Frequently Asked Questions and Answers(65G-8) Reactive Strategies: APD Seclusion and Restraint Rule

65G-8

65G-8 Is it correct that providers are expected to begin implementing this [rule] now (except for those provisions which have a grace period)?


65G-8.001 - Definitions

65G-8.001 Is the critical difference between "time out" and "seclusion" the fact that it is written into a behavior plan or that it is a consequence that is implemented consistently for a specific behavior? For example, if removing a person to a separate room or area is written into a behavior plan as an emergency procedure to be used only when other procedures (e.g. redirection, prompting alternative response, blocking, etc.) are ineffective and the behavior presents an immediate danger, is this considered "time out" or "seclusion"?

65G-8.001 If a person is currently using behavioral protective equipment or mechanical restraints as part of an LRC-approved behavior plan rather than as a reactive strategy, must the use of this equipment be reauthorized every hour as with a reactive strategy? (For example, person moves into group home and wears a helmet or arm splints. A plan is in place to gradually fade these out, but currently the person wears them 24-7.)

65G-8.001 If protective equipment is used for an individual and is NOT part of an LRC approved behavior plan (i.e. physician has written an order for protective helmet), does the use of this equipment fall under the criteria for mechanical restraint?

65G-8.001 Is medication prescribed by a physician to be given for sedation prior to a medical procedure considered chemical restraint?

65G-8.001 If a person goes into time out (per the behavior plan) and it lasts for 25 minutes, it is then seclusion since it is longer than 20 minutes. Is the total duration of seclusion reported as 25 minutes or 5 minutes?


65G-8.002 - Approved Emergency Procedure Curriculum

65G-8.002 Does the requirement to train staff in a manual restraint curriculum apply to every provider and facility (e.g. including companions, SL coaches, PCA's, single owner "Mom & Pop" foster homes, etc.) or does this only apply to those providers who serve people whose behavior might require the use of manual restraint?

65G-8.002 Does this [rule] apply to public and private ICF/DDs?

65G-8.002 For submission of the emergency procedure curricula:

  1. Will the Central Office be contacting major companies (e.g. PCM, CPI, Mandt, etc.) and requesting they apply for approval statewide, or should each APD provider/facility request approval individually for whatever system they use? For example, if a provider uses PCM as their crisis management system, does this mean that the Central office has contacted PCMA to submit the required information for approval so that providers can use PCM statewide? Is it the provider's responsibility to have PCM authorized or is it PCMA's responsibility?

    • The Central Office has sent notice to a wide variety of vendors of emergency procedure/reactive strategy curricula. Thus far we have been contacted by or received materials from Professional Crisis Management (PCM), Alternatives for Behavioral Crises (ABC), Facing Emergencies And Reacting, Crisis Intervention Training, Safe Crisis Management (SCM), Crisis Prevention Institute (CPI), Techniques for Effective Aggression Management (TEAM) and Mandt. There is an "Emergency Procedure Training Curriculum Review Tracking" link on the APD website that will be updated as reviews and approvals are completed.

      These materials have not been reviewed and approved, yet. The time frame for this review is prior to the end of the "grace period", Feb. 1st, 2009. Once reviewed and approved a list of approved curricula will be posted on the APD website. In most cases, the providers will not need to submit materials for review. In those cases where a "home-grown" or less commonly used curriculum is in place, the provider will need to submit materials for review.

  2. If it is the provider's responsibility, what should they do if the company they use does not allow them to copy its materials without permission?

    • For a curriculum to be approved, a full set of training materials, including photos or videos of procedures or moves must be submitted to enable a review and disposition as approved or not approved. If the author or training vendor will not submit their materials they cannot be reviewed and approved for use under 65G-8.
  3. If crisis management system companies are submitting applications to the Central Office directly, how can a provider determine if the system they use has already been submitted and/or approved?

    • A tracking tool will be created and posted on the APD website identifying which curricula have been received and what their status is in the review and approval process.
  4. Approximately how long will approval take?

    • No history yet to comment.
  5. If each provider needs to submit individually, will the Area offices have copies of the "Emergency Procedure Training Curriculum Application" form or will it be posted on the APD website, or should each individual provider/facility contact the Central Office themselves?

    • The "Emergency Procedure Training Curriculum Application" form will be posted on the APD website and can be obtained by calling the local APD Area Office or APD Central Office.
  6. Does each provider need to notify the Area Office or Central Office of which curriculum they are using?

    • The notification of the local Area Office indicating which curriculum they are using is being considered as an amendment to the current rule.

65G-8.002 Some agencies have written Emergency Procedure Curricula for their facility. Can an agency submit such a curriculum for review and approval by APD or must they adopt one of the approved commercial curricula?

