Department of Health Services Logo

 

Wisconsin Department of Health Services

Information memos

Numbered memos

Subscribe for email notification of each new memo

Shared Memo: Practices that are not to be used in Community Based Programs and Facilities

(DMHSAS 2010-06, DLTC 2010-09 and DQA 10-026)

Memo DMHSAS 2010-06, DLTC 2010-09 and DQA 10-026:
Practices that are not to be used in Community Based Programs and Facilities
(PDF, 48KB)

State of Wisconsin
Department of Health Services
Division of Mental Health and Substance Abuse Services
Division of Long Term Care
Division of Quality Assurance

Date: September 21, 2010

DLTC Numbered Memo Series 2010-09
DMHSAS Numbered Memo 2010-06
DQA Memo 10-026

Index Title: Practices that are not to be used in Community Based Programs and Facilities

To: DMHSAS, DLTC and the DQA Listserv’s

For:
Certified / Regulated Facilities for the Developmentally Disabled
Certified / Regulated Mental Health and Alcohol or Other Drug Abuse Treatment Programs
County Community Options Program Coordinators
County Departments of Developmental Disabilities Services Directors
County Departments of Human Services Directors
County Departments of Social Services Directors
County Mental Health Coordinators
County Waiver Coordinators
Tribal Chairpersons / Human Services Facilitators
Community-Based Residential Facilities CBRF 15
Adult Family Homes AFH 11
Adult Day Care Providers ADC 07
Residential Care Apartment Complexes RCAC 10
Community Support Programs
Comprehensive Community Services Programs
Medically Monitored Detoxification Programs
Home Health Agencies HHA 07
Hospice Providers HSPCE 10
Medicaid Certified Personal Care Providers
Family Care Managed Care Organizations

From: Karen E. Timberlake,
Secretary, Wisconsin Department of Health Services

Subject: Practices that are not to be used in Community Based Programs and Facilities.

Purpose and Applicability

The purpose of this memo is to delineate practices that are not at any time to be used in community based programs and facilities to control or as a response to a client’s violent or aggressive behavior. These practices have been demonstrated to present an inherently high risk for causing serious injury and possibly death and thus are to be avoided.

In certain situations, safety interventions may be required in response to a client’s violent behavior, to keep the individual safe from him / herself or to prevent injury to others. These situations sometimes require physical interventions. Such events may have two stages,

  1. the initial intervention to prevent further harm and
  2. any further intervention that may be necessary after the person has been initially contained to enable the person to regain control.

The initial control may be difficult to achieve due to the rapid need to contain the violent behavior. However, any necessary further intervention should be more planned and controlled. While physical restraints may be used as a last resort to gain control, they are not to be used for any extensive period following the initial containment and control. If any of the procedures listed below is inadvertently used during an initial intervention, it must be terminated immediately. It is also essential that, during any initial control or other physical intervention, great care be taken to protect the head or any other part of the body from injury.

Overview

The Wisconsin Department of Health Services (DHS) is in full support of the national trend to reduce restraint and other restrictive measures and physical interventions. The ultimate goal is to work toward systems and settings in which such interventions are not necessary and in which positive intervention strategies obviate the need for them. The vision of DHS is to promote recovery and healing within a treatment culture that is consumer driven, trauma informed, and recovery based. Toward these goals, DHS has undertaken efforts to provide training and technical assistance to providers who may be in situations in which physical interventions are used.

DHS also recognizes that there may be instances in which an individual’s behavior presents an imminent danger of harm to self or others and that safety interventions may be necessary to contain this risk and keep the individual and others safe. In these instances physical interventions are not to be used except in emergency situations in which there is an imminent risk of harm to self or others. In such situations, physical interventions are to be limited to the duration of time the imminent risk of harm persists. Physical interventions are not to be used in situations in which the individual’s dangerous behavior was foreseeable based on his or her history, unless the interventions were approved in advance by the Department and / or county department under the process mandated under The Wisconsin Administrative Code DHS 94.10 (Exit DHS, PDF) and further described in the Department’s Guidelines and Requirements for the Use of Restrictive Measures. Physical interventions are not to be seen as or used for treatment but rather as temporary emergency measures only.

