14-197-5 Me. Code R. § 3

Current through 2024-51, December 18, 2024

Section 197-5-3 - SUPPORTING A PERSON WHO IS ENGAGING IN CHALLENGING BEHAVIOR

Whenever a Person is engaging in Challenging Behavior, the Person's Planning Team must take steps to assist the Person to engage in Prosocial Behavior, reduce the Challenging Behavior, and prevent harm. Planning Teams must ensure they have evaluated and implemented supports at the least restrictive levels before considering more restrictive measures.

This rule identifies a hierarchy of supports, interventions and restrictions for supporting Persons with Challenging Behaviors (See Section 5.03 and Appendix Four) and describes the process a Planning Team must follow prior to implementation of each level of support or intervention. The processes described in this rule must be adhered to when a Planning Team is responding to a Person's Challenging Behavior or a precursor to Challenging Behavior.

The Planning Team must demonstrate that all monitoring and documentation requirements in this rule have been met.

5.03-1Positive Support (Levels 1-2)

A. Positive Supports are the first approach that the Planning Team must implement to assist a Person experiencing Challenging Behaviors. The Planning Team must ensure the development of a Functional Assessment and implement a Positive Support Plan. The goal of the Positive Support Plan must be to reduce Challenging Behavior and eliminate the need for more restrictive practices.

B. The entity or person who identifies the need to address a Challenging Behavior through a Positive Support Plan is responsible to initiate the Planning Team process. The Planning Team is responsible to ensure all documentation, assessments, plans and reviews are completed as required.

C. The Planning Team must ensure that Medical and Mental Health Assessment and Treatment, as described in Section 5.04-2, are part of the Positive Support Plan.

D. The Planning Team must develop a Psychiatric Medication Support Plan whenever Psychiatric Medications are used to address Challenging Behavior.

E. The Planning Team must develop an In-Home Stabilization Plan, as described in Appendix Three whenever In-Home Stabilization will be used under one hour for safety and assessment.

5.03-2Evidence and Documentation Required for Positive Support Plans

Planning Teams must maintain required documentation for all Positive Support Plans. Positive Support Plans at Level 1 or 2 must include:

A. A Positive Support Plan and Functional Assessment in the Personal Plan;

B. Documentation of implementation, evaluation and modification of the Positive Support Plan;

C. A transition plan for reduction of restrictions of Rights, and transition to more Positive Supports, naturally occurring Reinforcers and personal control for all Positive Support Plans at Level 2; and

D. A Psychiatric Medication Support Plan, if required, and documentation of usage.

Level 1	Support for the Person to participate meaningfully in his/her community life.
Description: - No restrictions of Rights - Non-coercive intervention with voluntary participation by the Person		Examples include, but not limited to: - Physical & mental health assessment and treatment - Environmental modification - Communication support - Teaching Skills - Physical prompts for teaching or personal support without Coercion - Voluntary Timeout
Required Approval: Planning Team, including the Case Manager		Required Documentation: Functional Assessment, Positive Support Plan

Level 2	Programs which are designed to modify or redirect a Person's behavior
Description: - Non-coercive intervention with voluntary participation by the Person - Some programs which restrict a Person's activities or Rights for safety reasons - Preservation of personal property and safety measures involving incendiary material or sharps - Positive Behavior Modification Techniques		Examples include, but not limited to: - In-Home Stabilization for a maximum of one hour for safety and assessment - Securing of incendiary material, clothes, shoes or sharps with documented safety issues or problematic misuse, when the Person does not communicate an objection. - Restriction of food or liquid (with doctor's health or safety recommendation) - Verbal Redirection or verbal prompting to redirect behavior - Non-Exclusionary Timeout - Locks that the Person is able to unlock
Required Approval: Planning Team, including the Case Manager		Required Documentation: Functional Assessment, Positive Support Plan, Transition Plan toward more naturally occurring reinforcers, In-Home Stabilization Plan as indicated

5.03-3Behavior Management (Levels 3-5)

A. If the Planning Team determines that Positive Supports alone are insufficient to prevent harm or danger to the Person or the community, the Planning Team must ensure the development of a Behavior Management Plan or follow Emergency intervention procedures within this rule. Behavior Management Plans must be developed in consultation with a qualified professional who must be a psychiatrist, a licensed psychologist or psychological examiner, a Licensed Clinical Social Worker, Licensed Clinical Professional Counselor, or a Board Certified Behavior Analyst.

B. The Behavior Management Plan must describe how to support the Person, including any proposed procedures that involve temporary restrictions of Rights or the use of Restraint. This rule describes planning and approval requirements necessary before the Behavior Management Plan can be implemented.

C. The entity or person who identifies the need to address a Challenging Behavior through a Behavior Management Plan is the member of the Planning Team responsible to initiate the Planning Team process. The Planning Team is responsible to ensure all documentation, assessment, plans and reviews are completed as required.

D. In all cases, Positive Supports must continue to be implemented and evaluated to address the Challenging Behavior.

E. This rule defines circumstances that require an Updated Functional Assessment, Psychological Assessment and/or Physician's Evaluation as part of Behavior Management Planning.

F. This rule also defines Prohibited Practices (See Section 5.06), which are those Practices which will not be approved and must not be implemented at any time.

5.03-4Evidence and Documentation Required for Behavior Management Plans

Planning Teams must submit required documentation when submitting a Behavior Management Plan for review.

