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RESTRICTIVE PRACTICES TIER AND GUARDIANSHIP BOARD

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					         RESTRICTED PRACTICE AUTHORISATON




Samaritans Disability Support Services Client Services Managers, Practitioners and
service Supervisors October 2010

Based on presentations developed previously by Tracey Harkness, Auria Garcia, Emma Read,
Kathyrn Latal, Jane Pfaff
Overview
•   What is a restricted practice?
•   Brief overview of why problem behaviours can occur
•   Objectives of Restricted Practice Authorisation
•   Restricted Practices
•   Prohibited Practices
•   Current DADHC process of Restricted Practice Authorisation.
•   Guardianship and RPA
•   Documentation required to support applications
•   Special requirements for ETO and Seclusion
•   Group activity
       What are Restricted Practices?

• Restricted practices refer to the use of any technique or
  method to direct, manage or change a person‟s behaviour

• They stop the person from doing what they want to do

Example
  When someone behaves in a way that hurts others or destroys property,
  they might need to be stopped quickly before they do too much damage.
  A restricted practice might have to be used for a short while, until people
  work out what is making them act in this way
         Restricted Practice Authorisation
• The RPA is an organizational monitoring and authorisation process for
  restricted practices, it includes:
   o Reviewing the use of restricted practices at an individual level;
   o Authorising the practice, providing interim authorisation, or not
      authorising practices.

• The RPA panel has a role in the monitoring of such practices to ensure
  that they meet good clinical and ethical standards.
                Behaviour is Communication!
• Challenging behaviour by a person generally indicates that
  some element of their life is not working.
• Such behaviour may be a way of communicating a message.
• It is our responsibility to try and understand the message and
  respond in the most appropriate way



•   Ageing and Disability Department, 1997,The positive approach to challenging
    behaviour
            Behaviour Management & Ethics
                 things to consider…
• Is the behaviour inhibiting the person from enjoying life as an active
  community member?
• Is the decision to intervene justified?
• Will the intervention improve the person‟s quality of life?
• What is the least restrictive or least intrusive option available?
• Has the program been discussed with the person or their advocate?
• Has consent been obtained?
• Are there sound reasons to believe the program will work?
• How and when will the program be reviewed?
• Does the program respect the rights and dignity of the individual?
Challenging behaviours - Can occur for a variety of reasons,
such as:-
 • Fear – A perceived need (sometimes irrational) to escape,
   defend against, or eliminate a perceived threat of personal injury
   or emotional well-being
 • Frustration – Attempting to gain control by physically attacking
   the source of frustration or someone or something else
 • Manipulation – Attempting to obtain or avoid something eg,
   temper tantrum, playing the numbers, promoting confusion
 • Intimidation – a calculated and deliberate attempt to get
   something in exchange for physical safety or freedom from
   threat, „don‟t make me hurt you‟ (often used by people diagnosed
   with an anti-social personality disorder)

     o Smith, Paul A, 2004, predict, assess and respond to challenging
       behaviour.
Some strategies and expected outcomes for dealing with
                challenging behaviour
Motivation          Intervention               Outcome

FEAR                 Threat Reduction          Perceived Safety

FRUSTRATION           Assisting with Control   Self-control

MANIPULATION          Detach and Redirect       Positive
                                                Re-engagement

INTIMIDATION          Identify and              Safe / Better choices
                      Communicate
                      Consequences

       Smith, Paul A, 2004, predict, assess and respond to challenging
       behaviour (PART).
            Restricted Practices

•   Restricted Access
•   Physical Restraint
•   Exclusionary Time out
•   Seclusion
•   Response Cost
•   PRN medication
Restricted Access
 Restricting a person‟s independent access to items, activities or
 experiences through physical barriers or staff intervention.


Physical restraint or unwanted physical contact
 The use of any device or strategy that restricts the person‟s movement
 in response to challenging behaviour.
            Special Approval Requirements for
                    Physical Restraint
Physical Restraint has special requirements for implementation.

   only to be used if necessary and where less intrusive alternatives have
   been demonstrated to be ineffective, and the person or others are likely to
   be harmed without restraint; and staff implementing restraint are trained and
   competent to do so.