Physical interventions are to be avoided whenever possible and all other feasible alternatives, including de-escalation techniques, are to be exhausted prior to using a physical intervention. When required, physical interventions may be used only for the shortest time possible in the individual circumstance and are to be carried out in a manner that causes the least possible physical or emotional discomfort, harm or pain to the individual. Any such procedures are inherently risky but certain practices present serious risk of injury and possibly even death. These procedures are not to be used in any circumstance.

Practices and Procedures That Are Not To Be Used

The following practices or procedures are not at any time to be used to control or as a response to a client’s violent or aggressive behavior:

  • Any maneuver or technique that does not give adequate attention and care to protection of the head;
  • Any maneuver or technique that places pressure or weight on the chest, lungs, sternum, diaphragm, back, or abdomen;
  • Any maneuver or technique that places pressure, weight, or leverage on the neck or throat, on any artery, or on the back of the head or neck, or that otherwise obstructs or restricts the circulation of blood or obstructs an airway, for example straddling or sitting on the torso;
  • Any type of choke hold;
  • Any maneuver or technique that involves pushing on or into an individual’s mouth, nose, or eyes, or covering the face with anything, including soft objects such as pillows or washcloths, blankets, bedding, etc. (However, the finger may be used in a vibrating motion to stimulate the person’s upper lip when they are biting themselves or other persons (to create a “parasympathetic response” that causes the mouth to open) and staff may “lean into” a bite with the least amount of force necessary to open the jaw); and
  • Any maneuver or technique that utilizes pain to obtain compliance or control, including punching, hitting, hyperextension of joints, or extended use of pressure points.
  • Any maneuver or technique that forcibly takes an individual face- forward from a standing position to a prone position

Conclusion

The use of physical interventions to control or as a response to a client’s violent or aggressive behavior is not treatment nor is it therapeutic. All facilities and programs should become familiar with the changing standards of care which focuses on the prevention of the need to use physical interventions and take steps to reduce their use immediately. Please call the DHS contacts listed below regarding possible training and technical assistance that will provide staff tools to prevent situations that give rise to the use of physical interventions and, should they occur, to ensure that the crises are therapeutically de-escalated and evaluated.

For additional information and questions regarding this memo:

Regional Office Contact:

Area Administrators

Central Office Contacts:

Division of Mental Health and Substance Abuse Services

Kenya Bright
DHS / DMHSAS
1 W. Wilson St., Room 951
Madison, WI 53703

Telephone: (608) 267-9392
Fax: (608) 267-4865
Email: Kenya.Bright@wisconsin.gov 

Division of Long Term Care

Julie Shew
Telephone: (920) 303-3026
Email: Julie.Shew@wisconsin.gov 

Division of Quality Assurance

Sherri Olson
Telephone: (715) 836-2299
Email: Sherri.Olson@wisconsin.gov

Dinh Tran
Telephone: (608) 266-6646
Email: Dinh.Tran@wisconsin.gov

CC:

Area Administrators / Human Services Area Coordinators
DHS Bureau Directors
DHS Section Chiefs
Disability Rights Wisconsin (Exit DHS)
Wisconsin Family Ties (Exit DHS)
Wisconsin Counties Human Services Association (Exit DHS)

Memo Websites:

The Wisconsin Department of Health Services website

DLTC / DMHSAS Memo Series web page.
The Division information and numbered memos are distributed electronically via a Listserv. The Listserv is free, but does require an active e-mail address. The memos are posted in both PDF and html formats.

DLTC and DMHSAS Memo Series E-mail Subscription Services web page.
Subscribing to the DLTC and DMHSAS Memo Series Listserv can be done from this page. You will receive a notice each time a new memo is released, which will include a link to the online version of the memo.

Division of Quality Assurance (DQA) Numbered Memos Webpage.
The Division of Quality Assurance (DQA) Numbered Memos deal with policies, information and interpretation of federal as well as state regulations and guidelines of the programs under DQA's jurisdiction.

DQA E-Mail Subscription Service Webpage.
Sign-up to receive E-mail notification of new DQA memos, DQA Quarterly Updates, and additional health care policy-related information via the DQA Subscription Service.

Last Revised:  June 25, 2014