Overview of Florida Administrative Code 65G-8.001-012

1. Overview of Florida Administrative Code 65G-8.001-012 Reactive Strategies

2. Overview of Rule 65G-8 • Establishes procedure for approval of crisis intervention curricula • Requires providers to establish policy and procedures for the use of reactive strategies • Requires periodic review and analysis • Requires assessment to rule out medical contraindications for use of reactive strategies • Establishes procedures for authorizing use of reactive strategies • Establishes limits on the use of reactive strategies

3. Overview of Rule 65G-8 (cont’d) • Includes prohibited procedures • Documentation and reporting mechanisms • Establishes procedure for enforcement of rule

4. In the Name Of Treatment

5. A Little History….. • Formerly called “Emergency Procedures” • HRSM 160-4 Appendix G • HRSM 205-1 • Hartford Courant Article: “Deadly Restraint” 1998 • ACT memo 1999 • Children’s Mental Health Act of 2000 • Title V of Public Health Services Act • Public Advisory from Advocacy Center

6. Change is good… • F.A.C. 65G-8 • applies to all providers • applies to any consumer who is funded under FS 393 • Requires curriculum that is approved by central office in Tallahassee • Each consumer must have initial assessment by physician upon admission • Use of authorizing agents per type of strategy used • “Use of any reactive strategy on a ‘PRN’ or ‘as needed ‘ basis is prohibited

7. Authorizing Agents • For any strategy, staff must notify highest level supervisor • For seclusion and restraint, the authorizing agent may be the staff directly involved in procedure

8. Types of Reactive Strategies • Seclusion • Manual Restraint • Mechanical Restraint • Chemical Restraint • Behavioral Protective Equipment

9. Manual Restraint Definition: “Use of hands or body to immobilize a person’s freedom of movement or normal access to his or her body for more than fifteen continuous seconds” • Does not include physically guiding individual during transport or skill training for up to 2 minutes. • Authorizing Agent must be certified in its use through Agency-approved curriculum • Only used if sufficient number of staff available for safe implementation • Staff must attempt to redirect first! • Requires continuous monitoring especially respiration rate • Requires reapproval if exceeds one hour • Requires Visual inspection (by authorizing agent of on-site designee) if longer than 2 hrs.

10. Seclusion Definition: “enforced isolation or confinement of an individual in a room or area” • Not Time out or medical isolation • Authorizing Agent must have Bachelor’s degree, two years experience in D.D., and certified in reactive strategies • Only used if sufficient number of staff available for safe implementation • Staff must attempt to redirect first! • Requires continuous monitoring especially respiration rate • Room must have: • Sufficient lighting • Proper ventilation • Room for person to lie down comfortably • Room must be inspected for safety and unsafe objects removed before use • Door is not locked; may be held shut by spring bolt or magnetic hold that releases if staff stops holding • Requires reapproval if exceeds one hour • Requires Visual inspection (by authorizing agent of on-site designee) if longer than 2 hrs.

11. Time Out (Not a Reactive Strategy) Definition: “procedure designed to interrupt a specific behavior of an individual by temporarily removing that individual to a separate area or room, or by screening him or her from others, or by signaling that the individual is in “time out. • Short for Time Out from Positive Reinforcement • Not a reactive strategy defined by this rule • Must be short in duration • Never more than 20 min. (or considered seclusion)

12. Time Out (cont’d) • Part of a written behavior plan, that includes a functional assessment and approve by LRC • Plan is implemented by BCBA, FL-CBA or licensed under 490 or 491 • Implemented in response to a specific behavior • Includes requirement that individual returns to previous activity at end of time out • Time out data must be collected and analyzed • Must include termination criteria (e.g. “one minute of calm”)

13. Mechanical Restraint Definition: “a physical device used to restrict an individual’s movement or restrict the normal function of the individual’s body Does not include: • Physical equipment or orthopedic appliances, surgical dressings or bandages, or supportive body bands or other restraints necessary for medical treatment, routine physical examinations, or medical tests • Support Devices • Equipment used for safety during transportation • Medical protective equipment (see next slide) • Authorizing Agent must be BCBA, FL CBA, Physician, or licensed under 490 or 491 • Requires continuous monitoring, monitor respiration • Reauthorization if longer than 1 hr. • Staff must attempt to redirect first! • Requires Visual inspection (by authorizing agent of on-site designee) if longer than 2 hrs. • Must have opportunity for movement, exercise for at least 10 minutes per hour

14. Behavioral Protective Equipment Definition: “a device used as a means of interfering with or preventing specific results of a targeted behavior as part of a behavior program approved by the Local Review Committee” • Used to prevent target behavior or results • Part of LRC-approved program • Authorizing Agent must be BCBA, FL CBA, or licensed under 490 or 491

15. Medical Protective Equipment • Health-related protective devices • Prescribed by a physician or dentist for use during specific medical or surgical procedures, or • Client protection in response to an existing medical condition

