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Freedom of Freedom of movement movement Training Module Training Module DDS Office for Human rights DDS Office for Human rights September 11, 2013 September 11, 2013

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Page 1: Freedom of movement

Freedom of Freedom of movement movement

Training ModuleTraining ModuleDDS Office for Human rightsDDS Office for Human rights

September 11, 2013September 11, 2013

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This module is intended to support the fundamental This module is intended to support the fundamental right to freedom of movement for all people. It gives right to freedom of movement for all people. It gives

program managers, house managers, program managers, house managers, administrators, human rights coordinators, human administrators, human rights coordinators, human

rights committee members and clinical staff of rights committee members and clinical staff of agencies an awareness of the boundaries for agencies an awareness of the boundaries for

potential restrictions of movement that they may feel potential restrictions of movement that they may feel compelled to consider. compelled to consider.

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Only when a person is at risk of serious physical Only when a person is at risk of serious physical harm due to either a physiological, or medical harm due to either a physiological, or medical condition, or procedure, or a threat to cause condition, or procedure, or a threat to cause physical or emotional harm to their selves or physical or emotional harm to their selves or

others through their own behavior, can an ISP others through their own behavior, can an ISP team consider restricting a person’s right to team consider restricting a person’s right to the freedom of movement. In a well defined the freedom of movement. In a well defined

emergency, programs do not need permission emergency, programs do not need permission of the ISP team. They must be well trained, of the ISP team. They must be well trained,

however, and prepared to handle such.however, and prepared to handle such.

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Rules Governing Rules Governing Limitations to the Right to Limitations to the Right to

Freedom of MovementFreedom of Movement

~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * Broader Legal SchemeBroader Legal Scheme

For Restrictions on For Restrictions on MovementMovement

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Legal Framework Legal Framework Rules Governing Limitation of MovementRules Governing Limitation of Movement

Any action or device thatAny action or device that limits the freedom of movement of limits the freedom of movement of any person must fit into one of the five categories any person must fit into one of the five categories

authorized in 115 CMR 2.01 authorized in 115 CMR 2.01 Limitation of MovementLimitation of Movement. .

The constitution thinks of this as part of the “Liberty” The constitution thinks of this as part of the “Liberty” interest and the due process requirements are delegated to interest and the due process requirements are delegated to the states to detail. Therefore, any procedure that limits a the states to detail. Therefore, any procedure that limits a person’s freedom of movement that is not reached by these person’s freedom of movement that is not reached by these

categories may not be implemented!categories may not be implemented!

Category 1. Emergency restraint, governed by 115 CMR 5.11Category 1. Emergency restraint, governed by 115 CMR 5.11 Category 2. Transportation restraint governed by 115 CMR Category 2. Transportation restraint governed by 115 CMR

5.135.13

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Legal Framework Legal Framework Rules Governing Limitation of Movement (Continued)Rules Governing Limitation of Movement (Continued)

Category 3. Support needed to achieve proper body position, Category 3. Support needed to achieve proper body position, or otherwise allow a person to safely participate in or otherwise allow a person to safely participate in programming, or other daily living activity, per 115 CMR programming, or other daily living activity, per 115 CMR 5.12.5.12.

Category 4. Health Related Protections also per 115 CMR Category 4. Health Related Protections also per 115 CMR 5.125.12

Category 5. Limitations implemented in accordance with Category 5. Limitations implemented in accordance with behavior planning, per 115 CMR 5.14behavior planning, per 115 CMR 5.14

The Use of Any and All Categories of Limitation of The Use of Any and All Categories of Limitation of Movement must be reported to the provider agency’s Movement must be reported to the provider agency’s Human Rights Committee according to prescribed Human Rights Committee according to prescribed proceduresprocedures

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Rules Governing Limitation Rules Governing Limitation of Movementof Movement

Legal Framework for category 1. Legal Framework for category 1. LOMLOM

Emergency RestraintEmergency Restraint

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Legal Framework Legal Framework Rules Governing Limitation on Movement Rules Governing Limitation on Movement

Emergency RestraintEmergency Restraint – Emergency Defined – Emergency DefinedEmergency means a reasonable person would perceive Emergency means a reasonable person would perceive

one or more of the following:one or more of the following:

A.A. Present occurrence of serious self-injurious Present occurrence of serious self-injurious behaviorbehavior

B.B. Present occurrence of serious physical assault.Present occurrence of serious physical assault.

