REFUGE HOUSE, INC.

PURPOSE:

To operationalize the Emergency Behavior Intervention Policy (FC-16.06) by detailing how EBI is authorized, administered, monitored, documented, reported, and reviewed. EBI is never discipline (see FC-16.07) and, within a crisis, is coordinated with FC-04 Crisis Management.

PRE-ADMISSION NOTIFICATION TO THE CHILD (TAC §749.115(e)):

Prior to admission, the Case Manager and foster/adoptive parent(s) explain to the child — based on the child's level of functioning — the agency's restraint policies and practices: who may use a restraint; the actions caregivers must first attempt to defuse the situation; the situations in which restraint may be used; the authorized restraint types; when restraint must cease and what the child must do to be released; how to report an inappropriate restraint; and how to provide voluntary comments during or after an EBI, including written comments (form FC 16-E or plain paper). The child's input on preferred de-escalation techniques is obtained at placement. The explanation is documented in the child's record.

AUTHORIZED AND PROHIBITED USE:

Consistent with TBRI®, caregivers first exhaust Connecting and Empowering de-escalation (felt safety, co-regulation, addressing unmet sensory/physiological needs, offering choices); EBI is reserved for a genuine emergency. The standards below apply uniformly across all Service Packages; package-specific de-escalation and clinical coordination (psychiatric, sensory/RN, recovery-supportive, TFFC on-call therapist) are operationalized in FC-04 Crisis Management.

Authorized (last resort, after de-escalation fails): personal restraint to prevent imminent harm to self, others, or significant property, or as approved in the child's service plan (TAC §749.2059, §749.2061). A short personal restraint (≤1 minute) may be used to protect a child from an external hazard (e.g., running into the street, a hot stove), to intervene in a physical altercation, or to prevent significant property damage. Only a caregiver qualified in EBI may administer EBI, except a short personal restraint.

Prohibited use (TAC §749.2063): as punishment, retribution, retaliation, to gain compliance, as a convenience, as a substitute for treatment, to demonstrate authority, or when a less-restrictive alternative is available. Prohibited techniques: any prone or supine restraint (including transitional holds), any non-SAMA technique, any restraint impairing breathing or obstructing the airway or the view of the child's face, any restraint interfering with the child's ability to communicate or that twists/places limbs behind the back; aversive conditioning, pressure points, rebirthing or hug/holding therapy, and emergency medication.

DURING A PERSONAL RESTRAINT:

A caregiver qualified in EBI must continuously monitor the restraint and the child's breathing, circulation, neurological, gastrointestinal, and musculoskeletal signs.

• Use the minimum reasonable and necessary force; protect the child's privacy (shield from onlookers) and dignity (body appropriately covered).
• As soon as possible, explain the behaviors the child must exhibit to be released or have the restraint reduced, and invite the child's suggestions; if the child does not appear to understand, re-explain every 15 minutes until understanding is reached or the child is released.
• Release the child as soon as the child is no longer a danger, and in any event no later than the maximum (1 minute short personal restraint; 30 minutes personal restraint, any age — TAC §749.2281).
• Terminate immediately and begin emergency medical care at any sign of distress (distressed breathing, disorientation, change in consciousness, blue extremities/lips, vomiting, seizure). Ensure the child can communicate distress throughout (including by sign).

Provisions during restraint (TAC §749.2231(c)): bathroom privileges as needed and at least every 2 hours; water at least every 2 hours; regularly prescribed medications unless otherwise ordered by a physician; regularly scheduled meals/snacks; and an adequately ventilated, heated/cooled, lighted, hazard-free environment.

IMMEDIATELY AFTER THE RESTRAINT:

Transition the child into a programmatic intervention (cooling-off period, listening, teaching self-control, problem-solving). Observe the child for 15 minutes after release. Provide the child an opportunity to discuss the situation privately as soon as possible and no later than 24 hours after release (a Refuge House standard stricter than the 48-hour ceiling in TAC §749.2301(a)(3)). The caregiver then debriefs with the Case Manager or on-call worker and makes reasonable efforts to debrief any children who witnessed the incident.

DOCUMENTATION AND REPORTING:

TRIGGERED REVIEW (TAC §§749.2331–749.2339):

The Case Manager ensures an ISP (triggered) review occurs when the same child is personally restrained 4 times within 7 days, more than 12 times in 30 days, or more often than the service-planning-team recommendation allows. The review (no later than 30 days after the trigger) examines the EBI records/orders, medical/psychiatric contraindications, alternatives, and produces a written plan to reduce the need for EBI. If there are more than 4 reviews within a 90-day period, the child must be examined by a licensed psychiatrist, psychologist, clinical social worker, professional counselor, or marriage-and-family therapist, who makes documented service-plan recommendations.

CRITICAL-INCIDENT LOOK-BACK AND QUALITY REPORTING:

• 48-hour look-back (TAC §749.513): reports of a child's death, suicide attempt, or substantial bodily harm must include complete documentation of any restraints implemented within 48 hours prior. A short personal restraint resulting in substantial injury is documented and attached to the serious-incident report.
• Quality Development: restraint data is collected and presented quarterly to the Quality Development Committee, which convenes at least annually to evaluate EBI use, trends (injuries, avoidability, de-escalation use, debriefs, triggered reviews), and the training curriculum.
• Quarterly HHSC reporting (TAC §749.2383): no later than 15 days after each calendar quarter, aggregate EBI statistics by type (excluding short personal restraints) are reported to HHSC CCR via the provider website; records are retained 5 years.

