direct care staff conducted by the state, facilities,
and educational institutions in order to reduce the use of seclusion
and behavioral restraints.
(e) The secretary or his or her designee shall make
recommendations to the Legislature on how to best assess the impact
of serious staff injuries sustained during the use of seclusion or
behavioral restraints, on staffing costs, and on workers'
compensation claims and costs.
(f) The agency shall not be required to implement this section if
implementation cannot be achieved within existing resources, unless
additional funding for this purpose becomes available. The agency and
involved departments may incrementally implement this section in
order to accomplish its goals within existing resources, through the
use of federal or private funding, or upon the subsequent
appropriation of funds by the Legislature for this purpose, or all of
these.
1180.1. For purposes of this division, the following definitions
apply:
(a) "Behavioral restraint" means "mechanical restraint" or
"physical restraint" as defined in this section, used as an
intervention when a person presents an immediate danger to self or to
others. It does not include restraints used for medical purposes,
including, but not limited to, securing an intravenous needle or
immobilizing a person for a surgical procedure, or postural
restraints, or devices used to prevent injury or to improve a person'
s mobility and independent functioning rather than to restrict
movement.
(b) "Containment" means a brief physical restraint of a person for
the purpose of effectively gaining quick control of a person who is
aggressive or agitated or who is a danger to self or others.
(c) "Mechanical restraint" means the use of a mechanical device,
material, or equipment attached or adjacent to the person's body that
he or she cannot easily remove and that restricts the freedom of
movement of all or part of a person's body or restricts normal access
to the person's body, and that is used as a behavioral restraint.
(d) "Physical restraint" means the use of a manual hold to
restrict freedom of movement of all or part of a person's body, or to
restrict normal access to the person's body, and that is used as a
behavioral restraint. "Physical restraint" is staff-to-person
physical contact in which the person unwillingly participates.
"Physical restraint" does not include briefly holding a person
without undue force in order to calm or comfort, or physical contact
intended to gently assist a person in performing tasks or to guide or
assist a person from one area to another.
(e) "Seclusion" means the involuntary confinement of a person
alone in a room or an area from which the person is physically
prevented from leaving. "Seclusion" does not include a "timeout," as
defined in regulations relating to facilities operated by the State
Department of Developmental Services.
(f) "Secretary" means the Secretary of California Health and Human
Services.
(g) "Serious injury" means significant impairment of the physical
condition as determined by qualified medical personnel, and includes,
but is not limited to, burns, lacerations, bone fractures,
substantial hematoma, or injuries to internal organs.
1180.2. (a) This section shall apply to the state hospitals
operated by the State Department of Mental Health and facilities
operated by the State Department of Developmental Services that
utilize seclusion or behavioral restraints.
(b) The State Department of Mental Health and the State Department
of Developmental Services shall develop technical assistance and
training programs to support the efforts of facilities described in
subdivision (a) to reduce or eliminate the use of seclusion and
behavioral restraints in those facilities.
(c) Technical assistance and training programs should be designed
with the input of stakeholders, including clients and direct care
staff, and should be based on best practices that lead to the
avoidance of the use of seclusion and behavioral restraints,
including, but not limited to, all of the following:
(1) Conducting an intake assessment that is consistent with
facility policies and that includes issues specific to the use of
seclusion and behavioral restraints as specified in Section 1180.4.
(2) Utilizing strategies to engage clients collaboratively in
assessment, avoidance, and management of crisis situations in order
to prevent incidents of the use of seclusion and behavioral
restraints.
(3) Recognizing and responding appropriately to underlying reasons
for escalating behavior.
(4) Utilizing conflict resolution, effective communication,
deescalation, and client-centered problem solving strategies that
diffuse and safely resolve emerging crisis situations.
(5) Individual treatment planning that identifies risk factors,
positive early intervention strategies, and strategies to minimize
time spent in seclusion or behavioral restraints. Individual
treatment planning should include input from the person affected.
(6) While minimizing the duration of time spent in seclusion or
behavioral restraints, using strategies to mitigate the emotional and
physical discomfort and ensure the safety of the person involved in
seclusion or behavioral restraints, including input from the person
about what would alleviate his or her distress.
(7) Training in conducting an effective debriefing meeting as
specified in Section 1180.5, including the appropriate persons to
involve, the voluntary participation of the person who has been in
seclusion or behavioral restraints, and strategic interventions to
engage affected persons in the process. The training should include
strategies that result in maximum participation and comfort for the
involved parties to identify factors that lead to the use of
seclusion and behavioral restraints and factors that would reduce the
likelihood of future incidents.
(d) (1) The State Department of Mental Health and the State
Department of Developmental Services shall take steps to establish a
system of mandatory, consistent, timely, and publicly accessible data
collection regarding the use of seclusion and behavioral restraints
in facilities described in this section. It is the intent of the
Legislature that data be compiled in a manner that allows for
standard statistical comparison.
(2) The State Department of Mental Health and the State Department
of Developmental Services shall develop a mechanism for making this
information publicly available on the Internet.
(3) Data collected pursuant to this section shall include all of
the following:
(A) The number of deaths that occur while persons are in seclusion
or behavioral restraints, or where it is reasonable to assume that a
death was proximately related to the use of seclusion or behavioral
restraints.
(B) The number of serious injuries sustained by persons while in
seclusion or subject to behavioral restraints.
(C) The number of serious injuries sustained by staff that occur
during the use of seclusion or behavioral restraints.
(D) The number of incidents of seclusion.
(E) The number of incidents of use of behavioral restraints.
(F) The duration of time spent per incident in seclusion.
(G) The duration of time spent per incident subject to behavioral
restraints.
(H) The number of times an involuntary emergency medication is
used to control behavior, as defined by the State Department of
Mental Health.
(e) A facility described in subdivision (a) shall report each
death or serious injury of a person occurring during, or related to,
the use of seclusion or behavioral restraints. This report shall be
made to the agency designated in subdivision (h) of Section 4900 of
the Welfare and Institutions Code no later than the close of the
business day following the death or injury. The report shall include
the encrypted identifier of the person involved, and the name, street
address, and telephone number of the facility.
