The Joint Commission R³ Report: New and Revised Restraint and Seclusion Requirements for Behavioral Health Care and Human Services Organizations

The Joint Commission R³ Report
Dated: June 20, 2024
Effective: January 1, 2025
New and Revised Restraint and Seclusion Requirements for Behavioral Health Care and Human Services Organizations

Strategies to identify behaviors of staff and individuals served, events, and environmental factors that may trigger circumstances that require the use of restraint and seclusion;

CPI Alignment

Nonviolent Crisis Intervention^® explores the effects of trauma and the psychology of the brain on the person in crisis as well as the responding individual. During the course, precipitating factors are explored and discussed how they play a factor in the behavior of both staff and the individual in distress.

Recognizing how factors such as age, developmental considerations, gender, ethnicity, history of abuse, etc. may affect the way in which an individual reacts to physical contact;

CPI Alignment

In the program, supportive communication considerations are discussed. It encourages staff to recognize a person’s age, cognitive functions, culture, gender identity, and previous life experiences including any trauma are all factors that need to be considered when using all forms of communication.

Use of nonphysical intervention skills;

CPI Alignment

CPI’s program stresses the importance of identifying a change in behavior and becoming supportive to that individual, as well as options to utilize if someone’s behavior is becoming defensive, such as, limit-setting, allowing the individual time and place to vent, utilizing a team approach to de-escalate the situation and making the environment as safe as possible. The importance of empathic listening is expanded on and strategies of delivering news an individual may not take well are practiced. These are all strategies that are emphasized to be used first in any moment of crisis.

Methods of choosing the least restrictive intervention based on an assessment of the behavioral or medical status or condition of the individual served;

CPI Alignment

To guide our objective, unbiased decisions, CPI uses a Decision-Making Matrix^SM, in which likelihood of the behavior and the severity of harm are assessed. This helps prevent an emotional response, so staff do not overreact or underreact to a situation. It also ensures that disengagements or restrictive interventions are only used as a last resort. When choosing a course of action in response to this risk behavior, staff must make a judgment about the level of risk and consider what harm is likely to occur as a consequence. Based on this judgment, staff should choose a response that is defendable as a last resort, reasonable, and proportionate action.

Safe application and use of all types of restraint or seclusion used in the organization, including training in how to recognize and respond to signs of physical and psychological distress;

CPI Alignment

The interventions provided by CPI are specifically designed to reduce the risk of injury to both individuals and staff. These interventions are intended to be non-invasive and do not utilize pressure points or joint locks. While it is important to acknowledge that no intervention can be entirely risk-free, all CPI interventions have undergone independent assessments to evaluate potential risks related to psycho-social, soft tissue, joint, structural, neurological, cardiovascular, and respiratory injuries for both individuals and staff.

Identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary;

CPI Alignment

Certified Instructors are guided to facilitating dynamic practice of physical skills when training. During this practice, staff have the opportunity to assess the de-escalation and decisions to be made to opt out of a physical hold. It is stressed that the individual has reached a level of tension reduction and is showing a decrease in physical and emotional energy. Staff is instructed to respond balanced and proportionate to the behavior and to recognize the goal is the exit the restraint as soon as it is safe to do so.

Monitoring the physical and psychological well-being of the individual;

CPI Alignment

During Safety Interventions, there is a discussion on the Risks of Restraint. In this discussion, staff are viewing a chart of warning signs of overall risk associated with restraint and corrective actions that need to be taken if these warning signs are apparent during a physical intervention. CPI teaches that all interventions should be continuously monitored face-to-face to assess the level of imminent risk and signs of distress that may occur when using restraint and/or seclusion.

EP 3: Staff providing training in restraint and seclusion have education, training, and experience in the techniques used to address behaviors of individuals served that necessitate the use of restraint and seclusion.

CPI Alignment

CPI's Nonviolent Crisis Intervention^® Instructor Certification Program models the course that the Certified Instructor will be teaching back at their organization and provides Instructor Training for participants to gain knowledge and practice related to teaching the course and integrating it within their organization. The classroom portion of the course includes use of an electronic presentation with activities that will aid participants in the implementation of the Nonviolent Crisis Intervention^® Training. Extensive application, case studies, examples, competency-based testing, and an exam ensure that participants gain knowledge and are able to demonstrate skills introduced in the program. Participants will also complete teach backs of the content.

EP 4: The organization documents in staff records that restraint and seclusion training and demonstration of competence were completed. 

CPI Alignment

All certified instructors are required to complete two formal trainings per year and document those trainings with CPI. Participants are issued Blue Cards^® for successful completion of the program with unique identification numbers that are registered within their documentation. Records can be accessed by certified instructors at any time.

