The Government of Guam's use of restraint or seclusion shall be strictly limited to emergencies when there is imminent risk of an individual physically harming himself or others and nonphysical intervention is not effective. This Section applies to all direct care providers within Government of Guam agencies and agents and employees of the Government of Guam who provide services to persons with mental difficulties, behavioral difficulties and developmental disabilities, but not the Department of Corrections and Guam Police Department. Direct care providers means personnel working with persons with mental difficulties, behavioral difficulties and developmental disabilities who are subject to a behavior plan, individualized educational plan or a similar plan.

• (a) Training Program. An agency employing direct care providers shall provide a minimum of sixteen (16) hours to newly hired providers and annual follow-up training at a minimum of eight (8) hours. The training shall instruct providers in the following:

• (1) reducing the use of seclusion and restraint through risk assessment and early intervention, which includes nonphysical intervention;

• (2) needs and behaviors of the population served (e.g. age, gender, adults, or children);

• (3) relationship building;

• (4) proper and permissible techniques for seclusion, physical holds and chemical restraints for the population served, including risks versus benefits;

• (5) preventive techniques for restraint and seclusion, including a safe and calm physical environment;

• (6) positive alternatives to restraint and seclusion;

• (7) de-escalation methods;

• (8) avoidance of power struggles;

• (9) thresholds for restraints and seclusion;

• (10) the physiological and psychological impact of restraint and seclusion;

• (11) monitoring physical signs of distress and obtaining medical assistance;

• (12) legal issues;

• (13) positional asphyxia;

• (14) escape and evasion techniques;

• (15) time limits;

• (16) the process for obtaining approval for continued restraints;

• (17) procedures to address problematic restraints;

• (18) documentation of restraints and seclusion;

• (19) debriefing after the use of restraints and seclusion with the client or student, the client's or student's family member, or authorized representative, as well as staff members; and

• (20) processing with clients or students, and follow-up with personnel, and investigation of injuries and complaints.

• (b) Reporting Requirements. Direct care providers shall document the use of every restraint defined in §§ 82101(h) and 82101(i), Article 1, Chapter 82, Title 10 GCA on an incident report. Any injury as a result of restraint or seclusion shall be reported immediately to professional staff, Guam Behavioral Health and Wellness Center, Department of Public Health and Social Services, and the territorial protection and advocacy office or its successor. Government of Guam agencies and agents and employees of the government of Guam who provide services to persons with mental difficulties, behavioral difficulties and developmental disabilities shall report all deaths and severe injuries to Guam Behavioral Health and Wellness Center, Department of Integrated Services for Individuals with Disabilities, and the territorial protection and advocacy office or its successor. Each agency shall maintain and update a list of all deaths, severe injuries, and the frequency of its facility's use of seclusion and restraint on an annual basis and shall post the same on its website with a proper regard for client and student confidentiality.

• (c) Prohibited Acts.

• (1) seclusion is prohibited in school settings;

• (2) chemical restraint is prohibited unless prescribed by a physician who specifies the duration and circumstances under which the restraints are to be used, and shall be indicated in a client or student's individualized treatment plan.

• (3) a physical restraint or containment technique that obstructs a person's respiratory airway or impairs the person's breathing or respiratory capacity, including techniques in which a staff member places pressure on a person's back or places his or her body weight against the person's torso or back is prohibited.

• (4) a pillow, blanket, or other item covering the person's face as part of a physical or mechanical restraint or containment process is prohibited.

• (5) prone restraint on a person at risk for positional asphyxiation as a result of one of the following risk factors that are known to the personnel is prohibited:

• (A) obesity;

• (B) pregnancy;

• (C) agitated delirium or excited delirium syndromes;

• (D) cocaine, methamphetamine, or alcohol intoxication;

• (E) exposure to pepper spray;

• (F) preexisting heart disease, including, but not limited to, an enlarged heart or other cardiovascular disorders; and/or

• (G) respiratory conditions, including emphysema, bronchitis, or asthma.

Manual addresses response, reporting, and training for student incidents involving restraint and seclusion.