WHO IS ACCREDITED?

Private Organization Accreditation

CSS Healthcare Services provides Community based health services to the young, the elderly and to Individuals with Developmental Disability. Founded in 1997, we have the ability to offer a variety of quality community-based services to our clients, which has greatly contributed to our growth and success.
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ORGANIZATION TESTIMONIAL

Orange County Government, Youth & Family Services Division

Rodney J. Hrobar Sr., LMHC, CPP, Quality Assurance Manager

As the lead agency in Orange County, providing the safety net for children and families, it is reassuring that our clients can be confident that their needs will be addressed in accordance with the most stringent standards of public, as well as private, accountability as monitored and reviewed by the Council on Accreditation. 
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Purpose

The organization’s behaviour support and management policies and practices promote positive behaviour and protect the safety of service recipients and staff.

FOC
CA-BSM 5: Restrictive Behavior Management Interventions

Restrictive behaviour management interventions are used in a manner that protects the safety and well-being of service recipients and program personnel in crisis situations when less-restrictive measures have proven ineffective.

Update:

  • Added Evidence - 05/07/18

Interpretation: The standard prohibits the use of seclusion, and manual or mechanical restraint for the purposes of routine discipline, compliance, or convenience.

As referenced in CA-BSM 1.01, organizations serving youth involved with the youth justice system should familiarise themselves with any federal and provincial laws and regulations addressing the behaviour management interventions they are permitted to employ.

NA The organization prohibits the use of restrictive behaviour management interventions.

Rating Indicators
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-BSM 5 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-BSM 5 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-BSM 5 Practice standard; and/or
  • One of the CA-BSM 5 Fundamental Practice Standards received a 3 or 4 rating.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-BSM 5 Practice standards; and/or
  • Two or more of the CA-BSM 5 Fundamental Practice Standards received a 3 or 4 rating.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Authorization and reauthorization procedures including qualifications of authorized personnel
    • Procedures for continuous monitoring during a restrictive intervention
    • Incident reports
    • Behaviour management logs
    • Documentation of compliance with legal requirements
    • Documentation of continuous monitoring during a restrictive intervention
    • Interview:
      1. Authorizing personnel
      2. Direct service personnel
      3. Supervisory personnel
      4. Persons served
    • Seclusion room observation

  • CA-BSM 5.01

    Qualified personnel authorize each restrictive behaviour management intervention, in accordance with any applicable federal or provincial requirements.

    Update:

    • Revised Interpretation - 05/07/18

    Interpretation: Personnel are qualified through annual training and evaluation. 

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • Authorization procedures need clarifying.
    3
    Practice requires significant improvement; e.g.,
    • There have been instances of restrictive intervention without authorization by qualified personnel but corrective action is occurring; or
    • Documentation is weak.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • There have been instances of restrictive intervention without authorization by qualified personnel and corrective action has not been initiated; or
    • Practices are in violation of applicable legal requirements; or
    • Written procedures do not address use of qualified personnel.

  • FP
    CA-BSM 5.02

    Service recipients are monitored continuously, face-to-face, and assessed at least every 15 minutes for any harmful health or psychological reactions.

    Update:

    • Added Note - 05/07/18

    Note: Refer to BSM 5.06 for the maximum time allowed for a restrictive intervention.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • In a few rare instances there was a lapse in monitoring or assessment but corrective action was taken immediately.
    3
    Practice requires significant improvement; e.g.,
    • In more than a few instances there was a lapse in monitoring or assessment but corrective action was taken immediately; or
    • Documentation is weak; or
    • Procedures need significant strengthening.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.
    • Lapses occur with some frequency and corrective action is not taken; or
    • There are no procedures; or
    • Procedures are not routinely followed.

  • FP
    CA-BSM 5.03

    Procedures address safe methods for involuntarily escorting individuals.

    Update:

    • Revised Standard - 05/07/18

    Interpretation: This includes methods such as the backwards escort.

    NA The organization does not escort individuals or use seclusion.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • Procedures need clarifying.
    3
    Practice requires significant improvement; e.g.,
    • Procedures are inadequate; or
    • There have been instances where procedures were not followed; or
    • Documentation is weak.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • There are no procedures; or
    • Procedures are not routinely followed.

  • FP
    CA-BSM 5.04

    Seclusion rooms conform to existing licensing and/or fire safety requirements and are limited to one person at a time.

    Update:

    • Revised Standard - 05/07/18

    Interpretation: Seclusion rooms need to be outfitted with a door that easily opens in case of emergency, such as a spring lock door.

