2023 Colorado Revised Statutes › Title 26 - HUMAN SERVICES CODE (§§ 26-1-101 — 26-24-101) › Article 20 - PROTECTION OF PERSONS FROM RESTRAINT (§§ 26-20-101 — 26-20-111) › Section 26-20-106 - Documentation requirements for restraint and seclusion - adults and youth

(1)
Each agency shall ensure that the use of restraint or seclusion is documented in the record of the individual who was restrained or secluded. Each agency that is authorized to promulgate rules or adopt ordinances shall promulgate rules or adopt ordinances applicable to the agencies within their respective jurisdictions specifying the documentation requirements for purposes of this section.
(2)
The division of youth services shall maintain the following documentation each time a youth is placed in seclusion as a result of an emergency in any secure state-operated or state-owned facility:
(a)
The date of the occurrence;
(b)
The race, age, and gender of the individual;
(c)
The reason or reasons for seclusion, including a description of the emergency and the specific facts that demonstrate that the youth posed a serious, probable, and imminent threat of bodily harm to himself, herself, or others, and that there was a present ability to effect such bodily harm;
(d)
A description of de-escalation measures taken by staff and the response, if any, of the youth in seclusion to those measures;
(e)
An explanation of why less restrictive alternatives were unsuccessful;
(f)
The total time in seclusion;
(g)
Any incidents of self-harm or suicide that occurred while the youth was in seclusion;
(h)
With respect to the interactions required by section
26-20-104.5
, documentation of the justification for keeping the youth in seclusion and specific facts to demonstrate that the emergency was ongoing;
(i)
The facility director or his or her designee's approval of continued seclusion at intervals as required by section
26-20-104.5
;
(j)
Documentation of notification within twelve hours to the parent, guardian, or legal custodian of the youth in seclusion as required by section
26-20-104.5
; and
(k)
The written approval by the director of the division of youth services for any seclusion that results from an emergency that extends beyond four consecutive hours, as required by section
26-20-104.5
. This written approval must include documentation of specific facts to demonstrate that the emergency was ongoing and specific reasons why a referral to a mental health facility was not warranted.
(3)
The division of youth services shall maintain the following documentation each time one or more youths are placed in confinement for administrative reasons pursuant to section
26-20-104.5(3)
in a secure state-operated or state-owned facility:
(a)
The number of youth confined;
(b)
The length of time the youth or youths were confined; and
(c)
The reason or reasons for the confinement.
(4)
On or before January 1, 2017, and on or before July 1, 2017, and every January 1 and July 1 thereafter, the division of youth services shall report on its use of restraint or seclusion in any secure state-operated or state-owned facility to the youth restraint and seclusion working group established in section
26-20-110
. The January report must include information from March 1 through August 31, and the July report must include information from September 1 through the last day of February. The reports must include the following:
(a)
An incident report on any use of seclusion on a youth due to an emergency for more than four consecutive hours, or for more than eight total hours in two consecutive calendar days. Each incident report must include length of seclusion, specific facts that demonstrate that the emergency was ongoing, any incidents of self-harm while in seclusion, the reasons why attempts to process the youth out of seclusion were unsuccessful, and any corrective measures taken to prevent lengthy or repeat periods of seclusion in the future. To protect the privacy of the youth, the division of youth services shall redact all private medical or mental health information and personal identifying information, including, if necessary, the facility at which the seclusion occurred.
(b)
A report that lists the following aggregate information, both as combined totals and totals by facility for all secure state-operated or state-owned facilities:
(I)
The total number of youths held in seclusion or restraint due to an emergency;
(II)
The total number of incidents of seclusion or restraint due to an emergency;
(III)
The average time in seclusion or restraint per incident;
(IV)
An aggregate summary of race, age, and gender of youths held in seclusion or restraint; and
(V)
The type of restraint or restraints used in each incident; and
(c)
An incident report for any youth whom the division isolates from his or her peers for more than eight hours in two consecutive calendar days. Each incident report must include the age, race, and gender of the youth; the name of the facility; the length of time that the youth was isolated from his or her peers; and the justification for the isolation on an hour-by-hour basis. To protect the privacy of the youth, the division shall redact all private medical or mental health information and personal identifying information, including, if necessary, the facility at which the seclusion occurred. If the division has prepared an incident report of an incident involving seclusion pursuant to subsection (4)(a) of this section, the division is not required to include a report of the same incident pursuant to this subsection (4)(c).
(5)
Reports prepared pursuant to this section must maintain the confidentiality of all youth. The reports made pursuant to this section are available to the public upon request.
(6)
Prior to January 1, 2018, the division of youth services shall meet the requirements of this section to the extent that it is able using its current reporting mechanisms. The division of youth services shall fully comply with all requirements of this section on or before January 1, 2018.
Amended by 2017 Ch. 381,§ 4, eff. 6/6/2017.
Amended by 2016 Ch. 345,§ 6, eff. 6/10/2016.
L. 99: Entire article added, p. 382, § 1, effective April 22. L. 2016: Entire section amended, (HB 16-1328), ch. 345, p. 1404, § 6, effective June 10. L. 2017: IP(2), (2)(k), IP(3), (4), and (6) amended, (HB 17-1329), ch. 381, p. 1962, § 4, effective June 6.