9 CSR 45-3.090 - Behavior Supports
(1) Definitions-
(A) Applied behavior analysis-The design,
implementation, and evaluation of environmental modifications, using behavioral
stimuli and consequences, to produce socially significant improvement in human
behavior, including the use of direct observation, measurement, and functional
analysis of the relationships between environment and behavior, as established
in section 337.300(1),
RSMo;
(B) Behavior analysis
services-Use of applied behavior analysis principles and technology to assist
support systems of individuals with challenging behaviors to prevent those
behaviors as well as teach, promote, encourage, and reinforce alternative
skills and behaviors;
(C) Behavior
support plan (BSP)-A part of the individual support plan that is comprised of
behavior analytic procedures developed to systematically address behaviors to
be reduced or eliminated and behavior skills to be learned;
(D) Blocking-A staff person using a part of
their body to prevent an individual from inflicting or incurring harm when an
individual is attempting to hit, kick, or otherwise harm himself or herself,
the staff, or another person. Use of pads, cushions, or pillows to soften or
prevent impact to the individual or others is also considered blocking.
Blocking does not involve grasping or holding any part of the individual's
body;
(E) Challenging
behaviors-Culturally undesirable behavior(s) likely to both limit access to the
community and interfere with independence and autonomy;
(F) Chemical restraint-Medications
(prescribed or over-the-counter) administered with the primary intent of
restraining an individual who presents a likelihood of serious physical injury
to himself or others, not prescribed to treat a person's medical condition (as
defined in section 630.005, RSMo);
(G) Due process-The right to be notified and
heard on the limitation or restriction, the right to be assisted through
external advocacy if an individual disagrees with the limitation or
restriction, and the right to be informed of available options to restore the
individual's rights;
(H) Emergency
interventions-Reactive strategies that are not part of the individual's plan
used to maintain safety of the individual or others in the threat of imminent
harm. These are strategies used for one (1) or two (2) incidents until a
planned intervention is developed in the safety crisis plan and/or BSP. These
emergency interventions may involve physical restraint strategies. These
interventions must be least restrictive and comply with statutes, rules,
regulations, and policies of the division;
(I) Emergency intervention system-also called
physical crisis management programs-A formal curriculum and training program to
teach prevention, de-escalation, and physical restraint, also called manual
holds, to maintain safety in emergency situations;
(J) Exclusion time out-The temporary
exclusion of an individual from access to reinforcement, as part of a formal
BSP, in which, contingent upon the individual's undesirable behavior(s), the
individual is excluded from the potentially reinforcing situation but remains
in the same area with others present;
(K) Functional Behavior Assessment
(FBA)-Information-gathering process used to understand the purpose of
challenging behavior. The functional assessment must be designed and monitored
by a licensed behavior analyst, or licensed psychologist, counselor, or social
worker trained in behavior analysis;
(L) Informed consent-Consent for treatment
based on certain basic elements that include: an understandable explanation and
purpose of the procedure to be followed, a description of physical, emotional,
or mental discomfort or risk to be expected, an offer to answer any inquiries
concerning the procedure, and an explanation that at any time consent can be
rescinded. Informed consent must be obtained from the individual, or the
guardian for individuals who have a guardian. Every effort should be made to
obtain informed agreement from individuals with guardians;
(M) Individual Support Plan (ISP)-A document
that results from the person centered planning process, which identifies the
strengths, capacities, preferences, needs, and personal outcomes of the
individual. The ISP includes a personalized mix of paid and non-paid services
and supports that will assist the person to achieve personally defined
outcomes;
(N) ISP team-The
individual, the individual's designated representative(s), and the support
coordinator. Providers of waiver-funded services may also participate in the
ISP team if the individual or guardian requests such participation;
(O) Least restrictive procedure-A procedure
that maximizes an individual's freedom of movement, access to personal
property, and/or ability to refuse while maintaining safety. The degree of
restrictiveness is based on a comparison of the various possible procedures
that would maintain safety for the individual in a given situation;
(P) Licensed behavioral support
professional-individual licensed in the state of Missouri under section
337.315 (6) and
(7), RSMo.