C.C. Imminent threat of serious self-injurious behavior Imminent threat of serious self-injurious behavior or behavior likely to lead to self-injury as person or behavior likely to lead to self-injury as person has ability and shown present inclination or has ability and shown present inclination or intention to carry out this behavior immediatelyintention to carry out this behavior immediately

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Legal Framework Legal Framework Rules Governing Limitation on Movement Emergency Rules Governing Limitation on Movement Emergency

Restraint – Emergency Defined (continued)Restraint – Emergency Defined (continued)

D. Imminent threat of serious physical assault, person has present D. Imminent threat of serious physical assault, person has present ability to assault, and has engaged in any act which indicates a ability to assault, and has engaged in any act which indicates a present intention to carry out assault, immediately (imminent present intention to carry out assault, immediately (imminent threat or occurrence of property damage, itself, is not an threat or occurrence of property damage, itself, is not an emergency, unless it has the potential to harm that person or emergency, unless it has the potential to harm that person or others)others)

Imminent threat can involve a lot of judgment. A clinician, or Imminent threat can involve a lot of judgment. A clinician, or clinical/ISP team may provide guidance in the form of a clinical/ISP team may provide guidance in the form of a description, with observable criteria, for consideration as to description, with observable criteria, for consideration as to how to determine imminent risk of harm to that person, or how to determine imminent risk of harm to that person, or others, may be present!others, may be present!

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Legal Framework Legal Framework Rules Governing Limitation on Movement Emergency Rules Governing Limitation on Movement Emergency

Restraint – Other Rules (continued)Restraint – Other Rules (continued)Other rules include:Other rules include: Use permitted only in an emergency; Use permitted only in an emergency; Use only when less restrictive measures have failed, Use only when less restrictive measures have failed,

or professional judgment concludes these are not or professional judgment concludes these are not appropriate to the existing circumstance; appropriate to the existing circumstance;

Use only for the period necessary to accomplish the Use only for the period necessary to accomplish the purpose, but never longer than times allowed in 115 purpose, but never longer than times allowed in 115 CMR 5.11 (6) (1 hour without renewal when CMR 5.11 (6) (1 hour without renewal when authorized by “authorized staff person,” no more than authorized by “authorized staff person,” no more than 6 consecutive hours, or 8 hours of a 24 hour period); 6 consecutive hours, or 8 hours of a 24 hour period);

No “P.R.N.” authorization (standing “as needed” No “P.R.N.” authorization (standing “as needed” order) is allowed.order) is allowed.

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Legal Framework Legal Framework Rules Governing Limitation on Movement Emergency Rules Governing Limitation on Movement Emergency

Restraint – Other Rules (continued)Restraint – Other Rules (continued) SeclusionSeclusion of a person alone in a room or other of a person alone in a room or other

area with egress blocked, absent a time out area with egress blocked, absent a time out provision in a duly authorized behavior plan is provision in a duly authorized behavior plan is prohibitedprohibited..

Locked buildings prohibited, except as Locked buildings prohibited, except as necessary for the safety of the occupants.necessary for the safety of the occupants.

Restraint is Restraint is not allowed as punishmentnot allowed as punishment.. Restraint is Restraint is not allowed for convenience of not allowed for convenience of

staff.staff.

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Legal Framework Legal Framework Rules Governing Limitation on Movement Emergency Rules Governing Limitation on Movement Emergency

Restraint – Other Rules (continued)Restraint – Other Rules (continued) If a person is headed unassisted to a door to a busy street, or If a person is headed unassisted to a door to a busy street, or

other specific point that could be harmful to them without other specific point that could be harmful to them without help, and you use force over active resistance to prevent this, help, and you use force over active resistance to prevent this, this is an emergency restraint.this is an emergency restraint.

If a person is headed to a door or other specific point and you If a person is headed to a door or other specific point and you gently guide them physically while encouraging them to go in gently guide them physically while encouraging them to go in another direction and they willingly go without struggle, this is another direction and they willingly go without struggle, this is not a restraint.not a restraint.

If you need to move a person to a specific destination to move If you need to move a person to a specific destination to move them away from a situation and use force over active them away from a situation and use force over active resistance, this is a physical escort form of emergency resistance, this is a physical escort form of emergency restraint.restraint.

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Legal Framework Legal Framework Rules Governing Limitation on Movement Emergency Rules Governing Limitation on Movement Emergency

Restraint – Other Rules (continued)Restraint – Other Rules (continued)

If one or two staff are holding a person in a comforting or If one or two staff are holding a person in a comforting or gentle manner, they may do so for up to five minutes without gentle manner, they may do so for up to five minutes without it being considered an emergency restraint. it being considered an emergency restraint.

Comforting or gentle holding can be supports to a person Comforting or gentle holding can be supports to a person experiencing a seizure, or to guide a person’s arms when they experiencing a seizure, or to guide a person’s arms when they are having an episode of spasticity. It can also represent hand are having an episode of spasticity. It can also represent hand over hand instruction and other non-restrictive supports.over hand instruction and other non-restrictive supports.

