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Effective January 1, 2025, The Joint Commission has approved new and revised requirements for Behavioral Health and Human Services organizations accredited under the Comprehensive Accreditation Manual for Behavioral Health and Human Services regarding the use of restraint and seclusion. These new and updated requirements aim to reduce redundancies, streamline processes, and remove specific requirements for the physical holding of children or youth. Joint Commission now classifies physical holding that restricts freedom of movement as a type of restraint. Thus, physical holding will be subject to the same requirements due to its associated risks, as shown by a study showing significant fatalities from physical holding restraints. The Joint Commission (TJC) has revised the definition of restraint to clarify what interventions are included. Now, the requirements only apply to physical actions that TJC defines as restraint or seclusion.

TJC New BHC Restraint Definition

A restraint is any method (chemical or physical) of restricting the freedom of movement of an individual served to manage their behavior. This includes any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of an individual to move their arms, legs, body, or head freely. It also includes any drug or medication when used as a restriction to manage the individual’s behavior or to restrict their freedom of movement and is not a standard treatment or dosage for their condition. 

Examples of interventions that would not meet the definition of restraint include the following: 

  • Briefly holding an individual without undue force to calm or comfort them 
  • Physically assisting someone to complete a task 
  • Escorting or guiding someone away from an area or situation 
  • Separating individuals to break up a fight 
  • Physical interventions that do not use undue force to prevent imminent danger (stopping an individual from running into traffic, tripping, or falling) 

Seclusion is defined as the involuntary confinement of an individual in a room alone, for any period of time, from which the individual is physically prevented from leaving. Seclusion does not include involuntary confinement for legally mandated but nonclinical purposes, such as the confinement of a person who is facing criminal charges or who is serving a criminal sentence.

Summary of Requirements

For organizations that use restraint or seclusion:

1) Written Policies and Procedures Guiding the Use of Restraint or Seclusion

Policies and procedures should cover topics such as definitions, techniques, training, monitoring, assessment, documentation, prevention, communication, orders, time limitations, post-restraint practices, data collection, and more.

2) Adequate Staffing

Maintain a cadre of staff sufficient to promote therapeutic interventions and reduce the use of restraint and seclusion. In addition, base staffing decisions on staff competencies, physical design of the environment, acuity levels of the individuals served, and consider age, emotional, behavioral and developmental functioning of individuals served.

3) Staff Training and Competence

Staff is trained and competence assessed during orientation and periodically thereafter related to restraint and seclusion as outlined in the standard. Plus, training and competency are documented.  

4) Trainers

Trainers possess the education, training, and experience in techniques for managing behaviors that require restraint or seclusion.

5) Take Action to Reduce the Need for Restraint and Seclusion

Assess for individuals at risk of harming self or others including signs of escalation, pre-existing medical conditions or disabilities, history of trauma, and plan to prevent imminent risk and control aggressive behavior.

6) Use Non Physical Techniques

Whenever possible, enact crisis response plans, verbal de-escalation, positive behavioral support, or sensory modulation. Tailor de-escalation plans to the individual’s needs within the plan for care, treatment and services.

7) Least Restrictive Measures

Only use restraint or seclusion when less restrictive or nonphysical interventions are not feasible or successful.

8) Prohibited Uses

Never use restraint or seclusion for purposes of coercion, discipline, convenience, or retaliation by staff.

9) Regular Assessment and Intervention

Staff assess the individual at the initiation of restraint or seclusion and at regular intervals.  Regular interventions are implemented such as checking for injury, addressing nutrition and hydration, checking circulation, performing range of motion exercises, monitoring vital signs, addressing hygiene and elimination needs, assessing physical and psychological comfort, and determining readiness for discontinuation of restraint or seclusion.  

10) Continuous Monitoring

A trained and competent staff member continuously monitors the individual in restraint or seclusion through in-person observation. If an individual is in seclusion without restraints, it’s acceptable to utilize simultaneous video and audio equipment, if it aligns with the individual’s condition or wishes and organizations’ policy.

11) Authorized Orders

A physician or LP authorized by organization policy and state law, orders the use or continuation of restraint and seclusion. Also, qualified, trained staff may initiate restraint or seclusion in an emergency before obtaining an order.

12) Timely Notification of Orders

As soon as possible after initiation restraint or seclusion, staff must notify and obtain an order (verbal or written) from an authorized physician or LP if they did not originally order it.

13) Time-Limited Orders

Orders for restraints and seclusion are limited to:

  • Fours hours for adults (18+)
  • Two hours for children and youth (ages 9-17)
  • On hour for children under 9
  • If restraint or seclusion needs to continue beyond the time limit, it requires a new order

14) Prohibited Practices

Standing orders or as-needed (PRN) use are not allowed for restraint or seclusion.

15) Evaluations

An in-person evaluation must occur before order renewal and every 24 hours or more often as required by state law, by a physician, LP or trained designee.  If performed by a designee, the person must consult with a physician or LP as soon as possible and within the time-frame set by organization policy.  Care planning must occur with each evaluation such as identifying ways to help the individual regain control, revision of the individual’s care plan as needed, and provision of a new order for restraint or seclusion if necessary.

16) Discontinuation of Restraint or Seclusion

This must occur as early as possible. In addition, the staff informs the individual about the reason for using restraint or seclusion and explains the specific behaviors that will lead to its discontinuation. Further, restraint or seclusion is stopped as soon as the individual demonstrates the desired behaviors.

17) Documentation

Document all care, treatment and services related to restraint or seclusion in the clinical/case record using the criteria outlined in the standard.

18) Data Collection

The organization determines how often to collect, aggregate, and analyze data on the use of restraint and seclusion. The data should include the criteria outlined in the standard. Further, the organization identifies opportunities for performance improvement in restraint and seclusion practices and implements a plan to address these areas. Lastly, at minimum, analyze the data annually.  

Helpful Resources

TJC References

See TJC R3 report

Barrins and Associates

Barrins stays up to date with current accreditor changes. By conducting mock surveys, we enable your organization to remain in continuous compliance with accreditation and regulatory requirements. We will include compliance with TJC standards related to restraint and seclusion. Contact us today to schedule a 2024 Mock Survey.

Barrins & Associates – “Elevating Client Safety: Empowering Healthcare Leaders to Achieve Excellence.”