1180.3. (a) This section shall apply to psychiatric units of
general acute care hospitals, acute psychiatric hospitals,
psychiatric health facilities, crisis stabilization units, community
treatment facilities, group homes, skilled nursing facilities,
intermediate care facilities, community care facilities, and mental
health rehabilitation centers.
(b) (1) The secretary or his or her designee shall develop
technical assistance and training programs to support the efforts of
facilities to reduce or eliminate the use of seclusion and behavioral
restraints in those facilities that utilize them.
(2) Technical assistance and training programs should be designed
with the input of stakeholders, including clients and direct care
staff, and should be based on best practices that lead to the
avoidance of the use of seclusion and behavioral restraints. In order
to avoid redundancies and to promote consistency across various
types of facilities, it is the intent of the Legislature that the
technical assistance and training program, to the extent possible, be
based on that developed pursuant to Section 1180.2.
(c) (1) The secretary or his or her designee shall take steps to
establish a system of mandatory, consistent, timely, and publicly
accessible data collection regarding the use of seclusion and
behavioral restraints in all facilities described in subdivision (a)
that utilize seclusion and behavioral restraints. In determining a
system of data collection, the secretary should utilize existing
efforts, and direct new or ongoing efforts, of associated state
departments to revise or improve their data collection systems. The
secretary or his or her designee shall make recommendations for a
mechanism to ensure compliance by facilities, including, but not
limited to, penalties for failure to report in a timely manner. It is
the intent of the Legislature that data be compiled in a manner that
allows for standard statistical comparison and be maintained for
each facility subject to reporting requirements for the use of
seclusion and behavioral restraints.
(2) The secretary shall develop a mechanism for making this
information, as it becomes available, publicly available on the
Internet. For data currently being collected, this paragraph shall be
implemented as soon as it reasonably can be achieved within existing
resources. As new reporting requirements are developed and result in
additional data becoming available, this additional data shall be
included in the data publicly available on the Internet pursuant to
this paragraph.
(3) At the direction of the secretary, the departments shall
cooperate and share resources for developing uniform reporting for
all facilities. Uniform reporting of seclusion and behavioral
restraint utilization information shall, to the extent possible, be
incorporated into existing reporting requirements for facilities
described in subdivision (a).
(4) Data collected pursuant to this subdivision shall include all
of the data described in paragraph (3) of subdivision (d) of Section
1180.2.
(5) The secretary or his or her designee shall work with the state
departments that have responsibility for oversight of the use of
seclusion and behavioral restraints to review and eliminate
redundancies and outdated requirements in the reporting of data on
the use of seclusion and behavioral restraints in order to ensure
cost-effectiveness.
(d) Neither the agency nor any department shall be required to
implement this section if implementation cannot be achieved within
existing resources, unless additional funding for this purpose
becomes available. The agency and involved departments may
incrementally implement this section in order to accomplish its goals
within existing resources, through the use of federal or private
funding, or upon the subsequent appropriation of funds by the
Legislature for this purpose, or all of these.
1180.4. (a) A facility described in subdivision (a) of Section
1180.2 or subdivision (a) of Section 1180.3 shall conduct an initial
assessment of each person prior to a placement decision or upon
admission to the facility, or as soon thereafter as possible. This
assessment shall include input from the person and from someone whom
he or she desires to be present, such as a family member, significant
other, or authorized representative designated by the person, and if
the desired third party can be present at the time of admission.
This assessment shall also include, based on the information
available at the time of initial assessment, all of the following:
(1) A person's advance directive regarding deescalation or the use
of seclusion or behavioral restraints.
(2) Identification of early warning signs, triggers, and
precipitants that cause a person to escalate, and identification of
the earliest precipitant of aggression for persons with a known or
suspected history of aggressiveness, or persons who are currently
aggressive.
(3) Techniques, methods, or tools that would help the person
control his or her behavior.
(4) Preexisting medical conditions or any physical disabilities or
limitations that would place the person at greater risk during
restraint or seclusion.
(5) Any trauma history, including any history of sexual or
physical abuse that the affected person feels is relevant.
(b) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 may use seclusion or behavioral
restraints for behavioral emergencies only when a person's behavior
presents an imminent danger of serious harm to self or others.
(c) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 may not use either of the
following:
(1) A physical restraint or containment technique that obstructs a
person's respiratory airway or impairs the person's breathing or
respiratory capacity, including techniques in which a staff member
places pressure on a person's back or places his or her body weight
against the person's torso or back.
(2) A pillow, blanket, or other item covering the person's face as
part of a physical or mechanical restraint or containment process.
(d) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 may not use physical or mechanical
restraint or containment on a person who has a known medical or
physical condition, and where there is reason to believe that the use
would endanger the person's life or seriously exacerbate the person'
s medical condition.
(e) (1) A facility described in subdivision (a) of Section 1180.2
or subdivision (a) of Section 1180.3 may not use prone mechanical
restraint on a person at risk for positional asphyxiation as a result
of one of the following risk factors that are known to the provider:
(A) Obesity.
(B) Pregnancy.
(C) Agitated delirium or excited delirium syndromes.
(D) Cocaine, methamphetamine, or alcohol intoxication.
(E) Exposure to pepper spray.
(F) Preexisting heart disease, including, but not limited to, an
enlarged heart or other cardiovascular disorders.
(G) Respiratory conditions, including emphysema, bronchitis, or
asthma.
(2) Paragraph (1) shall not apply when written authorization has
been provided by a physician, made to accommodate a person's stated
preference for the prone position or because the physician judges
other clinical risks to take precedence. The written authorization
may not be a standing order, and shall be evaluated on a case-by-case
basis by the physician.