Restraint is not justified to address property damage, unless Restraint is not justified to address property damage, unless such damage includes throwing objects that have the capacity such damage includes throwing objects that have the capacity to cause serious harm to others.to cause serious harm to others.

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Legal Framework Legal Framework Rules Governing Limitation on Movement Emergency Rules Governing Limitation on Movement Emergency

Restraint – Restraint – DocumentationDocumentation All agencies are responsible for documenting any All agencies are responsible for documenting any

emergency restraint event in the on-line HCSIS emergency restraint event in the on-line HCSIS restraint module. The agency has three calendar days restraint module. The agency has three calendar days to finalize the initial restraint form.to finalize the initial restraint form.

The Restraint Manager (intended to fill the role of the The Restraint Manager (intended to fill the role of the Head of Provider (HOP)Head of Provider (HOP) in monitoring restraints-see in monitoring restraints-see definition in 115 CMR 2.01) has five calendar days definition in 115 CMR 2.01) has five calendar days from the event, to review and finalize their report on from the event, to review and finalize their report on what happened.what happened.

Restraint Manager/HOP review should include a Restraint Manager/HOP review should include a post-restraint reviewpost-restraint review of the incident with those who of the incident with those who were involved in the restraint. were involved in the restraint.

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Legal Framework Legal Framework Rules Governing Limitation on Movement Emergency Rules Governing Limitation on Movement Emergency

Restraint – Restraint – Documentation (continued)Documentation (continued)

The provider’s Human Rights Committee also The provider’s Human Rights Committee also needs to review each restraint and the Human needs to review each restraint and the Human Rights Coordinator shall report their findings Rights Coordinator shall report their findings into the HRC portion of the HCSIS restraint into the HRC portion of the HCSIS restraint form.form.

Any safety checks should also be documented Any safety checks should also be documented in the form.in the form.

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Legal Framework Legal Framework Rules Governing Limitation on Movement Rules Governing Limitation on Movement

Emergency RestraintEmergency Restraint

In order for any provider agency to utilize emergency In order for any provider agency to utilize emergency restraints or physical holding in an addendum to a restraints or physical holding in an addendum to a behavior support program, any staff being called on behavior support program, any staff being called on to implement such holding must be trained under the to implement such holding must be trained under the provisions of a program for restraint training provisions of a program for restraint training curricula that is certified by DDS for these purposes. curricula that is certified by DDS for these purposes.

No restraint technique may be used that is not found No restraint technique may be used that is not found in the curriculum they use to train for these purposes. in the curriculum they use to train for these purposes.

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For further rules governing use of For further rules governing use of emergency restraints see “Restraint emergency restraints see “Restraint

Authorizer Legal” training atAuthorizer Legal” training at mass.gov/ddsmass.gov/dds and click on the and click on the

human rights link. The curriculum human rights link. The curriculum can be found toward the bottom of can be found toward the bottom of

the page.the page.

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Legal Framework for Category 1. Legal Framework for Category 1. LOMLOM

Emergency RestraintEmergency Restraint

Application of Chemical RestraintApplication of Chemical Restraint

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Legal Framework Legal Framework Rules Governing Limitation on Movement Emergency Rules Governing Limitation on Movement Emergency

Restraint – Chemical RestraintRestraint – Chemical Restraint

Chemical restraint is the involuntary administration Chemical restraint is the involuntary administration (ie. person is not typically consulted) of a chemical (ie. person is not typically consulted) of a chemical agent to at least partially incapacitate a person in agent to at least partially incapacitate a person in crisis. crisis.

Chemical restraint may only be initiated when a Chemical restraint may only be initiated when a physician determines it the most appropriate physician determines it the most appropriate alternative available for a person. This is typically alternative available for a person. This is typically rare and limited to supporting persons with frail rare and limited to supporting persons with frail bones when holding may be dangerous, or when bones when holding may be dangerous, or when restraints are historically exceptionally long.restraints are historically exceptionally long.

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Legal Framework Legal Framework Rules Governing Limitation on Movement Emergency Rules Governing Limitation on Movement Emergency

Restraint – Chemical RestraintRestraint – Chemical Restraint(continued)(continued)

Physician must either be present, or be consulted by Physician must either be present, or be consulted by phone by a registered nurse, nurse practitioner, or phone by a registered nurse, nurse practitioner, or certified physician’s assistant who is present with the certified physician’s assistant who is present with the person. person.

If ordered by phone, the medication to use must be If ordered by phone, the medication to use must be documented in the person’s medication treatment plan documented in the person’s medication treatment plan prior to implementation.prior to implementation.

Order must be documented by the physician or Order must be documented by the physician or medical professional consulting the physicianmedical professional consulting the physician

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Legal Framework Legal Framework Chemical Restraint v. Chemical Restraint v.

