Section 197-5-5 - BEHAVIOR MANAGEMENT (Levels 3-5)When a Planning Team proposes a Behavior Management Plan, that Planning Team is responsible for adhering to requirements in Behavior Management Planning. Conditions for use of Behavior Management and Behavior Management Practices as outlined in Section 5.05-1. Planning Teams must meet additional requirements, as outlined in Section 5.05-4, for Behavior Management Plans when those plans include the use of Restraint. Planning Teams are responsible, as outlined in Section 5.05-5, for monitoring the Behavior Management Plan and also for documenting the planned accommodations as described in Section 5.05-6, when a Behavior Management Plan might have an impact on others.
5.05-1Behavior Management PlanningA.Requirements for Planning Team to ActWhen a Person's Challenging Behavior presents a threat of Imminent Risk of harm or danger to the Person or the community, or threatens loss of placement, the Planning Team must act to ensure the Person's safety. The Planning Team must continue to evaluate and implement the Positive Support Plan while Emergency Intervention is utilized or a Behavior Management Plan is developed and implemented.
When a Person is subject to a court order or conditions of probation and the Planning Team decides that the Service Provider will need to use interventions that restrict the Person's rights in order to enforce those orders or conditions a Behavior Management Plan must be developed that is consistent with the court order.
B.Requirements for Updated Functional AssessmentWhenever the Planning Team determines that the use of Behavior Management is indicated, the Planning Team must obtain an Updated Functional Assessment which must be used in development of the Behavior Management Plan. When a Behavior Management Plan continues to be deemed necessary by the Planning Team, the Functional Assessment must be updated at least every three years.
An Updated Functional Assessment may be new or a review of the original Functional Assessment and must be developed or updated by or under the supervision of a Psychiatrist, a Psychologist or Psychological Examiner, a Licensed Clinical Social Worker, a Licensed Clinical Professional Counselor, or a Board Certified Behavior Analyst. The process for the Updated Functional Assessment must include, but is not limited to:
1. Meeting and observing the Person;2. Interviewing the Correspondent and Guardian (if either has been appointed), and direct support professionals; and3. A review of the Person's record.C.Requirements for a Behavior Management PlanBehavior Management Plans must describe all planned interventions which include restrictions of Rights or the use of Restraint. Behavior Management Plans must be developed by or 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.
The Behavior Management Plan must be approved by the Planning Team and shall include, but is not limited to:
1. Consent by the Guardian;2. A concise and accurate description of each specific Challenging Behavior that makes it clear to an objective observer what the Challenging Behavior looks like;3. A description of the baseline measurements of the frequency, duration, intensity and/or severity of each Challenging Behavior; and4. A precise description of the intervention(s) to be utilized, in language that is understandable to the people implementing the Behavior Management Plan. The description of interventions must include:a. Identification of any precursor behavior or predictive event that occurs prior to the Challenging Behavior;b. Instructions to staff on how to respond to each precursor behavior or predictive event in order to reduce the likelihood that the Challenging Behavior will occur;c. Instructions on how to implement the Behavior Management technique(s);d. Indicators for when the Behavior Management technique(s) should cease and the Person can be supported to return to normal activities;e. A description of strategies, which will be conducted or overseen by the qualified professional who provides consultation on the Behavior Management Plan, to ensure that the Behavior Management Plan will be consistently implemented. A plan for documentation of training and supervision of staff must be included. Training must be offered to others who may be supporting the Person, including family members, Guardians or Correspondents;f. A description of the method of recording and measuring the frequency, duration, intensity and/or severity of episodes of the Challenging Behavior and the use and effect of interventions, including (if applicable) strategies implemented to address precursor behaviors or predictive events;g. The identification of a method for the quarterly evaluation and documentation of the effectiveness of the Behavior Management Plan, including input from direct support professionals and others involved in implementing the plan;h. Criteria for the discontinuation of the Behavior Management 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; andi. A description of the methodology that will be used to reduce the intrusiveness of interventions used and eventually fade out the use of the Behavior Management Plan.5.05-2Conditions for Use of Behavior ManagementA. A Behavior Management Plan must be designed and approved as required by this