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

2. A CRONYMS 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. A UTHORITY F EDERAL 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. A UTHORITY F EDERAL 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. A UTHORITY S TATE State Statute 51.61 Anyone receiving services for mental illness, developmental disabilities or alcohol, or other drugs has rights…

6. A UTHORITY 51.61(1) R IGHTS (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. A UTHORITY 51.61(1) R IGHTS (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. A UTHORITY 51.61(1) R IGHTS (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. A UTHORITY 51.61(1) R IGHTS (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. A UTHORITY 51.61(2) D ENIAL OF R IGHTS Only for cause that is well documented as medically or therapeutically contraindicated Informed in writing Review procedure available

11. A UTHORITY 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. A UTHORITY 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. W ORKING D EFINITIONS Denial – No access to the right. Limitation – Access to part of the right, or access to the right when… “when” must be described

14. P ROCEDURE FOR D ENIAL OR L IMITATION OF R IGHTS – S UMMARIZED FROM DHS 94 S UBCHAPTER II - P ATIENT R IGHTS Documented as least restrictive approach - no denial if a limitation would work - no limitation more stringent then necessary

15. P ROCEDURE FOR D ENIAL OR L IMITATION OF R IGHTS – S UMMARIZED FROM DHS 94 S UBCHAPTER II - P ATIENT R IGHTS Written Notice to the individual,/guardian, record, and placing agency (MCO). 1. Right to a hearing 2. Conditions to restore the right 3. Duration of denial / limitation 4. Specific reason for denial/limitation

16. O THER ‘G EMS ” 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. S TATE R IGHTS S PECIFIC TO F AMILY C ARE M EMBERS - 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. S TATE R IGHTS S PECIFIC TO F AMILY C ARE M EMBERS - 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. W HAT 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. W HAT A BOUT … “P ROGRAM OR H OUSE R ULES ?” 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. W HAT A BOUT … “P ROGRAM OR H OUSE R ULES ?” 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. O THER I MPACTS ON B EHAVIOR S UPPORTS 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. W EBSITES AND C ONTACTS FOR M ORE I NFORMATION 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. R ESTRICTIVE M EASURES O VERVIEW Presented by : CCCW Behavior Support Oversight Committee (BSOC)

25. W HAT W ILL W E B E C OVERING T ODAY ? 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. R ESOURCES AND I NFORMATION F OR T ODAY ’ S T RAINING 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. D ISCLAIMER 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. P ROACTIVE S UPPORT P LANS 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. P ROACTIVE S UPPORT P LANS 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. B EHAVIOR S UPPORT P LANS 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. E FFECTIVENESS OF A P LAN Data collection, Data collection, Data collection. Review, Review, Review, Review. Team approach and input.

32. R ELATIONSHIP OF I NDIVIDUAL R IGHTS AND R ESTRICTIVE M EASURES Mail Access to Phone Prompt Treatment Visitors Storage Access to Funds Religion Voting Medications and Treatment Restraint Isolation Seclusion Least Restrictive Treatment and Conditions

33. W HAT IS A R ESTRICTIVE M EASURE ? 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. W HAT 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. M ANUAL R ESTRAINTS “Hands on,” holding limbs or body contingent upon behavior Restricting or preventing movement Not longer than 15 continuous minutes Examples:

36. M ANUAL R ESTRAINT D OES N OT I NCLUDE : 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. M ECHANICAL R ESTRAINT 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. M EDICAL R ESTRAINT 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. M EDICAL R ESTRAINT CONT. – S HORT -T ERM U SE 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. I SOLATION /S ECLUSION Involuntary physical or social separation from others by actions of staff Contingent upon behavior Examples:

41. P ROTECTIVE E QUIPMENT 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. M ECHANICAL S UPPORT 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. E XCEPTIONAL M EASURES 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. E XCEPTIONAL F ORMS OF … M ANUAL R ESTRAINT 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. E XCEPTIONAL F ORMS OF … M ECHANICAL R ESTRAINT Restraint vests, jackets, body wraps Seclusion Wrist or ankle restraints Removal of mobility aids Restraint chairs Bed enclosures

46. E XCEPTIONAL F ORM OF … I SOLATION Seclusion Person is physically set apart from others Use of locked doors

47. E MERGENCY U SE OF R ESTRICTIVE M EASURES 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. E MERGENCY U SE OF R ESTRICTIVE M EASURES P OLICY 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. E MERGENCY U SE OF R ESTRICTIVE M EASURES P OLICY C ONT.: Involve Law enforcement when necessary Critical Incident reporting DHS notification

50. E XAMPLE 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?

51. W HAT C AN B E E XPECTED OF CCCW IDT’ S R OLES W ITH R ESTRICTIVE M EASURES ? 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.

52. IDT R OLES, 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.

53. W HAT IS THE R OLE 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.

54. W HAT IS THE R OLE 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.

55. W HAT IS THE R OLE OF DHS/DLTS FOR D EVELOPMENTALLY D ISABLED P OPULATION ? 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.

56. W HAT IS THE R OLE 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.

57. T HE A PPROVAL P ROCESS FOR … I NDIVIDUALS WITH D EVELOPMENTAL D ISABILITIES

58. T HE A PPROVAL P ROCESS FOR … E LDERLY AND P HYSICALLY D ISABLED

59. A PPLICATION P ROCESS 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 Plan Pictures of Interventions

60. A PPLICATION P ROCESS Staff Training Plan Documentation Plan Reduction /Elimination Plan Physician order/support letter Proper signatures

61. A PPLICATION P ROCESS 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 Restraint Proposed Medical Restraint and Description (when, where, for how long) Picture of Intervention Written Authorization by Physician (type of restraint ordered, indications for use, time period recommended, etc.)

62. A PPLICATION P ROCESS C ONT. Training Description Reduction /Elimination Plan Proper Signatures

63. C RITERIA F OR A PPROVAL O F R ESTRICTIVE M EASURES 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.

64. C RITERIA F OR A PPROVAL O F R ESTRICTIVE M EASURES 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.

65. C RITERIA F OR A PPROVAL O F R ESTRICTIVE M EASURES 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.

66. D ECISION T YPE Unconditional approval (usually for one year) Approval with conditions Denial (with written reason why) Denial letters also come with description of appeal rights.

67. C ONTACTS Kris Kubnick: (715) 301-1889 CCCW Behavior Support Oversight Committee Chair Julie Strenn: (715) 204-1768 CCCW Provider Network Director 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 Glenn Lamping, DHS Member Care Quality Specialist Glenn.lamping@dhs.wisconsin.gov