(Q) Manual hold-also called physical
restraint and manual restraint-Any physical hold involving a restriction of an
individual's voluntary movement. Physically assisting someone who is unsteady,
or blocking to prevent injury, is not considered a manual hold;
(R) Mechanical restraints-Any device,
instrument, or physical object used to confine or otherwise limit an
individual's freedom of movement that cannot be easily removed. Examples may
include locking a wheelchair, taking crutches, taking power mechanism from
wheelchairs, special seat belts that cannot be removed by the individual, or
other ways of restricting an individual's mobility. Mechanical restraints are
prohibited from use in home and community based settings. The following are not
considered mechanical restraints:
1. Medical
protective equipment prescribed as part of medical treatment for a medical
issue;
2. Physical equipment or
orthopedic appliances, surgical dressings or bandages, or supportive body bands
or other restraints necessary for medical treatment, routine physical
examinations, or medical tests;
3.
Devices used to support functional body position or proper balance, or to
prevent a person from falling out of bed, or falling out of a
wheelchair;
4. Typical equipment
used for safety during transportation, such as seatbelts or wheelchair
tie-downs; or
5. Mechanical
supports or supportive devices used in normative situations to achieve proper
body position and balance;
(S) Person centered planning process-A
process directed by the individual, with the inclusion of a circle of support
created by or with the individual, a guardian, the responsible party or other
person as freely chosen by the individual, who are able to serve as important
contributors to the process. The person-centered planning process enables and
assists the individual to access a personalized mix of paid and non-paid
services and supports that will assist him/her to achieve personally defined
outcomes. These trainings, supports, therapies, treatments and/or other
services become part of the ISP;
(T) Preventative strategies-Clearly defined
protocols which describe knowledge and skill sets that providers and/or the
individual must implement in order to prevent occurrences of undesirable
behaviors or the use of restrictive supports while also creating increased
opportunities for success. Preventative strategies are documented in the
support section of the ISP;
(U)
PRN-A medical term meaning "when necessary";
(V) PRN Psychotropic medication for
behavioral support-Medication (pharmacologic agent) that affects a person's
mental status and is prescribed to be given according to circumstance rather
than at a scheduled time. If utilized, the BSP/ISP must include skill or
responses to be developed to reduce the need for the PRN and must specifically
describe strategies to address the situation prompting the PRN use. Use of PRN
psychotropic medication is considered both a reactive strategy and a
restrictive intervention;
(W)
Provider-Any entity or person under contract with the Department of Mental
Health (DMH) to serve individuals with developmental disabilities funded by
general revenue or through home and community-based waivers administered by
DMH;
(X) Psychotropic/behavior
control medica-tions-Any medication that affects the person's mental status or
behaviors regardless of their diagnoses;
(Y) Qualified personnel-Staff persons who
have received training, demonstrated competency, and maintained required
certification and understanding of the following:
1. The Physical Crisis Management System
utilized at the agency in which they are employed;
2. The implementation of the individual's
safety crisis plan;
3. The
implementation of the BSP and ISP;
4. All requirements as a service provider
outlined in the most current service definitions for providers;
(Z) Reactive strategies-Actions,
responses, and planned and unplanned interventions in response to challenging
behavior. Emergency interventions are types of reactive strategies. Reactive
strategies have the aim of bringing about immediate change in an individual's
behavior or control over a situation so that risk associated with the behavior
is minimized. Reactive strategies may take a number of forms and can include
environmental, psychosocial, and restrictive interventions. Such procedures may
be utilized as a first time response to an emergency situation. This also
includes responses that are more delayed such as restricting access to the
community or increased levels of supervision;
(AA) Reactive strategy threshold-The use of
five (5) or more reactive strategies within a one (1) month period. This
threshold applies to the use of reactive strategies that also meet the
definition of restrictive interventions;
(BB) Regional Behavior Supports Committee
(RBSC)-A committee consisting of a chairperson who is a Licensed Behavior
Analyst, employed by the division and appointed by the division director or
designee, along with qualified members, whose functions include meeting the
expectations set forth in this rule;
(CC) Regional Office (RO)-Local offices of
the Division of Developmental Disabilities (referred to as "the division"
throughout this document) serving a defined geographic region of the
state;
(DD) Restrictive
interventions-The use of interventions that restrict movement, access to other
individuals, locations or activities, restrict rights or employ aversive
methods to modify behavior. These may also be called restrictive supports,
procedures, or strategies;
(EE)
Safety assessment-An assessment by the planning team and a medical professional
of an individual's physical, and/or emotional status. This includes history and
current conditions that might affect safe usage of any reactive strategies, and
identifies those reactive strategies that should not be used with the
individual due to medical or psychological issues of safety. The safety
assessment should be completed annually or on the occasion of any significant
change;
(FF) Safety crisis plan-An
individualized plan outlining the reactive strategies designed to most safely
address dangerous behaviors at the time of their occurrence or to prevent their
imminent occurrence, included as part of a BSP or ISP;
(GG) Seat belt guard-A safety device to
prevent the release of the seat belt while the car is in motion. Seat belt
guards are not mechanical restraints;
(HH) Seclusion time-out-The involuntary
confinement of an individual alone in a room or an area from which the
individual is physically prevented from having contact with others or leaving.
