APPENDIX A REIMBURSEMENT RATES FOR ‘COMP’ SERVICES

APPENDIX A
Reimbursement Rates for COMP Services
The reimbursement rates outlined below are the maximum amount that Medicaid may reimburse providers, unless an exceptional rate has been authorized by the DBHDD Regional Office and the Office of Developmental Disabilities (see Part II, COMP Policies and Procedures Chapter 1000 for information on exceptional rate approval). The Department of Behavioral Health and Developmental Disabilities assigns the individual provider rates.
A. Adult Occupational Therapy:
Adult OT Evaluation (97003)
Adult OT Evaluation Self-Directed (97003-UC)
Unit = one evaluation
Limit = one evaluation per year
Maximum rate per unit = $52.99
Adult OT Therapeutic Activities (97530-GO)
Adult OT Therapeutic Activities Self-Directed (97530-GO/UC)
Unit = 15 minutes
Limit = 4 units per day
Maximum rate per unit = $19.76
Adult OT Sensory Integrative Techniques (97533-GO)
Adult OT Sensory Integrative Techniques Self-Directed (97533-GO/UC)
Unit = 15 minutes
Limit = 4 units per day
Maximum rate per unit = $24.46
Annual Limit for All Adult Therapies = $1,800.00
B. Adult Physical Therapy:
Adult PT Evaluation (97001)
Adult PT Evaluation Self-Directed (97001-UC)
Unit = one evaluation
Note: The reimbursement rates outlined below are the maximum amount that Medicaid will reimburse providers, unless an exceptional rate has been authorized by the DBHDD Regional Office and the Division of Developmental Disabilities. The Department of Behavioral Health and Developmental Disabilities may authorize individual provider rates up to the maximum amount or in extraordinary circumstances related to transition of an individual from an institution or imminent risk of institutionalization of an individual authorize an exceptional rate (see Part II, COMP Policies and Procedures Chapter 1000 for additional information on exceptional rate approval).
Rev. 01 2011
Rev. 01 2011
January 1, 2015 Comprehensive Supports Waiver Program A-2
Limit = one evaluation per year
Maximum rate per unit = $52.99
Adult PT Therapeutic Procedure (97110)
Adult PT Therapeutic Procedure Self-Directed (97110-UC)
Unit = 15 minutes
Limit = 4 units per day
Maximum rate per unit = $20.07
Annual Limit for All Adult Therapies = $1,800.00
C. Adult Speech and Language Therapy:
Adult Speech Language Evaluation (92523)
Adult Speech Language Evaluation Self-Directed (92523-UC)
Unit = one evaluation
Limit = one evaluation per year
Maximum rate per unit = $54.93
Adult Speech Language Therapy (92507-GN)
Adult Speech Language Therapy Self-Directed (92507-GN/UC)
One unit = One visit
Maximum rate per unit = $62.53
Adult Speech-Generating Device Therapy (92609)
Adult Speech-Generating Device Therapy Self-Directed (92609-UC)
One unit = One visit
Maximum rate per unit = $54.75
Annual Maximum for All Adult Therapies = $1,800.00
D. Behavioral Supports Consultation Services:
Behavioral Supports Consultation (H2019)
Behavioral Supports Consultation Self-Directed (H2019-UC)
Unit = 15 minutes
Limit = 104 annual units
Maximum rate per unit = $23.56
Annual Maximum = $2,450.24
Self-Directed
Limit: 1 unit = $1.00
Annual maximum = $2,450
E. Community Access Services:
Community Access Group (T2025-HQ)
Rev. 01 2014
Rev. 07 2014
January 1, 2015 Comprehensive Supports Waiver Program A-3
Community Access Group Self-Directed (T2025-HQ/UC)
Community Access Group Co-Employer (T2025-HQ/UA)
Unit = 15 minutes
Daily Limit = 24 units
Monthly Limit = 504 units
Annual Limit = 5760 units
Maximum rate per unit = $3.04
Community Access Individual (T2025-UB)
Community Access Individual Self-Directed (T2025-UB/UC)
Community Access Individual Co-Employer (T2025-UB/UA)
Unit = 15 minutes
Daily Limit = 40 units
Annual Limit = 1440 units
Maximum rate per unit = $7.26
Self-Directed
Community Access Group Limits: 1 unit = $1.00
Annual limit is as authorized in the individual budget
up to an annual maximum of $17,510.
Community Access Individual Limits: 1 unit = $1.00
Annual limit is as authorized in the individual budget
up to an annual maximum of $10,454.
F. Community Guide Services:
Community Guide Self-Directed (H2015-UC)
Community Guide Co-Employer (H2015-UA)
Unit = 15 minutes
Daily Limit = 32 units
Annual Limit = 224 units
Maximum rate per unit = $8.93
Annual Maximum = $2,000.32
Self-Directed
Limit: 1 unit = $1.00
Annual limit is as authorized in the individual budget up to an annual maximum of $2,000.
G. Community Living Support Services:
Community Living Support – 15 Minutes (T2025-U5)
Community Living Support – 15 Minutes Self-Directed (T2025-U5/UC)
Community Living Support – 15 Minutes Co-Employer (T2025-U5/UA)
Unit = 15 minutes
Maximum daily number of units = 26
Rev. 07 2014
Rev. 07 2014
January 1, 2015 Comprehensive Supports Waiver Program A-4
Maximum annual number of units = 9002
Maximum rate per unit = $4.93
Maximum amount billed per day is $128.52 or any approved exceptional rate
Community Living Support – Daily (T2025-U6)
Community Living Support – Daily Self-Directed (T2025-U6/UC)
Community Living Support – Daily Co-Employer (T2025-U6/UA)
Maximum unit per day = 1
Maximum annual number of units = 365
Participant specific rate
Maximum rate per unit = $128.52 or any approved exceptional rate
Community Living Support RN (T1002-U1)
Community Living Support RN Self-Directed (T1002-U1/UC)
Unit = 15 minutes
Maximum rate per unit = $10.00
Community Living Support LPN (T1003-U1)
Community Living Support LPN Self-Directed (T1003-U1/UC)
Unit = 15 minutes
Maximum rate per unit = $8.75
Total annual amount of all fifteen-minute CLS habilitation and CLS nursing units billed can not exceed $44,379.86 or any annual amount associated with an authorized exceptional rate when only 15-minute units are billed.
Total annual amount of all CLS daily habilitation services and CLS fifteen units billed (including nursing) can not exceed $46,909.80 or any annual amount associated with an authorized exceptional rate.
Self-Directed
Community Living Support: 1 unit = $1.00
Annual limit is as authorized in the individual budget up to an annual maximum of $46,909.
H. Community Residential Alternative
Community Residential Alternative – Daily (T2033)
Maximum unit per day = 1
Maximum units per month = 27
Maximum annual number of units = 324
Participant specific daily rate
Maximum rate per unit = $155.56
Community Residential Alternative RN (T1002-U2)
Rev. 04 2010
Rev 10 2010
Rev. 07 2014
January 1, 2015 Comprehensive Supports Waiver Program A-5
Unit = 15 minutes
Maximum rate per unit = $10.00
Community Residential Alternative LPN (T1003-U2)
Unit = 15 minutes
Maximum rate per unit = $8.75
Total annual amount of all CRA daily habilitation services and fifteen minute CRA nursing services units billed cannot exceed $50,401.44 or any annual amount associated with an authorized exceptional rate.
Note: CRA nursing (CRA LPN, CRA RN) services may be billed daily in fifteen minute increments for up to 365 days as authorized for the participant within the annual maximum for all CRA services or any annual amount associated with an exceptional rate.
I. Environmental Accessibility Adaptation:
Environmental Accessibility Adaptation (S5165)
Environmental Accessibility Adaptation Self-Directed (S5165-UC)
Participant Specific rate
Lifetime maximum per participant = $10,400.00
The reimbursement rate is the lower of three price quotes or the lifetime maximum.
J. Financial Support Services:
Financial Support Services (T2040-UC)
Monthly maximum unit = 1
Maximum annual number of units = 12
Maximum rate per participant = $75.00 per month
K. Individual Directed Goods and Services:
Individual Directed Goods and Services (T2025-U7/UC)
Maximum Annual number of units = 20
Annual maximum = $1,500.00
Limits: 1 unit = $1.00
$1,500 annual maximum.
L. Natural Support Training Services:
Natural Support Training (T2025-UD)
Natural Support Training Self-Directed (T2025-UD/UC
Unit = 15 minutes
Maximum annual of units = 86
Maximum rate per unit = $20.78
Rev. 10 2011
Rev. 07 2014
Rev. 10 2011
Rev 10 2013
January 1, 2015 Comprehensive Supports Waiver Program A-6
Self-Directed
1 Unit = $1.00
Annual limit is as authorized in the individual budget up to annual maximum of $1,787.
