federal_laws on restraint & seclusion

8/7/2019 federal_laws on restraint & seclusion

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Restraint and Seclusion Overview of Federal Laws

and Policies (2003)Prepared by Gary Gross, Beth Mitchell, & Aaryce Hayes

Advocacy, Incorporated

7800 Shoal Creek Boulevard, Suite 171-E, Austin, TX 78757512-454-4816, [email protected]
mailto:[email protected]:[email protected]


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Resources/Background Information

Center for Medicare and Medicaid Services(formerly Health Care Financing Administration) sets standards for all health care providers

that receive Medicare and Medicaid

- Licensing and certification of providers isconducted primarily by state (regulatory)

agencies; also conduct investigations

- The web site for the CMS is www.cms.gov
http://www.cms.gov/http://www.cms.gov/http://www.cms.gov/http://www.cms.gov/http://www.cms.gov/http://www.cms.gov/


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HHS Office of Inspector General Report on State abuseand neglect laws which describes the importantcomponents of a State system for identification, tracking,investigation and resolution of abuse incidents.

- The report finds that up to 90 percent of persons withdisabilities reside in facilities, such as group homes, residentialschools, and supervised apartments, that do not receiveMedicare or Medicaid funding, and thus are not covered byCMS standards

- State systems and laws for protecting persons with disabilities

from abuse or neglect can vary significantly from State toState.- The report might be used as a guide to assess the adequacy of

your state laws on abuse and neglect, including R/S.- The report is available on line at:

www.hhs.gov/progorg/oas/reports/region1/10002502.htm
http://www.hhs.gov/progorg/oas/reports/region1/10002502.htmhttp://www.hhs.gov/progorg/oas/reports/region1/10002502.htmhttp://www.hhs.gov/progorg/oas/reports/region1/10002502.htmhttp://www.hhs.gov/progorg/oas/reports/region1/10002502.htmhttp://www.hhs.gov/progorg/oas/reports/region1/10002502.htmhttp://www.hhs.gov/progorg/oas/reports/region1/10002502.htmhttp://www.hhs.gov/progorg/oas/reports/region1/10002502.htmhttp://www.hhs.gov/progorg/oas/reports/region1/10002502.htmhttp://www.hhs.gov/progorg/oas/reports/region1/10002502.htmhttp://www.hhs.gov/progorg/oas/reports/region1/10002502.htmhttp://www.hhs.gov/progorg/oas/reports/region1/10002502.htm


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U.S. General Accounting Office (GAO) Report onRestraint and Seclusion The GAO's October 1, 1999report confirms that there is no adequate system of R/Sreporting at the state level, making it impossible todetermine the true level of deaths and injuries thatresult from R/S abuses, and preventing independentagency investigations.

- GAO called on HCFA to issue regulations which: (1) establish strictstandards on the use of R/S in all facilities and (2) requirereporting to P&As regarding all deaths and serious injuries amongthose with mental illness or mental retardation indicating whetherR/S was used for investigation by P&As.

- Report is available on line at: http://www.access.gpo.gov Thengo to search GAO archives ; then type the following phrase in thesearch box (report number) HEHS-99-176"


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Joint Commission on Accreditation of Health Care Organizations (JCAHO) surveys its accredited hospitals every 3years to ensure compliance with JCAHOstandards

- See www.jcaho.org
http://www.jcaho.org/http://www.jcaho.org/


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Federal Regulations regardingRestraint and Seclusion

CMS issued three sets of regulations prior to effectivedate of Childrens Health Act, which presumably will berevised to conform to CHA; one set of regulations wasissued after the CHA, and other new regulations,covering other health care providers, are in the works.

CMS has issued interpretative guidelines and questionsand answers on the application of the regulations. Theyare both available at www.hcfa.gov/quality/4b.htm .]
http://www.hcfa.gov/quality/4b.htmhttp://www.hcfa.gov/quality/4b.htmhttp://www.hcfa.gov/quality/4b.htmhttp://www.hcfa.gov/quality/4b.htmhttp://www.hcfa.gov/quality/4b.htmhttp://www.hcfa.gov/quality/4b.htmhttp://www.hcfa.gov/quality/4b.htmhttp://www.hcfa.gov/quality/4b.htmhttp://www.hcfa.gov/quality/4b.htmhttp://www.hcfa.gov/quality/4b.htm


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Regulations for Hospitals

42 CFR 482.13(f) (CoPs) Emergency use only In the context of behavioral management, the rule

specifies that R/S may only be used in emergency situations if needed toensure the patients safety and less restrictive interventions have beendetermined to be ineffective .

