DHS 40.07(4)(b)3.3. Building relationships between youth and staff members that promote trust and safety. DHS 40.07(4)(b)4.4. Empowering youth to take responsibility for their behavior and regulating their emotions. DHS 40.07(4)(b)5.5. Sensory interventions within the treatment milieu to enhance functioning and assist with behavioral challenges. DHS 40.07(5)(5) Voluntary time out. Support services shall be provided to a youth prior to using a voluntary time out. Voluntary time out should be used as a least restrictive measure, prior to involuntary seclusion or physical restraint, unless there is imminent danger due to a youth’s aggression to self or others. Voluntary time out shall be encouraged for the shortest time possible and only for the length of time necessary for the youth to de-escalate or regulate his or her emotions. Programs shall encourage voluntary time out for youth who show signs of agitation or anxiety. DHS 40.07 HistoryHistory: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20; correction in (1) (g) made under s. 35.17, Stats., Register June 2020 No. 774; CR 23-053: cr. (1) (fm) Register September 2023 No. 813, eff. 10-1-23; CR 23-046: am. (2) (a) 2. Register April 2024 No. 820, eff. 5-1-24. DHS 40.08DHS 40.08 Emergency safety interventions. DHS 40.08(1)(1) Prohibited interventions. Mechanical restraints, with the exception of procedures in sub. (5) (e) and chemical restraints are prohibited. DHS 40.08(2)(2) General requirements for seclusion and physical restraint. Seclusion and physical restraint shall comply with the requirements under s. 51.61 (1) (i), Stats., s. DHS 94.10, and this chapter. DHS 40.08(3)(3) Staff requirements. Seclusion and physical restraint shall only be administered by program staff members who have completed orientation described in s. DHS 40.10 (6) (b). DHS 40.08(4)(4) Administration requirements. Seclusion and physical restraint may only be administered when all of the following requirements are met in addition to the requirements under s. 51.61 (1) (i), Stats., and s. DHS 94.10: DHS 40.08(4)(a)(a) When all other less restrictive methods have been exhausted. DHS 40.08(4)(b)(b) For the shortest time possible and only until the youth is no longer a danger to self or others. DHS 40.08(4)(c)(c) In a manner that is attentive to, and respectful of the trauma history, dignity, and civil rights of the youth. DHS 40.08(4)(d)(d) To avoid or cause the least possible physical or emotional discomfort, harm, and pain to the youth. DHS 40.08(4)(e)(e) Allowing adequate access to bathroom facilities, drinking water, and necessary medication. DHS 40.08(5)(a)(a) Program staff members shall provide uninterrupted supervision and monitoring of the youth and entire seclusion area during seclusion by being in the room with the youth or by observation through a window into the room. DHS 40.08(5)(b)(b) A program shall maintain an incident log to document the use of seclusion. The log shall include the time when the seclusion began, the youth’s behaviors and staff member’s response to those behaviors every 5 minutes, and the time seclusion ended. DHS 40.08(5)(c)(c) Seclusion rooms shall be free of objects or fixtures with which the youth could inflict bodily harm. DHS 40.08(5)(e)(e) A youth may only be kept in the seclusion area by means of one of the following: DHS 40.08(5)(e)1.1. A staff member is in a position, such as in a doorway, to prevent a youth from leaving the seclusion area. DHS 40.08(5)(e)3.3. A door to a seclusion room is latched by positive pressure applied by a staff member’s hand without which the latch would spring back allowing the door to open on its own accord, except that a hospital-based program may use a magnetic door lock or a lock which requires the turn of a knob to unlock a door. Other designs of door locks shall not be used, including padlock, key lock, or other locks of similar design. DHS 40.08(6)(6) Specific requirements for physical restraint. DHS 40.08(6)(a)(a) Physical restraint shall only be administered to a youth during an emergency, when there is a serious threat of violence to other youth or a staff member, personal injury, or attempted suicide. DHS 40.08(6)(b)(b) At a minimum, two staff members trained in the use of emergency safety interventions shall be physically present during the administration of physical restraint, and shall continually monitor the condition of the youth and the safe use of physical restraint throughout the duration of the intervention. DHS 40.08(6)(c)(c) Methods of physical restraint that are likely to cause bodily harm are prohibited, such as: DHS 40.08(6)(c)1.1. Pressure or weight on the chest, lungs, sternum, diaphragm, back, or