This is sometimes referred to as a safe room or calm room. Locked rooms (using
a key lock or latch system not requiring staff directly holding the mechanism)
are prohibited.
(II) Significantly
challenging behaviors- Actions of the individual which can be expected to
result in issues described in paragraphs 1.-6. below. Services to address these
behaviors may necessitate involvement of a licensed behavior analyst or other
licensed professional with appropriate training and experience-
1. Have resulted in external or internal
injury requiring medical attention or are expected to increase in frequency,
duration, or intensity such that medical attention may be necessary without
intervention by a licensed behavior support professional;
2. Have occurred or are expected to occur
with sufficient frequency, duration, or intensity that a life-threatening
situation might result because of self-injury, aggression, or property
destruction. Examples include excessive eating or drinking, vomiting,
ruminating, eating non-nutritive substances, refusing to eat, swallowing
excessive amounts of air, or running into traffic;
3. Have resulted or are expected to result in
major property damage or destruction, value of property more than two hundred
dollars ($200);
4. Have resulted in
or are expected to result in arrest and confinement by law enforcement
personnel;
5. Have resulted in the
need for additional staffing and/or behavioral/medical personal assistant
services; or
6. Have resulted in
the repeated use of emergency interventions and restrictive supports;
and
(JJ) Waiver
assurances-As a condition of waiver approval by the Centers for Medicare and
Medicaid Services, states collect and report performance data to measure
compliance with assurances specified in the Code of Federal
Regulations at 42
CFR 441.302.
(2) Rights of individuals and assurances.
(A) No individual shall experience
restrictive supports without due process. Restrictive supports include, but are
not limited to, any limitation of access to:
1. Communication with others;
2. Leisure activities;
3. The individual's own money or personal
property;
4. Goods or services per
typical routines;
5. Access to
parts of the home or the community; and
6. Privacy or independence via any direct
observation and procedures such as continuous one-to-one staffing during times
or places which would otherwise be considered private.
(B) In addition to those rights described in
and assured by federal and state law and
9 CSR
45-3.030, all individuals served by the division have
the right to be treated with dignity and respect, to receive services in the
least restrictive environment, and to be assured freedom from coercion and
aversive stimuli.
(C) All
individuals served by the division have strategies that may prevent problem
situations and challenging behaviors included in their ISPs. Preventive
strategies shall meet the following conditions:
1. If there is a BSP, preventive strategies
must be included;
2. Preventive
strategies may be developed by non-licensed team members if the behavior of
concern meets the following conditions:
A.
The behavior has not caused significant injury or danger to self, others, or
property; and
B. The behavior has
not restricted the individual's access to the community, and if the support
strategies involved typically may be considered public domain by promoting a
more positive environment, enriching the individual's daily routine, and
teaching more functional skills, but are not solely the practice of applied
behavior analysis.
(D) Individuals who are receiving paid
supports who have experienced or are considered by the person centered planning
team as likely to experience emergency interventions shall-
1. Have qualified personnel supporting them
who have been competency trained in an emergency intervention system, who
maintain current certification in the system; and
2. Have a safety assessment and a current
safety crisis plan with all support providers.
(3) Service delivery.
(A) Individuals have the right to receive
appropriate supports and services in accordance with their ISP and in
accordance with 9 CSR 45-2.017.
(B) Individuals are integrated in and have
access to the greater community in accordance with
42 CFR
441.301. The division ensures that services
provided are of good quality and comparable to those provided to persons in the
community without disabilities.
(C)
Providers comply with the terms and conditions of the home and community-based
waivers approved by the Centers for Medicare and Medicaid Services and operated
by the division and the MO HealthNet DD Waiver Provider
Manual.