(f) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 shall avoid the deliberate use of
prone containment techniques whenever possible, utilizing the best
practices in early intervention techniques, such as deescalation. If
prone containment techniques are used in an emergency situation, a
staff member shall observe the person for any signs of physical
duress throughout the use of prone containment. Whenever possible,
the staff member monitoring the person shall not be involved in
restraining the person.
(g) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 may not place a person in a
facedown position with the person's hands held or restrained behind
the person's back.
(h) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 may not use physical restraint or
containment as an extended procedure.
(i) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 shall keep under constant,
face-to-face human observation a person who is in seclusion and in
any type of behavioral restraint at the same time. Observation by
means of video camera may be utilized only in facilities that are
already permitted to use video monitoring under federal regulations
specific to that facility.
(j) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 shall afford to persons who are
restrained the least restrictive alternative and the maximum freedom
of movement, while ensuring the physical safety of the person and
others, and shall use the least number of restraint points.
(k) A person in a facility described in subdivision (a) of Section
1180.2 and subdivision (a) of Section 1180.3 has the right to be
free from the use of seclusion and behavioral restraints of any form
imposed as a means of coercion, discipline, convenience, or
retaliation by staff. This right includes, but is not limited to, the
right to be free from the use of a drug used in order to control
behavior or to restrict the person's freedom of movement, if that
drug is not a standard treatment for the person's medical or
psychiatric condition.
1180.5. (a) A facility described in subdivision (a) of Section
1180.2 or subdivision (a) of Section 1180.3 shall conduct a clinical
and quality review for each episode of the use of seclusion or
behavioral restraints.
(b) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 shall, as quickly as possible but
no later than 24 hours after the use of seclusion or behavioral
restraints, conduct a debriefing regarding the incident with the
person, and, if the person requests it, the person's family member,
domestic partner, significant other, or authorized representative, if
the desired third party can be present at the time of the debriefing
at no cost to the facility, as well as with the staff members
involved in the incident, if reasonably available, and a supervisor,
to discuss how to avoid a similar incident in the future. The person'
s participation in the debriefing shall be voluntary. The purposes of
the debriefing shall be to do all of the following:
(1) Assist the person to identify the precipitant of the incident,
and suggest methods of more safely and constructively responding to
the incident.
(2) Assist the staff to understand the precipitants to the
incident, and to develop alternative methods of helping the person
avoid or cope with those incidents.
(3) Help treatment team staff devise treatment interventions to
address the root cause of the incident and its consequences, and to
modify the treatment plan.
(4) Help assess whether the intervention was necessary and whether
it was implemented in a manner consistent with staff training and
facility policies.
(c) The facility shall, in the debriefing, provide both the person
and staff the opportunity to discuss the circumstances resulting in
the use of seclusion or behavioral restraints, and strategies to be
used by the staff, the person, or others that could prevent the
future use of seclusion or behavioral restraints.
(d) The facility staff shall document in the person's record that
the debriefing session took place and any changes to the person's
treatment plan that resulted from the debriefing.
1180.6. The State Department of Health Services, the State
Department of Mental Health, the State Department of Social Services,
and the State Department of Developmental Services shall annually
provide information to the Legislature, during Senate and Assembly
budget committee hearings, about the progress made in implementing
this division. This information shall include the progress of
implementation and barriers to achieving full implementation.
1180. (a) The California Health and Human Services Agency, in
accordance with their mission, shall provide the leadership and
coordination necessary to reduce the use of seclusion and behavioral
restraints in facilities that are licensed, certified, or monitored
by departments that fall within its jurisdiction.
(b) The agency may make recommendations to the Legislature for
additional facilities, or for additional units or departments within
facilities, that should be included within the requirements of this
division in the future, including, but not limited to, emergency
rooms.
(c) At the request of the secretary, the involved state
departments shall provide information regarding existing training
protocols and requirements related to the utilization of seclusion
and behavioral restraints by direct care staff who work in facilities
within their jurisdiction. All involved state departments shall
cooperate in implementing any training protocols established pursuant
to this division. It is the intent of the Legislature that training
protocols developed pursuant to this division be incorporated into
existing training requirements and opportunities. It is further the
intent of the Legislature that, to the extent feasible, the training
protocols developed pursuant to Section 1180.2 be utilized in the
development of training protocols developed pursuant to Section
1180.3.
(d) The secretary, or his or her designee, is encouraged to pursue
federal and private funding to support the development of a training
protocol that can be incorporated into the existing training
activities for direct care staff conducted by the state, facilities,
and educational institutions in order to reduce the use of seclusion
and behavioral restraints.
(e) The secretary or his or her designee shall make
recommendations to the Legislature on how to best assess the impact
of serious staff injuries sustained during the use of seclusion or
behavioral restraints, on staffing costs, and on workers'
compensation claims and costs.
(f) The agency shall not be required to implement this section if
implementation cannot be achieved within existing resources, unless
additional funding for this purpose becomes available. The agency and
involved departments may incrementally implement this section in
order to accomplish its goals within existing resources, through the
use of federal or private funding, or upon the subsequent
appropriation of funds by the Legislature for this purpose, or all of
these.
1180.1. For purposes of this division, the following definitions
apply:
(a) "Behavioral restraint" means "mechanical restraint" or
"physical restraint" as defined in this section, used as an
intervention when a person presents an immediate danger to self or to
others. It does not include restraints used for medical purposes,
including, but not limited to, securing an intravenous needle or
immobilizing a person for a surgical procedure, or postural
restraints, or devices used to prevent injury or to improve a person'
s mobility and independent functioning rather than to restrict
movement.
(b) "Containment" means a brief physical restraint of a person for
the purpose of effectively gaining quick control of a person who is
aggressive or agitated or who is a danger to self or others.
(c) "Mechanical restraint" means the use of a mechanical device,
material, or equipment attached or adjacent to the person's body that
he or she cannot easily remove and that restricts the freedom of
movement of all or part of a person's body or restricts normal access
to the person's body, and that is used as a behavioral restraint.
