Overview of Florida Administrative Code 65G-8.001-012

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Overview of Florida Administrative Code
65G-8.001-012
Reactive Strategies
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Overview of Rule 65G-8

• Establishes procedure for approval of crisis
  intervention curricula
• Requires providers to establish policy and
  procedures for the use of reactive strategies
• Requires 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

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Overview of Rule 65G-8 (contd)

• Includes prohibited procedures
• Documentation and reporting mechanisms
• Establishes procedure for enforcement of rule

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In the Name Of Treatment
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A Little History..

• Formerly called Emergency Procedures
• HRSM 160-4 Appendix G
• HRSM 205-1
• Hartford Courant Article Deadly Restraint 1998
• ACT memo 1999
• Childrens Mental Health Act of 2000
• Title V of Public Health Services Act
• Public Advisory from Advocacy Center

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Change is good

• F.A.C. 65G-8
• applies to all providers
• applies to any consumer who is funded under FS
  393
• Requires curriculum that is approved by central
  office in Tallahassee
• Each consumer must have initial assessment by
  physician upon admission
• Use of authorizing agents per type of strategy
  used
• Use of any reactive strategy on a PRN or as
  needed basis is prohibited

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Authorizing Agents

• For any strategy, staff must notify highest level
  supervisor
• For 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 bachelors degree, two years experience with DD, and certified in approved curriculum
Manual Restraint Staff certified in approved curriculum
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Types of Reactive Strategies

• Seclusion
• Manual Restraint
• Mechanical Restraint
• Chemical Restraint
• Behavioral Protective Equipment

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Manual Restraint

• Definition Use of hands or body to immobilize
  a persons 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 rate
• Requires reapproval if exceeds one hour
• Requires Visual inspection (by authorizing agent
  of on-site designee) if longer than 2 hrs.

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Seclusion

• Definition enforced isolation or confinement
  of an individual in a room or area
• Not Time out or medical isolation
• Authorizing Agent must have Bachelors 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.

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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 Reinforcement
• Not a reactive strategy defined by this rule
• Must be short in duration
• Never more than 20 min. (or considered seclusion)

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Time Out (contd)

• Part of a written behavior plan, that includes a
  functional assessment and approve by LRC
• Plan is implemented by BCBA, FL-CBA or licensed
  under 490 or 491
• Implemented in response to a specific behavior
• Includes requirement that individual returns to
  previous activity at end of time out
• Time out data must be collected and analyzed
• Must include termination criteria (e.g. one
  minute of calm)

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Mechanical Restraint

• Definition a physical device used to restrict
  an individuals movement or restrict the normal
  function of the individuals body
• Does 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 Devices
• Equipment used for safety during transportation
• Medical protective equipment (see next slide)
• Authorizing Agent must be BCBA, FL CBA,
  Physician, or licensed under 490 or 491
• Requires continuous monitoring, monitor
  respiration
• Reauthorization 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

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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 results
• Part of LRC-approved program
• Authorizing Agent must be BCBA, FL CBA, or
  licensed under 490 or 491

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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

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Chemical Restraint

• Definition use of medication to effect
  immediate control of an individuals 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 PRNs

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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

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Initial Assessment

• Completed upon admission, annually, change in
  condition
• Physicians report Medical conditions, physical
  limitations that place at risk and/or preclude
  specific procedures
• Document any trauma relevant to use of reactive
  strategies

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Conditions that might increase risk

• Obesity
• Cardiac conditions
• Pregnancy
• Asthma/respiratory
• Impaired gag reflex
• Back/Spinal cond.
• Seizure disorders
• Deafness

• Blindness
• Limited range of motion
• Osteoporosis/ Osteopenia
• Hemophilia
• Other

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All Reactive Strategies

• Require authorization by authorizing agent with
  clear rationale
• Authorizing agent notified of conditions leading
  up to use of strategy
• Agent is responsible for terminating procedure
  not in compliance with rule
• Requires continuous monitoring
• Must be least restrictive
• Terminate as soon as emergency ends
• Within 5 minutes after calm criteria is met
• Not used as punishment

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All Reactive Strategies (contd)

• Greatest possible comfort and protection from
  injury for client
• Limit 1 hour unless reauthorized
• Episode more than 15 minutes after release
  requires new authorization

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Prohibited Procedures

• Noxious or painful stimuli,
• Untested or experimental procedures
• Procedures that might restrict or obstruct an
  individuals airway or impair breathing
• including techniques whereby staff persons use
  their hands or body to place pressure on the
  clients head, neck, back, chest, abdomen, or
  joints (which causes pain)
• Restraint of an individuals 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)

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Prohibited Procedures (contd)

• Using a pillow, blanket, or other item is used to
  cover the individuals face as part of the
  restraint process
• Any reactive strategy that may exacerbate a known
  medical or physical condition, or endanger the
  individuals 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.

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Important things to remember

• The 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 services
• Provider must have
• written behavioral criteria for termination of a
  reactive strategy, to all staff trained in those
  techniques.

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Reactive Strategies Reporting

• Report on Reactive Strategy Report form
• Submit Monthly to Area APD Office due by 5th
  working day of month
• APD Submits Combined Report Monthly to Central
  Office due by 10th calendar day of month

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Documentation

• No later than end of work shift
• Behavior requiring use
• Strategy used
• Date, Start and End time
• Person who Initiated, Used, Authorized, Ended
  strategy
• Signed by Authorizing Agent within 24 hrs.

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Reactive Strategy Policy and Procedures Provider
responsibilities

• Approved 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

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Reactive Strategy Policy and Procedures Provider
responsibilities (contd)

• 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 Agencys 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.

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The Following Do Not Take Effect Until February
1, 2009

• 65G-8.002 Agency-approved Curriculum
• 65G-8.003 Policies and Procedures
• 65G-8.004 Initial Assessments

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Sample Scenarios
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Questions and Answers
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Contact Information

• Ken Winn, SunCoast Region Area Behavior Analyst
• Phone [phone]
• Fax [phone]
• Email Ken_Winn_at_apd.state.fl.us
• Diana Geller, SunCoast Region Quality Assurance
• Phone [phone]
• Fax [phone]
• Email Diana_Geller_at_apd.state.fl.us