6.3
INJURY & ABUSE PREVENTION
POSITIVE BEHAVIOR SUPPORTS AND EMERGENCY USE OF CONTROLLED PROCEDURES
PURPOSE: Individuals receiving services through LSS will be supported in a dignified manner. This
procedure provides guidance for staff in the use of positive behavioral supports and interventions
as well as safe guidelines for the use of a controlled procedure.
POLICY: Lutheran Social Service ensures that positive behavior supports are afforded the person in a
consistent, pro-active manner.
PROCEDURE:
I. Each individual will receive the behavior supports needed to maximize their ability to achieve independence.
The following interventions are listed from least intrusive through the use of emergency controlled
procedures.
A. Positive Reinforcement. (See Psychotropic Medication - Behavioral Support Plan).
B. Verbal prompt to redirection or constructive feedback.
C. Physical contact to redirect a person’s behavior. (Individual redirected within 60 seconds of physical
contact by staff).
D. Contingent observation – temporary interruption in activity participation. (Individual is able to observe
on-going activity; return to activity is contingent upon the display of appropriate behavior).
E. Temporary withdrawal or withholding of goods, services or activities. This action is used as a
consequence to a person’s inappropriate use of goods, services or activities. Withdrawal or withholding
lasts no more than several minutes (5-10 minutes).
F. Emergency Use of Controlled Procedure (EUCP).
II. Individuals who have behavioral challenges (i.e., physical, verbal, sexual aggression, withdrawal, excessive
repetition, self-abuse) will have individually designed behavior programs. The primary focus of the
behavioral management plan or Psychotropic Medication -Behavioral Support Plan should be the
development of positive behaviors. The behavioral management plan or Psychotropic Medication -
Behavioral Support Plan will be approved by the Interdisciplinary Team and will incorporate the use of
intervention which is more positive and least intrusive. The Interdisciplinary Team is responsible for the
following:
A. The individual’s record provides documentation of programs incorporating the use of least intrusive and
positive interventions that are implemented and proven to be effective. The documentation for the
individual includes the frequency of the behavior, possible antecedents, environmental factors, and the
communicative intent of the behavior.
B. If the individual’s service plan includes any exempted actions or procedures defined in Rule 40, then a
plan with a complete methodology will be included that is signed by the individual, case manager, and
authorized representative to ensure agreement.
C. For the safety of the individual, the federal and state regulations, guidelines, and law regarding behavior
management will be followed. The Controlled Procedures Compliance Checklist(Rule 40) may be used
as a reference tool.
D. In an ICF/MR the program’s Human Rights Committee (HRC, also known as Internal Review
Committee) will approve Rule 40 plans and psychotropic medications prior to implementation, EUCPs,
Rule 40 and psychotropic medication data on a quarterly basis. Psychotropic Medication – Behavioral
Support Plans (i.e., techniques, etc.) will be approved before implementation and annually thereafter.
This review and approval process will ensure that the interventions are employed with sufficient
safeguards and supervision.
III. Intervention Guidelines to ensure safety.
A. Staff will be familiar with the individual’s behavioral management plan or Psychotropic Medication -
Behavioral Support Plan (if applicable) and know the best possible response to each behavior.
B. The individual will be encouraged to find another activity, or staff will follow interventions identified in
his or her behavioral management plan or Psychotropic Medication – Behavioral Support Plan.
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6.3
INJURY & ABUSE PREVENTION
POSITIVE BEHAVIOR SUPPORTS AND EMERGENCY USE OF CONTROLLED PROCEDURES
C. The individual may be encouraged to move to another location or area. (i.e., go outside or to the other
end of the house.)
D. If an individual is targeting an object or another individual, remove that item or ask the individual being
targeted to leave the area. If this is not possible, then staff will position themselves between the
object/individual. If self-injurious behavior or property destruction is occurring, follow the Risk
Management Plan or the Psychotropic Medication – Behavioral Support Plan and/or use Physical
Intervention Alternatives (PIA) techniques.
E. The staff will continue to follow steps A-D until the situation is diffused. If the individual’s behavior
continues to escalate, an emergency use of controlled procedure may be implemented.
IV. Criteria for the emergency use of a controlled procedure. (If an individual exhibits a target behavior that is
addressed in a Rule 40 plan, that plan must be followed).
A. In order for an emergency use of controlled procedure to be permitted for manual restraints, the
individual’s primary care doctor must be consulted to determine if implementing the controlled
procedure is medically contraindicated. This must be documented on the Annual Physical Examination.
B. The least restrictive procedure possible is implemented to diffuse the emergency situation.
C. Immediate intervention is needed to protect the individual or others from physical injury or to prevent
severe property damage that is an immediate threat to the physical safety of the individual or others.
D. The individuals service plan does not include the use of a controlled procedure as defined in a Rule 40
program.
V. Controlled procedures permitted for emergency use.
A. Exclusionary Time-Out: The individual is removed from an ongoing activity to a location where he or
she cannot observe the ongoing activity after the individual demonstrates a behavior identified in IV. -C.
The individual must be continuously monitored during the exclusionary time-out. When possible, the
individual must be returned to the activity from which the individual was removed when the time out
procedure is completed. If the individual’s behavior has not abated or stopped, the staff must attempt to
return the individual to an ongoing activity at least every 30 minutes. Bathroom breaks and drinking
water must be offered to the individual every 30 minutes.