(d) "Physical restraint" means the use of a manual hold to
restrict freedom of movement of all or part of a person's body, or to
restrict normal access to the person's body, and that is used as a
behavioral restraint. "Physical restraint" is staff-to-person
physical contact in which the person unwillingly participates.
"Physical restraint" does not include briefly holding a person
without undue force in order to calm or comfort, or physical contact
intended to gently assist a person in performing tasks or to guide or
assist a person from one area to another.
(e) "Seclusion" means the involuntary confinement of a person
alone in a room or an area from which the person is physically
prevented from leaving. "Seclusion" does not include a "timeout," as
defined in regulations relating to facilities operated by the State
Department of Developmental Services.
(f) "Secretary" means the Secretary of California Health and Human
Services.
(g) "Serious injury" means significant impairment of the physical
condition as determined by qualified medical personnel, and includes,
but is not limited to, burns, lacerations, bone fractures,
substantial hematoma, or injuries to internal organs.
1180.2. (a) This section shall apply to the state hospitals
operated by the State Department of Mental Health and facilities
operated by the State Department of Developmental Services that
utilize seclusion or behavioral restraints.
(b) The State Department of Mental Health and the State Department
of Developmental Services shall develop technical assistance and
training programs to support the efforts of facilities described in
subdivision (a) to reduce or eliminate the use of seclusion and
behavioral restraints in those facilities.
(c) Technical assistance and training programs should be designed
with the input of stakeholders, including clients and direct care
staff, and should be based on best practices that lead to the
avoidance of the use of seclusion and behavioral restraints,
including, but not limited to, all of the following:
(1) Conducting an intake assessment that is consistent with
facility policies and that includes issues specific to the use of
seclusion and behavioral restraints as specified in Section 1180.4.
(2) Utilizing strategies to engage clients collaboratively in
assessment, avoidance, and management of crisis situations in order
to prevent incidents of the use of seclusion and behavioral
restraints.
(3) Recognizing and responding appropriately to underlying reasons
for escalating behavior.
(4) Utilizing conflict resolution, effective communication,
deescalation, and client-centered problem solving strategies that
diffuse and safely resolve emerging crisis situations.
(5) Individual treatment planning that identifies risk factors,
positive early intervention strategies, and strategies to minimize
time spent in seclusion or behavioral restraints. Individual
treatment planning should include input from the person affected.
(6) While minimizing the duration of time spent in seclusion or
behavioral restraints, using strategies to mitigate the emotional and
physical discomfort and ensure the safety of the person involved in
seclusion or behavioral restraints, including input from the person
about what would alleviate his or her distress.
(7) Training in conducting an effective debriefing meeting as
specified in Section 1180.5, including the appropriate persons to
involve, the voluntary participation of the person who has been in
seclusion or behavioral restraints, and strategic interventions to
engage affected persons in the process. The training should include
strategies that result in maximum participation and comfort for the
involved parties to identify factors that lead to the use of
seclusion and behavioral restraints and factors that would reduce the
likelihood of future incidents.
(d) (1) The State Department of Mental Health and the State
Department of Developmental Services shall take steps to establish a
system of mandatory, consistent, timely, and publicly accessible data
collection regarding the use of seclusion and behavioral restraints
in facilities described in this section. It is the intent of the
Legislature that data be compiled in a manner that allows for
standard statistical comparison.
(2) The State Department of Mental Health and the State Department
of Developmental Services shall develop a mechanism for making this
information publicly available on the Internet.
(3) Data collected pursuant to this section shall include all of
the following:
(A) The number of deaths that occur while persons are in seclusion
or behavioral restraints, or where it is reasonable to assume that a
death was proximately related to the use of seclusion or behavioral
restraints.
(B) The number of serious injuries sustained by persons while in
seclusion or subject to behavioral restraints.
(C) The number of serious injuries sustained by staff that occur
during the use of seclusion or behavioral restraints.
(D) The number of incidents of seclusion.
(E) The number of incidents of use of behavioral restraints.
(F) The duration of time spent per incident in seclusion.
(G) The duration of time spent per incident subject to behavioral
restraints.
(H) The number of times an involuntary emergency medication is
used to control behavior, as defined by the State Department of
Mental Health.
(e) A facility described in subdivision (a) shall report each
death or serious injury of a person occurring during, or related to,
the use of seclusion or behavioral restraints. This report shall be
made to the agency designated in subdivision (h) of Section 4900 of
the Welfare and Institutions Code no later than the close of the
business day following the death or injury. The report shall include
the encrypted identifier of the person involved, and the name, street
address, and telephone number of the facility.
1180.3. (a) This section shall apply to psychiatric units of
general acute care hospitals, acute psychiatric hospitals,
psychiatric health facilities, crisis stabilization units, community
treatment facilities, group homes, skilled nursing facilities,
intermediate care facilities, community care facilities, and mental
health rehabilitation centers.
(b) (1) The secretary or his or her designee shall develop
technical assistance and training programs to support the efforts of
facilities to reduce or eliminate the use of seclusion and behavioral
restraints in those facilities that utilize them.
(2) Technical assistance and training programs should be designed
with the input of stakeholders, including clients and direct care
staff, and should be based on best practices that lead to the
avoidance of the use of seclusion and behavioral restraints. In order
to avoid redundancies and to promote consistency across various
types of facilities, it is the intent of the Legislature that the
technical assistance and training program, to the extent possible, be
based on that developed pursuant to Section 1180.2.
(c) (1) The secretary or his or her designee shall take steps to
establish a system of mandatory, consistent, timely, and publicly
accessible data collection regarding the use of seclusion and
behavioral restraints in all facilities described in subdivision (a)
that utilize seclusion and behavioral restraints. In determining a
system of data collection, the secretary should utilize existing
efforts, and direct new or ongoing efforts, of associated state
departments to revise or improve their data collection systems. The
secretary or his or her designee shall make recommendations for a
mechanism to ensure compliance by facilities, including, but not
limited to, penalties for failure to report in a timely manner. It is
the intent of the Legislature that data be compiled in a manner that
allows for standard statistical comparison and be maintained for
each facility subject to reporting requirements for the use of
seclusion and behavioral restraints.