16. Chemical Restraint Definition: “use of medication to effect immediate control of an individual’s behavior. It does not include the medication administered as treatment for a medical or psychiatric condition” • Use of meds. for immediate behavioral control – not routine meds. for treatment • Authorizing Agent is physician • Only on written order by physician • Physician must be on-site or provide phone consultation to authorized person who is there and who has seen person • If physician is not onsite, then they must dictate order to on-site licensed medical professional • Order kept in records with: • Date issued • Expected results • Detailed description of behavior justifying order • Monitoring at least every ½ hour and record effects in record • No standing order PRN’s

17. Approved Emergency Procedure Curriculum • All providers and facilities that use reactive strategies must have an approved curriculum • Emergency procedure training curriculum must be approved by APD • Staff certification in approved curriculum is valid for one year only

18. Initial Assessment • Completed upon admission, annually, change in condition • Physician’s report: Medical conditions, physical limitations that place at risk and/or preclude specific procedures • Document any trauma relevant to use of reactive strategies

19. Obesity Cardiac conditions Pregnancy Asthma/respiratory Impaired gag reflex Back/Spinal cond. Seizure disorders Deafness Blindness Limited range of motion Osteoporosis/ Osteopenia Hemophilia Other Conditions that might increase risk

20. All Reactive Strategies • Require authorization by authorizing agent with clear rationale • Authorizing agent notified of conditions leading up to use of strategy • Agent is responsible for terminating procedure not in compliance with rule • Requires continuous monitoring • Must be least restrictive • Terminate as soon as emergency ends • Within 5 minutes after calm criteria is met • Not used as punishment

21. All Reactive Strategies (cont’d) • Greatest possible comfort and protection from injury for client • Limit 1 hour unless reauthorized • Episode more than 15 minutes after release requires new authorization

22. Prohibited Procedures • Noxious or painful stimuli, • Untested or experimental procedures • Procedures that might restrict or obstruct an individual’s airway or impair breathing • including techniques whereby staff persons use their hands or body to place pressure on the client’s head, neck, back, chest, abdomen, or joints (which causes pain); • Restraint of an individual’s hands, with or without a mechanical device, behind his or her back • Physical holds relying on the inducement of pain for behavioral control • Movement, hyperextension, or twisting of body parts • Any maneuver that causes a loss of balance without physical support (such as tripping or pushing)

23. Prohibited Procedures (cont’d) • Using a pillow, blanket, or other item is used to cover the individual’s face as part of the restraint process • Any reactive strategy that may exacerbate a known medical or physical condition, or endanger the individual’s life • Use of any containment technique medically contraindicated for an individual • Containment without continuous monitoring and documentation of vital signs and status with respect to release criteria • Use of any reactive strategy on a “PRN” or “as required” basis.

24. Important things to remember • The Agency may disapprove the use of any emergency procedure, system, strategy, or program that does not meet the above requirements or that contains procedures the Agency determines to be unsafe. • Reactive strategies occurring • More than 2 x in 30 day period • 6 x in 12 month period • Need to request for behavior analysis services • Provider must have • written behavioral criteria for termination of a reactive strategy, to all staff trained in those techniques.

25. Reactive Strategies Reporting • Report on “Reactive Strategy Report” form • Submit Monthly to Area APD Office – due by 5th working day of month • APD Submits Combined Report Monthly to Central Office – due by 10th calendar day of month

26. Documentation • No later than end of work shift • Behavior requiring use • Strategy used • Date, Start and End time • Person who Initiated, Used, Authorized, Ended strategy • Signed by Authorizing Agent within 24 hrs.

27. Reactive Strategy Policy and Procedures: Provider responsibilities • Approved emergency procedure curriculum • only the reactive strategies provided in the Agency-approved curriculum • Appropriate staff training, • Record maintenance, • Reporting and recording the use of any reactive strategy, • Training in the provisions of this rule chapter, • Data collection, • Reactive strategy consent information in client records

28. Reactive Strategy Policy and Procedures: Provider responsibilities (cont’d) • All staff implementing reactive strategies must be certified • A variation of a specific reactive strategy • if it is designed for a specific client with documented evidence of need and benefit, • only if evaluated and approved in advance of implementation by the Local Review Committee and the Agency’s Senior Behavior Analyst. • Must conduct an internal review at least annually with a written evaluation that addresses the following issues: • Proposed methods of reducing the use of reactive strategies; • Evaluations to ensure: • Reactive strategies are being conducted in accordance with the Agency-approved emergency procedure curriculum and • Administered in a safe manner • Compliance with this rule chapter, including appropriate records and reports of reactive strategies. • The facility or provider must maintain this written evaluation for a minimum of five years and make it available to the Agency upon request.

29. The Following Do Not Take Effect Until February 1, 2009: • 65G-8.002: Agency-approved Curriculum • 65G-8.003: Policies and Procedures • 65G-8.004: Initial Assessments

30. Sample Scenarios

31. Questions and Answers

32. Contact Information • Ken Winn, SunCoast Region Area Behavior Analyst Phone: 813-233-4356 Fax: 813-233-4307 Email: Ken_Winn@apd.state.fl.us • Diana Geller, SunCoast Region Quality Assurance Phone: 813-233-4358 Fax: 813-233-4307 Email: Diana_Geller@apd.state.fl.us