4.15 ICF – Risk and Safety Planning
The purpose of these objectives is to enhance quality of life, to promote positive relationships, and promote individual development, communication, and decision making. These objectives will be accomplished through reducing behaviors which may be construed as maladaptive by community standards. A proactive, positive approach to teaching alternative behaviors will be utilized by everyone providing services to the individual.
Person Centered Plans (PCP) will be developed with the consideration of the individuals’ priorities and preferences and each plan will be individualized to meet the specific needs and interests of the person being served. To do so a thorough assessment will be completed to determine the function of the existing behavior and potential alternative behaviors to be reinforced. The methods incorporated into formal support plans will be proactive and preventive in nature. Methods which restrict individual rights or privileges will be used as a last resort and only with the oversight by designated committees.
Prior to implementation of the Person-Centered Risks and Safety Plan, the supervising QIDP will conduct a thorough assessment of the presenting behavior. This assessment will include the following:
- Description of the behavior to be changed in observable and measurable terms which includes the frequency, intensity, and duration
- Description of the antecedents
- Environmental factors contributing to the behavior
- Communication abilities/obstacles which may affect the behavior
- Medical factors which may contribute to the behavior including physical or psychiatric conditions and medication interactions/side-effects, sleep patterns, and eating patterns
- Outcomes/responses that might perpetuate the behavior
- Potential reinforces for alternative behaviors
- Previous methods used to address the behavior
When medications are needed for a specific purpose such as doctor/dentist appointments, consent from the individual and/or guardian and the Human Rights Committee (HRC)/Behavior Support Committee (BSC) will be obtained for each occurrence. This would not include medicine that is normally administered during a procedure.
Person-Centered Risk and Safety Plans
For individuals whom are dully diagnosed, their plans will include the following components::
- Diagnosis per the current DSM IV with description of presenting symptoms
- Results of the assessment completed, including the theoretical function of the behavior
- Description of the target behavior to be modified in observable and measurable terms, including a summary of baseline data
- Description of the antecedents leading to the behavior and the methods used to prevent the behavior occurring
- Description of the interventions used once the behavior has begun, including identification of possible risks and anticipated results
- Fading plan for reducing limited or restricting methods if necessary
- Description of the data collection method
- Alternative behaviors to be trained
- Reinforcement strategies/schedules to be implemented
- Documentation of informed consent/Behavior Support Plan (BSP) consent
- Identification of the individual responsible for monitoring
- Documentation of review/approval by Behavior Support Committee/Human Rights Committee if applicable
All formal support plans receive written consent by the individual and his/her guardian, prior to implementation of a BSP containing aversive or restrictive measures. Witnessed and documented oral consent may be obtained for a plan requiring immediate implementation, with a signed consent as soon as reasonably possible and all consents must be updated on an annual basis. Individuals providing consent will receive information about the methods to be implemented, risks and benefits of each method, acceptable alternatives, and the right to refuse and the consequences of that refusal. If an individual or guardian refuse to give consent, an acceptable alternative must be offered with the description of risks and benefits.
Annual update of Informed Consent:
- If a person has been determined to be incapable of providing informed consent during a previous assessment of the capacity to consent to aversive behavioral interventions, the assessment doesn’t need to be repeated as it will generally be assumed that the incapacity persists. Rather, guardianship should have been pursued or the aversive should have been discontinued.
- If a person could provide informed consent during a previous assessment, then it doesn’t need to be updated unless the behavior plan has changed significantly or their condition has or is suspected to change leaving them no longer competent to provide consent.
- Any member of the PCP team may request a re-assessment of the person’s ability to provide informed consent.
- Disclosure of the nature of the procedure, risks, benefits should be provided on an annual basis, or more often if procedures change significantly during the year to all persons or guardians receiving aversive behavioral interventions.
Hierarchy of Interventions
The development of support strategies following a thorough assessment of an individual’s needs may involve several interventions. The primary focus of support should be on the development of positive skills and proactive strategies chosen to promote growth and development while minimizing the health and safety risks of maladaptive behaviors. The following areas outline the range of behavior support strategies as they increase from low risk, low restrictiveness to high risk, aversive.