(2) The secretary shall develop a mechanism for making this
information, as it becomes available, publicly available on the
Internet. For data currently being collected, this paragraph shall be
implemented as soon as it reasonably can be achieved within existing
resources. As new reporting requirements are developed and result in
additional data becoming available, this additional data shall be
included in the data publicly available on the Internet pursuant to
this paragraph.
(3) At the direction of the secretary, the departments shall
cooperate and share resources for developing uniform reporting for
all facilities. Uniform reporting of seclusion and behavioral
restraint utilization information shall, to the extent possible, be
incorporated into existing reporting requirements for facilities
described in subdivision (a).
(4) Data collected pursuant to this subdivision shall include all
of the data described in paragraph (3) of subdivision (d) of Section
1180.2.
(5) The secretary or his or her designee shall work with the state
departments that have responsibility for oversight of the use of
seclusion and behavioral restraints to review and eliminate
redundancies and outdated requirements in the reporting of data on
the use of seclusion and behavioral restraints in order to ensure
cost-effectiveness.
(d) Neither the agency nor any department shall be required to
implement this section if implementation cannot be achieved within
existing resources, unless additional funding for this purpose
becomes available. The agency and involved departments may
incrementally implement this section in order to accomplish its goals
within existing resources, through the use of federal or private
funding, or upon the subsequent appropriation of funds by the
Legislature for this purpose, or all of these.
1180.4. (a) A facility described in subdivision (a) of Section
1180.2 or subdivision (a) of Section 1180.3 shall conduct an initial
assessment of each person prior to a placement decision or upon
admission to the facility, or as soon thereafter as possible. This
assessment shall include input from the person and from someone whom
he or she desires to be present, such as a family member, significant
other, or authorized representative designated by the person, and if
the desired third party can be present at the time of admission.
This assessment shall also include, based on the information
available at the time of initial assessment, all of the following:
(1) A person's advance directive regarding deescalation or the use
of seclusion or behavioral restraints.
(2) Identification of early warning signs, triggers, and
precipitants that cause a person to escalate, and identification of
the earliest precipitant of aggression for persons with a known or
suspected history of aggressiveness, or persons who are currently
aggressive.
(3) Techniques, methods, or tools that would help the person
control his or her behavior.
(4) Preexisting medical conditions or any physical disabilities or
limitations that would place the person at greater risk during
restraint or seclusion.
(5) Any trauma history, including any history of sexual or
physical abuse that the affected person feels is relevant.
(b) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 may use seclusion or behavioral
restraints for behavioral emergencies only when a person's behavior
presents an imminent danger of serious harm to self or others.
(c) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 may not use either of the
following:
(1) A physical restraint or containment technique that obstructs a
person's respiratory airway or impairs the person's breathing or
respiratory capacity, including techniques in which a staff member
places pressure on a person's back or places his or her body weight
against the person's torso or back.
(2) A pillow, blanket, or other item covering the person's face as
part of a physical or mechanical restraint or containment process.
(d) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 may not use physical or mechanical
restraint or containment on a person who has a known medical or
physical condition, and where there is reason to believe that the use
would endanger the person's life or seriously exacerbate the person'
s medical condition.
(e) (1) A facility described in subdivision (a) of Section 1180.2
or subdivision (a) of Section 1180.3 may not use prone mechanical
restraint on a person at risk for positional asphyxiation as a result
of one of the following risk factors that are known to the provider:
(A) Obesity.
(B) Pregnancy.
(C) Agitated delirium or excited delirium syndromes.
(D) Cocaine, methamphetamine, or alcohol intoxication.
(E) Exposure to pepper spray.
(F) Preexisting heart disease, including, but not limited to, an
enlarged heart or other cardiovascular disorders.
(G) Respiratory conditions, including emphysema, bronchitis, or
asthma.
(2) Paragraph (1) shall not apply when written authorization has
been provided by a physician, made to accommodate a person's stated
preference for the prone position or because the physician judges
other clinical risks to take precedence. The written authorization
may not be a standing order, and shall be evaluated on a case-by-case
basis by the physician.
(f) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 shall avoid the deliberate use of
prone containment techniques whenever possible, utilizing the best
practices in early intervention techniques, such as deescalation. If
prone containment techniques are used in an emergency situation, a
staff member shall observe the person for any signs of physical
duress throughout the use of prone containment. Whenever possible,
the staff member monitoring the person shall not be involved in
restraining the person.
(g) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 may not place a person in a
facedown position with the person's hands held or restrained behind
the person's back.
(h) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 may not use physical restraint or
containment as an extended procedure.
(i) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 shall keep under constant,
face-to-face human observation a person who is in seclusion and in
any type of behavioral restraint at the same time. Observation by
means of video camera may be utilized only in facilities that are
already permitted to use video monitoring under federal regulations
specific to that facility.
(j) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 shall afford to persons who are
restrained the least restrictive alternative and the maximum freedom
of movement, while ensuring the physical safety of the person and
others, and shall use the least number of restraint points.
(k) A person in a facility described in subdivision (a) of Section
1180.2 and subdivision (a) of Section 1180.3 has the right to be
free from the use of seclusion and behavioral restraints of any form
imposed as a means of coercion, discipline, convenience, or
retaliation by staff. This right includes, but is not limited to, the
right to be free from the use of a drug used in order to control
behavior or to restrict the person's freedom of movement, if that
drug is not a standard treatment for the person's medical or
psychiatric condition.
1180.5. (a) A facility described in subdivision (a) of Section
1180.2 or subdivision (a) of Section 1180.3 shall conduct a clinical
and quality review for each episode of the use of seclusion or
behavioral restraints.