65G-8.002 The new rules state that training certification is valid for one year. Some systems have a two year approval. Will this now need to be annual? With PCM, it is one year, with an extra grace period of 3 months for staff and 6 months for instructors. Is this acceptable?

65G-8.002 Can the 12 direct hours of training include the time spent doing the competency-based evaluation and written test?

65G-8.002 Does the twelve direct training hours apply just to the initial emergency procedure training curriculum or also to the annual recertification? Some systems have a shorter training for annual recertification than they do for the initial time a person is certified. Must this recertification now be 12 hours?

65G-8.002 It appears that in order to authorize the use of seclusion, the authorizing agent must, among other things, be certified in an Agency-approved reactive strategies curriculum.

  1. Does this mean that if a facility/provider does not use or train staff to use manual restraint, they cannot use seclusion?

    • Unless the person(s) requiring seclusion is (are) compliant enough to respond to verbal prompts or shadowing, it's hard to imagine getting someone to seclusion without a "hands on" technique. Otherwise, that is correct, staff must be trained in those procedures that are used within the facility.
  2. Could a provider develop and have approved a reactive strategies curriculum that does not include manual restraint?

    • If the provider intends not to touch any client in a behavioral emergency or crisis, then it would appear that they are not using reactive strategies, and do not need an approved curriculum. However, uses of emergency medication, Baker Act, or Law Enforcement are considered reactive strategies for the purposes of reportable events. In turn, should individuals receiving services need reactive strategies more than twice in 30 days or six times in a 12-month period the development of a behavior plan is required (65G-8.006 - Limitations on Use and Duration of Reactive Strategies).

65G-8.003 - Reactive Strategy Policy and Procedures

65G-8.003 Does the consent for use of reactive strategies need to be updated annually?

65G-8.003 & 65G-8.005 Seclusion and restraint may not exceed 2 hours without visual review and approval of the procedure by an authorizing agent or the agent's on-site designee. a) How is this person designated? b) What are the qualifications of the designee? c) For example, if staff call for authorization of seclusion or restraint, when the authorizing agent calls back can he or she authorize someone to act as a designee (in case the procedure exceeds 2 hours) and then not come on-site?

  1. Each residential provider will need to develop policy and procedure to address 65G-8.003 Reactive Strategy Policy and Procedures as an initial step toward making these assignments;
  2. The authorizing agent's qualifications are identified in 65G-8.005 (3)(c) Authorizations for Specific Reactive Strategies.
  3. If an "on-site" designee is used, this person's qualifications should match as closely as possible those of the original authorizing agent. At the very least this person should be certified in the procedures being used, and have the authority to stop a procedure, if necessary.

65G-8.004 - Initial Assessments

65G-8.004 Must the initial assessment be completed before admission to the facility? If not, how long after the admission does the provider have to complete the assessment?

65G-8.004 Some providers (e.g. ADT's) serve a mix of people, many of whom do not display problem behavior. Must the initial assessment be done on everyone in the facility or only those for whom reactive strategies might reasonably be expected to be used?

65G-8.004 Does the requirement for an annual assessment apply to ADT's? Since they are not involved in physician's visits (especially for people living in family homes), how will they share the information on reactive strategies and get the physician's part of the assessment done?

65G-8.004 Is there any specific format or information that needs to be included in the physician's report for the initial assessment? Will there be a specific form?

65G-8.004 Who is responsible for asking the physician to write the physician's report?

65G-8.004 Whose responsibility is it to shrink or summarize the reactive strategies curriculum and to show the procedures to the physician so she/he can see what they entail?

65G-8.004 Is the physician also the person responsible for evaluating the information regarding previous trauma, history of sexual abuse, etc.? If so, whose responsibility is it to share this with the physician?

65G-8.004 If a physician is unwilling to sign a release statement regarding risk, how should this be handled? Is an actual release signed by the physician required, or is a statement from the physician of the risks and any contraindications sufficient?

65G-8.004 What is the difference between conditions that create a risk of injury with seclusion/restraint, and conditions that preclude the use of seclusion/restraint?

65G-8.004 If the physician says a person has a risk factor but says that restraint may still be used, what additional safeguards or procedures should the provider employ?

65G-8.004 If a person has an initial assessment at one facility and then transfers to another program in less than a year, is this assessment "transferable"? Can the new provider use the assessment from the old provider until it "expires" at the end of a year?


65G-8.005 - Authorizations for Specific Reactive Strategies

65G-8.005 Since reactive strategies are used in crisis situations, it may be difficult to get authorization at the time they are initiated. Is it permissible for staff to get the situation under control first and then call for authorization, notify the highest-level direct supervisor of use, etc.?

