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