regulation prior to implementation of any non-emergency restriction of Rights as enumerated in 34-B M.R.S. §5605 ("Rights and Basic Protections of a Person with Intellectual Disabilities or Autism"), including the use of Restraint.B. Whenever the Person or the Person's Guardian, as appropriate, communicates an objection to an intervention to a Challenging Behavior, the intervention must be treated as a restriction of Rights and must be designed and approved as required by this regulation prior to implementation.C. Restriction of Rights or the use of Restraint may be authorized only when there is documentation that less intrusive attempts to address the behavior have been tried and have not yet succeeded. (See also paragraph D below.)D. Whenever a Behavior Management Plan is proposed, the Planning Team must articulate the rationale for the use of Behavior Management in addition to less intrusive interventions. The rationale must be documented in the Personal Plan.E. Restriction of Rights or the use of Restraints may be used only to keep a Person or the community safe from harm. While they may have the effect of changing behavior, restriction of Rights or Restraint must not be used for that purpose or for the convenience of staff.F. Any proposed Behavior Modification or Management Plan must pose less risk of physical or emotional harm to the Person than the Challenging Behavior which it is designed to address. Only the least restrictive procedures needed to protect the Person or others may be used.G. A proposed Behavior Management Plan must incorporate information from and work in concert with all other required plans, including the Positive Support Plan, the Functional Assessment or Updated Functional Assessment, and the Psychological Assessment (when required).H. Direct Support Professionals must be trained in accordance with the Behavior Management Plan. Training on the Behavior Management Plan must also be offered to others such as parents, Guardians and Correspondents who may be involved in supporting the Person. Prior to any use of a physical restraint or Specialized Restraint being implemented, all staff must be trained in accordance with a physical restraint or Specialized Restraint program approved by the Department.5.05-3Behavior Management PracticesA. Any planned use of law enforcement in response to Challenging Behavior is considered Behavior Management and is subject to appropriate review.B. When restriction of Rights or the use of Restraints is used, it must be kept to a minimum in terms of frequency, duration, and degree of physical intrusion.C. The use of Restraint without an attempt to release must not continue for longer than fifteen minutes, unless approved as a special circumstance by the Review Team. Planning Teams that recommend the use of Restraint longer than fifteen minutes must substantiate the need in a Behavior Management Plan supported by data collected within the immediate prior 12 months of submission for review.D. In-Home Stabilization must be used only to ensure the safety of the Person or the community and must be the result of an assessment that the Person's Challenging Behavior may continue to pose an Imminent Risk to the Person or the community. In-Home Stabilization must be tied directly to safety and not be used as a teaching or Behavior Modification technique. Refer to Appendix Three E. Physical prompts, physical assistance and physical supports to intervene in a Challenging Behavior must be clearly described in the Personal Plan and comply with Section 5.10-6.F. Therapeutic Devices or approved Safety Devices to which the Person does not communicate an objection and which are not intended as an intervention to a Challenging Behavior, are not considered Restraints under this regulation.G. The use of Mechanical or Chemical Restraint is permitted only to prevent serious self-injury or injury to others when less restrictive methods of protecting the Person have been determined to be ineffective. A Behavior Management Plan describing the Mechanical or Chemical Restraint must be submitted and approved as an exception pursuant to Appendix Four (Level 5) and 5.07-2(C) of this regulation. H. Monitoring devices intended to enhance independence, to which the Person does not communicate an objection and which are not intended as an intervention to a Challenging Behavior, are not considered a restriction of Rights under this regulation. Monitoring devices to enhance independence might include buzzers, alarms, sensors, or other electronic monitoring devices (including video, ankle bracelets, etc.). Devices used in this context must be clearly described in the Personal Plan. When use of monitoring devices is approved by the Review Team every effort must be made to maintain privacy and confidentiality in the use of these devices. The Behavior Management Plan must include procedures used to maximize privacy and maintain confidentiality.I. Any use of a prohibited intervention, restriction or use of Restraint in a manner inconsistent with this regulation must be reported as required in Departmental rule 14-197 Chapter 12, §6.03(C) ("Regulations Governing Reportable Events, Adult Protective Investigations and Substantiation Hearings Regarding Persons with Intellectual Disability or Autism - Reportable Events