INDIVIDUAL RIGHTS AND BEHAVIOR SUPPORTSJULY 29 & 30, 2010

Bob Mitchell, DHS, Contract Coordinator

ACRONYMS MCO – Managed Care Organization (was CMO) BLTS - Bureau of Long Term Support, DHS DQA – Division of Quality Assurance DHS Department of Health Services, IDT – MCO Inter-Disciplinary Team OFCE –Office of Family Care Expansion ICF/MR Intermediate Care Facility for the

Mentally Retarded MCQS Member Care Quality Specialist

AUTHORITY FEDERAL Social Security Act - Collection of Federal

Laws that Describes How Assistance is Provided to Those in Need.

Title XIX – Grants to States for Medicaid Assistance Programs

Section 1915 – Creates Waiver to Support with Medical Assistance home or community- based services for individual that requires a level of care provided in a hospital, nursing facility or ICF/MR.

AUTHORITY FEDERAL

Section 1915(c) of the Social Security Act that the state ensure the health, and welfare of all individuals receiving services funded by Medicare and/or Medicaid.

Section 1932 – State Option to Use Managed Care

Section 1932(a.)(1)(A) In general subject to the succeeding provisions of this section.

AUTHORITY STATE

State Statute 51.61Anyone receiving services for mental illness, developmental disabilities or alcohol, or other drugs has rights…

AUTHORITY 51.61(1) RIGHTS

(a) to be informed of rights (b) to refuse labor (not including personal

housekeeping) (cm) to send and receive sealed mail (d) to petition review of commitment order (e) to least restrictive environment (f) to receive prompt and adequate treatment (g) to refuse medication and treatment (only

the court can order medication compliance)

AUTHORITY 51.61(1) RIGHTS

(h) to be free from unnecessary or excessive medication. Medication can not be used as punishment, convenience of staff, or substitute for a treatment program.

(i) to be free from physical restraints and isolation unless an emergency or part of a DHS approved treatment program.

(j) to not be subject to experimental research.

(k) consent to treatment

AUTHORITY 51.61(1) RIGHTS

(l) to religious worship or “not” (m) to humane psychological and physical

environment (n) confidentiality of records, access, and

challenge accuracy. (o) to not be filmed or taped unless consent (p) to reasonable access to phone (q) to wear own clothing and laundry (r) access to reasonable storage

AUTHORITY 51.61(1) RIGHTS

(s) privacy (t) see visitors (u) present grievances without reprisal (v) use own money as chooses (amount can

be limited for security) (w) informed of cost of care (x) treated with respect and dignity

AUTHORITY 51.61(2) DENIAL OF RIGHTS Only for cause

that is well documented as

medically or therapeutically contraindicated

Informed in writing

Review procedure available

AUTHORITY DHS 94

DHS 94 This is the Wisconsin Administrative Code

that describes how the Department of Health Services will promote the rights as defined in 51.61

Available online at: http://nxt.legis.state.wi.us

Look under Administrative Code Related, Health Services

AUTHORITY DHS 94

Denial or Limitation of Rights – Summarized from DHS 94 Subchapter II - Patient Rights

No rights can be denied except: Good cause for security Adverse effect on treatment Interfere with the rights of others

WORKING DEFINITIONS

Denial – No access to the right.

Limitation – Access to part of the right, or access to the right when…

“when” must be described

PROCEDURE FOR DENIAL OR LIMITATION OF RIGHTS – SUMMARIZED FROM DHS 94 SUBCHAPTER II - PATIENT RIGHTS

Documented as least restrictive approach

- no denial if a limitation would work

- no limitation more stringent then necessary

PROCEDURE FOR DENIAL OR LIMITATION OF RIGHTS – SUMMARIZED FROM DHS 94 SUBCHAPTER II - PATIENT RIGHTS

Written Notice to the individual,/guardian, record, and placing agency (MCO).

1. Right to a hearing2. Conditions to restore the right3. Duration of denial / limitation4. Specific reason for denial/limitation

OTHER ‘GEMS” FROM DHS 94

94.06 each service provider shall assist in the exercise of all rights No patient may be required to waive any rights

as a condition of admission or receipt of treatment services.

94.52 The Department may investigate any alleged violation.

STATE RIGHTS SPECIFIC TO FAMILY CARE MEMBERS - DHS 10.51 Defined in Wis. Admin. Code DHS 10.51

Freedom from discrimination Accuracy and confidentiality of information Prompt decisions and assistance Access to information Enrollment choice Information and access to ADRC Support of rights, grievance and appeal Support from MCO Outcomes, information,

participate in planning, service plan implementation.