Physical restraint does not include physical assistance for involuntary
  movement in instruction, function support devices / aids, safety devices to
  prevent injury of devices commonly used for specific medical, dental
  or surgical procedures.
Response cost

• Requires the person to lose or forego valued items or activities as a
  result their behaviour.
• The „cost‟ is not to be excessive or interfere with any medication
  regime.
• Predetermined items or activities that are not to be included in
  response cost procedures include access to basic needs and
  possessions and access to support persons.
• Proactive programs (eg, reward programs) are often a better option
• RC programs require the person to have the capacity to understand
  the „cost‟.
Exclusionary time out
 Following the occurrence of a particular behaviour, the person is
 removed from a setting for a period to withdraw their access to the
 thing that is causing their behaviour. This needs to be a planned
 response to the behaviour. The ability to leave this setting is
 prevented.
Seclusion
 Where a person is confined in a setting on his or her own in
 response to a crisis, and the person‟s capacity to leave is denied.
 This is only used until the crisis is over.

 Seclusion differs from ETO in that it may be an immediate
 response to a crisis – as opposed to the last option available - and
 duration may not be able to be specified as it is dependent on the
 duration of the crisis.
Special Requirements

Seclusion and Exclusionary Time Out
•   Physical requirements:
     o   adequate light,
     o   comfortable temperature,
     o    adequate ventilation,
     o   means of easy observation,
     o   fixed furnishings and appropriate flooring to avoid potential for harm.
                  Special Requirements
•   In addition:
     o seclusion does not necessarily require restricted access to all possessions,
     o accesses to toilet to be provided as necessary.
     o Continual observation is a mandatory requirement.

•   Duration: must not exceed 15 minutes unless imminent danger remains. Unit
    manager needs to be notified if duration needs to exceed 15 minutes.

•   Data must be recorded for each time it is used

•   Each use of seclusion or exclusionary time out must be reviewed within 24 to 72
    hours by unit manager, behaviour practitioner, and support staff representative.
PRN Psychotropic medication
Pro re nata is a Latin phrase that literally means "for the thing
  born". It is commonly used in medicine to mean "as needed" or
  "as the situation arises”.

   o  The administering of PRN psychotropic medication in
      response to challenging behaviour
   o PRN is not considered appropriate as the sole strategy or treatment and
     need to be detailed in a support plan after that incorporates and
     emphasises less intrusive methods.
   o Needs to be prescribed and reviewed by a psychiatrist or other relevant
     physician.
Some Key Rules about Restricted Practices

 1. They should be used when everything else has been tried/explored
 2. They must be used together with „positive programming‟
 3. There must be someone senior in charge responsible for
    o Monitoring and reviewing the use of restricted practices at an
       individual level;
    o Authorising the practice, providing interim authorisation, or not
       authorising the practice.
   Restricted Practice Authorisation
• Without organizational authorisation, staff implementing
  restricted practices are operating outside of policy and,
  some of the above practices without formal consent from a
  legal guardian may constitute punitive practices, wrongful
  imprisonment or assault. If this occurs internal disciplinary
  action may be taken and/or criminal charges may be
  pursued.
                  Prohibited practices
Practices implemented by staff that are abusive and constitute
   assault or wrongful imprisonment are unlawful.

These practices may constitute:-
• Corporal punishment or physical abuse such as hitting, hair pulling or slapping
• Over correction where the person has to repair more damage than caused
• Exclusionary time-out without proper approval and consent.
• Administering medication without authority or an overall plan.

•   Prohibited Practices can also include:
     o Restricted practices without authorisation and consent.
     o Restricted practices without planned positive programming.
Assault
• Any reckless and intentional act that is harmful, offensive,
  unwanted and unlawful.
• An act intended to arouse fear such as shouting and making
  threats.
• Accidental touching is not an assault.
Wrongful imprisonment
• The unauthorised, deliberate confining of a person in a setting
  where the person‟s capacity to leave is denied. Eg. seclusion and
  exclusionary time out without valid consent, or if the particular
  procedure or conditions of the consent are not adhered to, or if
  unreasonable force is used.
  Prohibited Practices cont…
Aversive Practices
  Is the application of painful or noxious conditions (eg. unwanted cold bath,
  unwanted application of chilli powder on food, unwanted squirting of liquid
  into person‟s face)

   Any planned behaviour intervention that produces pain or serious discomfort
   (including significant distress).
Consent and Guardianship
• Free Consent
• Restricted Practices Authorization and Consent
• The Guardianship Tribunal
                                Free Consent
•   The person who is the subject of intrusive or restrictive procedures may provide a
    valid consent if they have a general understanding of what is consented to.
•   Consent can be withdrawn at any time; If a person has previously consented to a
    behaviour management procedure and now physically resists it, this can be a
    withdrawal of consent.
•   Deciding whether a person with an intellectual disability has given a free and valid
    consent to an intrusive or restrictive behaviour management procedure is difficult to
    judge. If doubtful cases, an application should be made to the Guardianship Tribunal.
            RPA and Guardianship
• Guardianship Tribunal is a legal tribunal. It has the power to appoint legal
  guardians and/or financial managers for people with disabilities over 16 years
  of age who are not able to make decisions for themselves. The Tribunal can
  also consent to certain medical and dental treatments.