Can not use for discipline, staff convenience or as a substitute for activetreatment, and no PRNs.

Different standards for medical and surgical care - Consistent withthe approach used by JCAHO, the rule establishes different standards on theuse of R/S in the context of acute medical and surgical care (e.g., to ensurethat an IV or feeding tube will not be removed).

Time limitations Maximum duration of R/S orders are based on age:adults 4 hours; children and adolescents ages 9 to 17 2 hours; and

children under 9 1 hour.


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Regulations for Hospitals

42 CFR 482.13(f) (CoPs) Restraint and Seclusion includes:

1. Physical Restraint2. Mechanical Restraint3. Drug Used as a Restraint

4. Seclusion/Escort

No use permitted for discipline, staff convenience or as asubstitute for active treatment, and no PRNs.


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PHYSICAL RESTRAINT

(CoPs) Includes any manual method or

mechanical device, material or equipmentattached or adjacent to the patients bodythat he or she cannot easily remove thatrestricts the patients freedom of movement or normal access to ones body.


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RESTRAINT (CoPs) Definition clarified all sorts of practices may constitute aphysical restraint, the key consideration relating to howthe material or practice is being used For example,

tucking a patient's sheets in so tightly that he orshe cannot move is restraining him or her. In thatinstance, a sheet is a restraint.

Putting up side rails that inhibit the patient's abilityto get out of bed when he or she wants to constitutesa restraint.

Escorting the individual to an area


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DRUG USED AS A

RESTRAINT (CoPs)

Is a medication used to control behavior or torestrict freedom of movement and is not astandard treatment for the patients condition.

A doctor orders a PRN medication for his patient in a

detoxification program when he becomes violent. Themedication is not a restraint because PRN medicationis standard treatment to manage the violent behaviorof individuals going through drug or alcohol withdraw


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SECLUSION (CoPs)

Any involuntary confinement to a room or areawhere one is physically prevented from leavingor assisting a person to an area (Escorting).

It does not include confinement on a lockedunit or ward, but does include separating anindividual from others


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Regulations for Hospitals42 CFR 482.13(f) (CoPs)

Who may issue order R/S may be ordered by either a physicianor a licensed independent practitioner permitted by the State andhospital to order R/S without direct supervision.

This will vary by state

Assessments -- a physician or a licensed independent practitionermust see the patient and evaluate the need for the interventionwithin one hour after its initiation.

Training - ongoing education and training required of all staff withdirect patient contact; must cover safe and proper use of R/S andalternatives.


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Regulations for Hospitals42 CFR 482.13(f) (CoPs)

Reporting -- hospitals must report to CMS any death:

that occurs while a patient is in R/S, orwhere it is reasonable to assume that a death is a result of R/S.

Under these regulations a hospital is permitted to make asubjective determination about cause of death when it occursafter R/S is discontinued; compare with psychiatric treatmentfacility regulations -- reporting of all deaths provided.

CMS shares these reports with P&As. About 75 deaths have beenreported to date nationwide.


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General Provisions for Federally FundedHealth Care Facilities (CHA)

The Childrens Health Act of 2000 (Public106-310, Oct. 17, 2000) [Amends thePublic Health Service Act, 42 U.S.C.290aa, by adding sections 591-595]


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Coverage The Act covers all public and private health care facilities whichreceive support from any program supported with funds appropriated to anyFederal agency, including hospitals, nursing facilities, psychiatric facilities,and ICFs.

When R/S Can Be Used R/S may only be imposed by a facility toensure the physical safety of the resident or others and is not permittedfor discipline, staff convenience or as a substitute for active treatment.