Other Boundaries Regarding MedicationOther Boundaries Regarding Medication

PRN for PRN for treatmenttreatment purpose is not a form of purpose is not a form of restraint. It must be bound by a clinically restraint. It must be bound by a clinically derived set of observable criteria issued to staff derived set of observable criteria issued to staff for use to determine when it may be needed.for use to determine when it may be needed.

Difference between PRN and chemical restraint Difference between PRN and chemical restraint is that a PRN helps person become more able to is that a PRN helps person become more able to engage in program, while chemical restraint engage in program, while chemical restraint incapacitates a person.incapacitates a person.

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Legal Framework Legal Framework Chemical Restraint v. Chemical Restraint v.

Other Boundaries Regarding MedicationOther Boundaries Regarding Medication(Continued)(Continued)

Chemical relaxation for medical or dental Chemical relaxation for medical or dental treatment is not a restraint, but is deemed treatment is not a restraint, but is deemed incidental to treatment. This means the role it incidental to treatment. This means the role it plays is to help one more comfortably plays is to help one more comfortably participate in the treatment intervention, it participate in the treatment intervention, it isn’t intended as treatment, itself. Use of the isn’t intended as treatment, itself. Use of the medication must still be consented to.medication must still be consented to.

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Legal Framework for Category 1. Legal Framework for Category 1. LOMLOM

Emergency RestraintEmergency Restraint

Mechanical RestraintMechanical Restraint

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Legal Framework Legal Framework Rules Governing Limitation on Movement Rules Governing Limitation on Movement

1. 1. Emergency RestraintEmergency Restraint – – Mechanical Mechanical RestraintRestraint

No community provider may issue a mechanical restraint, No community provider may issue a mechanical restraint, other than for use of mitts, absent a waiver from the DDS other than for use of mitts, absent a waiver from the DDS Office for Human Rights, per 115 CMR 5.11 (6)(b)2. Please Office for Human Rights, per 115 CMR 5.11 (6)(b)2. Please contact your Human Rights Specialist if you need more contact your Human Rights Specialist if you need more information on this.information on this.

Mitts or mechanical restraints, where applied, must be checked Mitts or mechanical restraints, where applied, must be checked at least every 15 minutes for comfort, body alignment, and at least every 15 minutes for comfort, body alignment, and circulation by authorized staff person or staff in attendance circulation by authorized staff person or staff in attendance (see 115 CMR 5.11 (6)(e)1. for staff in attendance and (see 115 CMR 5.11 (6)(e)1. for staff in attendance and Restraint Legal Authorizer’s Curriculum for other rules)Restraint Legal Authorizer’s Curriculum for other rules)

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Rules Governing Limitation on Rules Governing Limitation on MovementMovement

Category 2. LOMCategory 2. LOM

Transportation RestraintTransportation Restraint

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Rules Governing Category 2. LOM Rules Governing Category 2. LOM Transportation RestraintTransportation Restraint

Transportation restraint is a planned strategy involving more Transportation restraint is a planned strategy involving more than a standard passenger seat belt, to support a person to than a standard passenger seat belt, to support a person to safely participate in vehicular transport from one site to safely participate in vehicular transport from one site to another.another.

The Team needs to identify the least restrictive means for The Team needs to identify the least restrictive means for accomplishing this, according to how and why they make their accomplishing this, according to how and why they make their selves unsafe, and address it in a modification of the person’s selves unsafe, and address it in a modification of the person’s ISP. ISP.

The Team further needs to identify any possible skill The Team further needs to identify any possible skill development, or strategies available for reducing or development, or strategies available for reducing or eliminating the need for such a restriction.eliminating the need for such a restriction.

No HCSIS form is required if documentation for the No HCSIS form is required if documentation for the intervention has fulfilled the above planning requirements.intervention has fulfilled the above planning requirements.

HRC will review the plan and advocate for changes if needed.HRC will review the plan and advocate for changes if needed.

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Rules Governing Limitation on Movement Rules Governing Limitation on Movement Transportation Restraint – Transportation Restraint – Unplanned Unplanned

If a program responsible for transporting an If a program responsible for transporting an individual experiences difficulty on the van on individual experiences difficulty on the van on several occasions and conceives of a strategy for several occasions and conceives of a strategy for keeping the person safe, such as safety belts the keeping the person safe, such as safety belts the person can’t undo, they may test their intervention, person can’t undo, they may test their intervention, without the full planning/participation of the Team.without the full planning/participation of the Team.

Any such trial is considered an unplanned use of a Any such trial is considered an unplanned use of a transportation restraint and must be reported in an transportation restraint and must be reported in an incident report in HCSIS as “Unplanned incident report in HCSIS as “Unplanned Transportation Restraint.” These will be reviewed by Transportation Restraint.” These will be reviewed by the HRC as with all such incidents.the HRC as with all such incidents.