B. Manual Restraint: A one or two person hold or escort that restricts the individual’s ability to move freely
or assists the individual to move from one location to another. This occurs when the individual resists
physical contact as an intervention for a behavior identified above. To ensure the welfare and safety of
the individual, he or she must be given an opportunity for release from the manual restraint and for
motion and exercise of the restricted body parts for at least ten minutes out of every 60 minutes. For the
individual’s comfort and safety efforts to lessen or discontinue the manual restraint must be made at least
every 15 minutes, unless contraindicated. The time each effort to release was made and the individual’s
response to the effort must be noted on the Emergency use of Controlled Procedure Report Form.
VI. Prohibited procedures will not be implemented.
A. Room time-out
B. Faradic shock
C. Mechanical restraints
D. Prone restraints
E. Abuse/neglect
F. Corporal punishment
G. Speaking to a person in a manner that ridicules, demeans, or threatens
H. Seclusion
I. Totally or partially restricting a person’s senses
J. Presentation of intense sounds, lights, or sensory stimuli
K. Use of noxious smell, taste, substance, or spray including water mist
L. Denying or restricting an individual’s access to equipment devices such as hearing aids and
communication devices that facilitate the individual’s functioning
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POSITIVE BEHAVIOR SUPPORTS AND EMERGENCY USE OF CONTROLLED PROCEDURES
M. Denying or restricting a individual’s use or access to nutritious diet, water, ventilation, medical care,
hygiene facilities, normal sleeping conditions, clothing, legal representative, next of kin
N. Requiring an individual to assume and maintain a specified physical position or posture
O. Positive practice overcorrection or restitutional overcorrection
P. Deprivation
VII. Internal Procedure – Reviewing and Reporting Emergency Use of Controlled Procedures
A. Any emergency use of controlled procedure governed by Minnesota rules, parts 9525.2700 to 9525.2810
must be reported and reviewed as specified in this policy by the designated staff person (QDDP). The
QDDP is responsible for reviewing, documenting, and reporting use of emergency procedures and will
use the forms specifically developed for review and reporting purposes.
B. Immediately following implementation of an emergency controlled procedure, staff must make a verbal
(telephone or in person) notification to specified person(s), i.e., case manager, legal representative, the
QDDP and the director.
C. Any direct support staff who implements an emergency procedure must fill out a written report before
the end of their shift. (See Emergency Use of Controlled Procedure Report Form).
D. Within three calendar days after an emergency use of a controlled procedure, the supervisor will ensure
that the report has been forwarded to the QDDP with the following information about the emergency use:
1. A detailed description of the incident leading to the use of the procedure as an emergency
intervention.
2. The controlled procedure that was used.
3. The time implementation began and the time it was completed.
4. The time of each attempted release.
5. The behavioral outcome that resulted.
6. Why the procedure used was judged to be necessary to prevent injury or severe property damage.
7. An assessment of the likelihood that the behavior necessitating emergency use will recur.
E. ICF/MR only: Within seven calendar days after the date of the emergency use of a controlled procedure,
the QDDP will review the report prepared by the staff member who implemented the emergency
procedure and ensure the report is sent to the case manager and Expanded Interdisciplinary Team (EIDT)
for review. If the emergency use involved manual restraint, mechanical restraint, or use of exclusionary
time out exceeding 15 minutes at one time or a cumulative total of 30 minutes or more in a 24-hour
period, the QDDP must ensure the report is sent to the internal review committee (Human Rights
Committee) within seven calendar days of the emergency use of the controlled procedure.
F. Within seven calendar days after the date of receipt of the emergency report, the case manager will
confer with members of the EIDT to:
1. Discus the incident reported.
2. Define the target behavior for reduction or elimination in observable and measurable terminology.
3. Identify the event(s) that gave rise to the target behavior.
4. Identify the perceived function that the target behavior served.
5. Determine what modifications should be made to the existing individual program plan so as to not
require the use of a controlled procedure.
G. If it is determined that a controlled procedure is necessary, an EIDT meeting must be held within 30
calendar days after the emergency use. The target behavior should be identified in the individual
program plan for reduction or elimination.
H. Within 15 calendar days after the EIDT meeting, the emergency use of a controlled procedure as well as
changes made to the adaptive skill acquisition portion of the plan must be incorporated into the
individual program plan. During this time, the QDDP will document all attempts to use least restrictive
alternatives including:
1. Adaptive skill acquisition procedures currently being used and why they were not successful.
2. Attempts made at less restrictive procedures that failed and why they failed.
3. Rationale for not attempting the use of other less restrictive alternatives.
I. ICF/MR only: The QDDP must ensure a copy of the report is sent to the HRC within five working days
after the EIDT meeting.
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INJURY & ABUSE PREVENTION
POSITIVE BEHAVIOR SUPPORTS AND EMERGENCY USE OF CONTROLLED PROCEDURES
J. The interdisciplinary team’s decision must be documented on the Interdisciplinary Team Meeting Notes.
VIII. All staff will be trained on Rule 40, emergency use of controlled procedures, the individual’s behavior
program and if appropriate, physical intervention alternatives. Staff training will be conducted during
orientation and on an on-going basis. Training will also include the Positive Behavior Supports and
Emergency Use of a Controlled Procedure Policy prior to implementing controlled procedures. All staff will
complete training on controlled procedures before being permitted to implement a controlled procedure under
emergency conditions as part of orientation. This must include practice and demonstration.
* If the individual has a Rule 40 plan in place, documentation that staff are competent to implement the controlled
procedure will be provided to the EIDT.
REFERENCES: State of Minnesota Rules and Regulations
State of Minnesota Rule 40
ISSUED BY: Personal Support Services
APPROVED BY: Vice President/LSS-MN Community Services
Revised November 8, 2010 Policy 6.3 Page 4 of 4