212 R.I. Code R. 212-RICR-10-05-1.12

Current through December 3, 2024

Section 212-RICR-10-05-1.12 - Behavioral Supports and Treatment

A. Behavioral Supports are interventions to develop and strengthen adaptive and appropriate behaviors through the application of behavioral interventions, and to simultaneously reduce the frequency of inappropriate behaviors. Behavioral Supports and interventions encompass behavioral analysis and other similar interventions that refer to purposeful, clinical support of behavior.

1. All behavioral supports and treatment shall conform to and abide by R.I. Gen. Laws Chapter 40.1-26 entitled "Rights for Persons with Developmental Disabilities."

2. Participants shall give written informed consent prior to the imposition of any plan designed to modify behavior including, but not limited to, those plans which utilize restrictive interventions or impairs the participant's liberty.

a. A guardian, family member or advocate can provide written informed consent if the participant is not competent to do so.

b. If a participant is competent to provide informed consent, but cannot provide written consent, the agency shall accept an alternate form of consent, such as verbal agreement obtained and witnessed, and document in the participant's record how such consent was obtained.

B. Behavioral Supports shall be developed and implemented in accordance with Positive Behavioral Intervention and Supports as an evidence-based approach to individual behavior and behavior interventions.

1.12.1Behavioral Intervention Policy and Procedure Manual

A. In accordance with best practices, each Organization shall develop Behavioral Intervention Policies and Procedures. Such policies, at a minimum, shall include staff training requirements, positive clinical strategies, crisis prevention and intervention procedures to be used to keep participants and others safe. Staffing levels will be addressed in a person-centered manner by identifying needs in the ISP.

B. The Behavioral Intervention Policies and Procedures shall utilize evidence-based positive strategy and intervention to reduce the ongoing use of emergency restraints or restrictions on a participant's rights. Such policies shall also include clear guidelines for:

1. Determining the need to develop a behavior support plan; and

2. How changes shall be made to the Behavioral Support plan.

1.12.2Staff Training and Support

A. There shall be documentation available in each Organization for inspection and review by the Department related to the following requirements:

1. A description of the specific training (type, content, number of hours, frequency) required of staff to assure that staff are competent to apply each behavioral intervention used, and to apply the provider emergency behavioral crisis prevention and intervention procedures;

2. Listing of staff trained in prevention and intervention techniques;

3. Staff who teach behavioral intervention procedures and techniques, as well as emergency crisis prevention and intervention, shall do so in accordance with the prevailing evidence-based practice;

4. Method to assess staff competency in behavioral intervention and crisis prevention procedures;

5. Monitoring and ongoing support in evidence-based and positive behavioral support plans;

6. Supervision will occur to ensure that the requirements are implemented and documented.

1.12.3Development of a Behavioral Support Plan

A. Any intervention to alter a participant's behavior must be based on positive behavioral supports and intervention and practice and must be:

1. Annually approved in writing by the participant, Legal Guardian, family and/or advocate where appropriate; and

2. Shall be made by the appropriate member of the ISP team with the informed consent of the participant and described in detail in the participant's record and ISP.

B. A decision to develop a plan to teach alternative skills or alter a person's behavior shall be made by the appropriate members of the ISP team. Behavioral plans shall be developed by the clinician based on assessed clinical needs and are generally to develop and strengthen adaptive, socially appropriate behaviors, and to facilitate communication, community integration, and social interactions. The plans shall be clinically approved and reviewed at least annually by the ISP team and the HRC, as needed.

1.12.4Functional Behavioral Assessment Required

A. A functional behavioral assessment, performed by the DDO, shall inform the basis for the behavioral support plan which includes restrictive procedures. The functional behavioral assessment shall include:

1. A clear, measurable description of the behavior which includes (as applicable) frequency, antecedents, duration and intensity of the behavior;

2. A clear description and justification of the need to alter the behavior;

3. An assessment of the meaning of the behavior, which accepts that all behavior is communicable in nature and includes the possibility that the behavior is one (1) or more of the following:

a. The result of medical conditions;

b. The result of psychiatric conditions;

c. The result of environmental causes or other factors;

d. The results of the person's inability to communicate emotions or concerns.

4. A description of the context in which the behavior occurs; and

5. A description of what currently maintains the behavior.

1.12.5Behavioral Support Plans

A. Behavioral Support Plans shall be approved in accordance with all applicable requirements of these regulations, to ensure that the predictable risks, as weighed against the benefits of the procedure, would not pose an unreasonable degree of intrusion, restriction of movement, physical or psychological harm. No Behavioral Support Plans shall be administered to any person in the absence of a written behavioral support plan.

