Quality Management and Performance Improvement Program

Chapter 900

Quality Management And Performance Improvement Program

Policy 9602

Reporting and Monitoring of Seclusion and RestraintTracking And Trending of Member And Provider Issues

962 Reporting and Monitoring of Seclusion And Restraint[1]

Revision Dates: 07/01/16, 10/01/15, 10/01/13, 04/01/12, 02/01/11, 10/01/09, 10/01/08, 02/01/07, 06/01/05, 04/01/05, 08/13/03, 10/01/01, 10/01/97

Initial

Effective Date: 10/01/1994

I.  OverviewPurpose[2]

This Policy applies to ALTCS/EPD), CRS and RBHA) Contractors, , and Fee-For-Service (FFS) Programs including: Behavioral Health providers providing services to Tribal Regional Behavioral Health Authorityies (TRBHAs) members, Hospital Presumptive Eligibility FFS Temporary, FFS Permanent, Prior Quarter Coverages and Federal Emergency Services, as delineated within this Policy for members determined to have a serious mental illness (SMI).

This Policy does not apply to Fee-For-Service (FFS) Programs/Populations including: Tribal ALTCS, and the American Indian Health Plans (AIHP), Hospital Presumptive Eligibility FFS Temporary, FFS Permanent, Prior Quarter Coverages and Federal Emergency Services.

This Policy establishes guidelines for reporting and monitoring the use of seclusion and restraint.

II.  Definitions[3]

Drug used as a restraint / Means a pharmacological restraint as used in A.R.S. § 36-513 that is not standard treatment for a client’s medical condition or behavioral health issue and is administered to:
A.  Manage the client’s behavior in a way that reduces
the safety risk to the client or others,
B.  Temporarily restrict the client’s freedom of movement as defined in A.A.C. R9-21-101(26).
Mechanical
Restraint[4] / Means any, device, article, or garment
attached or adjacent to a client’s body that the client
cannot easily remove and that restricts the client’s freedom
oof movement or normal access to the client’s body,
but does not include a device, article, or garment:
A.  . Used for orthopedic or surgical reasons, or
B.  . Necessary to allow a client to heal from a medical condition or to participate in a treatment program for
a medical condition. Aas defined in A.A.C. R9-21--101(44). XXX
Personal Restraint / Means the application of physical force without the use of any device, for the purpose of restricting the free movement of a client’s body, but for a behavioral health agency licensed as a level 1 RTC or a Level I sub-acute agency according to A.A.C. R9-20-102 does not include:
A.  Holding a client for no longer than five minutes,
B.  Without undue force, in order to calm or comfort the
client; or
C.  Holding a client’s hand to escort the client from one
area to another as defined in A.A.C. R9-21-101(50).
Restraint / Means personal restraint, mechanical restraint or drug used as a restraint and is the following in accordance with 42 CFR 482.13(e)(1):
1.  Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a behavioral health recipient to move his or her arms, legs, body, or head freely; or
2.  A drug or medication when it is used as a restriction to manage the behavioral health recipient’s behavior or restrict the behavioral health recipient’s freedom of movement and is not a standard treatment or dosage for the behavioral health recipient’s condition.
3.  A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a behavioral health recipient for the purpose of conducting routine physical examinations or tests, or to protect the behavioral health recipient from falling out of bed, or to permit the behavioral health recipient to participate in activities without the risk of physical harm (this does not include a physical escort).
Seclusion / The involuntary confinement of a behavioral health recipient in a room or an area from which the person cannot leave.[5]
Seclusion of Individuals Determined to have a Serious Mental Illness / The restriction of a behavioral health recipient to a room or area through the use of locked doors or any other device or method which precludes a person from freely exiting the room or area or which a person reasonably believes precludes his/her unrestricted exit. In the case of an inpatient facility, confining a behavioral health recipient to the facility, the grounds of the facility, or a ward of the facility does not constitute seclusion. In the case of a community residence, restricting a behavioral health recipient to the residential site, according to specific provisions of an individual service plan or court order, does not constitute seclusion.
Seclusion- Level I Programs / The involuntary confinement of a person in a room or an area where the person is physically prevented from leaving. (42 CFR 482.13(1)(ii))
Seclusion, Sub-Acute Agency / The involuntary confinement of a behavioral health recipient in a room or an area from which the behavioral health recipient cannot leave, but does not include the confinement of a behavioral health recipient in a correctional facility. (A.A.C. R9-21-101)

III.

