Current through 2024-38, September 18, 2024
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.
5.05-1
Behavior Management
Planning
A.
Requirements for
Planning Team to Act
When 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
Assessment
Whenever 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; and
3. A review of
the Person's record.
C.
Requirements for a Behavior Management Plan
Behavior 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; and
4. 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; and
i. 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.
5.05-2
Conditions for Use of Behavior
Management
A. 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.
5.05-3
Behavior Management Practices
A.
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").
5.05-4
Additional Requirements when
Restraint is part of a Behavior Management Plan
A. 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; and
4. 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; and
2. A conceptualization of the Challenging
Behavior and recommendations regarding the necessity and anticipated impact of:
a. Positive Supports;
b. Environmental modifications;
c. Restrictions of rights; and
d. The use of restraint.
C. 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; and
2. 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 Restraint
5.05-5
Monitoring the Behavior
Management Plan
The 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; and
2. The
Review Team may, at its discretion; request increased monitoring by the Case
Manager.
5.05-6
Impact of Behavior Management Plan on Other Persons
When 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.