Development of positive behaviors – A key aim of the Behavior Support Plan (BSP) is to help the individual develop positive behaviors to use in lieu of the undesirable behaviors the plan is trying to decrease. Conducting a motivational assessment or functional assessment can help identify the potential driving forces for the undesirable behaviors and help to develop the positive behaviors. Once the motivating forces are established that information can be useful in finding behaviors that help the individual expand their behavioral repertoire and develop more adaptive behaviors. Many of the positive skills/behavior strategies target one of the following three goals:
- Reinforce and teach alternative behaviors that serve the same function or meet the same need as the target behavior
- Assisting the individual in altering the problem situation by learning new interpersonal or social skills
- Using teaching opportunities to model to the individual to know how to cope with difficult and possibly avoidable situations
General support strategies – These strategies are an essential component of a positive culture as they are a primary means of supporting growth and development and may be implemented in a proactive or reactive manner as needed. General intervention strategies have a positive influence on the experiences of an individual by addressing lifestyle and ecological factors as well as social relationships which relate to otherwise detrimental behaviors.
These are instructional or preventative procedures, which may be used to prevent, increase, decrease, generalize, and or maintain behavior that involve minimal risk. When these strategies are employed, formal oversight by the HRC/BSC are not typically required, however, if there are indications or concerns that a person is adversely affected by an intervention then further assessment may be indicated and followed by the appropriate level of committee review. Proactive strategies are used non-contingently to address target behaviors.
Environmental interventions – Modifying the physical environment to foster learning and avoid provoking maladaptive behavior. For example, minimizing disruptions, distractions, and noise including offering commercially available sound mufflers for individuals whom are or may be agitated by noise.
Schedule/routine/activities – Modifying routines and schedules to prevent or minimize undesirable behaviors and increase desirable behaviors or situations that provoke them. For example, providing choices and developmentally appropriate activities and expectations that can also alternate between simple and complex activities.
Social/interpersonal – Modifying the style and the way that one interacts with the individual to prevent or minimize undesirable behaviors and to increase desirable or adapt alternative behaviors. For example, establishing a good rapport by developing a positive courteous, supportive atmosphere and calm, consistent interventions.
Positive reinforcement/other principles of learning – Applying the principles of learning to reduce undesirable behaviors and increase desirable behaviors. For example, using a positive consequence to increase a behavior through an activity, privilege, sensory, social, tangible, or edible.
Reactive interventions – Contingent responses to maladaptive behaviors that involve minimal risk to the individual through the following:
- Voluntary change of environment
- One on one supervision
- Response interruption, including blocking or brief hands down
- Simple self-correction – in this procedure an individual is required to repair any damage they did to their environment, this should not require the repair or cleaning of anything that they did not disrupt. Also, physical prompts should only be to assist with the task if necessary not to overcome resistance; this does not include financial restitution.
Restrictive interventions – Used as a last resort and include limiting an individual’s access to typical activities, possessions, experiences, or freedoms for the purposes of either preventing harm or minimizing the risks associated with a known or current behavior.
Proactive/preventative restrictions – Procedures used to minimize or prevent risks to health and safety due to a known history of behavioral or mental health problems which represent a threat to health and safety. Such interventions may either be part of the individuals’ PCP or BSP and are required to be reviewed by the HRC.
Contingent restrictions – Specific implementation of restrictive procedures which are implemented only following display of target behavior or specified criteria. These types of restrictions are part of a formal BSP and require documentation of implementation as well as review by BSP and HRC. When determining if an intervention represents a restriction of an individuals’ rights their abilities and needs must be considered.
Individuals with extensive or pervasive support needs may require levels of supervision and or environmental supports that when applied to a person with more limited needs may appear restrictive. However, if implemented in response to their lack of developed safety skills such interventions may not constitute a restriction.
The following list, while not inclusive, identifies procedures that constitute a restriction:
- Access to the phone, parts of the home, items in the home, types/listening time/volume of music or television, or access to the community
- Cameras, motion sensors, locked doors/windows or door/window chimes in the home
- Restricting alone time, cigarettes, dietary, money, or family visits
- Searches of personal property, space, or person
- Level systems which delay or withhold their access to preferred or routine items and activities contingent upon behavior
- Non – contingent wearing of protective clothing such cases typically involve those with significant cognitive disabilities in situations where there are habitual, high frequency behavioral concerns that are predominately motivated by sensory factors
Aversive interventions – A need for interventions which have the potential to be experienced as undesirable or aversive by an individual. The emphasis on creating a positive culture for the individuals require that such interventions are developed only in response to serious risks to well-being and after a lack of success with a variety of positive and less restrictive interventions. Aversive interventions should never be used as retaliation, staff convenience, or as a substitute for active treatment.