2INgage Quality-Improvement Oversight

SSCC-2INGAGE — addition start (provider-specific; remove this block if the 2INgage contract ends)

Refuge House cooperates with 2INgage Quality Improvement staff during scheduled and random facility/environmental walk-throughs that evaluate security, safety, staff training, and restraint/seclusion policies and processes, and makes EBI/restraint and SAMA training records available on request. (2INgage Provider Manual Rev. 1.2026 §12, p.51)

SSCC-2INGAGE — addition end

SSCC-EMPOWER — addition start (provider-specific; remove this block if the EMPOWER contract ends)

For the EMPOWER network, Refuge House cooperates with EMPOWER Quality Improvement staff during scheduled and random walk-throughs evaluating security, safety, staff training, and restraint/seclusion policies and processes, and makes EBI/restraint and training records available on request (EMPOWER Provider Manual Rev. 1.2026 §12, p.53).

SSCC-EMPOWER — addition end

SSCC-OCOK — addition start (provider-specific; remove this block if the OCOK contract ends)

For the OCOK network, Refuge House reports all Emergency Behavior Interventions/restraints as serious incidents via the Texas Provider Gateway, with required documentation (precipitating circumstances, duration, and outcome) (OCOK Network Management Operations Manual Rev. 7-1-2025 §4.10, pp.85–87).

SSCC-OCOK — addition end

TREATMENT TEAM:

For each child, the treatment team evaluates the use and effectiveness of behavior-intervention techniques as part of the service plan at each review, focusing on frequency, patterns, and strategies to reduce the need for behavior interventions and personal restraint.

TRAINING (SAMA):

Refuge House's authorized EBI training curriculum is Satori Alternatives to Managing Aggression (SAMA) — the licensed SAMA Study Guide (Satori Learning Designs, Inc.), a competency-based program (written and physical demonstration) covering early identification, de-escalation, and safe restraint, delivered instructor-led by a certified SAMA instructor. The curriculum document and the agency's EBI policy were previously submitted to the SSCC (temporary-reference/SSCC/SAMA.EBI Training.pdf — the SAMA Study Guide; temporary-reference/SSCC/EBI Policy.pdf) and are the evidence for the SSCC "Training Curriculum used for EBI training" monitoring item (4Kids4Families Joint Operations Manual, Dec 2025 — EBI defined p.171; EBI-training-curriculum monitoring item; Belong Stage I & II Provider Manual, Aug 2025, p.29 — behavior-intervention approach, restraint frequency/pattern review and reduction, "raising the yellow flag" early support; applies across all contracting SSCCs).

One foster parent must complete at least half of the required pre-service EBI hours before a child is placed; the remainder within 90 days. A caregiver may not administer any EBI other than a short personal restraint until all pre-service hours are complete. Pre-service is 75% early identification / less-restrictive intervention and 25% safe restraint implementation (TAC §749.887, §749.889); annual training is 8 hours, instructor-led by a certified SAMA instructor, competency-based with written and physical demonstration (TAC §749.939). One foster parent must hold current pediatric First Aid and CPR before placement (TAC §749.911).

AUTHORIZED CONTAINMENT TECHNIQUES:

Hug Containment: approach on body line; forearms in front, palms toward the person; contact triceps and move arms across the chest while making chest-to-back contact on one side with head below the shoulder; grab your wrist with a sticky grip; palms toward the person; elbows toward the ground; feet spread, knees bent. Hold with relaxation — do not squeeze.

Elbow-to-Hip Containment: approach on body line; forearms in front, palms toward the person; contact triceps and move arms across the chest while making chest-to-back contact on one side, head below the shoulder; slide hands down to secure the wrists with a sticky grip; keeping chest-to-back contact, slide your elbow to the top of the hip (head and elbow on the same side).

NO RETALIATION AND GRIEVANCE (TAC §749.115(h)):

Refuge House prohibits discharging or retaliating against any employee, child, foster parent, contractor, volunteer, or other person for filing a complaint or providing good-faith information about the misuse of EBI, including on another's behalf. A written Grievance and Appeal Process is provided via the Caregiver Handbook, the Foster Parent Agreement, and the Grievance/Appeal form.

REFERENCES:

Same as Policy FC-16.06.

SSCC alignment (FY-26): 2INgage Provider Manual Rev. 1.2026 — §12 (p.51 QI/restraint oversight). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC coverage tracker (temporary-reference/fy26-sscc-joint-monitoring/sscc-alignment/).

SSCC alignment (FY-26) — EMPOWER: EMPOWER Provider Manual Rev. 1.2026 — §12 (p.53 QI/restraint oversight). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

SSCC alignment (FY-26) — OCOK: OCOK Network Management Operations Manual Rev. 7-1-2025 — §4.10 (pp.85–87 EBI/restraint reporting). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

SSCC alignment (FY-26) — 4Kids: 4Kids4Families Joint Operations Manual (Dec 2025) / Subcontractor Agreement — reviewed; aligned (4Kids items here are casework/Minimum-Standards-level), no additional provider-specific provisions required in this document. Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

SSCC alignment (FY-26) — Belong: Belong Stage I & II Provider Manual (Aug 2025) / Provider Services Agreement — reviewed; aligned, no additional provider-specific provisions required in this document. Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

SSCC alignment (FY-26) — SFCS: SFCS Placement Provider Manual (July 2020, publicly-sourced — currency unconfirmed) / 2019 Affiliate Provider Agreement — reviewed; aligned, no additional provider-specific provisions required in this document. Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

FORMS/ATTACHMENTS:

• FC 16-A Personal Restraint Incident Report
• FC 16-B Short Personal Restraint Incident Report (substantial injury)
• FC 16-E Child Comment Form (EBI)
• Grievance and Appeal Form

This procedure operationalizes the principles established in FC-16.06 Emergency Behavior Intervention Policy. While policies require Board approval and remain relatively stable, procedures may be updated by the Executive Director to adapt to regulatory changes or operational improvements without requiring Board approval, provided such changes maintain alignment with the policy's intent.