-AND-

STATE RIGHTS SPECIFIC TO FAMILY CARE MEMBERS - DHS 10.51 DHS 10.51 specifically indicates members

receiving services for mental illness, a developmental disability or substance abuse also have all the rights under 51.61 Stats. And DHS 94. Wis. Admin. Code

WHAT ABOUT MEMBERS WHO ARE FRAIL ELDER OR PHYSICALLY DISABLED?

Many MCOs have developed policies based on DHS 94 defining member rights for frail elder and physically disabled members.

WHAT ABOUT… “PROGRAM OR HOUSE RULES?”

Rules that relate to basic health and safety that are required for safe management of the setting must be justifiable and on a safety and security basis.

Rules related to group living, work, or program expectations to maintain “harmony” must balance the rights of individuals against those of peers and be the least restrictive means of accomplishing the objective.

WHAT ABOUT… “PROGRAM OR HOUSE RULES?”

You should not have rules that make access to basic rights, community, leisure, or recreational opportunities contingent on a member’s compliance.

Those issues must be in an individual treatment program for the member needing that level of support.

Source : DHS Clients Rights Office, Community Programs Training, 2006

OTHER IMPACTS ON BEHAVIOR SUPPORTS

Access to addictive substances such as tobacco should not be contingent on behavior.

Individuals should not have to earn access to items that have been purchased with their own money. Reinforcers for behavior supports should be paid as a portion of the service costs.

An adult is an adult, is an adult, and should always be treated as one.

WEBSITES AND CONTACTS FOR MORE INFORMATION Social Security Acthttp://www.ssa.gov/OP_Home/ssact/comp-ssa.htm

Statute 51.61, DHS 94, and DHS 10.51http://nxt.legis.state.wi.us

51.61 Look under Statutes Related DHS 94 look under Administrative Code Related, Health

Services

Clients Rights Officehttp://dhs.wisconsin.gov/clientrights/index.htm

Bob Mitchell, DHS, Contract Coordinatorbob.mitchell@dhs.wisconsin.gov

RESTRICTIVE MEASURES OVERVIEWPresented by :

CCCW Behavior Support Oversight Committee (BSOC)

WHAT WILL WE BE COVERING TODAY ?

Proactive and Behavior Support Plan overview.

Definitions of Restrictive Measures per DHS 94.

Emergency Restrictive Measures Plan. Roles of CCCW Interdisciplinary Teams, CCCW

Behavior Support Oversight Committee (BSOC), and DHS/DLTS

Restrictive Measures Approval Process (what needs to be included).

RESOURCES AND INFORMATION FOR TODAY’S TRAINING

DHS 94 Guidelines And Requirements For The Use of

Restrictive Measures (DHS, DQA, DLTS) (February 2009).

Training on Restrictive Measures DQA/DLTS/MCO Process (May 2009).

CCCW Restrictive Measures Policy.

DISCLAIMER

We are putting the cart before the horse. Prior to even thinking about restrictive

measures, we need to have a behavior support plan in place.

Data documenting effectiveness or ineffectiveness.

Restrictive measures are the last resort option.

PROACTIVE SUPPORT PLANS

Designed to prevent the likelihood of negative, maladaptive behaviors from emerging, and places focus on positive behaviors, one’s strengths, and abilities.

Create an environment that is conducive of safe learning and expression, residents feel more comfortable and are more likely to respond favorably to staff support.

Evolve with the individual and are updated routinely as we learn more about each person’s abilities, improvement in certain life areas, and effective interventions and interactions.

PROACTIVE SUPPORT PLANS

Is the big picture plan. How do we support the individual throughout

the day - not just during crisis? More importantly, how do we assist the

individual in being more independent, by assisting in modifying behaviors?

Very clear step-by-step for consistency.

BEHAVIOR SUPPORT PLANS

Specific to each individual behavior. Define the behavior (what does it look like). Precursors, onset, severity, how often it occurs,

how long will it last - conclusion of the behaviors. Identified function of the behavior. Proactive prevention of behavior. Management of the behavior.

EFFECTIVENESS OF A PLAN

Data collection, Data collection, Data collection.

Review, Review, Review, Review. Team approach and input.

RELATIONSHIP OF INDIVIDUAL RIGHTS ANDRESTRICTIVE MEASURES

Mail

Access to Phone

Prompt Treatment

Visitors

Storage

Access to Funds

Religion

Voting

Medications and Treatment

RestraintIsolationSeclusionLeast Restrictive Treatment and Conditions

WHAT IS A RESTRICTIVE MEASURE?

The definition of Restrictive Measures applies to the forms of restraint, isolation, and protective equipment identified below: Manual Restraints Mechanical Restraint Medical Restraint Isolation/Seclusion Protective Equipment Mechanical Support

WHAT IS A RESTRAINT?