IV. Reporting to Human Rights Committee[6]

V.  Local, State and Federal Regulations and Requirements Related to Seclusion and Restraint

The use of seclusion and restraint shall only be used to the extent permitted by and in compliance with A.A.C. R9-21-204. If restraint or seclusion is used this shall be reported as described in this Policy to AHCCCS and the appropriate Human Rights Committee (HRC) via collaboration with the AHCCCS, DHCAA-HRC Coordinator.

AHCCCS, Office of Human Rights (OHR) and the HRCs review such reports to determine if there has been any inappropriate or unlawful use of restraint or seclusion and to determine if restraint or seclusion may be used in a more effective or appropriate fashion.[7]

If any Human Rights CommitteeHRC or OHR determines that restraint or seclusion has been used in violation of any applicable law or rule, the HRC or OfficeOHR may take whatever action is appropriate, including investigating the matter[8] itself or referring the matter to the AHCCCS Administration for remedial action. [9]

VI. Reporting Requirements

A.  Contractors and TRBHAs and Behavioral Health providers providing services to TRBHA assigned members [10]shall ensure that:

1.  All ADHS or state-licensed Behavioral Health Inpatient Facilities and programs, including out-of-state facilities, authorized to use seclusion or restraint[11] shall submit individual reports of incidents of seclusion and restraint with members designated as SMI within five days of the occurrence to the Contractors or to the DHCAA- HRC Coordinator for members assigned to the TRBHAor TRBHAs utilizing AMPM Exhibit 962-1.

2.  In the event that the use of seclusion or restraint requires face-to-face monitoring, as outlined in A.A.C. R9-21-204, a report shall be submitted to the Contractor or DHCAA-HRC Coordinator for TRBHA assigned membersor TRBHA.

3.  All ADHS or state-licensed Behavioral Health Inpatient Facilities and programs, including out-of-state facilities, authorized to use seclusion or restraint report the total number of occurrences of the use of seclusion and restraint with members designated as SMI in the prior month to the Contractors or to the DHCAA- HRC Coordinator for members assigned to the TRBHA or TRBHAs by the fifth calendar day of the month. If there were no occurrences of seclusion or restraint during the reporting period, the report should so indicate.

B.  Contractors, TRBHAs, and the AZSH shall distribute individual and summary reports, of the use of seclusion and restraint to the AHCCCS DHCAA-OHR as follows:

1.  Forward individual reports, utilizing AMPM Exhibit 962-1, concerning the use of seclusion and restraint with members designated as SMI - to the OHR on the 15th of each month. In accordance with A.R.S. § 36-509, the Contractor, TRBHA, and AZSH shouldshall redact any information on substance use or HIV/AIDS/communicable disease(s) from the reports.

2.  Submit monthly summary reports, utilizing AMPM Exhibit 962-2, and individual reports utilizing AMPM Exhibit 962-1 concerning of seclusion and restraint information involving members designated as SMI - on the 15th of each monthand childreto OHR.[12]

C.  Contractors, TRBHAs and the AZSH shall distribute individual and summary reports of the use of seclusion and restraint to the AHCCCS DHCAA-HRC Coordinator as follows:

1.  Forward individual reports utilizing, AMPM Exhibit 962-1, concerning the use of of the use of seclusion and restraint withf members designated as SMI - or all members to the AHCCCS HRCon a monthly basis on the 15th of each month.

2.  Submit monthly summary reports, utilizing AMPM Exhibit 962-2, ofconcerning seclusion and restraint information involving members designated as SMI - for all members to the AHCCCS HRCon a monthly basis on the 15th of each month.

3.  The Contractor, TRBHA, or AZSH shall ensure that the disclosure of protected health information is in accordance with state and federal laws.

4.  Monthly reports must be redacted of all personally identifiable information prior to submitting to the HRC in accordance with state and federal lawsA.R.S. §36-509 and 45 CFR 164.514.

D.  General Requirements[13] [14]Behavioral Health Providers providing services to TRBHA members will be required to send all submissions directly to the Office of Human Rights (OHR) via as follows:

1.  Forward individual reports, utilizing AMPM Exhibit 962-1, concerning the use of seclusion and restraint with members designated as SMI within five days of occurrence to OHR via .