• The restricted practices, that require a legally appointed Guardian with
  authority to consent, are:
   o Physical restraint and unwanted physical contact;
   o Exclusionary time out
   o Seclusion
   o There is a lack of clarity from ADHC if the range of restricted practices
     requiring consent has been expanded to include most practices.

    • Some cases may be referred to the Supreme Court eg, when invasive
      medical procedures are involved
         RPA and Guardianship (cont.)
• When a restricted practice does not by law require an appointed
  Guardian‟s approval, the service user or „person responsible‟ needs to
  be consulted and provide agreement to the use of the practice.

• RPA is designed to supplement and enhance the process of seeking
  consent from the Guardianship Tribunal, Guardian or responsible
  person. Whilst the Guardian can consent to the use of a practice,
  DADHC staff require RPA before they can implement a restricted
  practice so that they are operating within DADHC policy.

• RPA cannot override a Guardians objection to a restricted practice
What happens before the RPA meeting…
• New behaviour of concern requiring staff to use a restricted practice
   o Every occurrence of the relevant challenging behaviour must be
     recorded, eg data sheets (ABC), incident reports
   o These reports should identify if a RP has been used or may be
     required to manage the behaviour

• Initial meeting for developing interim or planned RPA submissions
   o The Service Supervisor should arrange an initial meeting as soon as
      practical and involve:
         The service user (when appropriate); service supervisor or
          delegate; BIS practitioner; direct support staff who know the
          person; the guardian or person responsible.
                  RPA Process (cont.)
The meeting is to complete the following:
• Operationally define the behaviours of concern and behaviour
  cycle (topography) what when where how
• Develop an interim incident response plan
• Develop / revise data collection formats
• Allocate tasks and time frames to complete work required for RPA (eg,
  LER, Behaviour assessment etc see workplan in RPA procedures).
• Review and update the Client Risk Management Profile, assess the risk
  and update the risk management plan ;and
• Minute the meeting, set time frames and allocate responsibilities for
  further assessment.
                      RPA Process
Interim Authorisation

  There may be an urgent need to implement a restricted practice as
  identified in the above meeting. If this is the case, the service supervisor
  or delegate should seek interim permission from the Client Services
  Manager

  For interim permission to be granted consent from the appropriate
  Guardian must also be obtained eg Public Guardian.
                   RPA Process
The meeting recommends a restricted practice as part of PLANNED
  intervention.
• further documentation will be required to support this including:

   o current Lifestyle and Environment requirements or Lifestyle
     Management Plan;
   o Behavioural assessment report;
   o Any relevant reports from other professionals eg, psychiatrists.
   o Evidence of skill development programs;
   o Incident Prevention and Response Plan;
   o Evidence of staff training and an ongoing coaching strategy; and
   o Monitoring and review procedures.
 RPA Process – Panel Composition (proposed)
• A Behaviour Support Practitioner – Not the person making the
  submission (chairperson)
• A Client Services Manager or Director
• An independent person (independent to the process or
  agency). In the absence of an independent a CSM, BSP or
  AC can sit in their stead.
                       The RPA Panel Hearing
(The ‘Approval Checklist’)
• Panel members will have read the information prior to coming to the panel meeting.
• The panel may ask for
    o A brief picture of the situation; the person, the practice and why this practice is
       being used. Questions will generally be around the following:
          Quality of the Lifestyle and Environment Review and Behaviour assessment (if there is
           one);
          the appropriateness of the restricted practice;
          staff implementation training;
          progress on recommendations made in reports;
          plans for implementation requirements - who will be responsible and when things will
           be completed;
          data collection formats and analysis;
          guardianship and consent status;
          evidence that Individual Plans have been implemented.
                     RPA Panel Hearing cont.
•   The panel will then make the decision about whether or not they will approve the
    practice/s.

•   Practices will either be
    o given approval for up to 12 months,
    o not given approval, or
    o given conditional/limited approval (usually be for periods less than 3 months)

•   A number of recommendations will often be made at the RPA panel meetings
    with respect to what needs to be completed between the authorisation period;
    these will often need to be completed before further authorisation will be
    considered.