abdomen, such as straddling or sitting on the torso. DHS 40.08(6)(c)2.2. Pressure, weight, or leverage on the neck or throat, on any artery, or on the back of the head or neck, or that otherwise obstructs or restricts the circulation of blood or obstructs an airway, such as choke holds or sleeper holds. DHS 40.08(6)(c)4.4. Covering the face with any object, such as a pillow, towel, washcloth, blanket, or other fabric. DHS 40.08(6)(c)10.10. Restraint in a vertical position, with upper body pressed against a wall or hard surface. DHS 40.08(6)(c)11.11. Any other physical restraint that is not administered during an emergency, that is administered for longer than necessary to prevent immediate injury to a youth or others, or that is administered for a purpose other than to prevent immediate injury to a youth or others. DHS 40.08(6)(d)(d) Immediately upon the termination of a physical restraint, a medical staff member, such as a physician, advanced practice nurse prescriber, physician assistant, advanced practice nurse, or registered nurse, shall conduct a follow-up assessment of the condition of the youth to ensure that the youth was not injured and shall document the finding of the assessment in the youth’s file. If a staff member who is a doctor or nurse is not present on site, a licensed treatment professional shall conduct the face-to-face assessment immediately upon termination of the physical restraint and notify a medical staff member. DHS 40.08(6)(e)(e) If any injury is noted following a physical restraint, a staff member shall notify the youth’s legal representative, if any, and make a referral for medical care. DHS 40.08(7)(a)(a) Following a seclusion or restraint, a staff member shall talk with the youth about each of the following: DHS 40.08(7)(a)1.1. The circumstances that contributed to the seclusion or physical restraint and what could have been handled differently by the staff member. DHS 40.08(7)(a)2.2. The youth’s psychological well-being and the emotional impact of the intervention. DHS 40.08(7)(a)3.3. What modifications can be made in the youth’s services or treatment plan to prevent future seclusion and physical restraint. DHS 40.08(7)(b)(b) The debriefing should occur within 24 hours following a seclusion and restraint, with the following exceptions: DHS 40.08(7)(b)2.2. When the 24 hour period falls during non-programming time such as on a weekend or holiday, then debriefing shall occur on the next programming day. DHS 40.08(7)(b)3.3. When a youth is suspended or discharged from programming following the incident and debriefing is contraindicated due to a serious risk of harm by the youth to others or to staff. DHS 40.08(7)(c)(c) A program shall notify a youth’s legal representative, if any, of any seclusion or physical restraint on the same day that it was administered to the youth. The program shall document in the youth’s file any situation in which notification has been attempted and the program has been unable to contact the legal representative. DHS 40.08(7)(d)(d) Each administration of seclusion or physical restraint shall be documented in the youth’s chart and shall specify all of the following: DHS 40.08(7)(d)1.1. Less restrictive interventions attempted prior to the seclusion or physical restraint. DHS 40.08(7)(d)4.4. Assessment of the appropriateness of the seclusion or physical restraint based on threat of harm to self or others. DHS 40.08(7)(d)5.5. Assessment of any physical injury to the youth, other clients, or to staff members. DHS 40.08(7)(e)(e) A licensed treatment professional shall review all seclusion and physical restraint documentation prior to the end of the shift in which the intervention occurred and determine whether changes to the youth’s safety plan or treatment plan are necessary. DHS 40.08(7)(f)(f) If seclusion or physical restraint is administered to a youth more than three times over a period of five days, or in a single instance for more than 30 minutes within 24 hours, the clinical coordinator, or designee, shall do all of the following: DHS 40.08(7)(f)1.1. Convene staff to discuss the emergency situation that required seclusion or physical restraint, including the precipitating factors that led up to the intervention and any alternative strategies that might have prevented the use of seclusion or physical restraint in those situations. DHS 40.08(7)(f)2.2. Convene staff to discuss the procedures, if any, to be implemented to prevent further administration of seclusion or physical restraint. DHS 40.08(7)(f)3.3. Convene staff to discuss the outcome of the seclusion or physical restraint including any injuries. DHS 40.08(7)(f)4.4. Convene the youth’s interdisciplinary