(a) The facilities to which this subchapter applies shall ensure that staff members are informed of their roles and responsibilities under this subchapter and are trained and demonstrate competence accordingly.
(b) The training program shall be consistent with the requirements of this subchapter and shall:
  (1) target the specific needs of each patient population being served;
  (2) be tailored to the competency levels of the staff members being trained;
  (3) emphasize the importance of reducing and preventing the use of restraint and seclusion;
  (4) be evaluated annually, which shall include evaluation to ensure that the training program, as planned and as implemented, complies with the requirement of this section;
  (5) incorporate evidence-based best practices;
  (6) provide information about declarations for mental health treatment, including:
    (A) the right of individuals to execute declarations for mental health treatment; and
    (B) the duty of staff members and other health care providers to act in accordance with declarations for mental health treatment to the fullest extent possible.
(c) Before assuming job duties involving direct care responsibilities, and at least annually thereafter, staff members other than physicians must receive training and demonstrate competence in at least the following knowledge and applied skills that shall be specific and appropriate to the population(s) the facility serves:
  (1) using team work, including team roles and techniques for facilitating team communication and cohesion;
  (2) identifying the causes of aggressive or threatening behaviors of individuals who need mental health services, including behavior that may be related to an individual's non-psychiatric medical condition;
  (3) identifying underlying cognitive functioning and medical, physical, and emotional conditions;
  (4) identifying medications and their potential effects;
  (5) identifying how age, weight, cognitive functioning, developmental level or functioning, gender, culture, ethnicity, and elements of trauma-informed care, including history of abuse or trauma and prior experience with restraint or seclusion, may influence behavioral emergencies and affect the individual's response to physical contact and behavioral interventions;
  (6) explaining how the psychological consequences of restraint or seclusion and the behavior of staff members can affect an individual's behavior, and how the behavior of individuals can affect a staff member;
  (7) applying knowledge and effective use of communication strategies and a range of early intervention, de-escalation, mediation, problem-solving, and other non-physical interventions, such as clinical timeout and quiet time; and
  (8) recognizing and appropriately responding to signs of physical distress in individuals who are restrained or secluded, including the risks of asphyxiation, aspiration, and trauma.
(d) Before any staff member may initiate any restraint or seclusion the staff member shall receive training and demonstrate competence in:
  (1) safe and appropriate initiation and use of seclusion as a last resort in a behavioral emergency;
  (2) safe and appropriate initiation and application, and use of personal restraint as a last resort in a behavioral emergency;
  (3) safe and appropriate initiation and application, and use of mechanical restraint devices as a last resort in a behavioral emergency or as a protective or supportive device, and knowledge of the mechanical restraint devices permitted under §415.256 of this title (relating to Mechanical Restraint Devices) and approved by the facility; and
  (4) management of emergency medical conditions in accordance with the facility's policies and procedures and other applicable requirements for:
    (A) obtaining emergency medical assistance; and
    (B) obtaining training in and using techniques for cardiopulmonary respiration and removal of airway obstructions.
(e) Before assuming job duties, and at least annually thereafter, a registered nurse or a physician assistant who is authorized to:
  (1) perform assessments of individuals who are in restraint or seclusion shall receive training, which shall include a demonstration of competence in:
    (A) monitoring cardiac and respiratory status and interpreting their relevance to the physical safety of the individual in restraint or seclusion;
    (B) recognizing and responding to nutritional and hydration needs;
    (C) checking circulation in, and range of motion of, the extremities;
    (D) providing for hygiene and elimination;
    (E) identifying and responding to physical and psychological status and comfort, including signs of distress;
    (F) assisting individuals in de-escalating, including through identification and removal of stimuli, that meet the criteria for a behavioral emergency if known;
    (G) recognizing when continuation of restraint or seclusion is no longer justified by a behavioral emergency; and
    (H) recognizing when to contact emergency medical services to evaluate and/or treat an individual for an emergency medical condition.
  (2) conduct evaluations of individuals, including face-to-face evaluations pursuant to §415.260(c) of this title (relating to Initiation of Restraint or Seclusion in a Behavioral Emergency) of individuals who are in restraint or seclusion, shall receive training, which shall include a demonstration of competence in:
    (A) identifying restraints that are permitted by the facility, by this subchapter, and by other applicable law;
    (B) identifying stimuli that trigger behaviors;
    (C) identifying medical contraindications to restraint and seclusion;
    (D) recognizing psychological factors to be considered when using restraint and seclusion, such as sexual abuse, physical abuse, neglect, and trauma.
(f) Before assuming job duties, and at least annually thereafter, staff members who are authorized to monitor, under the supervision of a registered nurse, individuals during restraint or seclusion shall receive training, which shall include a demonstration of competence in:
  (1) monitoring respiratory status;
  (2) recognizing nutritional and hydration needs;
  (3) checking circulation in, and range of motion of, the extremities;
  (4) providing for hygiene and elimination;
  (5) addressing physical and psychological status and comfort, including signs of distress;
  (6) assisting individuals in de-escalating, including through identification and removal of stimuli, if known.
  (7) recognizing when continuation of restraint or seclusion is no longer justified by a behavioral emergency; and
  (8) recognizing when to contact a registered nurse.
(g) For physicians who may order restraint or seclusion, the facility's credentialing and privileging processes must require that such physicians:
  (1) demonstrate competency in ordering restraint or seclusion; and
  (2) receive training and refresher training in:
    (A) the use of alternatives to restraint or seclusion; and
    (B) how to reduce the physical and emotional harm caused by restraint or seclusion.
(h) When a staff member's duties change, the facility shall reassess the staff member's training and competence and require and ensure the staff member's retraining, as required under this subchapter, based upon the facility's reassessment and the staff member's new duties.
(i) The facility shall maintain documentation of training for each staff member. Documentation shall include the date that training was completed, the name of the instructor, a list of successfully demonstrated competencies, the date competencies were assessed, and the name of the person who assessed competence.

Source Note: The provisions of this §415.257 adopted to be effective July 22, 2014, 39 TexReg 5581