Any device, garment or physical hold that

Restricts the voluntary movement of a person’s body or access to any part of the body

And cannot be easily removed by the individual

MANUAL RESTRAINTS

“Hands on,” holding limbs or body contingent upon behavior

Restricting or preventing movement Not longer than 15 continuous minutes

Examples:

MANUAL RESTRAINT DOES NOT INCLUDE:

Medical restraints. Holding limbs or body to provide functional

movement and positioning. Holding limbs or body to prevent falling. Self-protective blocking or passive redirecting

aggressive behavior. Graduated guidance as part of an approved

intervention.

MECHANICAL RESTRAINT

A device applied to any part of a person’s body contingent upon behavior

Restricts or prevents movement or normal use/functioning of the body part

Cannot be easily removed by the individual Cannot impair hearing, vision, or speech

(DHS)

Examples:

MEDICAL RESTRAINT

Apparatus or procedure that restricts voluntary free movement

Cannot be easily removed by the individual Used prior to, during, or subsequent to a medical

procedure Or to protect during the time a medical condition

exists

Examples:

MEDICAL RESTRAINT CONT. – SHORT-TERM USE

MD writes an order for use during the first 10 days. Guardian is notified.

If restraint continues past the initial 10 days, then guardian consent is required.

If this occurs regularly or becomes long-term, then application for use is required.

ISOLATION/SECLUSION

Involuntary physical or social separation from others by actions of staff

Contingent upon behavior

Examples:

PROTECTIVE EQUIPMENT

Device that does not restrict movement but does prevent access

Applied to any part of a person’s body to prevent tissue damage as a result of behavior

Cannot be easily removed by the individual

Examples:

MECHANICAL SUPPORT

An apparatus Properly aligns a person’s body or helps

maintain balance Designed by a qualified professional in

accordance with principles of good body mechanics, concern for circulation, and allow for change in position.

Generally not a restraint, but could be if it meets the definition.

Examples:

EXCEPTIONAL MEASURES

Specific forms of restraint that are considered highly restrictive and present a higher level of risk

Requires an additional level of review - Oversight Committee

Waiving or modifying any process requirement is considered an exceptional measure, as well

EXCEPTIONAL FORMS OF …MANUAL RESTRAINT

Any form of horizontal restraint Physically forcing a person to lay in a

horizontal position

Takedowns Physically forcing a person to a prone

position on the ground, floor, or mat

EXCEPTIONAL FORMS OF …MECHANICAL RESTRAINT

Restraint vests, jackets, body wraps Seclusion Wrist or ankle restraints Removal of mobility aids Restraint chairs Bed enclosures

EXCEPTIONAL FORM OF …ISOLATION

Seclusion Person is physically set apart from others Use of locked doors

EMERGENCY USE OF RESTRICTIVE MEASURES

Emergency is defined as: Sudden, unexpected behavior that places the

person or others in some danger of injury or onset of signs/symptoms known to be precursors

of such behavior After two incidents within 6 months no longer

unanticipated

EMERGENCY USE OF RESTRICTIVE MEASURES POLICY Requirements that must be addressed

for a provider to be able to use emergency restrictive measures: Written Policy Release Criteria Reauthorization of Use Time limits and Physician orders Trained Staff Measure employed must be monitored

EMERGENCY USE OF RESTRICTIVE MEASURES POLICY CONT.:

Involve Law enforcement when necessary Critical Incident reporting DHS notification

EXAMPLE Frank is non-ambulatory and uses a highly

modified wheelchair for proper body alignment. He often kicks his legs out, moves them off the foot rests, or lets them hang behind the foot rests. This has been resolved by providing a strap around each ankle that is, in turn, strapped down to the footrest holding his foot securely to the rest. The Physical Therapist has written into their evaluation, “ankle straps secured to footrests for safety during transportation.” This is repeated in his support plan.

  Is this a restraint?

WHAT CAN BE EXPECTED OF CCCW IDT’S ROLES WITH RESTRICTIVE MEASURES?

IDTs will monitor for the use of Restrictive Measures.

Assist providers/families with the development of Behavior Support Plans and/or Restrictive Measures applications.

IDTs to submit Restrictive Measures applications and/or Behavior Support Plans to their direct supervisor for review when received from providers .

IDTs will complete quarterly reviews of BSP and/or Restrictive Measures Plan for consistency, accuracy, and proper utilization with provider.

IDT ROLES, CONTINUED:

For members with approved Restrictive Measures, request and obtain monthly reports from providers on the frequency of use of Restrictive Measures and/or other interventions.

Meet monthly with IDT to discuss frequency report.

