Seclusion & Restraints: NAMI’s Advocacy Goals and Strategies
What federal protections exist regarding restraints and seclusions?
In October 2000, President Clinton signed the Children’s Health Act of 2000, P.L. 106-310. This significant new law established national standards that restrict the use of restraint and seclusion in all psychiatric facilities that receive federal funds and in "non-medical community-based facilities for children and youth."
What are NAMI’s advocacy efforts regarding restraints and seclusions?
- NAMI strongly supports full implementation of the restraint and seclusion provisions included in P.L 310-106;
- NAMI will monitor the progress of the Department of Health and Human Services in issuing national guidelines and regulations specifying adequate number of staff in facilities and appropriate training in the use of R/S and their alternatives;
- NAMI will also advocate for a national standard in schools, wilderness camps, jails, and prisons.
In addition, NAMI will be following the implementation of key provisions under the general requirements, which include:
- Restraints and involuntary seclusion (R/S) may only be imposed to ensure the physical safety of a patient. They cannot be used as punishment or for staff convenience.
- R/S may be imposed only under the written order of a physician or other licensed practitioner permitted to issue such orders under state law. Orders must specify the duration of and circumstances for the R/S.
- Although no timeframe is specified for conducting face-to-face evaluations of patients who have been or will be restrained or placed in seclusion, the legislation declares that the lack of a specified timeframe should not be interpreted as offsetting or impeding any federal or state regulations that provide greater protections for patients. This declaration then affirms hospital rules promulgated last year by the Health Care Financing Administration (HCFA) including the "one hour rule" that requires face to-face evaluations by licensed professional practitioners within one hour of initiating R/S.
- Facilities must report every death that occurs within 24 hours after a patient has been removed from R/S or where it is reasonable to assume that a death is the result of R/S. Reports must be made to agencies determined appropriate by the Department of Health & Human Services (HHS), which most likely will include state protection and advocacy agencies.
Within 12 months, HHS also must issue regulations specifying adequate numbers of staff for facilities and appropriate training for the use of R/S and its alternatives.
For children's non-medical community programs:
- R/S may be used with children in community programs only in emergencies and to ensure immediate physical safety for the child or others. Mechanical restraints are prohibited. Seclusion is allowed only when a staff member continuously monitors a child face-to-face. Time-outs, however, are not considered seclusion, and physical escorts are not considered physical restraints.
- Only individuals trained and certified by a state-recognized body may impose R/S. Until a state certification process is in place, R/S can be used only when a supervisory or senior staff person with skills and competencies specifically listed in the legislation conducts a face-to-face assessment of the child within an hour after R/S is imposed. The use of R/S must then be monitored by the supervisory or senior staff person.
- Required skills and competencies include an understanding of the needs and behaviors of the populations served, relationship-building, avoiding power struggles, de-escalation methods, alternatives to R/S, time limits, monitoring signs of physical distress, position asphyxia, obtaining medical assistance, and familiarity with relevant legal issues.
- Within six months, states (which license such facilities) must develop licensing and monitoring rules and HHS will begin to develop national staffing standards and guidelines.
NOTE: These R/S standards apply only to psychiatric treatment facilities that receive federal funding. They do not affect use of restraint and seclusion in schools, wilderness camps, jails, or prisons. P.L. 106-310 also does not impede any federal or state laws or regulations that provide greater protections than written in the Children’s Health Act of 2000. Thus, rules issued by the Health Care Financing Administration in 1999 that included a requirement for face-to-face evaluations by mental health professionals within one hour of initiating restraint are affirmed.