Doesnt state anything about only in an emergency situation or PRN usePersonal Escort is not considered a restraint

Time-Out is not considered seclusionAllows medical immobilization, adaptive support and medical protective devices

Orders - R/S may only be imposed upon the written order of a physician orother licensed independent practitioner permitted by the state and the

facility to order such restraint or seclusion, that specifies the duration andcircumstances under which the restraints are to be used.


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Regulation s - HHS is required to issue regulations requiring facilities to:ensure adequate staffing levels, provide appropriate training for staff, andprovide complete and accurate reporting on restraint-related deaths.

Reporting - must, within seven days, "notify the appropriate agency,as determined by the Secretary [of HHS]," (which has not yet beendone) of each death that occurs at each such facility while a patient is:

restrained or in seclusion,occurring within 24 hours after the patient has been removed from restraints or

seclusion, orwhere it is reasonable to assume that a patients death is a result of suchseclusion or restraint.

Funding termination - A facility's failure to comply with any of the aboveprovisions may result in its ineligibility for participation in federallysupported programs.


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Special Provisions for Non-Medical Community-Based Facilities for Children (CHA)

Coverage - Special provisions apply only to public and private non-medical,community-based facilities for children and youth (as defined in regulationsto be issued by HHS) that receive support from programs funded under thePublic Health Service Act. Even if other Federal Laws apply to a a facility,this Act must still be followed.

Personal Restraint and Seclusion Only These interventions arepermitted only in emergency circumstances (which is undefined) and toensure the immediate physical safety of the resident or others.

Escort not considered a restraint

Time out not considered seclusionAllows medical immobilization, adaptive support and medical protective devices

Mechanical and Chemical Restraints are Prohibited.

Monitoring - Seclusion may only be used when a staff member iscontinuously face-to-face monitoring the resident.


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Certification of Staff - R/S may only be imposed by an individualtrained and certified by a state-recognized body defined inregulations to be issued by HHS and pursuant to a processdetermined appropriate by the state and approved by HHS in theprevention and use of physical restraint and seclusion and in

specified related skills.

Interim Procedures - Until the state develops a training andcertification process, R/S may only be imposed if the facility assuresthat a senior staff person, who is competent to conduct a face-to-

face assessment (as defined in regulations issued by HHS), assessesthe well-being of the child subject to R/S. That individual mustconduct the assessment within one hour after the initiation of R/Sand continue to monitor the intervention for its duration.


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Reporting - Within 24 hours, covered facilities are required to provide anotification to the appropriate State licensing or regulatory agency, asdetermined by HHS, regarding all deaths occurring at the facility, andregarding the use of seclusion and restraint (in accordance with regulationsto be issued by HHS).

Regulations - HHS is required to issue within six months regulations whichrequire states that license covered facilities to develop (within a one yearperiod) licensing rules and monitoring requirements concerning behavior management practice. The regulations also will establish standards on the

qualifications of staff involved in R/S and their training and certification, andon reporting of deaths.

Funding termination - States which fail to comply with the Acts requirements shall be ineligible for participation in programs funded underthe Public Health Service Act.


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Regulations for Psychiatric ResidentialTreatment Facilities for Persons under 21

(42 CFR Part 483)

Coverage facility other than a hospital that provides psychiatric servicesfor persons under the age of 21, in an inpatient setting.

Effective date and comment deadline - These interim final regulationswere issued in January 2001 and amended in May 2001; they becameeffective on May 22, 2001.

Restraint and seclusion - Same definitions as hospital regulations, buta personal restraint does not include briefly holding without undue force aresident in order to calm or comfort him or her, or holding a residents handto safely escort a resident from one area to another.

Emergency is defined unanticipated resident behavior that places theresident of others at serious threat of violence or injury if no interventionoccurs and that calls for an emergency safety intervention

No use permitted for discipline, staff convenience or as a substitute foractive treatment, and no PRNs.


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(42 CFR Part 483)Who can issue orders? Orders for R/S must be issued by a physician or other licensed practitioner permitted by the state and the facility to order R/S and trained in the use of emergency safety interventions.

The original rule authorized only a board certified psychiatrist or a physician licensed to practice medicine with specialized training and experience in the diagnosis and treatment of mental diseases.