1. All procedures designed to decrease inappropriate behaviors may be used only in conjunction with positive reinforcement programs.

2. Restrictive behavioral interventions shall be used only to address specifically identified extraordinarily difficult or dangerous behavioral problems that significantly interfere with appropriate behavior and/or the learning of appropriate and useful skills, and/or that have seriously harmed or are likely to seriously harm, the individual or others.

3. Behavioral Support Plans written by the clinicians that serve as intervention guidelines, simple problem-solving strategies, or teaching recommendations do not fall within the scope of Behavioral Support Plans to ameliorate negative behavior.

4. All behavioral intervention plans shall conform to and abide by R.I. Gen. Laws Chapter 40.1-26.

B. Any behavioral intervention procedures that are restrictive should be used only as a last resort, subject to the most extensive safeguards and monitoring contained herein.

C. The Behavioral Support Plan shall include:

1. Strategies that are related to the function(s) of the behavior and are expected to be effective in reducing problem behaviors, as included in the functional behavioral assessment;

2. Specific instructions for staff to implement the strategies of the plan;

3. Positive behavioral supports that include the least intrusive intervention possible;

4. Early warning signals or predictors that may indicate a potential behavioral episode and a clearly defined plan of response and de-escalation;

5. Teaching functional behavioral replacement for the behavior targeted for reduction;

6. A procedure for evaluating the effectiveness of the plan, which includes a method of collecting and reviewing data on frequency, duration and intensity of the behavior. Staffing levels will be addressed in a person-centered manner by identifying the staffing needs via an ISP review to determine that appropriate staff levels are maintained; and

7. Adjusting environments to decrease the probability of occurrence of the undesirable behavior.

D. Behavioral Support Plans shall be formalized and written to include the following:

1. Specified, measurable target behaviors;

2. Specified, measurable baseline information;

3. Specified, measurable goals and objectives;

4. Specified, measurable intervention strategies and tactics;

5. A procedure for evaluating the effectiveness of the plan, which include a method of collecting and reviewing data on frequency, duration and intensity of the behavior and for reviewing and reporting progress;

6. Sufficient, qualified, trained staff to implement the behavior plan;

7. Specified named staff to implement and monitor the plan; and

8. Length of time of each program component or intervention.

1.12.6Notification of Policies and Procedures

The participant, family, legal guardian/advocate will receive a copy of the Behavioral Support Plan.

1.12.7Use of Restrictive Intervention

A. Restrictive Intervention may be used in such exceptional circumstances that shall meet the heaviest burden of review among all treatments. The use of such procedures will be allowed for a particular person only after a review and approval by clinicians, families, guardians and the Human Rights Committee. This process shall ensure that before the participant can be subjected to this type of procedure, that clinicians have exhausted other less restrictive interventions, and further, that the likely benefit of the procedure to the participant outweighs its apparent risk of life safety.

B. The application of an approved restrictive intervention shall be strictly monitored by the DDO, clinician and the Human Rights Committee.

C. All behavioral interventions, programs, methodologies and applications which utilize any interventions shall be implemented only under the following conditions:

1. At the time of the initial approval of any restrictive behavioral intervention, and at least annually, signature is required for both initial and annual plans from:

a. The participant with the participant's informed consent;

b. Family or advocate or legal guardian (as appropriate);

c. Medical professional;

d. Executive director, authorized representative;

e. Support coordinator;

f. Supervising clinician; and

g. Chair or designee of the human rights committee.

D. Procedures shall include safeguards to be implemented including but not limited to medical supervision, proposed and expected duration, frequency, and precautions to prevent injury. If the person with developmental disabilities shows symptoms of physical injury or distress during the use of any behavioral treatment procedure, the physical injury or distress shall be alleviated. Staff and the person's responses shall be documented.

E. A statement of possible risk, possible side effects, benefits, cautions, and precautions shall be documented, and shall be described to and discussed with the participant and/or parents, guardian, or advocate, prior to gaining their authorization signatures.

F. Staff shall also have access to a supervisor to determine whether to continue the intervention.

G. Any person receiving behavioral treatment shall have his/her health monitored by a physician or registered nurse over the course of behavioral treatment, as medically indicated. The physician or registered nurse shall document their monitoring activity.

H. Individual records pertaining to the use of behavioral interventions shall be made available for review by the executive director, or equivalent position of the DDO, representatives of the Department, the human rights committee, the participant and/or parent, advocate, or guardian (as appropriate).

I. Any use of restrictive intervention techniques that result in injury to either the participant or any other individual is reportable to the Department.