(b) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 shall, as quickly as possible but
no later than 24 hours after the use of seclusion or behavioral
restraints, conduct a debriefing regarding the incident with the
person, and, if the person requests it, the person's family member,
domestic partner, significant other, or authorized representative, if
the desired third party can be present at the time of the debriefing
at no cost to the facility, as well as with the staff members
involved in the incident, if reasonably available, and a supervisor,
to discuss how to avoid a similar incident in the future. The person'
s participation in the debriefing shall be voluntary. The purposes of
the debriefing shall be to do all of the following:
(1) Assist the person to identify the precipitant of the incident,
and suggest methods of more safely and constructively responding to
the incident.
(2) Assist the staff to understand the precipitants to the
incident, and to develop alternative methods of helping the person
avoid or cope with those incidents.
(3) Help treatment team staff devise treatment interventions to
address the root cause of the incident and its consequences, and to
modify the treatment plan.
(4) Help assess whether the intervention was necessary and whether
it was implemented in a manner consistent with staff training and
facility policies.
(c) The facility shall, in the debriefing, provide both the person
and staff the opportunity to discuss the circumstances resulting in
the use of seclusion or behavioral restraints, and strategies to be
used by the staff, the person, or others that could prevent the
future use of seclusion or behavioral restraints.
(d) The facility staff shall document in the person's record that
the debriefing session took place and any changes to the person's
treatment plan that resulted from the debriefing.
1180.6. The State Department of Health Services, the State
Department of Mental Health, the State Department of Social Services,
and the State Department of Developmental Services shall annually
provide information to the Legislature, during Senate and Assembly
budget committee hearings, about the progress made in implementing
this division. This information shall include the progress of
implementation and barriers to achieving full implementation.
1180. (a) The California Health and Human Services Agency, in
accordance with their mission, shall provide the leadership and
coordination necessary to reduce the use of seclusion and behavioral
restraints in facilities that are licensed, certified, or monitored
by departments that fall within its jurisdiction.
(b) The agency may make recommendations to the Legislature for
additional facilities, or for additional units or departments within
facilities, that should be included within the requirements of this
division in the future, including, but not limited to, emergency
rooms.
(c) At the request of the secretary, the involved state
departments shall provide information regarding existing training
protocols and requirements related to the utilization of seclusion
and behavioral restraints by direct care staff who work in facilities
within their jurisdiction. All involved state departments shall
cooperate in implementing any training protocols established pursuant
to this division. It is the intent of the Legislature that training
protocols developed pursuant to this division be incorporated into
existing training requirements and opportunities. It is further the
intent of the Legislature that, to the extent feasible, the training
protocols developed pursuant to Section 1180.2 be utilized in the
development of training protocols developed pursuant to Section
1180.3.
(d) The secretary, or his or her designee, is encouraged to pursue
federal and private funding to support the development of a training
protocol that can be incorporated into the existing training
activities for direct care staff conducted by the state, facilities,
and educational institutions in order to reduce the use of seclusion
and behavioral restraints.
(e) The secretary or his or her designee shall make
recommendations to the Legislature on how to best assess the impact
of serious staff injuries sustained during the use of seclusion or
behavioral restraints, on staffing costs, and on workers'
compensation claims and costs.
(f) The agency shall not be required to implement this section if
implementation cannot be achieved within existing resources, unless
additional funding for this purpose becomes available. The agency and
involved departments may incrementally implement this section in
order to accomplish its goals within existing resources, through the
use of federal or private funding, or upon the subsequent
appropriation of funds by the Legislature for this purpose, or all of
these.
1180.1. For purposes of this division, the following definitions
apply:
(a) "Behavioral restraint" means "mechanical restraint" or
"physical restraint" as defined in this section, used as an
intervention when a person presents an immediate danger to self or to
others. It does not include restraints used for medical purposes,
including, but not limited to, securing an intravenous needle or
immobilizing a person for a surgical procedure, or postural
restraints, or devices used to prevent injury or to improve a person'
s mobility and independent functioning rather than to restrict
movement.
(b) "Containment" means a brief physical restraint of a person for
the purpose of effectively gaining quick control of a person who is
aggressive or agitated or who is a danger to self or others.
(c) "Mechanical restraint" means the use of a mechanical device,
material, or equipment attached or adjacent to the person's body that
he or she cannot easily remove and that restricts the freedom of
movement of all or part of a person's body or restricts normal access
to the person's body, and that is used as a behavioral restraint.
(d) "Physical restraint" means the use of a manual hold to
restrict freedom of movement of all or part of a person's body, or to
restrict normal access to the person's body, and that is used as a
behavioral restraint. "Physical restraint" is staff-to-person
physical contact in which the person unwillingly participates.
"Physical restraint" does not include briefly holding a person
without undue force in order to calm or comfort, or physical contact
intended to gently assist a person in performing tasks or to guide or
assist a person from one area to another.
(e) "Seclusion" means the involuntary confinement of a person
alone in a room or an area from which the person is physically
prevented from leaving. "Seclusion" does not include a "timeout," as
defined in regulations relating to facilities operated by the State
Department of Developmental Services.
(f) "Secretary" means the Secretary of California Health and Human
Services.
(g) "Serious injury" means significant impairment of the physical
condition as determined by qualified medical personnel, and includes,
but is not limited to, burns, lacerations, bone fractures,
substantial hematoma, or injuries to internal organs.
1180.2. (a) This section shall apply to the state hospitals
operated by the State Department of Mental Health and facilities
operated by the State Department of Developmental Services that
utilize seclusion or behavioral restraints.
(b) The State Department of Mental Health and the State Department
of Developmental Services shall develop technical assistance and
training programs to support the efforts of facilities described in
subdivision (a) to reduce or eliminate the use of seclusion and
behavioral restraints in those facilities.
(c) Technical assistance and training programs should be designed
with the input of stakeholders, including clients and direct care
staff, and should be based on best practices that lead to the
avoidance of the use of seclusion and behavioral restraints,
including, but not limited to, all of the following:
(1) Conducting an intake assessment that is consistent with
facility policies and that includes issues specific to the use of
seclusion and behavioral restraints as specified in Section 1180.4.