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Rules Governing Limitation on MovementRules Governing Limitation on Movement Transportation v.Transportation v. Emergency Emergency RestraintRestraint

Any time an emergency occurs during transport and Any time an emergency occurs during transport and the program has not prepared a strategy to use for this the program has not prepared a strategy to use for this individual, nor is there any transportation restraint in individual, nor is there any transportation restraint in the person’s ISP, it should be considered to be an the person’s ISP, it should be considered to be an emergency restraint and a HCSIS restraint form must emergency restraint and a HCSIS restraint form must be reported.be reported.

If this occurs more than twice in a week or three If this occurs more than twice in a week or three times a month after the first 24 hours, the Team times a month after the first 24 hours, the Team should be convened to discuss the least restrictive should be convened to discuss the least restrictive manner for addressing this.manner for addressing this.

The agency’s Human Rights Committee will review The agency’s Human Rights Committee will review with other restraints.with other restraints.

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Rules Governing Category 2. LOM Rules Governing Category 2. LOM Transportation RestraintTransportation Restraint

The regulation discusses strategies to promote safe transport to The regulation discusses strategies to promote safe transport to and from the van. This was created to assist people safely to and from the van. This was created to assist people safely to vans when subject to risks from wheelchair use, unsafe gait or vans when subject to risks from wheelchair use, unsafe gait or when their anxieties, etc., may lead them to be unsafe in such when their anxieties, etc., may lead them to be unsafe in such transitions.transitions.

115 CMR 5.11 (1) 115 CMR 5.11 (1) Definition of TermsDefinition of Terms: : Transportation Transportation RestraintRestraint clearly states that this LOM may not be used for clearly states that this LOM may not be used for convenience of staffconvenience of staff

Provision is not intended to provide cover for agency to move Provision is not intended to provide cover for agency to move un-cooperativeun-cooperative persons to and from the van or other vehicle persons to and from the van or other vehicle by means of force, simply because they are choosing not to by means of force, simply because they are choosing not to leave when it is time to do so.leave when it is time to do so.

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Rules Governing Category 3. Rules Governing Category 3. LOMLOM

Application of Application of Supports for Proper Body Supports for Proper Body

Positioning and Safe Positioning and Safe Participation in ProgrammingParticipation in Programming

per 115 CMR 5.12per 115 CMR 5.12

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Rules Governing Category 3. LOMRules Governing Category 3. LOM Supports for Proper Body Positioning and Supports for Proper Body Positioning and

Safe Participation in ProgrammingSafe Participation in Programming This classification is intended to support persons who This classification is intended to support persons who

may need devices or other procedures to maintain may need devices or other procedures to maintain body position in wheelchairs, helmets for drop body position in wheelchairs, helmets for drop seizures, or other devices, etc. to help a person safely seizures, or other devices, etc. to help a person safely participate in programming, due to whatever physical participate in programming, due to whatever physical or medical frailty may cause the threat to their safety, or medical frailty may cause the threat to their safety, absent the device or strategy.absent the device or strategy.

While 115 CMR 5.12 (1) calls for a restraint form While 115 CMR 5.12 (1) calls for a restraint form when using physical holding over active resistance when using physical holding over active resistance for this process, this is in conflict with other for this process, this is in conflict with other regulatory citations and therefore, no longer required.regulatory citations and therefore, no longer required.

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Rules Governing Category 3. LOMRules Governing Category 3. LOM Supports for Proper Body Positioning and Supports for Proper Body Positioning and

Safe Participation in ProgrammingSafe Participation in Programming – – (continued)(continued)

Any support in this category must be crafted by the Team, Any support in this category must be crafted by the Team, including a “qualified practitioner” (including possibly OT or including a “qualified practitioner” (including possibly OT or PT, etc.) and placed in the ISP as the least intrusive approach PT, etc.) and placed in the ISP as the least intrusive approach to allow safe participation.to allow safe participation.

Procedures for safety checks and relief from any devices must Procedures for safety checks and relief from any devices must be spelled out in the description. Trained staff should be be spelled out in the description. Trained staff should be supervised by qualified practitioner to oversee use of this supervised by qualified practitioner to oversee use of this procedure.procedure.

Team should consider if there are any strategies available to Team should consider if there are any strategies available to reduce or eliminate the need for such a support.reduce or eliminate the need for such a support.

Tracking of the use of the strategy and its impacts should be Tracking of the use of the strategy and its impacts should be maintained.maintained.

