Missouri Code of State Regulations › Title 9 - DEPARTMENT OF MENTAL HEALTH › Division 45 - Division of Developmental Disabilities › Chapter 3 - Services and Supports › Section 9 CSR 45-3.090 - Behavior Supports

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule sets forth requirements for
				  providers under contract with the Department of Mental Health to support
				  individuals with intellectual and developmental disabilities and assure the
				  rights of individuals to receive best practice behavior strategies that lead to
				  greater independence and enhanced quality of life. This rule describes the
				  division's oversight of behavior supports, establishes and describes the role
				  and function of behavior supports review committees.
(1) Definitions.
(A) Applied behavior analysis-The design,
				implementation, and evaluation of environmental modifications, using behavioral
				stimuli and consequences, to produce socially significant improvement in human
				behavior, including the use of direct observation, measurement, and functional
				analysis of the relationships between environment and behavior, as established
				in section
				337.300(1),
				RSMo;
(B) Behavior analysis
				services-Use of applied behavior analysis principles and technology to assist
				support systems of individuals with challenging behaviors to prevent those
				behaviors as well as teach, promote, encourage, and reinforce alternative
				skills and behaviors;
(C) Behavior
				support plan (BSP)-A part of the individual support plan that is comprised of
				behavior analytic procedures developed to systematically address behaviors to
				be reduced or eliminated and behavior skills to be learned;
(D) Blocking-A staff person using a part of
				their body to prevent an individual from inflicting or incurring harm when an
				individual is attempting to hit, kick, or otherwise harm himself or herself,
				the staff, or another person. Use of pads, cushions, or pillows to soften or
				prevent impact to the individual or others is also considered blocking.
				Blocking does not involve grasping or holding any part of the individual's
				body;
(E) Challenging
				behaviors-Culturally undesirable behavior(s) likely to both limit access to the
				community and interfere with independence and autonomy;
(F) Chemical restraint-Medications
				(prescribed or over-the-counter) administered with the primary intent of
				restraining an individual who presents a likelihood of serious physical injury
				to himself or others, not prescribed to treat a person's medical condition (as
				defined in section
				630.005,
				RSMo);
(G) Due process-The right to
				be notified and heard on the limitation or restriction, the right to be
				assisted through external advocacy if an individual disagrees with the
				limitation or restriction, and the right to be informed of available options to
				restore the individual's rights;
(H) Emergency interventions-Reactive
				strategies that are not part of the individual's plan used to maintain safety
				of the individual or others in the threat of imminent harm. These are
				strategies used for one (1) or two (2) incidents until a planned intervention
				is developed in the safety crisis plan and/or BSP. These emergency
				interventions may involve physical restraint strategies. These interventions
				must be least restrictive and comply with statutes, rules, regulations, and
				policies of the division;
(I)
				Emergency intervention system-also called physical crisis management programs-A
				formal curriculum and training program to teach prevention, de-escalation, and
				physical restraint, also called manual holds, to maintain safety in emergency
				situations;
(J) Exclusion time
				out-The temporary exclusion of an individual from access to reinforcement, as
				part of a formal BSP, in which, contingent upon the individual's undesirable
				behavior(s), the individual is excluded from the potentially reinforcing
				situation but remains in the same area with others present;
(K) Functional Behavior Assessment
				(FBA)-Information-gathering process used to understand the purpose of
				challenging behavior. The functional assessment must be designed and monitored
				by a licensed behavior analyst, or licensed psychologist, counselor, or social
				worker trained in behavior analysis;
(L) Informed consent-Consent for treatment
				based on certain basic elements that include: an understandable explanation and
				purpose of the procedure to be followed, a description of physical, emotional,
				or mental discomfort or risk to be expected, an offer to answer any inquiries
				concerning the procedure, and an explanation that at any time consent can be
				rescinded. Informed consent must be obtained from the individual, or the
				guardian for individuals who have a guardian. Every effort should be made to
				obtain informed agreement from individuals with guardians;
(M) Individual Support Plan (ISP)-A document
				that results from the person centered planning process, which identifies the
				strengths, capacities, preferences, needs, and personal outcomes of the
				individual. The ISP includes a personalized mix of paid and non-paid services
				and supports that will assist the person to achieve personally defined
				outcomes;
(N) ISP team-The
				individual, the individual's designated representative(s), and the support
				coordinator. Providers of waiver-funded services may also participate in the
				ISP team if the individual or guardian requests such participation;
(O) Least restrictive procedure-A procedure
				that maximizes an individual's freedom of movement, access to personal
				property, and/or ability to refuse while maintaining safety. The degree of
				restrictiveness is based on a comparison of the various possible procedures
				that would maintain safety for the individual in a given situation;
(P) Licensed behavioral support
				professional-individual licensed in the state of Missouri under section
				337.315
				(6) and (7), RSMo.