M. Prevocational Services:
Prevocational Services (T2015)
Unit = 15 minutes
Daily Limit = 24 units
Monthly Limit = 504 units
Annual Limit = 5760 units
Maximum rate per unit = $3.04
N. Respite Services:
Respite – 15 Minutes (S5150)
Respite – 15 Minutes Self-Directed (S5150-UC)
Respite – 15 Minutes Co-Employer (S5150-UA)
Units = 15 Minutes
Daily Limit = 24 units
Annual Limit = 889 units
Maximum rate per unit = $4.21
Respite – Overnight (S5151)
Respite – Overnight Self-Directed (S5151-UC
Respite – Overnight Co-Employer (S5151-UA)
Daily Limit = 1 unit
Annual Limit = 39 units
Maximum rate per unit = $96.00
Annual Maximum for Respite Services = $3,744.00
Self-Directed
Respite: 1 unit = $1.00
Applies to 15 minutes Respite, not overnight Respite
Annual limit is as authorized in the individual budge up to the annual maximum of $3,744.
O. Specialized Medical Equipment:
Specialized Medical Equipment (T2029)
Specialized Medical Equipment Self-Directed (T2029-UC)
1 unit = $1.00
Annual maximum = $5,200.00
Rev. 10 2011
January 1, 2015 Comprehensive Supports Waiver Program A-7
The amount of funds per equipment purchase is the standard Medicaid reimbursement rate for the equipment or, in the absence of a standard Medicaid rate, the lower of three price quotes. The annual maximum number of units is 5,200 unless there is approval to exceed the annual maximum up to the lifetime maximum due to assessed exceptional needs of the participant.
Lifetime maximum per participant = $13,474.76
P. Specialized Medical Supplies:
Specialized Medical Supplies (T2028)
Specialized Medical Supplies Self-Directed (T2028-UC)
1 unit = $1.00
Annual maximum = $1,868.16
The annual maximum number of units is 1,816 unless there is approval to exceed annual maximum units due to assessed exceptional needs of the participant.
Q. Support Coordination:
Support Coordination (T2022)
Monthly maximum unit = 1
Maximum annual number of units = 12
Maximum rate per participant = $149.88 per month
R. Supported Employment Services:
Supported Employment Group (T2019-HQ)
Supported Employment Group Self-Directed (T2019-HQ/UC)
Supported Employment Group Co-Employer (T2019-HQ/UA)
Unit = 15 minutes
Monthly Limit = 320 units
Annual Limit = 3840 units
Maximum rate per unit = $1.80
Support Employment Individual (T2019-UB)
Support Employment Individual Self-Directed (T2019-UB/UC)
Support Employment Individual Co-Employer (T2019-UB/UA)
Unit = 15 minutes
Daily Limit = 40 units
Annual Limit = 1440 units
Maximum rate per unit = $7.26
Self-Directed
Supported Employment Group Limits: 1 unit = $1.00
Rev 01 2009
January 1, 2015 Comprehensive Supports Waiver Program A-8
Annual limit is as authorized in the individual budget up to an annual maximum of $6,912.
Supported Employment Individual Limits: 1 unit = $1.00
Annual limit is authorized in the individual budget up to an annual maximum of $10,454.
S. Transportation Services:
Transportation Encounter/Trip (T2003)
Transportation Encounter/Trip Self-Directed (T2003-UC)
Transportation Encounter/Trip Co-Employer (T2003-UA)
Unit = one-way trip
Annual Limit = 203
Maximum rate per unit = $13.78
Transportation Commercial Carrier, Multi-Pass (T2004)
Transportation Commercial Carrier, Multi-Pass Self-Directed (T2004-UC)
Annual Limit = 203
Participant specific rate for local commercial carrier, multi-pass
Annual Maximum for Transportation Services = $2,797.34
Self-Directed
Scheduled Encounter/Trip
Limit = $1.00
Annual limit is authorized in the individual budget up to annual maximum for all self-directed Transportation services of $2,797.
Commercial Carrier/Multipass/Intermittent Trip
1 unit = $1.00
Annual limit is as authorized in the individual budget up to annual maximum for all self-directed Transportation Services of $2,797.
T. Vehicle Adaptation Services:
Vehicle Adaptation (T2039)
Vehicle Adaptation Self-Directed (T2039-UC)
1 unit = $1.00
Lifetime maximum per participant = $6,240.00
Rev. 07 2014
January 1, 2015 Comprehensive Supports Waiver Program B-1
APPENDIX B
GUIDELINES FOR SUPPORTING ADULTS WITH CHALLENGING BEHAVIORS IN COMMUNITY SETTINGS
A Resource Manual for Georgia’s Community Programs
Serving Persons with Serious and Persistent Mental Health Issues And Persons with Mental Retardation or Developmental Disabilities
TABLE OF CONTENTS
I. Preface
Page 6
II. Purpose
Page 7
III. Values of the Division of DBHDD
Page 8
A. Consumer Choice
B. Inclusion
C. Appropriate Environment
D. Quality of Services
E. Individualized Services
IV. Person-Centered Planning
Page 9
V. Understanding Behavior
Page 12
A. What is behavior?
B. What influences behavior?
C. What are challenging behaviors?
D. How do we figure out what the challenging behavior is communicating or what is “causing” the challenging behavior?
E. Focus first on possible medical or psychiatric issues.
VI. Supporting People In Positive Ways
Page 20
A. What can I do on a day-to-day basis that might be helpful to the person?
B. Using positive behavior supports.
C. Combining person-centered planning with positive behavior supports.
D. In closing…
VII. What Do I Do First? Identify and Remove the Cause of
Challenging Behaviors
Page 24
A. Show me some real examples of what you are talking about.
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B. The Wellness Recovery Action Plan (WRAP) is an effective way to identify and remove the cause of challenging behaviors.
VIII. APPROACH I: Gather Information About The Challenging Behavior
Page 28
A. We have not been able to figure out the behavior! Now what do we do?
B. What is a functional assessment?
C. Looking for the A-B-C’s.
D. How much information needs to be collected and for how long?
E. How do I collect information about the A-B-C’s?
IX. APPROACH II: Call In a Professional To Develop a Positive Behavior Support Plan (PBSP)
Page 32
A. What is a Positive Behavior Support Plan (PBSP)?
B. Thirteen outcomes you should expect to find in a completed PBSP.
C. What kind of professional can write a positive behavior support plan (PBSP)?
D. How do I know that the plan is written using positive behavior approaches?
E. Checks and balances to be sure staff know what to do.
F. Review and oversight of the PBSP.
X. What Can We Do If The Behavior Support Plan Is Not Working?
Page 40
A. Seek additional review and consultation.
B. What if the challenging behavior is affecting the individual’s personal health and safety, or the health and safety of others?
XI. APPROACH IIIA: Develop A Crisis Plan
Page 42
A. What is a crisis plan?
B. What are the essential components of a crisis plan?
APPROACH IIIB: Develop A Safety Plan
Page 44
A. When should a safety plan be written?
B. Where does the PBSP leave off and the safety plan begin?
C. Are there any particular processes that must occur when a safety plan is used?
D. Can medication be used in a safety plan?
E. Should a safety plan be written when the health and safety of the individual or the health and safety of others is NOT affected?