2.  In accordance with A.R.S. §36-509, the provider shall redact information on substance use or HIV/AIDS/communicable disease(s) from the reports.

1. 

RBHA Contractors are required to provide to HRC’s member information and records as outlined in A.R.S. §41-3804. The following items shall be routinely provided to the HRC without the designation of personally identifiable information:

Seclusion and Restraint reports,

a.  Incident/Accident/Death (IAD) reports, and/or

b.  Quality Of Care (QOC) investigations as applicable.

Upon review of supplied information the HRC may request documentation, supplemental information, or an investigation regarding alleged violation of rights.

The Contractor shall provide Seclusion/Restraint Reports, and Incident/Accident/Death Reports concerning issues including, but not limited to, reports of possible abuse, neglect or denial of rights to HRC’s as specified in Contract, Exhibit-9, Deliverables. All Seclusion/Restraint Reports and Incident/Accident/Death reports shall have all information removed that personally identifies members, in accordance with federal and state confidentiality laws.[15]

If a QOC investigation has already been conducted by the Contractor and can be disclosed without violating any confidentiality provisions, the Contractor shall provide the requested documentation to the HRC via the Secured Quality Management System Portal.

2.  Requests for PHI of a Currently Enrolled Member

a.  When a HRC requests PHI concerning a currently or previously enrolled member, the HRC must first demonstrate that the information is necessary to perform a function that is related to the oversight of the behavioral health system or it must have written authorization from the member to review PHI.

b.  In the event it is determined that the HRC needs PHI and has obtained the member’s or representative’s written authorization, the Contractor shall first review the requested information and determine if any of the following types of information are present: Communicable disease related information, including confidential HIV information, and/or information concerning diagnosis, treatment or referral from an alcohol or drug abuse program. If no such information is present, then the Contractor shall provide the information adhering to the requirements of this Policy.

c.  If communicable disease related information, including confidential HIV information, and/or information concerning diagnosis, treatment or referral from an alcohol or drug abuse program is found, then the Contractor shall:

i.  Contact the member or representative if an adult, or the custodial parent or legal guardian if a child, and ask if the member is willing to sign an authorization for the release of communicable disease related information, including confidential HIV information, and/or information concerning diagnosis, treatment or referral from an alcohol or drug abuse program. The Contractor shall provide the name and telephone number of a contact person with the HRC who can explain the Committee’s purpose for requesting the protected information. If the member agrees to give authorization, the Contractor shall obtain written authorization as required below and provide the requested information to the HRC. Authorization for the disclosure of records of deceased member may be made by the executor, administrator or other personal representative appointed by will or by a court to manage the deceased member’s estate. If no personal representative has been appointed, PHI may be disclosed to a family member, other relative, or a close personal friend of the deceased member, or any other person identified by the deceased only that PHI directly relevant to such person’s involvement with the deceased members health care or payment related to the individual’s health care.

ii.  If the member does not authorize the release of the communicable disease related information, including confidential HIV information, and/or information concerning diagnosis, treatment or referral from an alcohol or drug abuse program, this information shall not be included or shall be redacted from any PHI which is authorized to be disclosed.

iii.  Requested information that does not require the member or representative’s authorization shall be provided within 15 working days of the request. If the authorization is required, requested information shall be provided within five working days of receipt of the written authorization.

d.  When PHI is sent, the Contractor shall include a cover letter addressed to the HRC that states that the information is confidential, is for the official purposes of the committee, and is not to be re-released under any circumstances.

e.  In the event that AHCCCS denies the HRC’s request for PHI:

i.  AHCCCS must notify the HRC within five working days that the request is denied, the specific reason for the denial, and that the Committee may request, in writing, that the AHCCCS Director, or designee, review this decision. The Committee’s request to review the denial must be received by the AHCCCS Director, or designee, within 60 days of the first scheduled committee meeting after the denial decision is issued.

ii.  The AHCCCS Director, or designee, shall conduct the review within five business days after receiving the request for review.

iii.  The AHCCCS Director’s or designee’s decision shall be the final agency decision and is subject to judicial review pursuant to A.R.S. Title 12, Chapter 7, Article 6.

iv.  No information or records shall be released during the timeframe for filing a request for judicial review or when judicial review is pending.