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Rules Governing Category 3. LOMRules Governing Category 3. LOM Supports for Proper Body Positioning and Supports for Proper Body Positioning and

Safe Participation in ProgrammingSafe Participation in Programming – – (continued)(continued)

No support under this provision may be No support under this provision may be implemented and be in place contingent upon implemented and be in place contingent upon the presence of emergency behavior. Such a the presence of emergency behavior. Such a response reflects an emergency intervention, response reflects an emergency intervention, not a support.not a support.

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Rules Governing Category 4. Rules Governing Category 4. LOMLOM

Application of Application of

Health Related ProtectionsHealth Related Protections

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Rules Governing Category 4. LOMRules Governing Category 4. LOMHealth Related ProtectionsHealth Related Protections

These are physical or mechanical strategies ordered These are physical or mechanical strategies ordered by a dentist or physician to support an individual by a dentist or physician to support an individual during a dental or medical procedure, or while during a dental or medical procedure, or while recovering from a wound or surgery.recovering from a wound or surgery.

Any staff assisting an individual in an appointment Any staff assisting an individual in an appointment during which such an order is made during which such an order is made should cooperate should cooperate with the physician, unless they are aware of physical with the physician, unless they are aware of physical or emotional contraindications for the specific or emotional contraindications for the specific intervention ordered for this particular person.intervention ordered for this particular person. They should inform the dentist or physician of any They should inform the dentist or physician of any such knowledge and determine the best course of such knowledge and determine the best course of action together.action together.

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Rules Governing Category 4. LOMRules Governing Category 4. LOMHealth Related ProtectionsHealth Related Protections (Continued)(Continued)

If this is not already in the person’s ISP and it is the If this is not already in the person’s ISP and it is the first time such an intervention under order of a dentist first time such an intervention under order of a dentist or physician is used, participating staff should report or physician is used, participating staff should report this to supervisors, and a HCSIS incident report form this to supervisors, and a HCSIS incident report form should be submitted under “Potential Mistreatment,” should be submitted under “Potential Mistreatment,” if concern exists whether appropriate, or “other,” if concern exists whether appropriate, or “other,” whichever best reflects the judgment of those whichever best reflects the judgment of those involved. involved.

In this case the Team should meet and discuss if this In this case the Team should meet and discuss if this is the least intrusive and most effective approach to is the least intrusive and most effective approach to use with this individual. use with this individual.

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Rules Governing Limitation on MovementRules Governing Limitation on MovementHealth Related ProtectionsHealth Related Protections (Continued) (Continued)

If the Team determines a more effective and less If the Team determines a more effective and less intrusive approach, they should identify an intrusive approach, they should identify an appropriate party to discuss this with the dentist or appropriate party to discuss this with the dentist or physician in advance of the next such procedure.physician in advance of the next such procedure.

If the Team supports the medical professional’s If the Team supports the medical professional’s judgment, all staff attending such appointments judgment, all staff attending such appointments should be prepared to implement such a procedure (or should be prepared to implement such a procedure (or any replacement procedure agreed to with the medical any replacement procedure agreed to with the medical professional), which also has been placed in the professional), which also has been placed in the person’s ISP, if there is an on-going need for the person’s ISP, if there is an on-going need for the procedure.procedure.

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Rules Governing Limitation on MovementRules Governing Limitation on MovementHealth Related ProtectionsHealth Related Protections (Continued) (Continued)

115 CMR 5.12 (1) orders staff to fill out a restraint 115 CMR 5.12 (1) orders staff to fill out a restraint form whenever using physical holding over active form whenever using physical holding over active resistance has been required for such a procedure. resistance has been required for such a procedure. This is in conflict with other regulatory references, so This is in conflict with other regulatory references, so this is no longer required.this is no longer required.

As with any limitation of movement the agency needs As with any limitation of movement the agency needs to present the plan for any such limitation to their to present the plan for any such limitation to their Human Rights Committee for their review.Human Rights Committee for their review.

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Rules Governing Category 5. Rules Governing Category 5. LOMLOM

Per 115 CMR 5.14Per 115 CMR 5.14

Application of Application of Behavioral Interventions Behavioral Interventions

Involving Holding or Other Involving Holding or Other Limitations on Freedom of Limitations on Freedom of

MovementMovement

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Rules Governing Category 5. LOMRules Governing Category 5. LOM Restrictive Behavioral InterventionsRestrictive Behavioral Interventions

Holding as an intervention must have a treatment purpose as Holding as an intervention must have a treatment purpose as derived from the functional assessment of the behavior to derived from the functional assessment of the behavior to decrease, if intervention involves any form of physical or decrease, if intervention involves any form of physical or mechanical holding.mechanical holding.