XII. Using Medications For Challenging Behaviors
Page 49
January 1, 2015 Comprehensive Supports Waiver Program B-3
A. Is it ok to give medication for challenging behaviors?
B. Are medications EVER appropriate to give to someone with challenging behaviors?
C. Are PRN medications ever OK to use for individuals living in the community?
D. When we take an individual to the doctor, what does the doctor need to know?
E. How should we prepare for a visit to the doctor?
F. What information needs to GO BACK to best support the individual?
G. In summary…
XIII. Emergency Safety Interventions of Last Resort
Page 56
XIV. Affording Respect To The Individual, Observing Client Rights, Federal and State Laws and Departmental Rules
Page 57
A. Afford respect to persons served.
B. Know the story of the person you serve.
C. Informed Consent.
D. Laws and Regulations.
XV. Strategies That Maintain Resilience in Caregivers
Page 59
XVI. We Hope The Manual Is Helpful
Page 60
XVII. Those Who Gave of Their Time, Energy and Expertise to
Make This Manual Possible
Page 61
APPENDICES
Appendix A: Learning to Listen
Page 1
Appendix B: Physiological Issues to Consider
Page 2
B.1 Pain
B.2 Medical Considerations In the Approach to Problematic Behavior
A. General Considerations
1. Pain
2. Medication Effects, Medication Side Effects and Medication Toxicity
B. Neurologic Effects
1. Headaches
January 1, 2015 Comprehensive Supports Waiver Program B-4
2. Meningitis/Encephalitis
3. Dementia
C. Eyes
D. Ears, Nose, and Throat
E. Pulmonary or Cardiovascular
F. Gastrointestinal
1. Constipation/Fecal Impaction
2. Diarrhea
3. Inflammatory Bowel Disease
4. Gastroesophageal Reflux/Hiatal Hernia
5. Ulcer Disease
6. Intestinal Parasites/Pinworms
G. Genitourinary
1. Dysmenorrhea and Urinary Tract Infection
2. Premenstrual Syndrome and Premenstrual Dysphoric Disorder
3. Vaginitis and Vaginal Candidiasis
H. Integumentary
I. Musculoskeletal
J. Endocrine
K. Menopause
L. Hematologic
Appendix C: Quality of Life Satisfaction Interview For Persons With
Challenging Behaviors
Page 9
Appendix D: Glossary of Non-Restrictive Techniques
Page 12
D.1 Brief Overview of Non-Restrictive Methods for Use in
Positive Behavior Support Plans
D.2 Definition and Characteristics of Non-Restrictive Methods That
May Be Used in PBSPs
1. Positive Reinforcement
2. Negative Reinforcement
3. Extinction of Maladaptive Behavior that is not Dangerous
4. Differential Reinforcement of Incompatible Behavior (DRI)
5. Differential Reinforcement of Other Behavior (DRO)
6. Differential Reinforcement of Alternative Behavior (DRA)
7. Behavioral Contracting with Positive Consequences (Earning Extra Privileges)
8. Reinforced Practice
9. Contingent Observation
10. Response Blocking or Interruption
11. Restoration of Environment
12. Non-Contingent Dietary Management
January 1, 2015 Comprehensive Supports Waiver Program B-5
13. Withdrawal to a quiet area
14. Brief Manual Hold
Appendix E: The Emergency Safety Intervention of Last Resort That
May Be Used in a Safety Plan or as Part of a Crisis Plan
Within The Community
Page 25
1. Personal (Manual) Restraint
2. Processes for documentation and debriefing after the use of an emergency safety intervention
Appendix F: Emergency Safety Interventions of Last Resort That
May Be Used Within the Community ONLY Within
Residential Crisis Stabilization Programs
Page 27
F.1 Specific Techniques
1. Seclusion of an Individual
2. Physical (Mechanical) Restraint
F.2 Chemical Restraint May Never Be Used
1. Chemical Restraints
I. PREFACE
This resource manual is intended to provide parameters for addressing behavioral
January 1, 2015 Comprehensive Supports Waiver Program B-6
concerns of persons with serious and persistent mental health issues and for addressing behavioral concerns of persons with mental retardation and other developmental disabilities who are served in community programs supported by funding, in whole or in part, that is authorized by the Georgia Department of Behavioral Health and Developmental Disabilities (DDBHDD). Additionally the manual is a resource for the development of individual local program policies for behavioral support planning and programming.
The manual sets forth both guidelines and requirements to be followed when behavioral supports are utilized in the care of persons served. Policies developed within community programs regarding behavioral supports are expected to comply with the guidelines and requirements set forth in this manual, including current regulatory standards, individual rights, core values and philosophy of treatment of the Division of DBHDD, and to be consistent with empirical knowledge related to behavior analysis.
This manual was developed in compliance with the Division’s Provider Manual for Georgia Department of Behavioral Health and Developmental Disabilities Providers Under Contract with the Georgia Department of Behavioral Health and Developmental Disabilities as well as federal and state law, rules and regulations.
Readers will note that disability groups use different language to describe similar things. For example, within MR/DD the Individualized Service Plan is referred to as the ISP. Within MH it is referred to as the Individual Recovery Plan, or IRP. And you will find similarities when discussing positive behavior supports and WRAP Plans. If the differences and similarities do not become clear as you read, feel free to contact staff in the respective disability sections of the Division of DBHDD.
Appreciation and recognition are expressed to those individuals who served on the task force to develop the manual and to the staff who offered their suggestions on its content. This manual is provided to be a useful resource to facilitate the best services possible within the Division of DBHDD.
II. PURPOSE
The manual has several purposes:
January 1, 2015 Comprehensive Supports Waiver Program B-7
 To provide person-centered guidance for supporting adults with challenging behaviors, regardless of their disability
 To promote consistent and effective services and supports in different settings and circumstances (e.g., families, supported living, etc.).
 To protect the rights of individuals served (client rights), especially the right to participate in and determine the development of their services and supports.
 To provide strategies that promote the highest quality of life possible as determined by the individual.
 To provide tools to enhance skills of persons supporting individuals (staff, family, etc.).
 To provide strategies that maintain resilience in caregivers.
III. VALUES OF THE DIVISION OF DBHDD
The Georgia Department of Behavioral Health and Developmental Disabilities hold these values with regard to persons served through the Division.
A. Consumer choice
Consumers and families have choices about DBHDD services through:
 Participation in designing the DBHDD service system;
 Full participation in development of their service plan;
 Selection of service providers, location of services and other factors related to implementation of the service plan; and
 Opportunity for and development of the capacity to make choices in every day life.
B. Inclusion
Consumers are supported to participate in the everyday life of their community, with their family, friends and natural/community support system. Children and adolescents are supported to remain in their own homes with their families.
January 1, 2015 Comprehensive Supports Waiver Program B-8
C. Appropriate environment
Consumers are served in the least restrictive, least intrusive environment possible that meets the needs of the individual served.
D. Quality of services
Consumers have the highest quality services provided by a competent staff, utilizing flexibility and incentives that reinforce quality and efficiency.
E. Individualized services
Individuals are provided services at the appropriate level of intensity based on their individual strengths, needs and choices with sensitivity to cultural differences, age appropriateness and gender specific needs.
IV. PERSON-CENTERED PLANNING
Person-centered planning is a way to get to know a person and their “story” so that you know what they want in life, where they want to live and what makes them happy. It is a planning process used within all disabilities that addresses all areas of a person’s life, including health, community involvement, relationships with friends and family, and work. It is a collaborative process to help individuals get the supports and services they need to live a quality life, based on their own preferences and values. The individual served and those who know the person best are the most important participants in the planning process.
The person-centered planning process starts with listening to the person and honoring his/her vision. A person-centered approach asks us to remember people as whole human beings with hearts, souls, and desires like everyone. To realize their wishes and potential, support and encouragement is required. Person-centered planning focuses on identifying and maximizing the strengths and preferences rather than creating lists of what the individual can’t do.
A person-centered approach for developing a behavior support plan is similar in that it requires listening to the person to gain an understanding of who the person is, the person’s wishes and hopes for his or her life, honoring his/her vision, understanding his or her strengths and challenges, and giving consideration to the context of his or her social and environmental setting, including any relevant medical or psychiatric
January 1, 2015 Comprehensive Supports Waiver Program B-9
conditions. It requires listening to the individual through their words and actions so that the significance of the behavior(s) can be understood.
When using a person-centered approach, it is most important to identify the gaps between the person’s life and how he or she wants his or her life to be. The person-centered planning process may include strategies for minimizing situations that cause stress for the person and maximizing the person’s control over his or her life.
Listening is a critical component of person-centered planning. What follows in Example 4.1 are some really good tips to use when communicating with people.
EXAMPLE 4.1
PERSONAL CONDUCT THAT SAYS YOU ARE LISTENING
And that will
MINIMIZE NEGATIVE RESPONSES FROM OTHERS
Following these suggestions in your daily interactions with others will assist you in minimizing and de-escalating negative responses from others. If at any time another person’s behavior starts to escalate beyond your own comfort zone, disengage from the situation.
DO THIS
DO NOT DO THIS
Focus your full attention on the other person to let them know you are listening and interested in what they are saying.
Encourage the other person to talk. Listen patiently and with empathy.
Maintain a pleasant, open and accepting attitude.
Know the person before you use humor… it can be misinterpreted as making fun of someone.
Stay calm. Move and speak slowly, quietly and project confidence. Watch your own body language, voice pattern, facial expressions and rate of speech.
Do not use a style of communication that suggests apathy, “the brush-off”, coldness, sarcasm, condescension, minimizing concerns, or giving the run-around.
Maintain a relaxed posture, positioning yourself at a right angle.
Don’t stand directly fact-to-face, hands on hips, crossing arms, finger pointing, or hard stare eye contact. These are very challenging behavioral messages.
Make sure there are 3 to 6 feet between you and person with whom you are speaking.
Don’t invade another person’s personal space. Don’t lean into or over the person.
Don’t touch the person if the person is not harming himself or herself or someone else. Touching escalates behaviors at the
January 1, 2015 Comprehensive Supports Waiver Program B-10
moment.
Make sure you are at a level of eye contact with the person. Adjust your position so that you are communicating with the person literally at the level of their physical height so that their eyes can look at your eyes without difficulty.
Don’t tower over a short person or a person in a bed, chair or wheelchair.
Be direct and to the point.
Don’t speak with a lot of technical terms, use large vocabulary words, or use complicated information especially when emotions are high.
Listen objectively.
Don’t take sides with what the person is saying. Don’t agree with distortions.
Acknowledge the other person’s feeling even if you disagree. Let them know that it is clear that what they are saying is important to them.
Don’t challenge, threaten or dare the other person. Never belittle or make fun.
When acknowledging a person’s feelings, use words like “frustrated,” “upset” or other words that describe a softer version of the emotion displayed.