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(42 CFR Part 483)Assessments - Within one hour of the R/S initiation, a face-to-facephysical and psychological assessment must be conducted by aphysician or other licensed practitioner trained in the use of emergency safety interventions and permitted by the state and the

facility to assess the physical and psychological well being of residents.The original rule had required that this assessment be conducted by aphysician or a clinically qualified registered nurse.

Duration of R/S - R/S use must be limited in duration based onthe age of patient (identical to the hospital rules), and must bedocumented in detail in the residents record.

Notification to residents - The facility must provide incomingresidents and/or parents/guardians with contact information for the

local P&A as part of a notification on the facilitys policy on R/S use.


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(42 CFR Part 483)Monitoring - Staff must be physically present to continuallymonitor residents in R/S.

Debriefing - Within 24 hours after the use of R/S, staff involved inthe intervention, supervisory staff, and the resident must engage ina debriefing to discuss the circumstances resulting in the use of R/Sand strategies to be used to prevent future R/S.

Training The facility must require staff to have ongoingeducation, training and demonstrated knowledge regarding eventsthat may trigger emergencies, alternatives to R/S, and safe use of R/S, including responding to signs of physical distress; staff mustdemonstrate their competencies on a semiannual basis.


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(42 CFR Part 483)Reporting

Facilities are required to report, unless prohibited by state law, directly to P&As(and to State Medicaid agencies) ANY:

resident death,serious injury to a resident (as defined in the regulations); orsuicide attempt of a resident.

Regardless of whether the incident related to R/S

Timing and Contents The reports must be made by the close of the next business day and

include the name of the resident; a description of the occurrence; and

the name, address and phone number of the facility.


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ICF/MR Regulations(42 CFR.483.420 and 483.450)

No use permitted for discipline, staff convenience or as a substitutefor active treatment, and no PRNs.One hour limit in time out room (but emergency seclusion is notpermitted) as part of approved time-out program; requires constant

direct visual observation by staff.Emergency use of restraints only is permitted; may not exceed 12hours; must be used as part of an individual program plan, inemergency or for specific medical reasons.Drugs may only be used to control behavior if approved by an

interdisciplinary team, as part of individual program plan and only if harmful effects of behavior outweigh the potential harmful effects of the drugs.Training requirements are not addressed.


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Nursing Home Regulations(42 CFR 483.13)

Right to be free of physical or chemical restraintsimposed for discipline or convenience, and involuntaryseclusion.No standards on when R/S can be used

No standards on training, length of use or procedures.

All alleged violations of rights involving abuse or neglectare reported to facility administrator and other officialsas required by state law. Facility must investigate andtake corrective action.


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Regulations for Hospitals42 CFR 482.13(F) (COPs)

In December of 2006, after 6 years of revision, the final rule was published onthe conditions of participation forhospitals.


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Links to Restraint Materials on the Web

Press Articles http://courant.ctnow.com/projects/restraint/ - TheHartford Courant articles that revitalized the battle toregulate the use of restraint. Includes valuable data basetracking deaths from the use of restraint across thenation.http://www.aradvocate.com/News119.html - Article onthe improper use of restraint in nursing homes inLouisiana.
http://courant.ctnow.com/projects/restraint/http://www.aradvocate.com/News119.htmlhttp://www.aradvocate.com/News119.htmlhttp://www.aradvocate.com/News119.htmlhttp://www.aradvocate.com/News119.htmlhttp://www.aradvocate.com/News119.htmlhttp://www.aradvocate.com/News119.htmlhttp://www.aradvocate.com/News119.htmlhttp://www.aradvocate.com/News119.htmlhttp://www.aradvocate.com/News119.htmlhttp://www.aradvocate.com/News119.htmlhttp://www.aradvocate.com/News119.htmlhttp://courant.ctnow.com/projects/restraint/http://courant.ctnow.com/projects/restraint/http://courant.ctnow.com/projects/restraint/http://courant.ctnow.com/projects/restraint/http://courant.ctnow.com/projects/restraint/http://courant.ctnow.com/projects/restraint/http://courant.ctnow.com/projects/restraint/