(4) Contracted
providers shall monitor and implement positive proactive strategies to reduce
the likelihood that an individual will require reactive strategies or
restrictive interventions. Providers shall develop processes to review the
problem situations when the reactive strategy threshold is reached.
(A) Individuals reaching the reactive
strategy threshold trigger the planning team's extensive review and analysis of
the problem situations. The planning team should-
1. Convene within five (5) business days to
complete the review and any restrictions of the supports, environment, training
for staff, medications, or other issues that might affect the
individual;
2. Identify triggers,
preventative strategies, and barriers to using the least restrictive
strategies;
3. Consider the need
for a functional behavior assessment, and development of a formal BSP or
revision of an existing BSP; and
4.
Develop new or revised proactive strategies and strategies to prevent
situations that are likely to result in use of reactive strategies.
(B) Any individual meeting the
reactive strategy threshold for three (3) consecutive quarters should be
referred to the Regional Behavior Support Review Committee for consultation. If
an individual meets the reactive strategy threshold of five (5) or more in a
one (1) month period, the planning team should request the support coordinator
submit a request for behavioral services.
(5) Restrictive Interventions other than
approved physical crisis management procedures shall not be used as an
emergency or crisis intervention.
(A) Use of
restrictive procedures that meet the definition of reportable events must be
reported in accordance with
9 CSR
10-5.206.
(B) Restrictive interventions are utilized
only as alternatives to more restrictive placements and only as a means to
maintain safety and allow the teaching of alternative skills that the
individual can utilize to more successfully live in the community.
(C) The ISP must include justification for
any restrictions. The following requirements must be documented in the ISP:
1. Identification of a specific and
individualized assessed need;
2.
Documentation that the positive interventions and supports used prior to any
modifications to the ISP;
3.
Documentation that less intrusive interventions were tried but were not
successful;
4. Regular collection
and review of data to measure the ongoing effectiveness of the
intervention;
5. Established time
limits for periodic reviews to determine if the intervention is still necessary
or can be terminated;
6. Informed
consent of the individual or their legal guardian; and
7. Assurances that interventions and supports
will cause no harm to the individual as described in
42 CFR
441.301(c)(2)
(xiii).
(D) Prohibited
procedures-The following interventions are prohibited by the division and are
considered at high risk for causing harm:
1.
Any technique that interferes with breathing or any strategy in which a pillow,
blanket, or other item is used to cover the individual's face;
2. Prone restraints (on stomach); restraints
positioning the individual on their back supine; or restraints against a wall
or object;
3. Restraints which
involve staff lying/sitting on top of an individual;
4. Restraints that use the hyperextension of
joints;
5. Any technique or
modification of a technique which has not been approved by the division, and/or
for which the person implementing the technique has not received
division-approved training;
6.
Mechanical restraints;
7. Any
strategy that may exacerbate a known medical or physical condition, or endanger
the individual's life, or is otherwise contraindicated for the individual by
medical or professional evaluation;
8. Use of any reactive strategy or
restrictive intervention on a "PRN" or "as needed" basis;
9. Standing orders for use of restraint
procedures not part of a comprehensive safety crisis plan that delineates
prevention, de-escalation, and least restrictive procedures to attempt prior to
use of restraint;
10. Any procedure
used as punishment, for staff convenience, or as a substitute for engagement,
active treatment, or behavior support services;
11. Use of law enforcement or emergency
departments cannot be incorporated into ISPs or BSPs as "PRN" procedures or as
contingencies to eliminate or reduce problem behaviors;
12. Reactive strategy techniques administered
by other individuals who are being supported by the agency;
13. Corporal punishment or use of aversive
conditioning-Applying painful stimuli as a penalty for certain behavior, or as
a behavior modification technique;
14. Overcorrection strategies- Requiring the
performance of repetitive behavior as a consequence of undesirable behavior
designed to produce a reduction of the frequency of the behavior;
15. Placing persons in totally enclosed cribs
or barred enclosures other than cribs; and
16. Any treatment, procedure, technique, or
process prohibited by federal or state statute.
(E) Procedures that may be conditionally
approved in writing by the division-
1. Any
modification to a physical crisis management technique or any non-nationally
recognized physical crisis management system;
2. Seclusion time-out placement of a person
alone in a secured room or area which the person cannot leave at will shall
only be utilized as part of an approved BSP. The use of seclusion time-out
requires ongoing services from a licensed behavioral service provider and prior
review and approval by the RBSC; and
3. Use of physical crisis management
procedures when part of a comprehensive safety crisis plan that delineates
prevention, de-escalation, and least restrictive procedures to attempt prior to
use of restraint.