1.12.8Prohibited Restrictive intervention

A. In addition to those prohibited under R.I. Gen. Laws §§ 40.1-26-3, 40.1-26-4.1, and 42-158-4, the following procedures shall be specifically prohibited from use under any circumstances:

1. Utilizing law enforcement in lieu of a clinically approved therapeutic emergency intervention or behavioral treatment program.

2. Utilization of behavioral interventions for the convenience of the staff.

3. Utilization of behavioral interventions for any reason except for emergency protocol.

1.12.9Crisis Prevention and Intervention

A. Restraints shall not be employed as punishment, for the convenience of the staff, or as a substitute for an individualized plan. Restraints shall impose the least possible restrictions consistent with their purpose and shall be removed when the emergency ends. Restraints shall not cause physical injury to the participant and shall be designed to allow the greatest possible comfort, pursuant to R.I. Gen. Laws § 40.1-26-3(8). Restraints shall be subject to the following conditions:

1. Physical restraint shall be used to protect the participant or others from imminent injury;

2. Chemical or mechanical restraint shall only be used when prescribed by a physician in extreme emergencies in which physical restraint is not possible and the harmful effects of the emergency clearly outweigh the potential harmful effects of the chemical restraints; and

3. Any restraint that is conducted shall be in accordance with state statute and federal statutes 42 U.S.C. § 290ii(b) and 42 U.S.C. § 15009(a)(3)(B).

4. Any restraint that is conducted shall also be in accordance with federal regulations 42 C.F.R. § 483.420(a); 42 C.F.R. § 483.450(d); and 45 C.F.R. § 1326.19, incorporated herein by reference pursuant to R.I. Gen. Laws § 42-35-3.2, as were in effect in June 2018 and not including later amendments thereof.

1.12.10Physical Intervention Techniques in Emergency Situations

A. In the DDO's Behavioral Intervention Policy and Procedure Manual, methods of dealing with behavioral crisis within the DDO shall be developed and documented. Emergency behavioral crisis prevention and intervention procedures, including any provision for individualized techniques or methods shall be documented.

B. In the event that only one (1) staff person is available during a restraint or a hold, that individual is responsible to act as both the lead person, as well as the observer.

C. Use of physical intervention techniques that are not part of an approved plan of behavior support in emergency situations must:

1. Be reviewed by the DDO's executive director, or equivalent position (or designee) within one (1) hour of resolution of the emergency;

2. Be used only until the participant is no longer an immediate threat to self or others;

3. Prompt an ISP team meeting if an emergency intervention is used more than three (3) times in a six (6) month period or at the request of the participant, their designee, or guardian; and

4. Immediate verbal notification will be provided to the participant's designee or guardian.

D. Description of the application of all approved physical and/or mechanical restraints and holds, must be detailed in writing in the ISP. The following procedural stipulations must be strictly adhered to and specifically stated:

1. One (1) qualified and trained person must be designated the lead person on site for each hold situation, with primary responsibility for directing any other person(s) who is (are) involved in the restraint.

2. No staff can lay across the back of a participant in a hold.

a. The participant shall not be placed in a prone restraint, as prohibited by R.I. Gen. Laws § 42-158-4.

3. One (1) person should have responsibility for observing the participant involved in the hold to watch for any problems that may be a signal of a life-threatening situation. The lead person should determine who shall have this responsibility.

E. Documentation of all physical/mechanical behavioral interventions, both behavior treatment and crisis, shall include, but shall not be limited to:

1. Signs and symptoms of physical condition during all behavioral interventions; and,

2. Specific outcomes of behavioral interventions.

1.12.11Restraint Report

A. Any use of physical intervention(s) shall be documented in a restraint report which is received by the treating clinician, the participant, their designee and guardian within seventy-two (72) hours of the incident and shall be made available to the Department upon request, consistent with R.I. Gen. Laws § 40.1-26-4(d). The reports shall be kept on file for ten (10) years. The incident report shall include:

1. The name of the participant to whom the physical or mechanical intervention was applied;

2. The date, type, and length of time the restraint;

3. A description of the antecedent incident precipitating the need for the use of the physical or mechanical intervention;

4. Signs and symptoms of physical condition during all behavior interventions, including those resulting from injury.

5. The name and position of the staff member(s) applying restraint;

6. The name(s) and position(s) of the staff witnessing the restraint; and

7. The name of the lead person providing the initial review of the use of the restraint.

1.12.12DDO Annual Restraint Report

All physical and mechanical restraints that are used to control acute, episodic behavior of participants shall be reported to the Department on an annual basis. All DDOs shall submit an Agency Annual Restraint Report during an annual timeframe specified by DDO.

212 R.I. Code R. 212-RICR-10-05-1.12

Adopted effective 1/7/2019