The following list while not inclusive identifies procedures that constitute an aversive intervention:
- Chemical, mechanical, or manual (physical crisis intervention) restraints
- Involuntary change of environment
- Monetary restitution
- Response cost which involves the loss of previously earned reinforcement following a target behavior
- Suspension from work or money making activities
- Emerging methods which refers to new methods of restraint or seclusion that create possible health and safety risk including ones that weren’t developed prior to the Behavioral Support Rule OAC 5123:2-1-02 (J) and require prior approval from the Director of Ohio Department of Developmental Disabilities (DODD)
Guidelines for use of restraint – Restraints should be used only as a last resort in a systematic, planned, and positively focused plan and discontinued if it results in harm or injury to the individual or does not achieve the desired results as defined in the BSP. They may also be used as an emergency procedure but the MUI guidelines must be followed and if the restraint occurs on a regular basis implementing a BSP incorporating those techniques should be considered. Types of restraints include the following:
Manual behavioral restraints – Physically holding an individual to inhibit control or limit the movement or normal function of any portion of a persons’ body. Open Door trains all employees during orientation and refresher training annually on “Responding to a person in crisis” training module. This course provides staff training on non-violent intervention techniques that may be used as a last resort after all verbal means of managing the situation have been exhausted, and there is no other way to protect the individual and others from injury and or prevent major property destruction. Each plan must clearly outline the technique for staff intervention specifically.
Mechanical restraints – Devices used to inhibit, control, or limit the movement or normal function of any portion of a persons’ body applied for the purposes of behavior support excluding the following: mechanical supports, medical restraints, and seatbelts on buses, cars, and cabs. Mechanical restraints may include easily removeable restraints that the individual is not permitted to remove or are put back on upon their removal, all use of restraints should be utilized in keeping with the individuals’ comfort and cooperation in mind.
Medical or therapeutic restraint – Type of restraint that involves using items or measures to inhibit, control or limit the movement or normal function of any portion of an individuals’ body to permit medical treatment, promote healing, or prevent an infection to protect the individual from injuring themselves. Medical restraints aren’t considered mechanical restraints; they are used to promote healing or prevent injury in individuals whom don’t have an ongoing behavior problem as the source of the medical problem. Use of a medical restraint must be determined and monitored by the interdisciplinary team with a consultation from either a nurse, physician, Occupational Therapist, or Physical Therapist.
Chemical restraints – Defined by the Ohio Administrative Code as a prescribed medication for modifying, diminishing, controlling, or altering a specific behavior and is subject to oversight per the DODD and as indicated in the Ohio Administrative Code 5123:2-1-02 (J). As with mechanical and manual restraints, they require review and approval by the BSC/HRC prior to implementation and notification to DODD within five working days of the approval and all other requirements associated with the use of aversive procedures.
- PRN medication – Due to the potential for misuse, questions pertaining to the classification of PRN medications as chemical restraint receive additional scrutiny, in general the following guidelines should be noted in regards to psychotropic PRN use:
- Referral for a psychotropic PRN review should be made to the physician
- Orders for psychotropic PRN medication that clearly specify the medication is to be given only at the request of the individual will not be considered a chemical restraint
- Orders for psychotropic PRN medication prescribed for addressing anxiety or related symptoms prior to or during medical appointments will not be classified as chemical restraint
- For all other psychotropic PRN orders, the order will not be classified as a chemical restraint only if each of the following criteria in addition to those given above are met:
- Clear instructions from the physician as to the conditions which the PRN is offered to the individual and the instructions should describe the symptoms and duration for which they should be present prior to administration
- There is no evidence that the medication is being used for staff convenience, to compensate for poor staff training, or as an alternative to sound psychosocial planning and supports
- Consistent with medication administration requirements, each administration of the PRN is documented and there is a procedure in place for documented supervisory review of the PRN use; at least once a month
- Many of these same standards may apply even when a psychotropic medication is used that does not employ chemical restraints:
- Evidence that a Registered Nurse (RN) or other appropriately qualified health care professional has reviewed the BSP regarding the use of the chemical restraint, including possible adverse side effects
- There must be documentation of ongoing communication between the prescribing physician and a member of the individuals’ team
- There should be a description of the type of data that will be used to evaluate the need for chemical restraint such as frequency and or intensity of the target behaviors and should also be identified via collaboration with the BSC/HRC
Prohibited actions/interventions – These are potentially harmful to an individuals’ health, safety, mental/emotional well-being, personal dignity, or self-esteem, and are expressly prohibited by Open Door. For example, any physical, psychological, verbal, gestural, or sexual abuse.