(2) Utilizing strategies to engage clients collaboratively in
assessment, avoidance, and management of crisis situations in order
to prevent incidents of the use of seclusion and behavioral
restraints.
(3) Recognizing and responding appropriately to underlying reasons
for escalating behavior.
(4) Utilizing conflict resolution, effective communication,
deescalation, and client-centered problem solving strategies that
diffuse and safely resolve emerging crisis situations.
(5) Individual treatment planning that identifies risk factors,
positive early intervention strategies, and strategies to minimize
time spent in seclusion or behavioral restraints. Individual
treatment planning should include input from the person affected.
(6) While minimizing the duration of time spent in seclusion or
behavioral restraints, using strategies to mitigate the emotional and
physical discomfort and ensure the safety of the person involved in
seclusion or behavioral restraints, including input from the person
about what would alleviate his or her distress.
(7) Training in conducting an effective debriefing meeting as
specified in Section 1180.5, including the appropriate persons to
involve, the voluntary participation of the person who has been in
seclusion or behavioral restraints, and strategic interventions to
engage affected persons in the process. The training should include
strategies that result in maximum participation and comfort for the
involved parties to identify factors that lead to the use of
seclusion and behavioral restraints and factors that would reduce the
likelihood of future incidents.
(d) (1) The State Department of Mental Health and the State
Department of Developmental Services shall take steps to establish a
system of mandatory, consistent, timely, and publicly accessible data
collection regarding the use of seclusion and behavioral restraints
in facilities described in this section. It is the intent of the
Legislature that data be compiled in a manner that allows for
standard statistical comparison.
(2) The State Department of Mental Health and the State Department
of Developmental Services shall develop a mechanism for making this
information publicly available on the Internet.
(3) Data collected pursuant to this section shall include all of
the following:
(A) The number of deaths that occur while persons are in seclusion
or behavioral restraints, or where it is reasonable to assume that a
death was proximately related to the use of seclusion or behavioral
restraints.
(B) The number of serious injuries sustained by persons while in
seclusion or subject to behavioral restraints.
(C) The number of serious injuries sustained by staff that occur
during the use of seclusion or behavioral restraints.
(D) The number of incidents of seclusion.
(E) The number of incidents of use of behavioral restraints.
(F) The duration of time spent per incident in seclusion.
(G) The duration of time spent per incident subject to behavioral
restraints.
(H) The number of times an involuntary emergency medication is
used to control behavior, as defined by the State Department of
Mental Health.
(e) A facility described in subdivision (a) shall report each
death or serious injury of a person occurring during, or related to,
the use of seclusion or behavioral restraints. This report shall be
made to the agency designated in subdivision (h) of Section 4900 of
the Welfare and Institutions Code no later than the close of the
business day following the death or injury. The report shall include
the encrypted identifier of the person involved, and the name, street
address, and telephone number of the facility.
1180.3. (a) This section shall apply to psychiatric units of
general acute care hospitals, acute psychiatric hospitals,
psychiatric health facilities, crisis stabilization units, community
treatment facilities, group homes, skilled nursing facilities,
intermediate care facilities, community care facilities, and mental
health rehabilitation centers.
(b) (1) The secretary or his or her designee shall develop
technical assistance and training programs to support the efforts of
facilities to reduce or eliminate the use of seclusion and behavioral
restraints in those facilities that utilize them.
(2) Technical assistance and training programs should be designed
with the input of stakeholders, including clients and direct care
staff, and should be based on best practices that lead to the
avoidance of the use of seclusion and behavioral restraints. In order
to avoid redundancies and to promote consistency across various
types of facilities, it is the intent of the Legislature that the
technical assistance and training program, to the extent possible, be
based on that developed pursuant to Section 1180.2.
(c) (1) The secretary or his or her designee shall take steps to
establish a system of mandatory, consistent, timely, and publicly
accessible data collection regarding the use of seclusion and
behavioral restraints in all facilities described in subdivision (a)
that utilize seclusion and behavioral restraints. In determining a
system of data collection, the secretary should utilize existing
efforts, and direct new or ongoing efforts, of associated state
departments to revise or improve their data collection systems. The
secretary or his or her designee shall make recommendations for a
mechanism to ensure compliance by facilities, including, but not
limited to, penalties for failure to report in a timely manner. It is
the intent of the Legislature that data be compiled in a manner that
allows for standard statistical comparison and be maintained for
each facility subject to reporting requirements for the use of
seclusion and behavioral restraints.
(2) The secretary shall develop a mechanism for making this
information, as it becomes available, publicly available on the
Internet. For data currently being collected, this paragraph shall be
implemented as soon as it reasonably can be achieved within existing
resources. As new reporting requirements are developed and result in
additional data becoming available, this additional data shall be
included in the data publicly available on the Internet pursuant to
this paragraph.
(3) At the direction of the secretary, the departments shall
cooperate and share resources for developing uniform reporting for
all facilities. Uniform reporting of seclusion and behavioral
restraint utilization information shall, to the extent possible, be
incorporated into existing reporting requirements for facilities
described in subdivision (a).
(4) Data collected pursuant to this subdivision shall include all
of the data described in paragraph (3) of subdivision (d) of Section
1180.2.
(5) The secretary or his or her designee shall work with the state
departments that have responsibility for oversight of the use of
seclusion and behavioral restraints to review and eliminate
redundancies and outdated requirements in the reporting of data on
the use of seclusion and behavioral restraints in order to ensure
cost-effectiveness.
(d) Neither the agency nor any department shall be required to
implement this section if implementation cannot be achieved within
existing resources, unless additional funding for this purpose
becomes available. The agency and involved departments may
incrementally implement this section in order to accomplish its goals
within existing resources, through the use of federal or private
funding, or upon the subsequent appropriation of funds by the
Legislature for this purpose, or all of these.
