Post on 18-Dec-2015
Overview of Rule 65G-8Establishes procedure for approval of crisis
intervention curriculaRequires providers to establish policy and
procedures for the use of reactive strategiesRequires 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
Includes prohibited procedures
Documentation and reporting mechanisms
Establishes procedure for enforcement of rule
Overview of Rule 65G-8 (cont’d)
In the Name Of Treatment
A Little History…..Formerly called “Emergency
Procedures”HRSM 160-4 Appendix GHRSM 205-1Hartford Courant Article: “Deadly
Restraint” 1998ACT memo 1999Children’s Mental Health Act of 2000Title V of Public Health Services Act Public Advisory from Advocacy Center
Change is good…F.A.C. 65G-8
applies to all providersapplies to any consumer who is funded under FS
393Requires curriculum that is approved by central
office in TallahasseeEach consumer must have initial assessment by
physician upon admissionUse of authorizing agents per type of strategy
used“Use of any reactive strategy on a ‘PRN’ or ‘as
needed ‘ basis is prohibited
Authorizing AgentsFor any strategy, staff must notify highest level supervisorFor seclusion and restraint, the authorizing agent may be
the staff directly involved in procedure
Strategy Used Authorizing Agent
Medical Protective Equipment
Licensed physician
Chemical Restraint Licensed physician
Behavioral protective Device BCBA, FL-CBA, person licensed under 490 or 491
Mechanical Restraint BCBA, FL-CBA, person licensed under 490 or 491, Licensed physician
Seclusion Staff with bachelor’s degree, two years experience with DD, and certified in approved curriculum
Manual Restraint Staff certified in approved curriculum
Types of Reactive Strategies
SeclusionManual RestraintMechanical RestraintChemical RestraintBehavioral Protective Equipment
Manual RestraintDefinition: “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 rateRequires reapproval if exceeds one hourRequires Visual inspection (by authorizing agent of on-site
designee) if longer than 2 hrs.
SeclusionDefinition: “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.
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 ReinforcementNot a reactive strategy defined by this ruleMust be short in duration
Never more than 20 min. (or considered seclusion)
Part of a written behavior plan, that includes a functional assessment and approve by LRCPlan is implemented by BCBA, FL-CBA or
licensed under 490 or 491Implemented in response to a specific behavior Includes requirement that individual returns to
previous activity at end of time outTime out data must be collected and analyzedMust include termination criteria (e.g. “one minute of
calm”)
Time Out (cont’d)
Mechanical RestraintDefinition: “a physical device used to restrict an individual’s movement or restrict the normal function of the individual’s bodyDoes 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 DevicesEquipment used for safety during transportationMedical protective equipment (see next slide)
Authorizing Agent must be BCBA, FL CBA, Physician, or licensed under 490 or 491
Requires continuous monitoring, monitor respirationReauthorization 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
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 resultsPart of LRC-approved programAuthorizing Agent must be BCBA, FL CBA, or
licensed under 490 or 491
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
Chemical RestraintDefinition: “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
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
Initial AssessmentCompleted upon admission, annually, change in
conditionPhysician’s report: Medical conditions, physical
limitations that place at risk and/or preclude specific procedures
Document any trauma relevant to use of reactive strategies
Conditions that might increase riskObesityCardiac conditionsPregnancyAsthma/respiratoryImpaired gag reflexBack/Spinal cond.Seizure disordersDeafness
BlindnessLimited range of motionOsteoporosis/
OsteopeniaHemophiliaOther
All Reactive StrategiesRequire authorization by authorizing agent
with clear rationaleAuthorizing agent notified of conditions
leading up to use of strategy Agent is responsible for terminating procedure not in compliance
with rule
Requires continuous monitoringMust be least restrictiveTerminate as soon as emergency ends
Within 5 minutes after calm criteria is metNot used as punishment
Greatest possible comfort and protection from injury for client
Limit 1 hour unless reauthorizedEpisode more than 15 minutes
after release requires new authorization
All Reactive Strategies (cont’d)
Prohibited ProceduresNoxious or painful stimuli, Untested or experimental proceduresProcedures 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)
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.
Prohibited Procedures (cont’d)
Important things to rememberThe 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 servicesProvider must have
written behavioral criteria for termination of a reactive strategy, to all staff trained in those techniques.
Reactive Strategies ReportingReport on “Reactive Strategy Report” formSubmit Monthly to Area APD Office – due by 5th
working day of monthAPD Submits Combined Report Monthly to Central
Office – due by 10th calendar day of month
Documentation
No later than end of work shiftBehavior requiring useStrategy usedDate, Start and End timePerson who Initiated, Used, Authorized, Ended
strategySigned by Authorizing Agent within 24 hrs.
Reactive Strategy Policy and Procedures: Provider responsibilitiesApproved 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
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.
Reactive Strategy Policy and Procedures: Provider responsibilities (cont’d)
The Following Do Not Take Effect Until February 1, 2009:65G-8.002: Agency-approved Curriculum65G-8.003: Policies and Procedures65G-8.004: Initial Assessments
Sample Scenarios
Questions and Answers
Contact InformationKen Winn, SunCoast Region Area Behavior
AnalystPhone: 813-233-4356Fax: 813-233-4307Email: Ken_Winn@apd.state.fl.us
Diana Geller, SunCoast Region Quality AssurancePhone: 813-233-4358Fax: 813-233-4307Email: Diana_Geller@apd.state.fl.us