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Listservs, Interest Groups http://www.contac.org - West Virginia Mental Health Consumer Associationhas page with many links to restraint/seclusion items.http://www.angelfire.com/co/CharlyDMiller/panewz.html - Detailed info onthe dangers of positional asphyxia.

http://www.breggin.com/jcah.html - Principles enunciated by Dr. Peter R.Breggin, Center for the Study of Psychiatry and Psychology, for theelimination of the use of restraint.http://groups.yahoo.com/group/RESTRAINT_INFO - A list serve dedicatedto discussion of issues relating to the use of restraint.

http://users.1st.net/cibra/ - Children Injured by Restraint and Aversives.Organization of families concerned with harm to children from use of restraint and aversive.http://www.stopabuse.net - Website dedicated to exposing abuse inmental health hospitals.
http://www.contac.org/http://www.angelfire.com/co/CharlyDMiller/panewz.htmlhttp://www.breggin.com/jcah.htmlhttp://groups.yahoo.com/group/RESTRAINT_INFOhttp://users.1st.net/cibra/http://www.stopabuse.net/http://www.stopabuse.net/http://users.1st.net/cibra/http://groups.yahoo.com/group/RESTRAINT_INFOhttp://www.breggin.com/jcah.htmlhttp://www.breggin.com/jcah.htmlhttp://www.breggin.com/jcah.htmlhttp://www.breggin.com/jcah.htmlhttp://www.breggin.com/jcah.htmlhttp://www.breggin.com/jcah.htmlhttp://www.breggin.com/jcah.htmlhttp://www.breggin.com/jcah.htmlhttp://www.breggin.com/jcah.htmlhttp://www.angelfire.com/co/CharlyDMiller/panewz.htmlhttp://www.angelfire.com/co/CharlyDMiller/panewz.htmlhttp://www.angelfire.com/co/CharlyDMiller/panewz.htmlhttp://www.angelfire.com/co/CharlyDMiller/panewz.htmlhttp://www.angelfire.com/co/CharlyDMiller/panewz.htmlhttp://www.angelfire.com/co/CharlyDMiller/panewz.htmlhttp://www.angelfire.com/co/CharlyDMiller/panewz.htmlhttp://www.angelfire.com/co/CharlyDMiller/panewz.htmlhttp://www.angelfire.com/co/CharlyDMiller/panewz.htmlhttp://www.contac.org/http://www.contac.org/http://www.contac.org/http://www.contac.org/http://www.contac.org/http://www.contac.org/http://www.contac.org/


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Position Statements, Guidelines http://www.nami.org/update/unitedrestraint.html - NAMI position statement on theuse of restraint and seclusion.http://www.aap.org/policy/re9713.html - American Academy of Pediatrics positionstatement on the use of restraint on children.http://www.accreditinfo.com/howto/acutecare/restraintguidelines.cfm American

Hospital Association (AHA) and the National Association of Psychiatric Health Systemsguidelines on the use of restraint and seclusion.http://www.jcaho.org/lwapps/online/rstprcpl.html - JCAHO Restraint Use Taskforceprinciples.http://www.nasmhpd.org/posses1.htm - National Association of State Mental HealthProgram Directors on the use of restraint and seclusion.