1180.4. (a) A facility described in subdivision (a) of Section
1180.2 or subdivision (a) of Section 1180.3 shall conduct an initial
assessment of each person prior to a placement decision or upon
admission to the facility, or as soon thereafter as possible. This
assessment shall include input from the person and from someone whom
he or she desires to be present, such as a family member, significant
other, or authorized representative designated by the person, and if
the desired third party can be present at the time of admission.
This assessment shall also include, based on the information
available at the time of initial assessment, all of the following:
(1) A person's advance directive regarding deescalation or the use
of seclusion or behavioral restraints.
(2) Identification of early warning signs, triggers, and
precipitants that cause a person to escalate, and identification of
the earliest precipitant of aggression for persons with a known or
suspected history of aggressiveness, or persons who are currently
aggressive.
(3) Techniques, methods, or tools that would help the person
control his or her behavior.
(4) Preexisting medical conditions or any physical disabilities or
limitations that would place the person at greater risk during
restraint or seclusion.
(5) Any trauma history, including any history of sexual or
physical abuse that the affected person feels is relevant.
(b) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 may use seclusion or behavioral
restraints for behavioral emergencies only when a person's behavior
presents an imminent danger of serious harm to self or others.
(c) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 may not use either of the
following:
(1) A physical restraint or containment technique that obstructs a
person's respiratory airway or impairs the person's breathing or
respiratory capacity, including techniques in which a staff member
places pressure on a person's back or places his or her body weight
against the person's torso or back.
(2) A pillow, blanket, or other item covering the person's face as
part of a physical or mechanical restraint or containment process.
(d) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 may not use physical or mechanical
restraint or containment on a person who has a known medical or
physical condition, and where there is reason to believe that the use
would endanger the person's life or seriously exacerbate the person'
s medical condition.
(e) (1) A facility described in subdivision (a) of Section 1180.2
or subdivision (a) of Section 1180.3 may not use prone mechanical
restraint on a person at risk for positional asphyxiation as a result
of one of the following risk factors that are known to the provider:
(A) Obesity.
(B) Pregnancy.
(C) Agitated delirium or excited delirium syndromes.
(D) Cocaine, methamphetamine, or alcohol intoxication.
(E) Exposure to pepper spray.
(F) Preexisting heart disease, including, but not limited to, an
enlarged heart or other cardiovascular disorders.
(G) Respiratory conditions, including emphysema, bronchitis, or
asthma.
(2) Paragraph (1) shall not apply when written authorization has
been provided by a physician, made to accommodate a person's stated
preference for the prone position or because the physician judges
other clinical risks to take precedence. The written authorization
may not be a standing order, and shall be evaluated on a case-by-case
basis by the physician.
(f) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 shall avoid the deliberate use of
prone containment techniques whenever possible, utilizing the best
practices in early intervention techniques, such as deescalation. If
prone containment techniques are used in an emergency situation, a
staff member shall observe the person for any signs of physical
duress throughout the use of prone containment. Whenever possible,
the staff member monitoring the person shall not be involved in
restraining the person.
(g) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 may not place a person in a
facedown position with the person's hands held or restrained behind
the person's back.
(h) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 may not use physical restraint or
containment as an extended procedure.
(i) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 shall keep under constant,
face-to-face human observation a person who is in seclusion and in
any type of behavioral restraint at the same time. Observation by
means of video camera may be utilized only in facilities that are
already permitted to use video monitoring under federal regulations
specific to that facility.
(j) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 shall afford to persons who are
restrained the least restrictive alternative and the maximum freedom
of movement, while ensuring the physical safety of the person and
others, and shall use the least number of restraint points.
(k) A person in a facility described in subdivision (a) of Section
1180.2 and subdivision (a) of Section 1180.3 has the right to be
free from the use of seclusion and behavioral restraints of any form
imposed as a means of coercion, discipline, convenience, or
retaliation by staff. This right includes, but is not limited to, the
right to be free from the use of a drug used in order to control
behavior or to restrict the person's freedom of movement, if that
drug is not a standard treatment for the person's medical or
psychiatric condition.
1180.5. (a) A facility described in subdivision (a) of Section
1180.2 or subdivision (a) of Section 1180.3 shall conduct a clinical
and quality review for each episode of the use of seclusion or
behavioral restraints.
(b) A facility described in subdivision (a) of Section 1180.2 or
subdivision (a) of Section 1180.3 shall, as quickly as possible but
no later than 24 hours after the use of seclusion or behavioral
restraints, conduct a debriefing regarding the incident with the
person, and, if the person requests it, the person's family member,
domestic partner, significant other, or authorized representative, if
the desired third party can be present at the time of the debriefing
at no cost to the facility, as well as with the staff members
involved in the incident, if reasonably available, and a supervisor,
to discuss how to avoid a similar incident in the future. The person'
s participation in the debriefing shall be voluntary. The purposes of
the debriefing shall be to do all of the following:
(1) Assist the person to identify the precipitant of the incident,
and suggest methods of more safely and constructively responding to
the incident.
(2) Assist the staff to understand the precipitants to the
incident, and to develop alternative methods of helping the person
avoid or cope with those incidents.
(3) Help treatment team staff devise treatment interventions to
address the root cause of the incident and its consequences, and to
modify the treatment plan.
(4) Help assess whether the intervention was necessary and whether
it was implemented in a manner consistent with staff training and
facility policies.
(c) The facility shall, in the debriefing, provide both the person
and staff the opportunity to discuss the circumstances resulting in
the use of seclusion or behavioral restraints, and strategies to be
used by the staff, the person, or others that could prevent the
future use of seclusion or behavioral restraints.
(d) The facility staff shall document in the person's record that
the debriefing session took place and any changes to the person's
treatment plan that resulted from the debriefing.
1180.6. The State Department of Health Services, the State
Department of Mental Health, the State Department of Social Services,
and the State Department of Developmental Services shall annually
provide information to the Legislature, during Senate and Assembly
budget committee hearings, about the progress made in implementing
this division. This information shall include the progress of
implementation and barriers to achieving full implementation.