Any unplanned or emergency use of restrictive measures must be reported through the Critical Incident process, and to IDT Supervisor within 24 hours of the event.

WHAT IS THE ROLE OF CCCW BSOC?

Once the IDT has brought back the information and/or waiver application, what is the next step?

BSOC will review the information received by the IDT to determine if there is a restrictive measure being utilized, and what type. This will all be communicated to the IDT.

A letter will be drafted and sent to the provider with what is needed to move the process along.

WHAT IS THE ROLE OF CCCW BSOC?

For Restrictive Measures waiver applications, the BSOC will: Review initial applications for restrictive measures and

rights restrictions. Provide written feedback and support to providers

and/or IDTs and supervisors in the development of plans.

Offer assistance when appropriate to the provider and IDT through the process.

Provide the initial approval and submit to DHS/DLTS for individuals with developmental disabilities.

WHAT IS THE ROLE OF DHS/DLTS FOR DEVELOPMENTALLY DISABLED POPULATION?

DHS/DLTS restrictive measures review panel will review waiver application once it is approved by the MCO.

DHS/DLTS will inform applicants of decisions/ feedback within 15 working days of the receipt of the application (complex case may take longer).

DHS/DLTS restrictive measures review panel will verbally communicate concerns as early as they are indentified and work with the MCO and provider to identify more appropriate interventions.

DHS/DLTS restrictive measures review panel will provide input, advice, and technical assistance.

WHAT IS THE ROLE OF DQA?

For the Physically Disabled, and Elderly Populations.

Within CBRF, AFH, RCAC, and Adult Day Care. Waiver variance are submitted to both MCO

and DQA Regional Director. DQA (WAVE Committee)reviews and

approves/denies waiver of variance request. Review usually occurs concurrently with

CCCW BSOC.

THE APPROVAL PROCESS FOR …INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES

THE APPROVAL PROCESS FOR …ELDERLY AND PHYSICALLY DISABLED

APPLICATION PROCESS

What needs to be included in the submitted application for restrictive measures as part of a behavior plan:

2607 Application (D. D. population)

Behavior Support Plan/ Proactive Support Plan

Restrictive Measures PlanPictures of Interventions

APPLICATION PROCESS

Staff Training PlanDocumentation PlanReduction /Elimination PlanPhysician order/support letterProper signatures

APPLICATION PROCESS

What needs to be included in the submitted application for use of a medical restraint:

2608 Application (D.D. population)Description of Medical Condition

Requiring RestraintProposed Medical Restraint and

Description (when, where, for how long) Picture of InterventionWritten Authorization by Physician (type

of restraint ordered, indications for use, time period recommended, etc.)

APPLICATION PROCESS CONT.

Training DescriptionReduction /Elimination PlanProper Signatures

CRITERIA FOR APPROVAL OF RESTRICTIVE MEASURES

The individual's behavior presents an imminent danger to self or other persons.

The restrictive measure proposed is the least restrictive approach available to achieve an acceptable level of safety for the individual.

There is documentation that less restrictive interventions have been tried and were not effective.

The measure is adequately supported by the training provided to all staff involved in use or monitoring of the measure.

CRITERIA FOR APPROVAL OF RESTRICTIVE MEASURES

The supervision, monitoring plan and back-up arrangements are adequate to ensure effective responses to unanticipated reactions to the measures that might arise.

With the use of the measure, the health, safety, welfare, dignity, and other rights of the individual are adequately ensured.

The application contains a reasonable plan for reducing and/or eliminating the need for using the measure.

CRITERIA FOR APPROVAL OF RESTRICTIVE MEASURES

The restrictive measure is used only for the duration necessary to ensure the individual's safety or that of others.

The restrictive measure are not used in lieu of adequate staffing.

DECISION TYPE

Unconditional approval (usually for one year)

Approval with conditions Denial (with written reason why) Denial letters also come with description of

appeal rights.

CONTACTS Kris Kubnick: (715) 301-1889

CCCW Behavior Support Oversight Committee Chair

Julie Strenn: (715) 204-1768CCCW Provider Network Director

Social Security Acthttp://www.ssa.gov/OP_Home/ssact/comp-ssa.htm

Statute 51.61, DHS 94, and DHS 10.51http://nxt.legis.state.wi.us 51.61 Look under Statutes Related DHS 94 look under Administrative Code Related, Health

Services

Clients Rights Officehttp://dhs.wisconsin.gov/clientrights/index.htm

Bob Mitchell, DHS Contract CoordinatorBob.mitchell@dhs.wisconsin.gov

Glenn Lamping, DHS Member Care Quality SpecialistGlenn.lamping@dhs.wisconsin.gov