A. All new Behavior Management Plans submitted for review must include:

1. The Personal Plan;

2. The Updated Functional Assessment;

3. The Positive Support Plan;

4. A history of Positive Support interventions;

5. A Psychiatric Medication Support Plan, if required, and documentation of usage;

6. The proposed Behavior Management Plan;

7. A summary of reportable events for the past year;

8. The Psychological Assessment, if required; and

9. Documentation of the Physician's Evaluation.

B. Behavior Management Plans submitted for ongoing approval must be submitted at least ten working days prior to the review date and unless the Review Team specifies otherwise must include the following information:

1. Documentation from the monthly monitoring of the Behavior Management Plan by the overseeing clinician;

2. Minutes reflecting the discussion of the Behavior Management Plan in quarterly reviews by the Planning Team;

3. Notes of quarterly monitoring of the Behavior Management Plan conducted by the Case Manager;

4. A summary of data gathered as indicated in the approved Behavior Management Plan;

5. A summary of reportable events since the previous approval date;

6. Updated or modified Behavior Management Plans and assessments; and

7. A Psychological Assessment within the past three years, if required.

Level 3	Programs which restrict a Person's Rights as enumerated in 34-B M.R.S. §5605
Description: - Planned Restriction of Rights - An intervention to which the Person or the Person's Guardian, as appropriate, communicates an objection - Use of Coercion		Examples include, but not limited to: - Physical Redirection - In-Home Stabilization for more than one hour for safety and assessment, not to exceed 24 hours. - Property Removal (other than for Imminent Risk) - Restriction of communication (other than to a Guardian, Advocate or Crisis Team); - Restriction of privacy - Search of the Person or personal space - Restriction of food or liquid - Buzzers/alarms/sensors or locks that the Person is unable to disarm or unlock on doors/windows, etc. -Electronic monitoring Devices (video, ankle bracelet, etc.), - Releasing (briefly holding the Person in order to release oneself and/or another person from a physical hold such as a bite or hair hold) - Planned use of Law Enforcement - Restriction of a communication device that prohibits the Person's ability to communicate. - Restriction of a communication device when the device is being used for an illegal activity.
Required Approval: Planning Team, including the Case Manager, Case Management Supervisor, Review Team Signatures		Required Documentation: Functional Assessment (Updated), Positive Support Plan, Behavior Management Plan, In-Home Stabilization Plan as indicated, Physician's Evaluation, Psychiatric Medication Plan as indicated

Level 4	All programs with a Restraint component
Description: - Planned Use of Restraint - Planned Removal of staff - Use of Coercion - Must not include Prohibited Practices		Examples include, but not limited to: - Physical Restraint/interventions - Any physical force or threat thereof to cause a Person to move. - Physically confining a Person - Blocking - Temporary removal of staff - In-Home Stabilization for more than one hour for safety and assessment, when Behavior Management Plan includes possibility of renewal of In-Home Stabilization after 24 hours. -Use of a Restraint without an attempt to release, longer than 15 minutes -Use of a Specialized Restraint - Restraint that prohibits the Person's ability to communicate, such as a restraint that interferes with a person's ability to use gestural communication or sign language
Required Approval: Planning Team, including the Case Manager, Case Management Supervisor, Review Team Signatures		Required Documentation: Functional Assessment (Updated), Positive Support Plan, Behavior Management Plan, Psychological Assessment, Physician's Evaluation, In-Home Stabilization Plan as indicated, Psychiatric Medication Plan as indicated

Level 5	Programs considered only in exceptional and rare instances where no less restrictive measure can safely meet the need to keep a Person from danger to self or others.
Description: - Programs that propose significant restriction or unusual risk to the Person - The level of risk or restriction must not outweigh the potential harm from the Challenging Behavior being addressed - Programs that pose a potential harm that the Statewide Review Panel deems atypical may be required to meet Level 5 review requirements - Prohibited Practices will not be considered for approval.		Examples include, but not limited to: - Some Mechanical Restraints (other than those expressly prohibited by these regulations), such as splints, mitts, or helmet may be approved for use in unusual circumstances for purposes of Behavior Management. Examples of unusual circumstances may include transitioning from institutional programs or family settings into a setting governed by these regulations. - Supine, or face-up floor Restraint - Chemical Restraint - Noxious Interventions - Binding of wrist to waist or wrist to bed
Required Approval: Planning Team, including the Case Manager Case Management Supervisor Review Team Signatures Commissioner or designee Signature		Required Documentation: Functional Assessment (Updated), Positive Support Plan, Behavior Management Plan In-Home Stabilization Plan as indicated Psychological Assessment, Physician's Evaluation, Psychiatric Medication Plan as indicated Second Clinical Opinion Statewide Review Panel Recommendation

5.03-5Requirements for Plans and Assessments

The following plans and assessments are described within this rule. When required, plans and assessments must meet the standards described herein.

A. Functional Assessment (see Appendix One)

B. Positive Support Plan (see §5.04-1 and Appendix Two)

C. Psychiatric Medication Support Plan (see §5.04.3)

D. Updated Functional Assessment (see §5.05-1)

E. Behavior Management Plan (see §5.05-1)

F. In-Home Stabilization Plan (see Appendix Three)

G. Psychological Assessment (see §5.05-5)

H. Physicians' Evaluation (see §5.05-5)

14-197 C.M.R. ch. 5, § 3