    Note: Please see Facility Observation Checklist - Private, Public, Canadian for additional assistance with this standard.

    NA The organization does not use locked seclusion.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • The organization does not have evidence of conformance to licensing and/or fire safety requirements for one of its isolation or seclusion rooms, but has initiated a process to obtain it.
    3
    Practice requires significant improvement; e.g.,
    • The organization does not have evidence of conformance with licensing and/or fire safety requirements for one or more of its isolation or seclusion rooms and has not initiated a process to obtain it; or
    • There have been instances where a seclusion or isolation room has been used for more than one person.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • FP
    CA-BSM 5.05

    During a restrictive behaviour management intervention staff assess the service recipient’s need for food, water, and use of bathroom facilities and provide access when safe and appropriate.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • Procedures need clarifying.
    3
    Practice requires significant improvement; e.g.,
    • Procedures are inadequate; or
    • There have been instances where procedures were not followed, but corrective action has been initiated; or
    • Documentation needs significant strengthening.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • There are no procedures; or
    • Procedures are not routinely followed.

  • FP
    CA-BSM 5.06

    Restrictive behaviour management interventions are used only in crisis situations when less-restrictive measures have proven ineffective, are discontinued as soon as possible, and are limited to the following maximum time periods per episode:

    1. 15 minutes for children aged nine and younger, for all restrictive behaviour management interventions;
    2. 30 minutes for individuals aged ten and older, undergoing manual or mechanical restraint;
    3. 30 minutes for individuals aged ten to thirteen in seclusion; and
    4. one hour for individuals aged fourteen and older in seclusion.

    Update:

    • Added Interpretation - 05/07/18

    Interpretation: If local or provincial law is more stringent in the maximimum time periods per episode, then the organization must follow the time frames set by the local or provincial law.

    Interpretation: Restrictive behaviour management interventions are discontinued immediately if they produce adverse side effects such as illness, severe emotional or physical stress, or physical injury. Timeframes may be extended on a case-by-case basis, but qualified staff with the authority to make such decisions must approve all extensions, as referenced in CA-BSM 5.07.

    Interpretation: As referenced in CA-BSM 1.02, organizations serving youth involved with the youth justice system may also be authorized to use restrictive interventions to prevent escapes or protect property, but should only do so when absolutely necessary, as referenced throughout these standards.

    Further, although organizations serving youth involved with the youth justice system may be authorized to use time limits that exceed those listed in the standard, COA expects these organizations to meet the timeframes outlined in the standard whenever possible. When it is necessary to extend timeframes in order to maintain safety, security, and order (for example, when youth must be transported in mechanical restraints in order to prevent escape, and travel time is greater than 30 minutes), qualified staff must approve the extension, and the intervention should be discontinued as soon as possible.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • Procedures need clarifying.
    3
    Practice requires significant improvement; e.g.,
    • Procedures are inadequate; or
    • There have been instances where procedures were not followed, but corrective action has been initiated; or
    • Documentation needs significant strengthening.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • There are no procedures; or
    • Procedures are not routinely followed.

  • FP
    CA-BSM 5.07

    Re-authorization by qualified personnel is required for each instance of isolation, locked seclusion, manual restraint, or mechanical restraint that exceeds the maximum time limit.

    Update:

    • Revised Standard - 05/07/18

    Interpretation: Individuals are qualified to reauthorize a restrictive intervention through training and evaluation and in accordance with any applicable legal, regulatory, or contractual requirements.

    Re-authorization will be provided by a trained, qualified person who is not directly involved in the initial decision making process. In Youth Custody Services (CA-YC), this person is legally delegated this responsibility and is normally in a position senior to the local supervisor involved in the initial decision.

    Note: See maximum time limits outlined in CA-BSM 5.06.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • Procedures need clarifying.
    3
    Practice requires significant improvement; e.g.,
    • Procedures are inadequate; or
    • There have been instances where procedures were not followed, but corrective action has been initiated; or
    • Documentation needs significant strengthening.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • There are no procedures; or
    • Procedures are not routinely followed.

  • CA-BSM 5.08

    The organization has procedures to address the safe removal of individuals in seclusion or mechanical restraint in the event of an emergency evacuation.

    Update:

    • Added Standard - 05/07/18
    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g.,  
    • Procedures need clarifying.
    3
    Practice requires significant improvement; e.g., 
    • Procedures are inadequate; or
    • There have been instances where procedures were not followed, but corrective action has been initiated; or
    • Documentation needs significant strengthening.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g., 
    • There are no procedures; or
    • Procedures are not routinely followed.
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