treatment team to review the individualized treatment plan and make any necessary revisions to reduce the need for and likelihood of further use of seclusion or physical restraint, and document the discussion and any resulting changes to the plan in the youth’s chart. DHS 40.08(7)(f)5.5. Determine whether a higher level of care is required for the youth and if a referral for inpatient or residential placement is necessary. DHS 40.08(8)(a)(a) Programs shall report all incidences of seclusion, physical restraint, injury, and involvement of law enforcement to the department within 24 hours of the incident occurring. Reporting shall be completed through the department’s online reporting system. DHS 40.08(8)(b)(b) The department will evaluate the circumstances of each incident, conduct any appropriate follow-up, and identify programs in need of technical assistance, training, policy development, or other quality improvement. DHS 40.08 HistoryHistory: CR 19-018: cr. Register June 2020 No. 774, eff. 7-1-20; correction in (4) (intro.), (5) (e) 3., (6) (d), (7) (e) made under s. 35.17, Stats., Register June 2020 No. 774; CR 23-053: am. (7) (a) (intro.) Register September 2023 No. 813, eff. 10-1-23. DHS 40.09(1)(a)(a) Each staff member shall have the professional certification, training, experience, and ability to carry out his or her assigned duties. DHS 40.09(1)(b)(b) Each staff member shall pass a criminal history and patient abuse record search as provided in s. 50.065, Stats., and a caregiver background check under ch. DHS 12, before working for the program. DHS 40.09(1)(c)(c) Programs shall comply with caregiver misconduct reporting and investigation requirements in ch. DHS 13. DHS 40.09 NoteNote: For a state of Wisconsin background check, information on the process and fees can be found on-line at: http://www.doj.state.wi.us/dles/cib/Fees.asp, or contact the Crime Information Bureau, Wisconsin Department of Justice, P.O. Box 2718, Madison, WI 53701-2718. DHS 40.09(2)(2) Qualifications of program director. The program director shall meet all of the following requirements: DHS 40.09(2)(b)(b) Have at least one year of experience in a mental health setting working with youth. DHS 40.09(2)(c)(c) Have at least 2 years of experience as an administrator of a program that provides mental health services to youth and families. DHS 40.09(3)(a)(a) The clinical coordinator shall meet all of the following qualifications: DHS 40.09(3)(a)2.2. Have at least 1,500 hours of clinical experience in a practice with youth who have mental illness or severe emotional disturbance. DHS 40.09(3)(b)(b) A psychiatrist shall be a physician licensed to practice medicine and surgery and meet the requirements for certification in child psychiatry by the American board of psychiatry and neurology. If a program can demonstrate that no board-certified or eligible child psychiatrist is available, the program may employ a psychiatrist who has a minimum of 1 year of clinical experience working with youth. DHS 40.09(3)(c)(c) Advanced practice nurse prescribers shall be certified in mental health treatment by an appropriate board and shall have had either training in providing psychiatric services, including work with youth with mental illness or severe emotional disturbance, or one year of experience working in a clinical setting with youth. An advanced practice nurse prescriber shall issue only those prescription orders appropriate to the advanced practice nurse prescriber’s areas of competence, as established by his or her education, training, or experience. Advanced practice nurse prescribers shall facilitate collaboration with other health care professionals, at least one of whom shall be a physician. Advanced practice nurse prescribers shall have completed 3,000 hours of supervised clinical psychotherapy experience in order to also provide psychotherapy. DHS 40.09(3)(d)(d) Licensed mental health professionals shall have a minimum of one year of experience working in a clinical setting serving youth with mental illness or severe emotional disturbance. DHS 40.09(3)(e)(e) Physician assistants, advanced practice nurses, registered nurses, and occupational therapists shall have either training in providing services to youth with mental illness or severe emotional disturbance, or one year of experience working in a clinical setting with youth. DHS 40.09(3)(f)(f) Qualified treatment trainees shall have one year of a graduate level education program specific to serving youth with mental illness or severe emotional disturbance and shall provide psychotherapy to clients only under clinical supervision.
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