http://www.aacap.org/publications/policy/Ps44.htm - American Academy of Child andAdolescent Psychiatry Policy Statement on the Prevention and Management of Aggressive Behavior in Psychiatric Institutions with Special Reference to Seclusionand Restraint. http://www.americangeriatrics.org/products/positionpapers/restrain.shtml - AmericanGeriatrics Society position statement of the use of restraint.
http://www.nami.org/update/unitedrestraint.htmlhttp://www.aap.org/policy/re9713.htmlhttp://www.accreditinfo.com/howto/acutecare/restraintguidelines.cfmhttp://www.jcaho.org/lwapps/online/rstprcpl.htmlhttp://www.nasmhpd.org/posses1.htmhttp://www.aacap.org/publications/policy/Ps44.htmhttp://www.americangeriatrics.org/products/positionpapers/restrain.shtmlhttp://www.americangeriatrics.org/products/positionpapers/restrain.shtmlhttp://www.americangeriatrics.org/products/positionpapers/restrain.shtmlhttp://www.americangeriatrics.org/products/positionpapers/restrain.shtmlhttp://www.americangeriatrics.org/products/positionpapers/restrain.shtmlhttp://www.americangeriatrics.org/products/positionpapers/restrain.shtmlhttp://www.americangeriatrics.org/products/positionpapers/restrain.shtmlhttp://www.americangeriatrics.org/products/positionpapers/restrain.shtmlhttp://www.americangeriatrics.org/products/positionpapers/restrain.shtmlhttp://www.americangeriatrics.org/products/positionpapers/restrain.shtmlhttp://www.aacap.org/publications/policy/Ps44.htmhttp://www.aacap.org/publications/policy/Ps44.htmhttp://www.aacap.org/publications/policy/Ps44.htmhttp://www.aacap.org/publications/policy/Ps44.htmhttp://www.aacap.org/publications/policy/Ps44.htmhttp://www.aacap.org/publications/policy/Ps44.htmhttp://www.aacap.org/publications/policy/Ps44.htmhttp://www.aacap.org/publications/policy/Ps44.htmhttp://www.aacap.org/publications/policy/Ps44.htmhttp://www.aacap.org/publications/policy/Ps44.htmhttp://www.nasmhpd.org/posses1.htmhttp://www.nasmhpd.org/posses1.htmhttp://www.nasmhpd.org/posses1.htmhttp://www.nasmhpd.org/posses1.htmhttp://www.nasmhpd.org/posses1.htmhttp://www.nasmhpd.org/posses1.htmhttp://www.nasmhpd.org/posses1.htmhttp://www.nasmhpd.org/posses1.htmhttp://www.nasmhpd.org/posses1.htmhttp://www.nasmhpd.org/posses1.htmhttp://www.jcaho.org/lwapps/online/rstprcpl.htmlhttp://www.jcaho.org/lwapps/online/rstprcpl.htmlhttp://www.jcaho.org/lwapps/online/rstprcpl.htmlhttp://www.jcaho.org/lwapps/online/rstprcpl.htmlhttp://www.jcaho.org/lwapps/online/rstprcpl.htmlhttp://www.jcaho.org/lwapps/online/rstprcpl.htmlhttp://www.jcaho.org/lwapps/online/rstprcpl.htmlhttp://www.jcaho.org/lwapps/online/rstprcpl.htmlhttp://www.jcaho.org/lwapps/online/rstprcpl.htmlhttp://www.accreditinfo.com/howto/acutecare/restraintguidelines.cfmhttp://www.accreditinfo.com/howto/acutecare/restraintguidelines.cfmhttp://www.accreditinfo.com/howto/acutecare/restraintguidelines.cfmhttp://www.accreditinfo.com/howto/acutecare/restraintguidelines.cfmhttp://www.accreditinfo.com/howto/acutecare/restraintguidelines.cfmhttp://www.accreditinfo.com/howto/acutecare/restraintguidelines.cfmhttp://www.accreditinfo.com/howto/acutecare/restraintguidelines.cfmhttp://www.accreditinfo.com/howto/acutecare/restraintguidelines.cfmhttp://www.accreditinfo.com/howto/acutecare/restraintguidelines.cfmhttp://www.aap.org/policy/re9713.htmlhttp://www.aap.org/policy/re9713.htmlhttp://www.aap.org/policy/re9713.htmlhttp://www.aap.org/policy/re9713.htmlhttp://www.aap.org/policy/re9713.htmlhttp://www.aap.org/policy/re9713.htmlhttp://www.aap.org/policy/re9713.htmlhttp://www.aap.org/policy/re9713.htmlhttp://www.aap.org/policy/re9713.htmlhttp://www.aap.org/policy/re9713.htmlhttp://www.nami.org/update/unitedrestraint.html


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Federal Regulationshttp://www.cms.hhs.gov/cop/2b.asp - CMS Interpretative Guidelinesfor Hospital Conditions of Participation for Patients' Rights.