•   The BSP sends the Service Supervisor and Area Coordinator a copy of the
    signed approval.

•   BSP updates the RPA database
Documentation Required for Application
• Lifestyle and Environment Review / Plan
• Data collection documentation and summary.
• Behaviour intervention Plan, including Skill development plans,
  Reactive Strategy, etc.
• Evidence of staff training and support strategies.
• Current IP, and information on progress & goals
• Documented consent.
• Rationale for the practice
• Prior Improvement Plan (for reviews)
• Any other Relevant report, eg. psychiatrist report
 Restricted Practices as part of a risk Management Plan
• Under our Duty of Care we put safeguards in place for many of
  our clients who may not have sufficient safety skills that can be
  viewed as restrictive
• We record and monitor these practices but may not need the
  level of documentation and level of scrutiny that some restricted
  practices may require, eg full BIS plan
• Still need a current Lifestyle and Environment Review, Client
  Risk Profile, and positive programs
• The Behaviour Support Policy (2009) makes no distinction
  between “safety skill deficit” restricted practices and other
  restricted practices
         Lifestyle and Environment Review
The Lifestyle and Environment Review is a process of reviewing a person‟s
current lifestyle and environment requirements.

This review is to identify what actions might need to occur to improve the
current lifestyle and address the behaviours of concern.

For the purposes of RPA, evidence of a current Lifestyle and Environment
Review is required for all submissions as well as the implementation of the
Panel‟s recommendations for improvement.
               Lifestyle Management Plan

The recommendations from the Lifestyle and Environment Review
should be acted upon, and written into the person‟s updated Lifestyle
Management Plan as part of their Individual Plan.

It is to inform all support people of the person‟s support needs in all
aspects of daily living and any plans in place that need to be followed in
order to meet the client‟s needs effectively.
           Behaviour Assessment Report
             *By Behaviour Support Practitioner
•   Behavioural assessment involves the systematic collection of
    information about the person, the behaviour and their environment.

•   A detailed functional analysis of the behaviours occurs

•   A hypotheses or statement as to why the person engages in the
    behaviour of concern is generated

•   Recommendations are then made for the environmental, skill building
    and reactive strategies

•   The complexity of the assessment will vary depending on the
    complexity of the client and their problem behaviours.
       Behaviour Management Plans Behaviour
       Support Plan
       BIS Plans
There are three main components of a behavioural Support Plan:

   o The Lifestyle Management component

   o Skill Development component

   o Reactive Strategies/Incident Prevention Response Plan
                 Skill Development Plans
                 (positive programming)
• Skill development, in behaviour intervention, are plans to teach the
  person skills to provide them with more efficient ways of having their
  needs met instead of using challenging behaviour.

• Skills taught may include coping skills, communication skills, social
  skills, anger management skills, or skills to enhance his or her
  independence and self esteem in doing things around the home, work,
  recreation, and community.

• The behavioural assessment informs what skills are required.

• Skill development programs need to be embedded in the Individual
  Plan for monitoring and timely review.
        Examples of Skill Development Plans:
• A communication program that teaches a client how to say, “I don’t
  want to do that” instead of using assaultive behaviour to
  communicate the same message.

•   A relaxation procedure that helps a person to manage their stress;

•   A timetable that shows an anxious person what activity they‟ll be
    doing next;

•   An exercise class that gives an active person the opportunity to burn
    off some excess energy;

•    A social skills group that shows a person how to appropriately
    interact with others
       Incident Prevention & Response Plans
• Plans to prepare staff in advance on how to prevent, manage or end a
  challenging incident safely and effectively.

• Aim to provide a means of consistency in support.

• Should still have a focus on prevention of behaviours, not just response
  strategies.

• All people who know the client well should be encouraged to participate
  in the development and review of these plans.

• Plans need to have endorsement from the person responsible and the
  unit manager.
                  Further reading
• DADHC resources available on the Intranet
       Behaviour Support: Policy and Practice manual (2009)
       Restricted Practice Authorisation (RPA) Mechanism: Operational
        Guide (June 2010)
       DADHC RPA procedures and templates (2006)
       DADHC Behaviour Intervention Policy (2003)
       Consent for Specific Behaviour Intervention Practices, Exchange of
        Consumer Information and for Medical and Dental Treatment
       Positive Approach to Challenging Behaviour, 1997
• Guardianship act (1987)

				
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