Don’t use words that are emotionally charged, like “angry” or “pissed off.” If the emotion that you named is NOT on target, allow the individual the control of naming the emotion!
Don’t try to make it all seem less serious than it is. Do NOT minimize the person’s feelings!
Even if you disagree, you can still listen to someone. You might say something like “I hear what you are saying, but I don’t share that same view…”or “I hear what you are saying… but have you considered XXX?”
Don’t argue back to or over the person. Don’t try to change their mind about something.
Accept criticism in a positive way. If a complaint is valid, use statement like “you are probably right”. If the criticism is invalid, ask clarifying questions.
Don’t criticize or act impatiently toward an agitated individual.
Break big problems into smaller, more manageable problems.
Ask for small, specific responses from them such as moving to a quieter area or lowering their voice. Focus on small requests.
Be reassuring and point out the choices available to the person. Allow them to have control of the choice made to the extent possible given the circumstance.
Be truthful.
Don’t make false statements or promises you know you cannot keep. If you are
January 1, 2015 Comprehensive Supports Waiver Program B-11
unsure, say that you are unsure.
Establish ground rules or set boundaries if unreasonable behavior continues. Calmly describe the consequences of any inappropriate behavior.
Don’t attempt to bargain or bribe a threatening person.
Ask for their opinions or recommendations. Paraphrase back to the individual what they said.
Don’t immediately reject demands made without listening and communicating to the individual that you are hearing the words and/or the message that is not directly in the words.
Use delaying tactics that will give the person time to calm down. For example, offer a drink of water in a paper cup.
Position yourself to have access to an exit if need be. Be aware of surroundings and people walking in and out, but try to maintain a soft eye contact.
Refer to Appendix A for a real example of the impact of NOT listening.
V. UNDERSTANDING BEHAVIOR
A. What is behavior?
Behavior is what all people do. It includes our observable actions such as smiling, talking, eating and dressing. Everybody “behaves” almost all the time.
Different situations or environments have different rules or expectations about how to behave. For example, we are expected to behave differently in a library than we do at a ball game. Also, beliefs about what is expected may differ with each person. When someone does not understand these expectations or fails to conform to them, his/her behavior may limit the opportunity for success, participation, status, and friendship.
B. What influences behavior?
Behavior is related to many things. Usually it has a purpose and has a function. Examples of purpose and function are getting something, avoiding something undesirable or enjoying something.
Some behaviors, like unexplained movements or sounds, are neurologically based and cannot be changed with behavioral interventions. These behaviors often “just seem to happen.” While the individual has no control over these behaviors, sometimes the individual or staff is able to figure out that certain stimuli in the environment are helping
January 1, 2015 Comprehensive Supports Waiver Program B-12
to trigger their occurrence.
Behavior is a result of or response to something the person is experiencing or has
experienced. The stimulus for a particular behavior can come from any of these sources:
 Physiological (from within the physical part of us);
 Social (from any situation involving all people we have ever encountered);
 Psychological (from emotions, feelings or thought processes); or
 Environmental (from any part of our surroundings).
Some examples of internal and external sources just listed are:
1. Physiological – such as feeling full or satisfied, feeling pain, having skips in your heart [that can mean you have less oxygen to the brain], low blood sugar so you feel really hungry and can’t think, needing to go to the bathroom, etc.;
2. Social – such as seeing a face that reminds you of someone you don’t like, going to a party, seeing the same faces day after day, sitting in church, going to a movie, being at a dance, etc.
3. Psychological – such as an angry response to a particular word, hearing someone laugh when we don’t understand why, being called a name, being given a compliment, feeling frustrated because things are not as you want them to be, thinking about something nice that happened, etc.; and
4. Environmental – such as a dark corner, a rainstorm, a beautiful garden, a hot sultry day, a car horn blowing, coffee brewing, etc.
Too often we jump to behavior programs as soon as an “undesirable behavior” is present.
We need to first ask the question “What is the person’s behavior communicating to
us?” Example 5.1 has many examples of physiological, environmental, psychological
or social issues that may be affecting a person’s behavior. Be sure to take a look!
EXAMPLE 5.1
While what is going on inside our bodies is hard to see, behavior can be observed and described. But remember to consider what might be going on inside! Most people would find it difficult to concentrate if they had to go to the bathroom, had a toothache, were incredibly thirsty, were hearing voices telling us what to do or had a fight with
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family member before coming to work.
BEHAVIORAL “CAUSES” OR INFLUENCES
PHYSIOLOGICAL
ENVIRONMENTAL
PSYCHOLOGICAL
SOCIAL
Allergies
Arthritis
Attention deficit
Constipation
Delusions
Dementia
Ear aches
Energy – too much
Energy – too little
Fractures
Headaches
Hallucinations
Hunger
Hyperactivity
Itching
Medication reactions
Medication side effects
Pain
Premenstrual syndrome
Seizures
Sex drive
Thirst
Tobacco craving
And many more possibilities!
Air quality
Close proximity to others
Humidity
Lighting
Limited physical space
Noise
Smells
Temperature
Uncomfortable furniture
And many more possibilities!
Anxiety
Assertiveness
Attitudes
Beliefs
Boredom
Dominance
Fear
How thoughts are processed
Loneliness
Phobias
Personality traits
Sex drive
Shyness
Submissiveness
Suspiciousness
Vengeance
Worry
And many more possibilities!
Being stared at
Change in staff
Criticism
Danger
Demands
Disapproval
Disruption
Frequent change
Lack of social attention
Not having choices Presence of specific person(s)
Relocation
Sexual provocation
Teasing by others
Tone of voice
Too little to do
Too much to do
And many more
possibilities!
C. What are challenging behaviors?
Challenging behaviors are behaviors that are defined as problematic or maladaptive by others noticing the behavior or by the person displaying the behavior.
Challenging behaviors are those actions that come into conflict with what is accepted by the individual’s community. Challenging behaviors are behaviors that often
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isolate the person from their community or are behaviors that can be barriers to the person living or remaining in a specific community. Challenging behaviors vary in seriousness and intensity.
What is determined to be a challenging behavior can vary depending on what is accepted by the individual, a community or by society.
D. How do we figure out what the challenging behavior is communicating or what is “causing” the challenging behavior?
First, medical and psychiatric conditions have been found to play a direct
role in “causing” challenging behaviors. This is especially true for persons who communicate in ways we are not used to hearing. Is the person constipated? [This is a very common side effect of certain medications or not having enough fluids, fruits or vegetables]. Is the person taking their medication for the voices they hear? [Often people will say that the side effects of the medication are worse than hearing the voices tell them what to do]. Does the person have an infection? [How would you know when this is true?].
A second and similarly important consideration is that challenging behaviors result from being lonely, being on the outside looking in. Again, this is especially true for persons who communicate in ways we are not used to hearing. Is the quality of the person’s life acceptable (in their opinion)? Do relationships exist in the person’s life that support choice and maximize social and personal skills? Are the relationships between staff and the individual appropriate from a professional perspective? Does the person have opportunity for involvement in the community that would support personal social relationships?
There is a HUGE difference between developing an appropriate relationship with an individual and simply being with that person because it is your job. If the interventions used do not lead to a meaningful life and relationships for an individual, what have we accomplished?2
E. Focus first on possible medical or psychiatric issues.
We do not usually look at medical or psychiatric issues or personal satisfaction as reasons
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for challenging behaviors. Instead we get frustrated and say, “they are just being a pain” or “she’s just ‘that way.’” And sometimes caregivers get frustrated to the point of acting or reacting in ways that make things worse. The challenging behaviors of the individual coupled with our reaction can become a downward spiral!
However, looking at medical or psychiatric issues is imperative! One expert in the MR/DD field who works with persons with challenging behaviors said, “Until proven wrong, my first assumption is that part of the body hurts. Until we help the person feel better, the behavior will not stop. If the person is in pain they have two choices: 1) the pain controls me; or 2) I control the pain. The behavior is a form of intentional communication.”1
As further illustration, in the state of Massachusetts a hospital psychiatric unit was set up to work with MR/DD individuals who had very difficult challenging behaviors. They were taken to the psychiatric unit when the “cause” of the challenging behavior could not be figured out in the community. In that psychiatric unit, it was documented that better than 75% of issues determined to be “causing” challenging behaviors were medical in origin, such as chronic infection, enlarged prostate, etc.
For persons with MH issues, challenging behaviors often result from internal physiological or psychological stimuli that cannot be tolerated, or from misperception of social or environmental situations.
We owe it to the person served and to ourselves to try to figure out what the challenging behavior is communicating! Here are some questions to keep in mind while analyzing what is “causing” complex, challenging behaviors:
1. Is the challenging behavior a symptom of a medical disorder? For example, a person with a neurological disorder may strike out when becoming excited due to involuntary movements or poor muscular control.
2. Is the quality of the person’s life acceptable (in their opinion) in terms of personal relationships, personal choices or living situation, etc?