(6) BSPs are developed by a licensed
behavioral service provider in collaboration with the individual's support
system. The techniques included in the plan are based on a functional
assessment of the target behaviors. The techniques meet the requirements for
the practice of applied behavior analysis under sections
337.300 through
337.345, RSMo. The BSP includes
the following information:
(A) Alternative
behaviors for reduction and replacement of target behaviors, defined in
observable and measurable terms. They are specifically related to the
individual and relevant environmental variables based on FBA;
(B) Goals and objectives for acquisition of
appropriate alternative behaviors;
(C) Interventions aligned with positive
functional relationships described in FBA including strategies to address
establishing operations, contextual factors, antecedent stimuli, contributing
and controlling consequences, and physiological and medical
variables;
(D) Data collected must
include antecedents/triggers, description of events, duration,
consequence/result, and effects of interventions;
(E) If physical restraint or seclusion
time-out are used, health status is monitored and data documented for one (1)
hour after the event in fifteen (15) minute intervals. Health status data
includes monitoring of vital signs including pulse, visual observations of
ener-gy/lethargy level, engagement with others, and other observed
reactions;
(F) Description of
specific data collection methods for target behaviors to assess the
effectiveness of the strategies and data collection methods to assess the
fidelity of implementation strategies;
(G) Data displayed in graphic format in the
monthly progress reports, with indications for the environmental conditions and
changes relevant to target behaviors;
(H) Proactive strategies to prevent
challenging behaviors, improve quality of life, promote desirable behaviors,
and teach skills, that are specifically described for consistent implementation
by family and/or staff;
(I)
Specific strategies with detailed instructions for reinforcement of desirable
target behaviors;
(J) Specific
strategies to generalize and maintain the desired effects of the BSP, including
strategies for fading contrived contingencies to natural contingencies to
support system changes and maintain these strategies after BSP is
faded;
(K) A safety crisis plan if
it is necessary to have strategies to intervene with at risk behaviors to
maintain safety;
(L) If a plan
includes physical restraint or seclusion time-out, specific criteria and
procedures are identified;
(M)
Target behavior(s) related to the symptoms for which psychotropic medications
were prescribed and when they should be administered and the process for
communicating data with the prescribing physician;
(N) Description of less restrictive methods
attempted in the past, their effectiveness, and rationale that proposed BSP
strategies are the least restrictive and most likely to be effective as
demonstrated by research or history of individual;
(O) The method of performance based training
to competency for caregivers and staff providing oversight;
(P) The qualified behavioral service provider
reviews data at least monthly; and
(Q) Description of how the plan will be
communicated to all supports and services including the frequency with which
the ISP team will receive updates.
(7) A safety crisis plan is developed by the
support team after the first use of any reactive strategy or when the personal
history of the individual indicates there is a likelihood that reactive
strategies may be needed in the future, or where the individual's support team
plans to use reactive strategies.
(A) If
reactive strategies are considered likely and necessary, the team should be
proactive and consider the need for more specialized support strategies in the
ISP and services such as Person Centered Strategies Consultant or Behavior
Analysis Services (see Medicaid Waiver service definitions).
(B) Procedures identified are least
restrictive and within safety parameters of the safety assessment. These are
used as a last resort after implementation of proactive, positive
approaches.
(C) If a safety crisis
plan includes physical restraint, exclusion time-out, or seclusion time-out,
specific criteria and procedures are identified.
(D) The plan includes the informed consent of
the person, their parent, or guardian.
(E) The safety crisis plan is a part of the
ISP.
(F) Safety crisis plans are
part of any BSP.
(8) If a
safety crisis plan includes the use of physical restraint, the name of the
approved or nationally recognized crisis management program must be included in
the individual's safety crisis plan (as per section 630.175.1, RSMo).
Restraints are only used in situations of imminent harm to prevent an
individual from injuring self or others. Less restrictive crisis management
procedures, including de-escalation techniques and environmental management,
should be attempted prior to use of any type of restraint. Use of physical
restraints are documented in a safety crisis plan.
(A) Physical Restraints. Techniques used to
physically restrain individuals are limited to those from nationally recognized
physical crisis management programs or internally developed programs approved
by the division.