State Statutes, Regulations, Policies http://www.doe.mass.edu/lawsregs/603cmr46.html - MassachusettsDepartment of Education regulations on the use of restraint inschools.http://www.taba.org/restraint.htm - Tennessee DMHRR policy onthe use of restraint.

http://www.cqc.state.ny.us/chap334.htm - New York statue on useof emergency restraint in psychiatric facilities.http://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htm Wisconsin licensing policy regarding the reporting of deaths.
http://www.cms.hhs.gov/cop/2b.asphttp://www.doe.mass.edu/lawsregs/603cmr46.htmlhttp://www.taba.org/restraint.htmhttp://www.cqc.state.ny.us/chap334.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.dhfs.state.wi.us/rl_DSL/Publications/00074a.htmhttp://www.cqc.state.ny.us/chap334.htmhttp://www.cqc.state.ny.us/chap334.htmhttp://www.cqc.state.ny.us/chap334.htmhttp://www.cqc.state.ny.us/chap334.htmhttp://www.cqc.state.ny.us/chap334.htmhttp://www.cqc.state.ny.us/chap334.htmhttp://www.cqc.state.ny.us/chap334.htmhttp://www.cqc.state.ny.us/chap334.htmhttp://www.cqc.state.ny.us/chap334.htmhttp://www.cqc.state.ny.us/chap334.htmhttp://www.cqc.state.ny.us/chap334.htmhttp://www.cqc.state.ny.us/chap334.htmhttp://www.cqc.state.ny.us/chap334.htmhttp://www.cqc.state.ny.us/chap334.htmhttp://www.taba.org/restraint.htmhttp://www.taba.org/restraint.htmhttp://www.taba.org/restraint.htmhttp://www.taba.org/restraint.htmhttp://www.taba.org/restraint.htmhttp://www.taba.org/restraint.htmhttp://www.taba.org/restraint.htmhttp://www.taba.org/restraint.htmhttp://www.taba.org/restraint.htmhttp://www.doe.mass.edu/lawsregs/603cmr46.htmlhttp://www.doe.mass.edu/lawsregs/603cmr46.htmlhttp://www.doe.mass.edu/lawsregs/603cmr46.htmlhttp://www.doe.mass.edu/lawsregs/603cmr46.htmlhttp://www.doe.mass.edu/lawsregs/603cmr46.htmlhttp://www.doe.mass.edu/lawsregs/603cmr46.htmlhttp://www.doe.mass.edu/lawsregs/603cmr46.htmlhttp://www.doe.mass.edu/lawsregs/603cmr46.htmlhttp://www.doe.mass.edu/lawsregs/603cmr46.htmlhttp://www.doe.mass.edu/lawsregs/603cmr46.htmlhttp://www.doe.mass.edu/lawsregs/603cmr46.htmlhttp://www.doe.mass.edu/lawsregs/603cmr46.htmlhttp://www.doe.mass.edu/lawsregs/603cmr46.htmlhttp://www.doe.mass.edu/lawsregs/603cmr46.htmlhttp://www.cms.hhs.gov/cop/2b.asphttp://www.cms.hhs.gov/cop/2b.asphttp://www.cms.hhs.gov/cop/2b.asphttp://www.cms.hhs.gov/cop/2b.asphttp://www.cms.hhs.gov/cop/2b.asphttp://www.cms.hhs.gov/cop/2b.asphttp://www.cms.hhs.gov/cop/2b.asphttp://www.cms.hhs.gov/cop/2b.asphttp://www.cms.hhs.gov/cop/2b.asphttp://www.cms.hhs.gov/cop/2b.asphttp://www.cms.hhs.gov/cop/2b.asphttp://www.cms.hhs.gov/cop/2b.asphttp://www.cms.hhs.gov/cop/2b.asp


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Restraint Policies of Schools and other Institutions http://www.acsu.buffalo.edu/~drstall/restrain.html - Example of arestraint policy from a nursing home.http://www.amarillo.isd.tenet.edu/speced/physrest.html - Restraint

policy of Amarillo Independent school District.http://204.98.1.2/isu/conduct_code/punish.html - Jefferson CountyColorado Policy on the use of restraint in schools.http://www.worcestershire.gov.uk/educontent/education_info/restraint.htm - Worcestershire County Council Policy on the Use of