3. Is the challenging behavior a side effect of a medication they are getting?
1 Pitonyak, David, Ph.D., “Supporting Persons with Difficult Behaviors”, a workshop held September 27, 2004
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4. Is the challenging behavior part of a cluster or chain of related behaviors? For example, if a person does not want to go to a workshop, the person may use several behaviors to keep from going, such as refusing to get up, pretending to be sick, running away or attacking others. If so, one intervention may solve many challenges. If not, priorities will have to be set because trying to change many different behaviors at the same time is likely to cause confusion and reduce the chance for success.
5. Is the challenging behavior the result of a lack of a skill or skills? Often challenging behaviors occur because of a missing skill. If a person is asked to do something that he or she does not understand or is unable to do, the person may become frustrated and strike out or hurt him or her self to make the demand go away.
In summary, be certain to ask these questions:
1. What does the behavior get for the person? What is experienced as positive is entirely in the eyes of the beholder! For example, some people enjoy attention of any kind! Some people prefer to be quiet and alone. Behavior that results in a change that the person perceives as positive in some way is likely to be repeated. Therefore it is important to give people choice as a form of personal control.
2. What does the behavior help the person escape? For example, hitting others who are making too much noise may result in getting sent away from the noise, which is what the person wants!
3. What does the behavior help the person avoid? For example, playing sick may result in getting to stay home from school, which may be a very stressful place.
Example 5.2 is a very extensive list of common “problem” behaviors and what their causes might be. Take a look.
EXAMPLE 5.2
COMMON “PROBLEM” BEHAVIORS AND
SPECULATIONS ABOUT THEIR CAUSES
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BEHAVIOR
SUSPECTED CAUSE
Biting side of hand/whole mouth
 Sinus problems
 Ears/Eustachian tubes
 Eruption of wisdom teeth
 Dental problems
 Paresthesias/painful sensations (e.g., pins & Needles) in the hand
Biting thumbs/objects with front teeth
 Sinus problems
 Ears/Eustachian tubes
Biting with back teeth
 Dental
 Otitis (ear)
Fist jammed in mouth/down throat
 Gastroesophageal reflux
 Eruption of teeth
 Asthma
 Rumination
 Nausea
General Scratching
 Eczema
 Drug effects
 Liver/renal disorders
 Scabies
Head Banging
 Pain
 Depression
 Migraine
 Dental
 Seizure
 Otitis (ear ache)
 Mastoiditis (inflammation of bone behind the ear)
 Sinus problems
 Tinea capitis (fungal infection in the head)
“High pain tolerance”
 A lot of experience with pain.
 Fear of expressing opinion.
 Delirium
 Neuropathy (disease of the nerves/many causes)
Intense rocking/preoccupied look
 Visceral pain
 Headaches
 Depression
Odd un-pleasant masturbation
 Prostatitis
 Urinary tract infection
 Candida vagina
 Pinworms
 Repetition phenomena, PTSD
Pica
 General: OCD, hypothalamic problems, history of
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under-stimulating environments
 Cigarette butts: nicotine addiction, generalized anxiety disorder
 Glass: suicidality
 Paint chips: lead intoxication
 Sticks, rocks, other jagged objects: endogenous opiate addiction
 Dirt: iron or other deficiency state
 Feces: PTSD, psychosis
Scratching/hugging chest
 Asthma
 Pneumonia
 Gastroesophageal reflux
 Costochondritis/”slipped rib syndrome”
 Angina
Scratching stomach
 Gastritis
 Ulcer
 Pancreatitis (also pulling at back)
 Porphyria (bile pigment that causes, among other things, skin disorders)
 Gall bladder disease
Self-restraint/binding
 Pain
 Tic or other movement disorder
 Seizures
 Severe sensory integration deficits
 PTSD
 Paresthesias
Stretched forward
 Gastroesophageal reflux
 Hip/back pain
 Back pain
Sudden sitting down
 Altlantoaxial dislocation (dislocation
 Between the vertebrae in the neck)
 Cardiac problems
 Seizures
 Syncope/orthostasis (fainting or light-headedness caused by medications or other physical conditions)
 Vertigo
 Otitis (thrown off balance by problems in the ear)
Uneven seat
 Hip pain
 Genital discomfort
 Rectal discomfort
Walking on toes
 Arthritis in ankles, feet, hips or
 Knees
 Tight heel cords
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Waving fingers in front of the eyes
 Migraine
 Cataract
 Seizure
 Rubbing caused by blepharitis (inflammation of the eyelid) or corneal abrasion
Waving head side to side
 Declining peripheral vision or
 Reliance on peripheral vision
Whipping head forward
 Atlantoaxial dislocation (dislocation between the vertebrae in the neck)
 Pain in hands/arthritis
Won’t sit
 Akasthisia (inner feeling of restlessness)
 Back pain
 Rectal problem
 Anxiety disorder
2Ruth Ryan, M.D. James Salbenblatt, M.D., Melodie Blackridge, M.D.
Pain is often a very real cause of challenging behaviors. Look at Appendix B.1 for excellent ideas to consider about pain being the source of the challenging behavior. And in Appendix B.2 you will find an extensive list of medical issues that should be considered. Be sure to look at both of these for additional ideas.
VI. SUPPORTING PEOPLE IN POSITIVE WAYS
No matter who the person is that we work with (friend, co-worker, person that we support), we can ALL support people in positive ways. You probably already use these approaches and don’t know that they are also called “positive behavior supports”.
A. What can I do on a day-to-day basis that might be helpful to the person?
Consistency is important in working with others. Keep your word! Follow through on what you promise. This is very important in cultivating the trust of persons we serve. Being genuine goes hand-in-glove with consistency.
Treat people in ways that you would want to be treated. Remember that you hope to get MORE support, not less, when you need help. When was the last time you said, “I was non-compliant today, so I don’t believe I’ll smoke that cigarette.” Instead, if you’re having a really hard time and someone knows you are a smoker, they will likely
2 Ruth Ryan, MD, The Community Circle; 1556 Williams Street, Denver, Colorado 80218; Handbook of Mental Health Care for Persons with Developmental Disabilities. (1999)
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offer you a cigarette!
Have you noticed that we often ask those who have the least adaptive skills, or persons struggling to deal with their internal world and the world around them, to make the most accommodation within their lives? Would you want to live your life in the same way you are asking of them?
All of us working with other persons can be sensitive to the comfort needs of an individual. For example:
1. If the person is hungry, provide a snack, if permitted.
2. If the person is thirsty, provide water or other suitable drink, if permitted.
3. If the person is hot or cold, alter the environment or assist them into more comfortable clothing.
4. If the person is sad, talk with them about what is making them sad.
5. If the person is bored, talk with them about what they want to do; help them with getting the resources necessary to feel occupied and productive.
6. If a person is uncooperative, provide incentives or offer choices.
7. If a person is being annoying to you, try ignoring the behavior or see if you can figure out what is behind the behavior that is annoying to you.
8. If the person needs to get away from stimulation, support them in finding a quiet place.
9. If the person cannot concentrate during an activity or event, see what you can do to structure the activity or event to be more manageable for them.
10. If the person is not feeling well and does not want to attend what is “required”, permit a “sick day” or figure out how to help them feel better.
B. Using positive behavior supports.
All of us can use positive approaches when working with persons we serve and support. These approaches are called “positive behavior supports.” The purpose of positive behavior supports is to support individual growth, enhance the person’s quality of life, and make the use of more intrusive measures unnecessary. Positive behavior supports work best when we understand what works from the point of view of the individual.
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Positive behavior supports include ways to minimize situations or issues that are stressful for the individual and ways to help the individual have maximum control over their life. Positive behavior supports don’t emphasize rewards and punishments. Positive behavior support strategies include:
 Understanding how and what the individual is communicating;
 Understanding the impact of other’s presence, voice, tone, words, actions, and gestures, and modifying these as necessary;
 Supporting the individual in communicating choices and wishes;
 Supporting staff to change their behavior when it has a detrimental impact;
 Temporarily avoiding situations that are too difficult or too uncomfortable for the individual;
 Allowing the individual to exercise as much control and decision-making as possible over day-to-day routines;
 Assisting the individual to increase control over life activities and environment;
 Teaching the person coping, communication and emotional self-regulation skills;
 Anticipating situations that will be challenging and assisting the individual to cope or to respond in a calm way;
 Filling up the person’s life with opportunities such as valued work, enjoyable physical exercise and preferred recreational activities; and
 Modifying the environment to remove stressors (such as irritating noise, light or cold air).
C. Combining person-centered planning with positive behavior supports
All of us have dreams or goals we want to achieve. And every environment has certain rules and regulations that we must follow in order to achieve those goals or dreams. When working with someone who has identified a goal or dream, you must find out what the person already understands AND what skills the person already has before you teach new rules or skills that will help them achieve the goal or dream.
The steps to take to help the person reach a goal or dream may not be immediately clear. Sometimes you have to figure out how you can help someone reach a goal of “I want to get a part-time job in housekeeping” or “I want to live with my sister.” What follows is one example of how staff helped an individual increase control over his
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environment so that he could reach a desired goal.