(Q) Manual hold-also called physical
				restraint and manual restraint-Any physical hold involving a restriction of an
				individual's voluntary movement. Physically assisting someone who is unsteady,
				or blocking to prevent injury, is not considered a manual hold;
(R) Mechanical restraints-Any device,
				instrument, or physical object used to confine or otherwise limit an
				individual's freedom of movement that cannot be easily removed. Examples may
				include locking a wheelchair, taking crutches, taking power mechanism from
				wheelchairs, special seat belts that cannot be removed by the individual, or
				other ways of restricting an individual's mobility. Mechanical restraints are
				prohibited from use in home and community based settings. The following are not
				considered mechanical restraints:
1. Medical
				protective equipment prescribed as part of medical treatment for a medical
				issue;
2. 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;
3.
				Devices used to support functional body position or proper balance, or to
				prevent a person from falling out of bed, falling out of a
				wheelchair;
4. Typical equipment
				used for safety during transportation, such as seatbelts or wheelchair
				tie-downs; or
5. Mechanical
				supports or supportive devices used in normative situations to achieve proper
				body position and balance;
(S) Person centered planning process-A
				process directed by the individual, with the inclusion of a circle of support
				created by or with the individual, a guardian, the responsible party or other
				person as freely chosen by the individual, who are able to serve as important
				contributors to the process. The person-centered planning process enables and
				assists the individual to access a personalized mix of paid and non-paid
				services and supports that will assist him/her to achieve personally defined
				outcomes. These trainings, supports, therapies, treatments and/or other
				services become part of the ISP;
(T) Preventative strategies-Clearly defined
				protocols which describe knowledge and skill sets that providers and/or the
				individual must implement in order to prevent occurrences of undesirable
				behaviors or the use of restrictive supports while also creating increased
				opportunities for success. Preventative strategies are documented in the
				support section of the ISP;
(U)
				PRN-A medical term meaning "when necessary";
(V) PRN Psychotropic medication for
				behavioral support- Medication (pharmacologic agent) that affects a person's
				mental status and is prescribed to be given according to circumstance rather
				than at a scheduled time. If utilized, the BSP/ISP must include skill or
				responses to be developed to reduce the need for the PRN and must specifically
				describe strategies to address the situation prompting the PRN use. Use of PRN
				psychotropic medication is considered both a reactive strategy and a
				restrictive intervention;
(W)
				Provider-Any entity or person under contract with the Department of Mental
				Health (DMH) to serve individuals with developmental disabilities funded by
				general revenue or through home and community-based waivers administered by
				DMH;
(X) Psychotropic/behavior
				control medications-Any medication that affects the person's mental status or
				behaviors regardless of their diagnoses;
(Y) Qualified personnel-Staff persons who
				have received training, demonstrated competency, and maintained required
				certification and understanding of the following:
1. The Physical Crisis Management System
				utilized at the agency in which they are employed;
2. The implementation of the individual's
				safety crisis plan;
3. The
				implementation of the BSP and ISP;
4. All requirements as a service provider
				outlined in the most current service definitions for providers;
(Z) Reactive strategies-Actions,
				responses, and planned and unplanned interventions in response to challenging
				behavior. Emergency interventions are types of reactive strategies. Reactive
				strategies have the aim of bringing about immediate change in an individual's
				behavior or control over a situation so that risk associated with the behavior
				is minimized. Reactive strategies may take a number of forms and can include