Levels of review – The PCP may require levels of review and formal plan beyond individual consent when they contain restrictions to their rights or aversive interventions.
The following strategies may be incorporated into the PCP and do not require the development of a formal plan:
- Rights restrictions not related to behavioral supports, these may be restrictions imposed by external factors such as courts, medical prescriptions, or factors of the environment. Any rights restrictions require HRC review and approval.
- Behavior guidelines/support strategies intended to promote the maintenance or development of positive behavior, these are often considered preventative in nature. Guidelines are not considered to be treatment and do not require documentation of specific behavioral incidents, responses to strategies, or specific monitoring of procedures. Specialized training is not required but Open Door includes this training during individual specific training with the employees.
Person-centered BSP – Intended to promote the development of positive behavior and reduce the frequency, intensity, or duration of maladaptive behaviors. This may include positive, restrictive, and aversive intentions.
- BSPs are treatments and prescribe specific responses to negative or maladaptive behavior and are intended to result in a measurable impact on their behavior
- BSPs require data collection procedures to assess the impact of the intervention on the frequency, intensity, and duration of the behaviors and the frequency of the implementation of the interventions
- BSPs which include non-contingent restrictions intended to prevent target behaviors or promote the development of adaptive skills may not require BSC review or approval but will, due to rights restrictions require review and approval from the HRC.
- BSPs that include the use of proactive strategies, contingent restrictions, and aversive interventions require individual/guardian, PCP team, BSP, and HRC approval. All aversive measures must be reported to DODD within five days after HRC approval and prior to implementing the plan.
This includes all methods designed to help an individual reduce the intensity of an anticipated behavior which may result in immediate harm to self or others. Any limited or restricted methods apart from utilization of time-out rooms may be used for crisis intervention. If a behavioral event occurs with a frequency of more than three times per months or six times per year, the behavior is no longer considered a “crisis” and must be addressed in a BSP. This plan must undergo the assessment and approval process outlined above. The use of chemical restraint for an individual in a crisis requires physician approval prior to each administration, the chemical restraint will only be administered by a physician or licensed nurse. Whenever crisis intervention is required, Direct Support Professionals (DSPs) must complete an accident/incident (A&I) report, notify nursing and the incident hotline. The incident hotline will notify Franklin County Case Management and the guardian if applicable.
All employees receive training in general behavior support principles as well as individual specific BSPs during orientation and documented via the Individual Specific Training (IST) forms and on the job training forms. Plans are also reviewed in staff meetings to ensure thorough understanding of specified strategies. Trainings including crisis prevention can be provided more frequently if necessary.
Prior to an individual being referred to the psychiatrist for intervention, the following steps must be taken:
- An assessment of the theoretical function of all target behaviors exhibited by the individual must be completed by the supervising QIDP; this includes a review of environmental factors that may be contributing to the observed behaviors and the baseline data
- Medical factors which may be contributing to the target behavior will be evaluated and treated, when possible prior to initiating a psychiatric referral; the PCP team must agree to the referral
- Once the need for a psychiatric referral has been determined, the psychiatrist will receive data regarding the behaviors exhibited and the response to the intervention used
- In the case of a behavioral crisis, the QIDP or medical department may contact the physician to refer the individual for in-patient psychiatric care or for medication adjustments
An A&I must be completed for any use of a limited or restricted strategy which is not included in a formal BSP or any incorrect use of a limited or restrictive which is specified in the plan. If the instance does not result in injury to the individual, the Incident Hotline will notify Franklin County Case Management for an unusual incident and if it results in injury then the Incident Hotline will notify Franklin County Case Management for a major unusual incident (MUI).
Last Revised: 4/29/22