Emmanuel wanted to continue to live with his sister, Beatrice. Beatrice said he could not live with her because Emmanuel leaves smoldering cigarettes in the ashtrays. So the “rule” was that Emmanuel must put out his cigarettes completely in order to continue living there.
Emmanuel DID know how to get his cigarettes into an ashtray, but he DID NOT extinguish the cigarette. Staff had to teach Emmanuel how to completely extinguish his cigarettes. Staff also had to figure out what he needed that would help him get the cigarette all the way out.
By figuring out what the person already knows how to do, what they don’t know how to do, and what they might need to achieve a goal, we can come to understand how we need to support the person in reaching that goal. Below is an example of how this information might be captured.
EXAMPLE 6.1
BEHAVIOR
WHAT THE PERSON KNOWS
REQUIRED SKILL OR BEHAVIOR
SKILL TO BE TAUGHT
RESOURCE REQUIRED
Leaves cigarette butts smoldering in ashtray
Puts cigarettes in an ash tray
Put the cigarette completely out
Extinguish cigarettes completely
Ashtray with sand
If you look at Appendix C you will find examples of questions that could be used to help you determine an individual’s level of satisfaction with their life and circumstances that surround it.
D. In closing…
As we close this chapter on positive behavior supports, remember that it is important that people have choice in decisions that must be made, that people have supports necessary to help them reach their goal or dream, and that there are things to look forward to. It is important that we understand the strengths, skills and preferences of the individual as well as their needs or limitations. And it is important that we help people develop enduring, positive relationships.
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The use of positive behavior supports toward helping people live purposeful and satisfying lives should be a natural part of how we support and care for individuals.
VII. WHAT DO I DO FIRST? Identify and Remove the Cause of Challenging Behaviors
We’ve got to understand what the person is communicating through the challenging
behavior or what is “causing” the challenging behavior. Have you answered these questions found in Section V.D.?
1. Is the challenging behavior a symptom of a medical disorder?
2. Is the quality of the person’s life acceptable (in their opinion) in terms of personal relationships, personal choices or living situation, etc?
3. Is the challenging behavior a side effect of a medication they are getting?
4. Is the challenging behavior part of a cluster or chain of related behaviors?
5. Is the challenging behavior the result of a lack of a skill or skills?
6. What does the behavior get for the person?
7. What does the behavior help the person escape?
8. What does the behavior help the person avoid?
Remember to consider the details that are part of these questions. Consider the examples of physiological, social, psychological or environmental issues that may be “causing” a person’s behavior that are listed in Section V.B., Example 5.1. Look at the list of common “problem” behaviors and speculations about their causes in Section V.D, Example 5.2. And refer Appendix B for examples of how pain might be communicated and for an extensive list of medical issues and how they may be communicated through behavior.
A. Show me some real examples of what you are talking about.
What follows are three examples of how situations could have been avoided if providers had looked at some common sense causes before assuming that the challenging behavior was due to some “out-of-control” mental illness or developmental disability.
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EXAMPLE 7.1
Mr. Jones has severe cognitive challenges and he cannot speak. He has no history of being violent or destructive. One evening, he displayed rage and began throwing the furniture in his home. He was taken to the local emergency room to be seen by a psychiatric crisis intervention specialist. He was admitted to a psychiatric hospital with a diagnosis of psychosis.
However, the physician at the hospital determined that Mr. Jones was suffering from a severe bowel impaction. Mr. Jones was promptly treated and his outburst did not reappear. His diet and fluid intake were adjusted and his home provider was trained to look for signs of constipation and irregularity. By dealing with these causes, Mr. Jones did not require further psychiatric admission nor did he need a behavior support plan.
EXAMPLE 7.2
Ms. Smith is a person who had never been known to act up. She began to show considerable withdrawal at her work-training program and would not participate in the program. In fact, over a period of days, her withdrawal turned to anger and she would refuse to attend the program. She began complaining of illness and making excuses to avoid going to work. She was taken to the outpatient mental health clinic for psychiatric evaluation. She was prescribed medication for both depression and psychosis.
Days later, a counselor who had worked closely with Ms. Smith in another agency came to work at Ms. Smith’s work-training program. This counselor knew Ms. Smith very well and recalled that Ms. Smith had been a victim of rape years earlier. The rapist was a tall man with tattooed forearms. The work-training staff recognized that about the
time Ms. Smith’s challenging behavior began to surface, she had been assigned to a new work group. In this group was a man whose forearms were tattooed. Although this man was not the rapist, his appearance had triggered a post-traumatic stress reaction in Ms. Smith. Armed with this knowledge, the work-program staff reassigned Ms. Smith to work with others and away from the man with the tattoos. Ms. Smith’s withdrawal, anger, and refusal to cooperate with the work-program vanished immediately. Ms. Smith did not require further medication or a behavior support plan, although she did resume therapy at the local mental health center to help her develop coping strategies for when she encountered men with tattoos.
EXAMPLE 7.3
Ms. Stacy is a woman in her thirties who has autism. She does not communicate with words, but has strong opinions about what she likes and
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dislikes. Ms. Stacy lives in her own home, with 24-hour support. For many years, Ms. Stacy attended the local day habilitation center. The center had strict rules about “appropriate conduct,” but Ms. Stacy never followed them. While she liked individual staff at the center, she refused to participate in many of the organized group activities. During these group activities, she would regularly scream, throw things and occasionally strip down to her underwear. On community outings she would often wreak havoc while on the center’s van by yelling, stripping or lying on the van floor, or by refusing to get up.
The center’s staff was incredibly stressed and frustrated by Ms. Stacy’s behavior. Ms. Stacy was only calm when she was allowed to look at her magazines without others around her, often with the support of one staff. However, the center could not guarantee individual staffing all of the time, because it took attention away from other clients. Ms. Stacy, her family, and her providers had numerous meetings about Ms. Stacy’s infractions of the center’s rules and tried a number of behavior modification techniques to address the unacceptable behavior. Nothing worked.
The center discharged Ms. Stacy for repeatedly failing to follow the center’s rules. Ms. Stacy’s personal support provider began supporting Ms. Stacy during her day. Ms. Stacy was no longer required to participate in group activities, could plan her own activities and was accompanied by a companion she adored. Her stripping stopped almost immediately and her other challenging behaviors greatly decreased. Ms. Stacy now smiles more and is much calmer. While she still yells and throws things occasionally, this behavior is typically a result of menstrual cramps or anger about a specific event. Her “behaviors” are more isolated, making them easier to address. Because of individualized supports in an environment that is comfortable for her, Ms. Stacy is able to experience her community on her terms and is enjoying her life more.
B. The Wellness Recovery Action Plan3 (WRAP Plan) is an effective way to identify and remove the cause of challenging behaviors
In Georgia, many consumers and staff have been introduced to the process of developing a Wellness Recovery Action Plan. The Wellness Recovery Action Program is a structured system for monitoring uncomfortable and distressing symptoms and, through planned responses, reducing, modifying or eliminating those symptoms. It also includes plans for responses from others when an individual’s symptoms have made it
3 Wellness Recovery Action Plan: A System for Monitoring, Reducing and Eliminating Uncomfortable or Dangerous Physical Symptoms and Emotional Feelings, Mary Ellen Copeland, MS, MA, Peach Press, Revised 2002
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impossible for the individual to continue to make decisions, take care of him or her self and keep him or her safe. When the WRAP Plan is used, the person is able to MINIMIZE or AVOID challenging behaviors that can result when symptoms are not properly addressed.
While this approach is being taught and used in mental health care, persons in MR/DD care who have the cognitive and verbal or expressive skills to describe how they feel and what helps them feel better or worse could also use it.
Anecdotal reporting from persons who are using this system indicates that by helping them feel prepared, they feel more in control of their lives resulting in a better quality of life, even when symptoms of the illness are troublesome.
What follows is the basic outline of a WRAP Plan. Refer to the publication noted in the footnote for full detail. Crisis plans will be discussed in greater detail in Section XI of this manual.
EXAMPLE 7.4
BASIC OUTLINE OF A WRAP PLAN
Section 1 Daily Maintenance Plan
Part 1: Description of how you feel when you feel well
Part 2: List everything you need to do every day to maintain wellness
Section 2 Triggers
Part 1: Events or situations that might cause symptoms to begin
Part 2: A plan of what to do if the triggers occur
Section 3 Early Warning Signs
Part 1: Identification of subtle signs that indicate a worsening situation
Part 2: A plan of what to do if these early warning signs occur
Section 4 Symptoms That Indicate Worsening
Part 1: What to do if these symptoms occur
Section 5 The Crisis Plan
Part 1: What I’m like when I’m feeling well
Part 2: Symptoms that say I’m not doing well
Part 3: Who are my supporters?
Part 4: Medication that works; medication that does not work
Part 5: Treatments that work; treatments that do not work
Part 6: Where can I go in the community?