Requirement
Standard CTS.05.05.07: The organization takes action to reduce the need for restraint and seclusion.

EP 1: To minimize the use and impact of restraint and seclusion, the organization performs an initial assessment on an individual who is at risk of endangering themselves or others and identifies the following: 

Techniques and/or tools that would help the individual;

CPI Alignment

The CPI training program guides participants to utilize the Crisis Development Model^SM and Decision-Making Matrix^SM to individually assess behaviors and crisis situations and provide support. 

Signs of escalation, to prevent reaching the point of imminent risk;

CPI Alignment

The Nonviolent Crisis Intervention^® curriculum focuses on prevention by recognizing the early warning signs of potential crisis situations and equipping staff with nonverbal and verbal de-escalation skills.  

Interventions that preserve the dignity of the individual if placed in restraint and seclusion;

CPI Alignment

CPI training programs are built on the fundamental principles of Care, Welfare, Safety and Security^SM for clients/patients and staff alike. Abuse of any kind including the infliction of emotional trauma, humiliation and other verbal abuse is not consistent with the tenants of our programs.  

Preexisting medical conditions or any physical, intellectual, developmental or cognitive disabilities and limitations that would place the individual at greater risk during restraint and seclusion; 

CPI Alignment

CPI training shares these are considerations staff need to think about when utilizing the Decision-Making Matrix^SM and weighing the risk of doing something vs. the risk of doing nothing.  

History of sexual or physical abuse or other trauma that would place the individual at greater psychological risk during restraint and seclusion. 

CPI Alignment

In addition to the considerations above, CPI is built around principles of trauma informed and person-centered care. In any situation, past experience including trauma should be considered when intervening in a crisis situation.  

EP 2: Whenever possible, the organization uses nonphysical techniques based on the initial assessment in managing behaviors of individuals served. 

CPI Alignment

CPI employs verbal and physical techniques to manage and prevent aggressive behavior. The emphasis of CPI training is on prevention, which is central to our approach. Additionally, CPI provides training in verbal de-escalation and physical disengagement strategies to effectively address situations that staff may be unable to prevent. 

EP 2 Note 1: Such techniques may include implementing a crisis response plan, redirecting focus, employing verbal de-escalation and positive behavioral support or using sensory modulation.  

CPI Alignment

The Nonviolent Crisis Intervention^® curriculum focuses on prevention by recognizing the early warning signs of potential crisis situations and equipping staff with nonverbal and verbal de-escalation skills. 

Requirement
Standard CTS.05.05.09 The organization assesses and monitors the individual in restraint or seclusion.

EP 1: These assessments and interventions include the following, as relevant:

• Assessing for signs of injury;
• Addressing nutrition and hydration status;
• Assessing physical and psychological status and comfort;
• Assessing hygiene and elimination needs;
• Addressing readiness for discontinuation of the restraint and seclusion.

CPI Alignment

In the training materials, CPI provides a chart for the continual assessment of signs of distress. The chart reviews things an observer might hear or see and draws a correlation to which system of the body could be in distress as a result of the intervention.

Requirement
Standard CTS.05.05.15 Restraint and seclusion use are discontinued when the individual served meets the behavior criteria for discontinuation.

EP 1: As early as feasible in the restraint and seclusion process, the individual is made aware of the rationale for restraint and seclusion and the behavior criteria for its discontinuation. Restraint and seclusion are then discontinued as soon as the individual meets the criteria.

CPI Alignment
Verbal de-escalation is a critical focus when addressing any signs of distress. If an individual poses a risk to themselves or others, and all other intervention strategies have been fully utilized, staff may ultimately determine that a physical intervention is necessary as a last resort. Even in such circumstances, CPI’s program underscores the importance of supporting the individual in distress. This includes clearly communicating to the individual the reasons behind staff actions and outlining the specific behavior or criteria that must be demonstrated for staff to safely disengage or opt-out of the hold.

Requirement
Standard CTS.05.05.17 The individual served and staff participate in a debriefing about the restraint or seclusion episode.

EP 2: The debriefing about each episode of restraint or seclusion is used to do the following: 

• Identify what led to the incident and what could have been handled differently;
• Ascertain that the physical well-being, psychological comfort, and right to privacy were addressed;
• Counsel the individual served for any trauma that may have resulted from the incident;
• Assess the impact of the restraint or seclusion episode on their behavioral functioning;
• When indicated, modify the individual’s plan for care, treatment or services.

CPI Alignment

CPI training emphasizes the importance of post-incident assessments after a restraint was used. The Nonviolent Crisis Intervention^® Training program emphasizes understanding the past, so staff are informed from the individual’s perspective what happened, supporting in the present, to help the individual stay in a de-escalated state and learning for the future, so staff can assist in preventing this behavior from happening again.