65G-8.005 The authorizing agent for behavioral protective devices and mechanical restraint includes behavior analysts certified by the Agency pursuant to 65G-4.003. Does this include all FL CBA's or only those who would meet the criteria for expanded privileges (e.g. Master's degree, etc.)?

65G-8.003 & 65G-8.005 Seclusion and restraint may not exceed 2 hours without visual review and approval of the procedure by an authorizing agent or the agent's on-site designee. a) How is this person designated? b) What are the qualifications of the designee? c) For example, if staff call for authorization of seclusion or restraint, when the authorizing agent calls back can he or she authorize someone to act as a designee (in case the procedure exceeds 2 hours) and then not come on-site?

  1. Each residential provider will need to develop policy and procedure to address 65G-8.003 Reactive Strategy Policy and Procedures as an initial step toward making these assignments;
  2. The authorizing agent's qualifications are identified in 65G-8.005 (3)(c) Authorizations for Specific Reactive Strategies.
  3. If an "on-site" designee is used, this person's qualifications should match as closely as possible those of the original authorizing agent. At the very least this person should be certified in the procedures being used, and have the authority to stop a procedure, if necessary.

65G-8.007 - Seclusion and Restraint

65G-8.007 If protective equipment is used as part of an LRC approved behavior plan, what are the requirements for use, monitoring and opportunity for motion and exercise? The same as mechanical restraint?

65G-8.007 What does "monitor respiration rate" mean? Are direct care staff supposed to measure respiration or just observe respiration patterns? The term "rate" has a measurement connotation.


65G-8.008 - Chemical Restraint

65G-8.008 For the use of chemical restraint, must the authorizing agent (the physician) be contacted every time it is used?

65G-8.008 For chemical restraint, is it acceptable to have a "PRN" order from the physician for use of a medication that says when it should be used? If not, would it be acceptable to have a standing order, already have the prescription filled, and then just call the physician for authorization to use it?

65G-8.008 If a person has a prescription for medication to be used "PRN" when the person feels "agitated" and requests it (i.e. client initiates it, not staff), is this still considered chemical restraint according to this rule?

65G-8.008 For how long must staff record the effects of chemical restraint?


65G-8.009 - Prohibited Procedures

65G-8.009 It states under "Prohibited Procedures" that movement of body parts is prohibited. Many crisis management systems utilize movement in order to get the person's body in the right position for the procedure or to transport/escort the person to another location. Is this permissible? What kinds of movement of body parts are prohibited?

65G-8.009 Under "Prohibited Procedures" it states that documentation of vital signs must be completed for containment. Which vital signs are required? What kind of documentation is required and how often?

65G-8.009 Under "Prohibited Procedures" it states that using reactive strategies on a PRN or as required basis is prohibited. How is "PRN" defined? Can a behavior analyst state in the behavior plan when a reactive strategy should occur? Can reactive strategies be used in an emergency (i.e. since this is essentially PRN or when needed to keep a person or others safe)?


65G-8.010 - Documentation and Notification

65G-8.010 a. When should the Reactive Strategy Report be filled out? b. Is it whenever a listed procedure is used regardless of the consumer having a Behavior Plan or not? c. Which providers fill out the Report (e.g. Companions, PCAs, CBAs, ResHab, ADT, etc.) or is it only for specific providers?

  1. If the Reactive Strategy Report is your primary means of recording these procedures, then all uses of reactive strategies or "reportable events" should be entered at the time of an event requiring a reactive strategy. Some providers may choose to use another "working document" for the ease of staff recording and then enter the information electronically into the Excel-based report daily, weekly or at the end of the month for submission to the Area Office.
  2. Reactive strategies should be entered into the Reactive Strategy Report whether there is a Behavior Plan or not.
  3. All uses of reactive strategies should be reported, regardless of who the provider is. Keep in mind that this is at least one data source for determining whether formalized behavioral procedures are needed and whether they are effective or not.

65G-8.010 Are facilities required to maintain any documentation that demonstrates that the following occurred during use of each reactive strategy procedure: 1)continuous monitoring occurred, 2)vital signs were taken as indicated according to rule, 3)opportunity for motion and exercise provided if restraint exceeded one hour, 4)documentation of authorization of and 5)reauthorization of procedure?

65G-8.010 On the reactive strategies reporting form, there is no choice for "ICF" (other than state DSI's) in the dropdown box under "Type of Facility". Should ICF's use "Other"?

65G-8.010 On the reactive strategies reporting form, what is the difference between "Chemical Restraint" and "Stat Meds"? If a medication is already prescribed and is given at a different time or dose than usual on a physician's orders for the purpose of behavioral control, wouldn't this still be chemical restraint? If it is given at a different time/dose for some other reason, wouldn't this be a medication change (if there was a physician's order) or a medication error (if no physician's order)?

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