Home/Community Care/Respite Center
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Part 7: Treatment facilities that are options for me
Part 8: What help do I need from my supporters?
Part 9: How do my supporters know I am better?
Section 6 Post Crisis Planning
Descriptive behaviors, feelings and activities that will indicate healing is
under way.
VIII. APPROACH I: GATHER INFORMATION ABOUT THE CHALLENGING BEHAVIOR
A. We have not been able to figure out the behavior! Now what do we do?
Not all cases are like the above examples. And not all persons have the cognitive and verbal or expressive skills to develop a WRAP Plan.
When a WRAP Plan is NOT appropriate and when the less obvious causes of a challenging behavior cannot be determined, it is time to figure out the source of challenging behavior by doing a functional assessment.
B. What is a functional assessment?
A functional assessment is a systematic way to look at information. Functional assessment is based on the understanding that ALL behavior is influenced by the person’s internal AND external environment.
Functional assessment involves looking at what is happening before and after a behavior occurs in order to understand how the behavior is influenced by those events. Such events can take place within the person’s external environment or internal environment. In this sense, a challenging behavior might be influenced by external events like a noisy, over-crowded social situation, but might also be influenced by internal events such as a headache or a feeling of frustration.
Events that take place before a behavior occurs are called antecedents. Events that take place after a behavior occurs are called consequences. By collecting information about events that occur BEFORE a behavior takes place (antecedents), we will begin to see that when the particular event occurs, the behavior of concern
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will likely occur. Conversely, when these events do not occur, or when the events are modified or interrupted in some way, the behavior of concern is less likely to occur.
By collecting information about events that occur AFTER a behavior takes place (consequences), we will begin to see that if a behavior results in a DESIRABLE consequence for the person, he or she is more likely to repeat that behavior in similar situations. Conversely, if the behavior results in an undesirable consequence for the person, he or she is less likely to repeat that behavior in the future in similar situations.
C. Looking for the A-B-C’s
The analysis of antecedents and consequences is often referred to as the A-B-C Model of functional assessment:
 A stands for the influential events that take place before a behavior occurs (antecedents)
 B stands for the behavior (appropriate or challenging); and
 C stands for the influential events that take place after a behavior occurs (consequences).
Conducting a systematic, organized assessment helps to identify those events that are likely to have the greatest influence on the behavior of concern.
D. How much information needs to be collected and for how long?
It is important to look for the A-B-C’s over time and to gather information each time the behavior is repeated. Some functional assessments can be completed after only a few recorded observations of the behavior. Others may require numerous observations or may even continue after some treatment interventions have been implemented.
Sometimes a functional assessment can be conducted informally by looking at what happened before a challenging behavior occurred. For challenging behaviors that occur with some degree of regularity, it is helpful to write down your observations, to help take a “fresh look” at the situation.
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E. How do I collect information about the A-B-C’s?
Examples of ways to document this information are available in books and on the Internet, but basically the process looks something like the following.
EXAMPLE 8.1
COLLECTING THE A-B-C’S
A = Events that occur before the behavior, or antecedents
B = The behavior
C = Events that occur after the behavior, or consequences
 Physiological
 Social
 Psychological
 Environmental
The behavior should be described in measurable and observable terms that everyone understands
 Did the behavior result in a reward for the person?
 Did the behavior result in escape from a particular situation?
 Did the behavior allow the person to avoid something?
To further illustrate the use of this form, read the case below, and then refer to the grid
that follows.
James, a nonverbal individual with severe mental retardation, had a habit of plopping down in front of the refrigerator when he wanted something to eat. He was in the way when staff tried to cook, and because he would not move, they could not open the refrigerator. He also occasionally hurt himself when he plopped himself down on the floor.
EXAMPLE 8.2
COLLECTING THE A-B-C’S – AN EXAMPLE
A = Events that occur before the behavior, or antecedents
B = The behavior
C = Events that occur after the behavior, or consequences
 James smacks his lips
 James sits on the floor only when people are cooking
James “plops” himself down in front of the refrigerator, often with enough force that he bruises himself. He then refuses to move, sitting in a place that blocks the refrigerator door.
 Staff give James bits of food while they cook
 James makes happy-sounding noises after getting something to eat
As a result of collecting the data, staff decided that giving James food in front of the refrigerator was encouraging him to repeat the behavior. They also decided that James
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should be offered food ONLY at the table. Staff decided to teach James to use sign language for “eat” and for “drink”. When he used the sign, staff rapidly responded to the sign with a snack or drink, which was given to him at the dining table.
It took a while to replace the behavior of sitting in front of the refrigerator because James would exhibit both behaviors – plopping down in front of the refrigerator and signing – at the same time. Since the food was offered at the table and not while he was in the floor in front of the refrigerator, he gradually began going to the table and signing for what he wanted.
The analysis of the event showed staff that James’ internal response (hunger) was being rewarded by an external action or response by the staff (the socialization with staff as they cook AND getting to eat bits of food).
And there can be negative responses to social situations. For example, Johnny loves to watch TV alone. But when others who live in the home come into the room during his TV time, Johnny begins to bang his head. If the others are asked to leave the room, Johnny quits banging his head.
Sometimes you can figure out the “why” of a behavior based on watching the events that occur right before and right after the behavior. But if it is not obvious or you cannot figure it out after trying to collect data on your own, then it is time to call in a professional!
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X. APPROACH II: CALL IN A PROFESSIONAL TO DEVELOP A POSITIVE BEHAVIOR SUPPORT PLAN (PBSP)
When a WRAP Plan is NOT appropriate AND when collecting the A-B-C’s described in Approach I DOES NOT result in identifying the “cause” of the challenging behavior, the provider should call in a professional who is qualified to develop a positive behavior support plan.
A. What is a Positive Behavior Support Plan ((PBSP)?
A positive behavior support plan (PBSP) is a formal plan to help everyone do the same thing on a consistent basis. The plan is based on an assessment of the challenging behavior that includes understanding the strengths, preferences and interests of the individual, the goal that is to be achieved, and the A-B-C’s related to the behavior that is of concern,
The plan consists of using the fewest interventions or support strategies possible coupled with reinforcement for appropriate alternative behaviors that will modify, decrease, re-direct or eliminate the challenging behavior. Success is measured by reductions in challenging behaviors, performance of alternative skills, and improvements in quality of life.
1. Understanding the person’s “story,” including their strengths, skills and limitations;
2. Having respect for the person’s desire to follow his or her dreams to live life as normally as possible while being supported to overcome the challenging behavior;
The person with the challenging behavior must be made aware of the plan as evidenced by their signature or the signature of their representative or legal guardian.
3. Respect of his or her dignity, the right to make choices, and the right to live as independently as possible.
The plan uses ONLY positive interventions to replace the challenging behavior with other behavior judged to be more acceptable. The PBSP does not use any restrictive or unpleasant techniques to modify challenging behaviors.
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The PBSP couples the science of behavior analysis with person-centered values that respect the individual. These values include but are not limited to:
Positive behavior support plans involve all of the components of Approach I “and then some.” It is the “and then some” that makes it a new approach.
B. Thirteen outcomes you should expect to find in a completed PBSP
The development of a PBSP includes a written plan for ALL involved persons to follow. The following thirteen outcomes are critical in achieving a consistently positive approach in all aspects of the person’s life. This is the “and then some” mentioned above.
1. Ensure that a person-centered approach is used in developing the plan. This may seem obvious, but plans can quickly become “controlling,” in the name of safety when addressing severely challenging behaviors.
2. Establish clear operational definitions of behaviors to be decreased as well as those to be increased. This means using descriptive terms that everyone understands so that there is consistency in identifying the challenging behavior:
a. There must be agreement between the professional and staff as to the behavior that is occurring.
i. Behaviors must be described in observable terms
ii. Behaviors must be described in measurable terms
3. Ensure that the plan is practical… that it can be done. A plan that is not practical, that is cumbersome, that does not consider practical, day-to-day issues WILL FAIL.
4. Identify the antecedents and consequences that influence the occurrence of the behaviors of concern. It is critical to a PBSP to know what events, both before and after a behavior, increase the likelihood of that behavior’s occurrence.
5. Ensure that functional skills are taught as part of the active treatment routine. Learning efforts should focus on meaningful and purposeful skills that:
a. Support the individual’s choices and goals;
b. Are essential to personal independence;
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c. Are needed often;
d. Afford opportunity to participate in meaningful, purposeful and age-appropriate activities;
e. Enable the individual to do and attain the things they desire as well as to avoid those things they dislike.
6. Ensure the person’s environment is a positive, healthy, educational, supportive, nurturing, safe and therapeutic environment that:
a. Encourages and honors choices by the individual;
b. Promotes normalcy;
c. Is suited to the individual’s needs; and
d. Includes the individual’s preferred items and events.
