(a) Safety-Based Seclusion beyond Four Hours.
  (1) An initial safety-based seclusion review shall be held no later than four hours after a resident is placed in safety-based seclusion. If the fourth hour of seclusion occurs during non-program hours, the review shall be held no later than two hours after the start of the ensuing day's program schedule.
  (2) The initial safety-based seclusion review shall be held by the facility administrator or designee.
  (3) The initial safety-based seclusion review shall determine whether the alleged behavior meets criteria for safety-based seclusion as established in §343.288 of this title and whether continued seclusion is appropriate.
    (A) If the review results in a finding that the alleged behavior does not meet criteria for placement in safety-based seclusion or that continued seclusion is not appropriate, the seclusion shall be immediately discontinued.
    (B) If safety-based seclusion is continued, documentation shall be maintained that shows the resident was notified of the reason for continued seclusion.
(b) Safety-Based Seclusion beyond 24 Hours. A safety-based seclusion review is required before the end of each 24-hour period of seclusion. If the 24th hour of seclusion occurs during non-program hours, the review shall be conducted no later than two hours after the start of the ensuing day's program schedule.
  (1) The review shall be held by a staff member who was not directly involved in the decision to place the resident in seclusion. The resident shall be present for the review.
  (2) The review shall determine if continued seclusion is warranted. Seclusion shall not be continued unless:
    (A) there is a reasonable belief that the resident continues to meet criteria in §343.288(a) of this title; and
    (B) the facility administrator approves the continued seclusion.
  (3) Documentation of each review shall be retained in the resident's file.
(c) Safety-Based Seclusion beyond Five Days.
  (1) A resident shall not be secluded beyond five consecutive calendar days unless:
    (A) the chief administrative officer or administrative designee determines the resident continues to meet criteria in 343.288(a) of this title; and
    (B) the placing agency, if different from the agency operating the facility, is notified of the resident's status.
  (2) The finding and notice requirements in paragraph (1) of this subsection apply to every 24-hour period beyond five calendar days.

Source Note: The provisions of this §343.289 adopted to be effective June 1, 2016, 40 TexReg 7430 and 41 TexReg 850