INDIVIDUAL RIGHTS AND BEHAVIOR SUPPORTS

1. INDIVIDUAL RIGHTS AND BEHAVIOR SUPPORTS JULY 29 & 30, 2010 Bob Mitchell, DHS, Contract Coordinator

2. 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

3. 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.

4. 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.

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

6. 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)

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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). • Right to a hearing • Conditions to restore the right • Duration of denial / limitation • Specific reason for denial/limitation

16. 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.

17. 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-

18. 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

19. 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.

20. 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.

21. 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

22. 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.

23. Websites and Contacts for More Information • Social Security Act http://www.ssa.gov/OP_Home/ssact/comp-ssa.htm • Statute 51.61, DHS 94, and DHS 10.51 http://nxt.legis.state.wi.us • 51.61 Look under Statutes Related • DHS 94 look under Administrative Code Related, Health Services • Clients Rights Office http://dhs.wisconsin.gov/clientrights/index.htm • Bob Mitchell, DHS, Contract Coordinator bob.mitchell@dhs.wisconsin.gov

24. Restrictive Measures Overview Presented by : CCCW Behavior Support Oversight Committee (BSOC)

25. 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).

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.

31. Effectiveness of a Plan • Data collection, Data collection, Data collection. • Review, Review, Review, Review. • Team approach and input.

32. Relationship of Individual Rights andRestrictive Measures Individual Rights Mail Access to Phone Prompt Treatment Visitors Storage Access to Funds Religion Voting Medications and Treatment Restrictive Measures Restraint Isolation Seclusion Least Restrictive Treatment and Conditions

33. 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

34. 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

35. Manual Restraints • “Hands on,” holding limbs or body contingent upon behavior • Restricting or preventing movement • Not longer than 15 continuous minutes • Examples:

36. Manual Restraint Does NotInclude: • 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.

37. 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:

38. 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:

39. 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.

40. Isolation/Seclusion • Involuntary physical or social separation from others by actions of staff • Contingent upon behavior • Examples:

41. 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:

42. 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:

43. 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

44. 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

45. Exceptional Forms of …Mechanical Restraint • Restraint vests, jackets, body wraps • Seclusion • Wrist or ankle restraints • Removal of mobility aids • Restraint chairs • Bed enclosures

46. Exceptional Form of …Isolation • Seclusion • Person is physically set apart from others • Use of locked doors

47. 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

48. 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

49. Emergency Use of Restrictive Measures Policy Cont.: • Involve Law enforcement when necessary • Critical Incident reporting • DHS notification

50. 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?