1. Requests for use of
physical crisis management systems other than those that are nationally
recognized must be made, in writing, to the Chief Behavior Analyst of the
division. If internally developed systems are approved and utilized, a
quarterly analysis of the use of the restraint procedures and strategies to
eliminate the need is completed and submitted to the Chief Behavior
Analyst.
2. The physical restraint
techniques are used only in the manner designed, are formally trained to
competency, and staff maintain certification as specified by the physical
crisis management system.
3.
Physical restraint techniques are only employed for situations of imminent harm
to self or others and not to protect property.
4. Any improper or unauthorized use of a
physical restraints or excessive application of force may be considered abuse
and may prompt an investigation.
5.
Blocking is not considered a physical restraint procedure if used as defined in
this rule.
(B) Chemical
restraints include prescription and over the counter medications and require
the approval of the division director or his/her designee prior to
implementation of these restraints. Any use of a chemical restraint must be
included in an approved safety crisis plan meeting the following criteria:
1. Identification of chemical restraints to
be used;
2. Written physician
orders for any chemical restraints are time limited and for no longer than
three (3) hours;
3. Written
physician orders are placed in the individual's record and contain at least the
following information:
A. Brief description of
the imminent harm situation including ongoing activities, staff actions, and
the individual's actions that relate to the imminent harm;
B. Type of chemical restraint used;
C. The time when the order was
written;
D. The time when the
chemical restraint was first administered;
4. Ongoing visual observation and safety
checks during the time that the chemical restraint is affecting the
individual;
5. Standing or PRN
orders for chemical restraints shall not be used. Specification in a safety
crisis plan or reactive strategies deemed safe for an individual and/or
recommended as the most likely to be effective will not be considered as PRN
orders;
6. The authorized medical
professional designated by the physician writing the order observes the
individual and evaluates the situation within thirty (30) minutes from the time
chemical restraints were initiated; and
7. In an emergency in which an on-site
authorized physician is not available, only a registered nurse or a qualified
licensed practical nurse may administer chemical restraints to an individual
and only after receiving an oral order from an authorized physician.
A. The documentation of such oral orders
include the following:
(I) Name of physician
who gave the order;
(II) Name of
nurse who received the order;
(III)
Name of nurse who actually administered the chemical restraint-identify
behaviors requiring the chemical restraint in specific terms that allow
measurement;
(IV) Anticipated
effects of the medication and time frame related to the effects.
B. The person administering the
chemical restraints documents the information required and the physician's oral
order in the individual's record or equivalent record.
C. The oral order is signed by a physician as
soon as possible after the initial administration of the chemical
restraint.
(C)
Mechanical restraints are prohibited.
(9) Utilization of a seclusion time-out (or
safe-room) procedure requires prior approval from the Chief Behavior Analyst.
Request for such approval must include a functional assessment of the target
behavior, a BSP, the rationale for the use of the procedure, and data
supporting the need for the procedure and that less restrictive interventions
were ineffective. The Chief Behavior Analyst must also approve of the
designated time-out area or room.
(A)
Seclusion time-out will become a prohibited procedure as of July 1,
2021.
(B) Behavioral services
remain active during the time period in which the BSP (seclusion time-out
intervention) is in place.
(C) The
BSP with a seclusion time-out procedure includes all elements identified in
section (6) of this rule as well as the following:
1. Specification that only qualified
personnel may use seclusion time-out for an individual under conditions set out
in an approved BSP;
2. If the BSP
includes time-out, it is reviewed and approved by the following:
A. RBSC;
B. The individual or the family, or legal
guardian as appropriate; and
C. The
Chief Behavior Analyst or designee;
3. Target behaviors, operationally defined,
and consistent with the function identified in the functional assessment for
the target behavior;
4. Description
of strategies to ensure high rates of positive reinforcement and engaging
activities are available for the individual making "time in" an enriched
situation;
5. Criteria for release
from seclusion time-out and discontinuation of a seclusion time-out episode-
A. Release from seclusion time-out criteria
is limited to no more than five (5) minutes of calm behavior;
B. Total duration for the seclusion time-out
episode is no more than one (1) hour except in extraordinary instances (during
initial stage of program) that are personally approved at the time of
occurrence by the behavior analyst and reviewed within one (1) business day by
the region's assigned area behavior analyst;
C. Continuous observation of the person in
time-out;
D. Seclusion time-out
will be discontinued if there are any signs of injury or medical emergency and
the person will be assessed by appropriate medical personnel; and
E. The date, time, and duration of each
seclusion time-out intervention is documented on a data sheet and on an event
management form.