Such holding must not be contingent on the presence or Such holding must not be contingent on the presence or imminent risk of physical or emotional harm, such as found in imminent risk of physical or emotional harm, such as found in an emergency. Emergency responses are subject to Category an emergency. Emergency responses are subject to Category 1. LOM, emergency restraints, under 115 CMR 5.11. This 1. LOM, emergency restraints, under 115 CMR 5.11. This would represent a failure of treatment and is not consistent would represent a failure of treatment and is not consistent with a treatment purpose.with a treatment purpose.

Must meet the requirements of the series of reviews found in Must meet the requirements of the series of reviews found in 115 CMR 5.14 (4) (d), including Peer Review and HRC 115 CMR 5.14 (4) (d), including Peer Review and HRC review and review and approvalapproval..

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Rules Governing Category 5. LOMRules Governing Category 5. LOM Restrictive Behavioral Interventions Restrictive Behavioral Interventions

(Continued)(Continued) As with all restrictive interventions, such a plan must As with all restrictive interventions, such a plan must

include interventions related to the functional role of include interventions related to the functional role of the person’s behavior that provide for teaching new the person’s behavior that provide for teaching new skills to replace the challenging or otherwise socially skills to replace the challenging or otherwise socially inappropriate behavior.inappropriate behavior.

In the very near future these rules will be In the very near future these rules will be strengthened and physical holding against active strengthened and physical holding against active resistance in emergency situations will not be resistance in emergency situations will not be allowed to be declared as having a treatment allowed to be declared as having a treatment purpose and will always be treated as emergency purpose and will always be treated as emergency restraints.restraints.

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Rules Governing Category 5. LOMRules Governing Category 5. LOM Restrictive Behavioral Interventions Restrictive Behavioral Interventions

(Continued)(Continued) Use of time out procedures per 115 CMR 5.14 (2); Use of time out procedures per 115 CMR 5.14 (2);

115 CMR 5.14 (3); and115 CMR 5.14 (4) (b) 10. are 115 CMR 5.14 (3); and115 CMR 5.14 (4) (b) 10. are not deemed as seclusion, or a form of emergency not deemed as seclusion, or a form of emergency restraint, though if the person is alone in the room restraint, though if the person is alone in the room with the door open, or the door is closed and staff is with the door open, or the door is closed and staff is in the room, it still must not exceed 15 minutes.in the room, it still must not exceed 15 minutes.

No door may be closed by a lock, or by a device that No door may be closed by a lock, or by a device that keeps it closed when staff leave area.keeps it closed when staff leave area.

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Rules Governing Category 5. LOMRules Governing Category 5. LOM Restrictive Behavioral Interventions Restrictive Behavioral Interventions

(Continued)(Continued) Closed door time outsClosed door time outs with the staff not present in the with the staff not present in the

room have been determined to present more than a room have been determined to present more than a minimal risk of serious physical or emotional harm minimal risk of serious physical or emotional harm and as such and as such deemed Level II interventions or subject deemed Level II interventions or subject to the rules for Intensive Behavior Support Plansto the rules for Intensive Behavior Support Plans . . No such time out may exceed one fifteen minute No such time out may exceed one fifteen minute period. Multiple time out periods consisting of more period. Multiple time out periods consisting of more than 15 cumulative minutes are not allowed.than 15 cumulative minutes are not allowed.

Staff not in the room must be able to see the person at Staff not in the room must be able to see the person at all times.all times.

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Rules Governing Category 5. LOMRules Governing Category 5. LOM Restrictive Behavioral Interventions Restrictive Behavioral Interventions

(Continued)(Continued) As with all intrusive interventions, before time As with all intrusive interventions, before time

outs are proposed for use in a Level II or outs are proposed for use in a Level II or intensive behavior support plan, there must be intensive behavior support plan, there must be a replacement behavior in the plan to provide a replacement behavior in the plan to provide teaching in a manner that replaces the function teaching in a manner that replaces the function of the target behavior to decrease. This may of the target behavior to decrease. This may eliminate or reduce the need for the time out eliminate or reduce the need for the time out provision. provision.

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Rules Governing Category 5. LOMRules Governing Category 5. LOM Restrictive Behavioral Interventions Restrictive Behavioral Interventions

(Continued)(Continued) Behavior Support Plans involving any intervention that is Behavior Support Plans involving any intervention that is

more than minimally restrictive, intrusive or limiting of more than minimally restrictive, intrusive or limiting of freedom of movement must include all the provisions of freedom of movement must include all the provisions of 115 CMR 5.14 (4) for what is currently recognized as 115 CMR 5.14 (4) for what is currently recognized as Level II behavior support plans (under current regulations Level II behavior support plans (under current regulations for Behavior Modification).for Behavior Modification).

Provision of baseline data in any plan is critical for use to Provision of baseline data in any plan is critical for use to measure the course of treatment over time. This includes measure the course of treatment over time. This includes data on treatment behavior to decrease, treatment data on treatment behavior to decrease, treatment behavior to increase and on-going data on the use of any behavior to increase and on-going data on the use of any intervention.intervention.