				environmental, psychosocial, and restrictive interventions. Such procedures may
				be utilized as a first time response to an emergency situation. This also
				includes responses that are more delayed such as restricting access to the
				community or increased levels of supervision;
(AA) Reactive strategy threshold-The use of
				five (5) or more reactive strategies within a one (1) month period. This
				threshold applies to the use of reactive strategies that also meet the
				definition of restrictive interventions;
(BB) Regional Behavior Supports Committee
				(RBSC)-A committee consisting of a chairperson who is a Licensed Behavior
				Analyst, employed by the division and appointed by the division director or
				designee, along with qualified members, whose functions include meeting the
				expectations set forth in this rule;
(CC) Regional Office (RO)-Local offices of
				the Division of Developmental Disabilities (referred to as "the division"
				throughout this document) serving a defined geographic region of the
				state;
(DD) Restrictive
				interventions-The use of interventions that restrict movement, access to other
				individuals, locations or activities, restrict rights or employ aversive
				methods to modify behavior. These may also be called restrictive supports,
				procedures, or strategies;
(EE)
				Safety assessment-An assessment by the planning team and a medical professional
				of an individual's physical, and/or emotional status. This includes history and
				current conditions that might affect safe usage of any reactive strategies, and
				identifies those reactive strategies that should not be used with the
				individual due to medical or psychological issues of safety. The safety
				assessment should be completed annually or on the occasion of any significant
				change;
(FF) Safety crisis plan-An
				individualized plan outlining the reactive strategies designed to most safely
				address dangerous behaviors at the time of their occurrence or to prevent their
				imminent occurrence, included as part of a BSP or ISP;
(GG) Seat belt guard-A safety device to
				prevent the release of the seat belt while the car is in motion. Seat belt
				guards are not mechanical restraints;
(HH) Seclusion time-out-The involuntary
				confinement of an individual alone in a room or an area from which the
				individual is physically prevented from having contact with others or leaving.
				This is sometimes referred to as a safe room or calm room. Locked rooms (using
				a key lock or latch system not requiring staff directly holding the mechanism)
				are prohibited.
(II) Significantly
				challenging behaviors-Actions of the individual which can be expected to result
				in issues described in paragraphs 1.-6. below. Services to address these
				behaviors may necessitate involvement of a licensed behavior analyst or other
				licensed professional with appropriate training and experience-
1. Have resulted in external or internal
				injury requiring medical attention or are expected to increase in frequency,
				duration, or intensity such that medical attention may be necessary without
				intervention by a licensed behavior support professional;
2. Have occurred or are expected to occur
				with sufficient frequency, duration, or intensity that a life-threatening
				situation might result because of self-injury, aggression, or property
				destruction. Examples include excessive eating or drinking, vomiting,
				ruminating, eating non-nutritive substances, refusing to eat, swallowing
				excessive amounts of air, or running into traffic;
3. Have resulted or are expected to result in
				major property damage or destruction, value of property more than two hundred
				dollars ($200);
4. Have resulted in
				or are expected to result in arrest and confinement by law enforcement
				personnel;
5. Have resulted in the
				need for additional staffing and/or behavioral/medical personal assistant
				services; or
6. Have resulted in
				the repeated use of emergency interventions and restrictive supports; and
(JJ) Waiver
				assurances-As a condition of waiver approval by the Centers for Medicare and
				Medicaid Services, states collect and report performance data to measure
				compliance with assurances specified in the
Code of Federal
				Regulations
at
				42 CFR
				441.302.