and Protective Responsibilities").5.05-4Additional Requirements when Restraint is part of a Behavior Management PlanA. When a Behavior Management Plan includes Restraint, the Planning Team must ensure that it specifies strategies for continuous monitoring and assessment of:1. The Person's physical condition, breathing, circulation or pain;2. Criteria for attempting release and reengaging the Restraint if necessary;3. Indicators that identify when the restriction of Rights or the use of Restraint should cease; and4. How the Person should be supported to resume normal activities.B. When a Behavior Management Plan includes Restraint, the Planning Team must ensure that a Psychological Assessment has been conducted in the past six months and is considered in the design of the Behavior Management Plan. If Restraint use continues to be recommended in the Behavior Management Plan, the Psychological Assessment must be updated at least every three years. The Psychological Assessment must include, but is not limited to:
1. Review, consideration and clarification of current and historic diagnoses; and2. A conceptualization of the Challenging Behavior and recommendations regarding the necessity and anticipated impact of: b. Environmental modifications;c. Restrictions of rights; andC. When a Behavior Management Plan includes Restraint, the Planning Team must ensure completion of a Physician's Evaluation, in which a physician (as described in 02-373 CMR Ch. 1) or a physician assistant (as described in 02-373 CMR Ch. 2) evaluates the Person no more than thirty (30) days prior to the implementation of the Behavior Management Plan and yearly thereafter. Whenever a significant change in physical or medical condition occurs, a new evaluation must be conducted. In order for a Behavior Management Plan including restraint to be implemented, the Physician's Evaluation must state in writing that: 1. The proposed Plan is safe, given the Person's physical and emotional condition; and2. The behavior cannot be better treated medically.D. When a Behavior Management Plan includes a Specialized Restraint, the Planning Team must take into account the particular medical condition of the Person, the Person's history of physical or sexual trauma, or other relevant factors that necessitate the use of a Specialized Restraint. In addition to all other required elements the Behavior Management Plan must include: identification of the need; and a description of the Specialized Restraint5.05-5Monitoring the Behavior Management PlanThe Planning Team and the responsible qualified professional (as defined at 5.03-3(A)) must continue to monitor implementation of an approved Behavior Management Plan and make modifications as necessary. Their roles are:
A. The qualified professional must oversee implementation and must monitor and document progress at least on a monthly basis. Documentation must include a description of the current and baseline measurements of the frequency, duration, intensity and/or severity of each Challenging Behavior, the interventions used and the result. Documentation must also include recommendations about continuation or modification of Plan elements. The qualified professional must meet and observe the individual at least twice annually.B. At a minimum, one representative from each agency responsible for the implementation of the approved Plan must be present during these monthly clinical reviews with the qualified professional. Their role is to provide documentation and discussion regarding the effectiveness of the approved Plan and to provide other pertinent input regarding less restrictive alternatives.C. The individual's guardian and assigned Case Manager must also be provided the option to participate in the monthly clinical reviews with the qualified professional.D. The Planning Team, with in consultation with the qualified professional must review, monitor and document the effectiveness of the Plan at least quarterly.E. Any increase of restrictive measures must be approved by the Planning Team and the Review Team prior to implementation. F. All modifications of the Behavior Management Plan which include a reduction of restrictive measures must be approved by the Planning Team prior to implementation, and the revised Behavior Management Plan must be sent to the Review Team within thirty (30) days.G. When a Person has a Behavior Management Plan, the Case Manager must conduct an in-person review of the implementation of the Plan at least quarterly. When the Person does not have a Case Manager, the Q.I.D.P. must monitor the Behavior Management Plan. 1. For the purpose of this review, the Case Manager shall be granted unrestricted access to direct support professionals and the Person's record; and2. The Review Team may, at its discretion; request increased monitoring by the Case Manager.5.05-6Impact of Behavior Management Plan on Other PersonsWhen a Person has a Behavior Management Plan that contains restrictions of Rights or the use of Restraint that may impact other Persons in the home or program, accommodations must be identified to minimize the impact on the other Persons. The Personal Plan of each Person affected by the restrictive procedure must indicate how that Person will be supported to minimize the negative impact of any restriction.