(D) Time-out areas or rooms shall meet the
following safety and comfort requirements:
1.
Areas and rooms to be utilized for seclusion time-out and the procedures for
the use of seclusion time-out are reviewed and approved by the Chief Behavior
Analyst or designee;
2. Continuous
observation of the individual in the area is maintained at all times;
3. Adequate lighting and ventilation is used
at all times;
4. The area or room
is void of objects and fixtures such as light switches, electrical outlets,
door handles, wire, glass, and any other objects that could pose a potential
danger to the individual in time-out;
5. If there is a door to the room or area, it
will open in the direction of egress such that the individual in the room is
not able to bar the door to prevent entry;
6. The door is void of any locks or latches
that could allow the door to be locked without continuous engagement by a staff
person; and
7. The room or area
will be at least six (6) feet by six (6) feet in size or large enough for any
individual who will utilize the room to lie on the floor without head or feet
hitting walls or door.
(10) The division provides oversight for
services provided to individuals with significantly challenging behaviors
through RBSCs. The division establishes at least two (2) RBSCs. Additional
RBSCs may be established depending upon need and staff capacity.
(A) Members of the RBSC are appointed by the
division director or designee.
(B)
The RBSC consists of three (3) to five (5) members including:
1. A chairperson who is a licensed behavior
analysis employed by the division;
2. A member or members of the provider
community licensed to practice applied behavior analysis or who provided
behavior therapy under contract with DMH prior to January, 2012 or who are
working towards Board Certified Behavior Analyst (BCBA) or Board Certified
Assistant Behavior Analyst (BCaBA) certification under the supervision of a
licensed behavior analysis; and
3.
A medical consultant or other professionals as indicated by the information
under review or requested by the chairperson.
(C) The RBSC meets at least once every three
(3) months, and may meet as often as needed to fulfill
responsibilities.
(D) The purpose
of RBSCs is to promote the implementation of best practice strategies that lead
to greater independence and enhanced quality of life for individuals
experiencing challenging behaviors. RBSCs ensure the following:
1. That waiver assurances are met;
2. That best practice behavioral services are
followed;
3. That ethical
guidelines are followed;
4. That
behavioral strategies are least restrictive; and
5. That implementation of strategies
documented in the ISPs and BSPs support progress toward greater independence
and enhanced quality of life.
(E) The division establishes RBSC review
criteria to prioritize the individuals with significantly challenging behaviors
and those individuals whose supports include restrictive interventions.
1. Individuals experiencing significantly
challenging behaviors reaching threshold criteria for reactive strategies, or
who have been prescribed psychotropic/behavior control medications, or who have
PRN psychotropic medication for behavioral support.
2. A BSP may be reviewed based on a request
by the members of the ISP, including, but not limited to, the parent/guardian,
support coordinator, or Regional Director (or designee) to provide technical
assistance.
3. The Regional
Director and the RBSC prioritize reviews to ensure appropriate representation
based upon issues that represent regional challenges to meet identified
objectives.
4. The RBSC shall
respond to requests for review within thirty (30) calendar days of receipt of
the request.
5. The support
coordinator and provider of BSPs and ISPs reviewed by the RBSC will receive
written summary of the RBSC's recommendations within five (5) working days of
the RBSC's review of the BSPs or ISPs.
(11) If use of prohibited or unauthorized
procedures is discovered, the following occurs:
(A) Regional Director is notified of the use
of prohibited procedures, the agency involved, persons for whom the procedures
were utilized, and reasons for use;
(B) Regional Director directs regional staff
and Area Behavior Analyst to conduct a focused review of the agency;
(C) If the focused review confirms that
prohibited or unauthorized procedures were used, the Regional Director will be
informed and notify the provider and support coordinator;
(D) Area Behavior Analyst works with planning
teams to determine appropriateness of strategies and need for additional
services to assist the provider to address the situations positively,
proactively, and preventatively;
(E) Area Behavior Analyst refers supports of
individuals, for whom the prohibited practices have been used, to the RBSC;
and
(F) Follow up reviews of the
provider will occur to ensure that appropriate procedures and supports are
utilized and prohibited practices have been discontinued for a duration
determined by the Chief Behavior Analyst.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.