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Rules Governing Category 5. LOMRules Governing Category 5. LOM Restrictive Behavioral Interventions Restrictive Behavioral Interventions

Positive Behavioral SupportsPositive Behavioral Supports The Department is moving toward implementation of The Department is moving toward implementation of

Positive Behavioral Supports which are defined as Positive Behavioral Supports which are defined as follows:follows:

Positive Behavioral Supports - A systematic, person-Positive Behavioral Supports - A systematic, person-centered approach to understanding reasons for centered approach to understanding reasons for behavior and applying evidence-based practices for behavior and applying evidence-based practices for prevention, proactive intervention, teaching, and prevention, proactive intervention, teaching, and responding to behavior, with the goal of achieving responding to behavior, with the goal of achieving meaningful social outcomes, facilitating learning, meaningful social outcomes, facilitating learning, and enhancing quality of life across the life span.and enhancing quality of life across the life span.

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Rules Governing Category 5. LOMRules Governing Category 5. LOM Restrictive Behavioral Interventions Restrictive Behavioral Interventions

Positive Behavioral SupportsPositive Behavioral SupportsPositive Behavior Supports is Based on Positive Behavior Supports is Based on

Three Tiers of Analysis and ResponseThree Tiers of Analysis and Response Creating positive environments that take into Creating positive environments that take into

consideration the needs and concerns of each consideration the needs and concerns of each individual, in relation to others.individual, in relation to others.

Generic responses to low level behavioral Generic responses to low level behavioral concerns, based on a simple analysis of the concerns, based on a simple analysis of the reasons for the behavior including teaching reasons for the behavior including teaching and reinforcement procedures.and reinforcement procedures.

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Rules Governing Category 5. LOMRules Governing Category 5. LOM Restrictive Behavioral Interventions Restrictive Behavioral Interventions

Positive Behavioral SupportsPositive Behavioral Supports

Intensive supports for a small number of Intensive supports for a small number of people, focused on teaching new skills and people, focused on teaching new skills and safe supports that minimize or eliminate the safe supports that minimize or eliminate the need for restrictive management procedures.need for restrictive management procedures.

As with current Level II interventions, these As with current Level II interventions, these intensive plans will continue to be reviewed intensive plans will continue to be reviewed and approved or denied by HRC.and approved or denied by HRC.

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Rules Governing Category 5. LOMRules Governing Category 5. LOM Restrictive Behavioral Interventions Restrictive Behavioral Interventions

Positive Behavioral SupportsPositive Behavioral Supports As DDS works in the next years to fully As DDS works in the next years to fully

implement PBS more will be said in this implement PBS more will be said in this module. For now, please understand that at module. For now, please understand that at core, for the most challenging behavior the core, for the most challenging behavior the goal is the same. We work hard to understand goal is the same. We work hard to understand why someone is acting in harmful ways and why someone is acting in harmful ways and work to determine how we may provide new work to determine how we may provide new skills to give them more healthy ways to skills to give them more healthy ways to communicate their needs.communicate their needs.

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ConclusionsConclusions All limitations on freedom of movement must be All limitations on freedom of movement must be

focused on the person and represent the least focused on the person and represent the least restrictive approach to solving a compelling problemrestrictive approach to solving a compelling problem

There are standards for who can craft each type of There are standards for who can craft each type of limitation, these guidelines are important.limitation, these guidelines are important.

All forms of limitation on the freedom of movement All forms of limitation on the freedom of movement should be monitored at the implementing agency to should be monitored at the implementing agency to ensure they obtain the stated goal.ensure they obtain the stated goal.

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Conclusions – Conclusions – (Continued)(Continued)

Agencies may not utilize procedures of any sort that Agencies may not utilize procedures of any sort that limit a person’s freedom of movement that are not limit a person’s freedom of movement that are not sanctioned by one of these categories!sanctioned by one of these categories!

All persons are different and agencies should focus All persons are different and agencies should focus on what strategies or teaching practices can best on what strategies or teaching practices can best address the goals and needs of the individual in front address the goals and needs of the individual in front of them, rather than just going back to specific of them, rather than just going back to specific strategies that worked for others!strategies that worked for others!

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Any Questions?Any Questions?

Please contact your regional Human Rights Please contact your regional Human Rights Specialist, contact information is on the Specialist, contact information is on the

Human Rights Link at mass.gov/ddsHuman Rights Link at mass.gov/dds

Or contact Tom Anzer, Director for Human Or contact Tom Anzer, Director for Human Rights to find out how to make contact with Rights to find out how to make contact with your Human Rights Specialist at 617-624-7738your Human Rights Specialist at 617-624-7738