Subsection 144-101-II-18.11 - BEHAVIORAL INTERVENTIONSA provider of services under this Section must comply with the following provisions in planning for and carrying out any intervention to correct or modify a member's behaviors.
18. 11-01 Process for Review and Approval of Behavioral InterventionsUse of a particular intervention to change or eliminate a specific behavior of a member requires a written plan, incorporated within the member's Care Plan, that is developed, reviewed, and approved as follows.
A. Functional Behavior Assessment: The use of an intervention must always be preceded by a Functional Analysis of Behavior and documented efforts to address the dangerous or maladaptive behavior by the use of positive techniques or less intrusive approaches, which have been tried systematically and determined to be ineffective. B. Clinician Input: An intervention that is mildly or moderately intrusive as defined in section 18. 11-02, must be developed and approved by a licensed clinician who has direct experience working with individuals with a brain injury and is approved by the DHHS Program Manager for Brain Injury. C. Planning Team Review: A planning team must meet to review proposed interventions and approve their use. The planning team must include: (1) the individual and guardian, where one has been appointed; (2) the Care Coordinator, who will be responsible for coordinating the inclusion of any other relevant individuals; and (3) representatives from every site at which the behavioral treatment procedure is to be implemented. Prior to approval, the team must evaluate factors that may be contributing to the occurrence of the behavior, which may include: 1. Illness, Disease, Medication Interaction;2. Impact of brain injury on behavior;3. Psychiatric conditions; and4. Significant life events. In the event that factors such as those listed above exist, the planning team may still determine that a behavioral plan is indicated, but the planning team shall include, as part of the plan, its rationale for so deciding.
D. Documentation in Care Plan: The behavioral intervention procedure must be documented in the Care Plan, and must include all of the following elements: 1. A concise and accurate identification and description of the specific behavior(s) to be addressed and the behavioral goal;2. A Functional Analysis of Behavior including the history of the behavior and what positive methods have been utilized in the past;3. A description of the baseline measurements of the frequency, duration, intensity and/or severity of the behavior(s);4. A concise and precise description of the methodology for consistently implementing the plan;5. A description of the means of recording and measuring of the frequency, duration, intensity and/or severity of episodes of the specific behavior(s) and the use of interventions;6. A schedule for periodic review by the planning team of the plan which shall be at least semiannually;7. Criteria for the discontinuation of the plan, whether because it has been successful, its continued implementation is unlikely to be successful, or it is causing the individual more harm than benefit. There may be behavioral plans which show slow progress. These plans may require implementation and monitoring over an extended period of time. E. Department Oversight Committee Review:All Plans involving mildly or moderately intrusive interventions require review and approval by a Department oversight committee consisting of the Program Manager of Brain Injury Services and at least two other Department staff with expertise in the behavioral health field. Review shall be conducted both initially and on a semi-annual basis. F. Written Consent: The intervention must be approved, in writing, by the individual or by the guardian, when one has been appointed. Such written consent must be incorporated within the Care Plan. Withdrawal of approval requires immediate termination of the intervention. 18. 11-02 Categories of Behavioral InterventionsA.Positive Behavioral Supports1. Positive behavioral supports are those which are directed toward reducing an individual's maladaptive behavior, but which do not entail any limitations upon the individual's rights. Examples of such interventions include but are not limited to: a. Rewarding positive behavior;b. Rewarding the absence of dangerous behavior;c. Modeling of appropriate behavior;d. Environmental alteration;f. Teaching of Coping Skills, self-management, self-calming skills; and2. Positive or neutral interventions may be used on an informal basis for individual safety or to promote a harmonious, supportive environment. The planning team must approve systematic use of an intervention. B.Mildly Intrusive Interventions1. Mildly intrusive interventions are characterized as those in which some form of limitation is imposed upon the individual, but the individual voluntarily complies with this imposition. Examples of mildly intrusive interventions include but are not limited to: a. Non-exclusionary timeout;c. Extinction (withdrawal of attention or planned ignoring of the target behavior that is in response to the behavior that is disruptive but not harmful or destructive. This is a mildly intrusive intervention.)2. An individual's voluntary compliance in a mildly intrusive plan is essential. Coercion is not permitted. Even in cases where a guardian has approved a plan, implementation is predicated upon the individual's voluntary compliance. C.Moderately Intrusive Interventions1. Moderately intrusive interventions are characterized by a greater degree of limitation being imposed upon the individual, but the individual voluntarily complies with this imposition. Examples of moderately intrusive interventions include, but are not limited to: c. Contingent Reinforcement using rewards based upon normal rights of access; and 2. An individual's voluntary compliance in a moderately intrusive plan is essential. Coercion is not permitted, but planning teams must be mindful of the possibility of more extreme behavior if compliance is not achieved. Even in cases where a guardian has suggested a procedure, implementation is predicated upon the individual's voluntary compliance. 18. 11-03 ProhibitionsA.Prohibited Practices: The following procedures and interventions are expressly forbidden in all circumstances: 1. Intentional infliction of pain or injury;2. The intentional instilling of fear, of pain or injury;3. Actions or language intended to humiliate, dehumanize or degrade an individual;4. Denial of basic rights including, but not limited to meals, sleep, adequate clothing, medications, medical treatment, and therapy; and5. The use of experimental interventions or those without scientific basis or merit. B.Violations: A service provider's use of any of the above procedures will be cause for investigation and action by the Department, including, when appropriate, referral to a law enforcement agency, licensing authority or other similar oversight bodies. C.Rights Limitations: Any limitation, whether actual or implied, upon an individual's freedom of movement or exercise of a right is expressly forbidden unless there is a formal and approved portion of an individual's CarePlan authorizing the rights limitations. D. Unusual or Noxious Interventions: In unusual circumstances, a planning team may propose an unusual or noxious intervention in an attempt to assure the health and safety of an individual who is engaging in extremely dangerous behaviors. Unusual or noxious interventions must be denied unless the designer of the intervention shows to the Department Oversight Committee, by a preponderance of the evidence, why that program should be allowed. In order to be considered, the benefits of the intervention need to clearly outweigh the harm to the member. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-18, subsec. 144-101-II-18.11