Restraint in Schools.http://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htm - Australian state policy on the use of restraintsin schools .
http://www.acsu.buffalo.edu/~drstall/restrain.htmlhttp://www.amarillo.isd.tenet.edu/speced/physrest.htmlhttp://204.98.1.2/isu/conduct_code/punish.htmlhttp://www.worcestershire.gov.uk/educontent/education_info/restraint.htmhttp://www.worcestershire.gov.uk/educontent/education_info/restraint.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://education.qld.gov.au/corporate/doem/studeman/sm05000/sections/procedur.htmhttp://www.worcestershire.gov.uk/educontent/education_info/restraint.htmhttp://www.worcestershire.gov.uk/educontent/education_info/restraint.htmhttp://www.worcestershire.gov.uk/educontent/education_info/restraint.htmhttp://www.worcestershire.gov.uk/educontent/education_info/restraint.htmhttp://www.worcestershire.gov.uk/educontent/education_info/restraint.htmhttp://www.worcestershire.gov.uk/educontent/education_info/restraint.htmhttp://www.worcestershire.gov.uk/educontent/education_info/restraint.htmhttp://www.worcestershire.gov.uk/educontent/education_info/restraint.htmhttp://www.worcestershire.gov.uk/educontent/education_info/restraint.htmhttp://www.worcestershire.gov.uk/educontent/education_info/restraint.htmhttp://www.worcestershire.gov.uk/educontent/education_info/restraint.htmhttp://www.worcestershire.gov.uk/educontent/education_info/restraint.htmhttp://204.98.1.2/isu/conduct_code/punish.htmlhttp://204.98.1.2/isu/conduct_code/punish.htmlhttp://204.98.1.2/isu/conduct_code/punish.htmlhttp://204.98.1.2/isu/conduct_code/punish.htmlhttp://204.98.1.2/isu/conduct_code/punish.htmlhttp://204.98.1.2/isu/conduct_code/punish.htmlhttp://204.98.1.2/isu/conduct_code/punish.htmlhttp://204.98.1.2/isu/conduct_code/punish.htmlhttp://204.98.1.2/isu/conduct_code/punish.htmlhttp://204.98.1.2/isu/conduct_code/punish.htmlhttp://204.98.1.2/isu/conduct_code/punish.htmlhttp://204.98.1.2/isu/conduct_code/punish.htmlhttp://204.98.1.2/isu/conduct_code/punish.htmlhttp://www.amarillo.isd.tenet.edu/speced/physrest.htmlhttp://www.amarillo.isd.tenet.edu/speced/physrest.htmlhttp://www.amarillo.isd.tenet.edu/speced/physrest.htmlhttp://www.amarillo.isd.tenet.edu/speced/physrest.htmlhttp://www.amarillo.isd.tenet.edu/speced/physrest.htmlhttp://www.amarillo.isd.tenet.edu/speced/physrest.htmlhttp://www.amarillo.isd.tenet.edu/speced/physrest.htmlhttp://www.amarillo.isd.tenet.edu/speced/physrest.htmlhttp://www.amarillo.isd.tenet.edu/speced/physrest.htmlhttp://www.amarillo.isd.tenet.edu/speced/physrest.htmlhttp://www.amarillo.isd.tenet.edu/speced/physrest.htmlhttp://www.amarillo.isd.tenet.edu/speced/physrest.htmlhttp://www.amarillo.isd.tenet.edu/speced/physrest.htmlhttp://www.acsu.buffalo.edu/~drstall/restrain.htmlhttp://www.acsu.buffalo.edu/~drstall/restrain.htmlhttp://www.acsu.buffalo.edu/~drstall/restrain.htmlhttp://www.acsu.buffalo.edu/~drstall/restrain.htmlhttp://www.acsu.buffalo.edu/~drstall/restrain.htmlhttp://www.acsu.buffalo.edu/~drstall/restrain.htmlhttp://www.acsu.buffalo.edu/~drstall/restrain.htmlhttp://www.acsu.buffalo.edu/~drstall/restrain.htmlhttp://www.acsu.buffalo.edu/~drstall/restrain.htmlhttp://www.acsu.buffalo.edu/~drstall/restrain.htmlhttp://www.acsu.buffalo.edu/~drstall/restrain.html


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