7. Identify and reduce or eliminate conflicts regarding individual choice making. Ensure that choice is built into the plan and that everyone involved knows how to help the individual express choices (especially if the person is unable to talk).
a. Not having choice means not having control;
b. Not having control means anger;
c. Anger will be expressed by challenging behaviors
8. Ensure that positive and meaningful social interactions are available both with peers and staff. Identify and reduce or eliminate social interactions that contribute to the occurrence of challenging behavior. Ensure that everyone involved knows how to interact with the individual in a group setting, how to interact in a positive way, and how to interact in a manner that is suited to the individual’s capacity as well as chronological age.
9. Ensure that everyone involved knows how to use prompts, error correction, and task analysis to increase the likelihood of desirable appropriate behavior. These methods help increase consistency from setting to setting and from person to person.
10. The plan should identify teaching methods such as “shaping” and “chaining.” These methods make teaching and learning easier by conducting learning activities in smaller segments at a pace suited to the individual’s abilities.
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a. If you ever taught someone to throw a ball, you used “shaping”
b. If you ever taught someone to memorize his or her phone number, you used “chaining.”
11. Ensure that the fundamental components of the PBSP are clearly described and understood by everyone involved. Regardless of the format used for a PBSP, the fundamental components should address the following:
a. What are the behaviors to increase?
b. What are the behaviors to decrease?
c. What things should be provided in the individual’s environment on a day-to-day basis to decrease the likelihood of challenging behaviors?
d. What things should be avoided in the individual’s environment on a day-to-day basis to decrease the likelihood of challenging behaviors?
e. What event(s) are likely to occur right before a behavior of concern?
f. What should you do if that event(s) happens, or what can you do to keep it from happening?
g. What should you do if the behavior to increase occurs?
h. What should you do if the behavior to decrease occurs? This should not involve punitive reprisals, unpleasant consequences or any other restrictive interventions.
12. Ensure that staff knows when to ask for help! You have a right and responsibility to ask! The professional should identify, with the help of staff, the types of problems that may occur when implementing a PBSP, and should be certain that everyone knows who to ask for help if implementation problems occur.
13. Ensure that there is some form of reliable data collection taking place. This should be simple, efficient and manageable for staff. The professional should establish the means for evaluating effectiveness of the PBSP using an efficient, reliable data collection method. This is essential to making sound decisions regarding continuation, revisions, or discontinuation of a PBSP.
C. What kind of professional can write a positive behavior support plan (PBSP)?
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A PBSP should ONLY be written, implemented and supervised by a qualified professional. The PBSP is considered to be part of the treatment plan for the person served and must be incorporated into the Individualized Service Plan (ISP) or Individual Recovery Plan (IRP) by reference.
The same professional requirements apply to the development of a PBSP that apply to the development of a treatment plan. Generally people in mental health services will develop their own WRAP Plan with the support of a professional. However, if a PBSP is developed:
1. For an individual in mental health services, it must be developed by someone who is a Qualified Mental Health Professional (QMHP)
2. For an individual in MR/DD services, it must be developed by someone who is a Qualified Developmental Disability Professional (QDDP)
For more information about professional qualifications for QMHP or QDDP, refer to the Provider Manual for Georgia Department of Behavioral Health and Developmental Disabilities with the Georgia Department of Behavioral Health and Developmental Disabilities, Section III B, “Core Requirements for All Providers,” section C, “Professional Designations.”
In both cases, someone who has experience with positive behavior supports MUST develop the PBSP. When you are researching to find a professional, here are some suggestions to consider:
1. Network in the field to get names of several professionals
2. Get references!
3. Talk to other providers who have had a plan written by that professional
a. Was the plan clear?
i. Refer to the list of thirteen outcomes (above)
b. Did the plan include practical considerations?
i. Could it be implemented in the “real world”?
c. Did the professional train the staff
i. About the plan?
ii. About how it should be implemented?
d. Was the professional available to the staff?
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e. How much support did the professional provide?
f. Was the professional willing to figure out an alternative plan when the original plan needed to be modified?
g. Did the professional see the plan through until there was a satisfactory outcome?
D. How do I know that the plan is written using positive behavior approaches?
Remember that the plan uses ONLY positive interventions to replace the challenging behavior with other behavior judged to be more acceptable. The PBSP does not use any restrictive or unpleasant techniques to modify challenging behaviors.
In Appendix B, a variety of positive behavioral approaches are identified. If you have a concern, check Appendix B.
E. Checks and balances to be sure staff know what to do
Below are four things that SHOULD BE CHECKED to be certain you understand the plan. If you can answer these questions, the plan is likely a complete and comprehensive plan.
1. Do you understand the behaviors of concern that are targeted by the plan?
a. What are the behaviors to increase?
b. What are the behaviors to decrease?
2. Do you know what environmental supports MUST be in place on a day-to-day basis to reduce the likelihood that problems will occur?
a. What things need to be in place on a daily basis to support the individual?
i. For example, Gina was known to HAVE to have her purse with her at all times! If she forgot her purse, she became inconsolable and absolutely nothing else could be done until she had her purse. This is an example of an environmental support for Gina.
b. What things should be avoided to support the individual?
i. For example, it was well known that loud sudden noises triggered a post-traumatic stress reaction for Joe that would become psychotic
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in nature. Therefore it was important to try to avoid settings where this might occur.
3. Do you know the antecedents to look for?
a. The plan needs to identify those things that occur prior to the challenging behavior. This is AS IMPORTANT as knowing what the target behavior is.
b. When those events happen, what needs to happen to modify, re-direct, interrupt, remove or prevent the challenging behavior?
NOTE that ALL PBSPs need to identify the antecedents. If you can’t respond before the behavior occurs, that leaves ONLY an option of responding after, which is NOT proactive but is reactive.
4. Do you know what you should do following a challenging behavior?
a. What do we do when appropriate behaviors occur?
b. How do we respond in a non-restrictive way when challenging behaviors occur?
This means doing as little as possible or only what is necessary to stop the challenging behavior or to assure that no one gets hurt.
IF YOU CANNOT ANSWER THESE QUESTIONS, YOU DO NOT KNOW WHAT TO DO! It is a good idea for staff to write their own answers to these questions after the plan is developed. That way the professional can see what staff understands in their own words, and the professional can be certain that everyone has a correct understanding of the plan and how to implement the plan.
F. Review and oversight of the PBSP
As stated, all consumers have a treatment plan that must be developed and approved by
either an interdisciplinary treatment team or a multidisciplinary treatment team. The
PBSP must be incorporated by reference into ISP or the IRP. The rules set within
each agency for the monthly, quarterly, and annual review of ISP’s should be made
applicable also to the PBSP.
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Review and approval by all of the above stakeholders should occur when a PBSP is first developed. When the plan is first implemented, it may need tweaking as often as weekly, monthly or quarterly. Additionally, the plan should be reviewed and re-authorized more frequently if the PBSP undergoes a significant revision. The data should be reviewed at least annually thereafter. NOTE that annually is the LEAST frequent interval that the plan should be reviewed.
Remember to obtain appropriate consents and authorizations from:
1. The consumer or his or her representative
2. The interdisciplinary team
3. And to incorporate it into the ISP
Despite your best efforts, there will be occasions when serious and challenging behaviors represent a danger to the individual or to others. If the individual has this sort of history OR if this becomes the case, there should be a safety plan or crisis plan to fall back on. These plans, along with parameters for implementation and management, will be discussed next.
X. WHAT CAN WE DO IF THE BEHAVIOR SUPPORT PLAN IS NOT WORKING?
A. Seek additional review and consultation
The first and most obvious answer is to re-evaluate the PBSP as well as re-evaluate the implementation of the plan. Actions to take and issues to consider in the re-evaluation of any plan include but may not be limited to the following:
1. Call the professional who wrote the PBSP and ask for an evaluation of:
a. The plan
b. The implementation of the plan
2. Talk with the individual to the extent possible regarding:
a. The plan
b. The implementation of the plan
3. Talk with the staff regarding
a. The plan
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b. The implementation of the plan
i. Assure that the plan has been implemented in a personal, caring and consistent manner
4. Affirm with staff what they are doing right
5. Tweak the plan as necessary
6. Invite the interdisciplinary or multidisciplinary team to review and discuss the concerns
7. Invite subject experts to sit in, including regional or state DBHDD staff
8. Seek additional consultation as required
REMEMBER: something that works initially will not be effective indefinitely. The plan WILL have to be tweaked and revised on more than one occasion!
B. What if the challenging behavior is affecting the individual’s personal health
and safety, or the health and safety of others?
If the challenging behavior is affecting or is likely to affect the individual’s personal health and safety or the health and safety of others, then a crisis plan or safety plan should be done.
1. A crisis plan should be developed as a part of the WRAP Plan by the individual with the support of a professional.
2. If the person is in MR/DD care and a WRAP Plan is not appropriate for them, a safety plan should be done by a professional.
The same recommendations and requirements about professionals discussed in Section IX. C. applies here.
Both the safety plan and the crisis plan (as part of the WRAP Plan) should be incorporated by reference into the ISP or IRP.
XI. APPROACH III A: DEVELOP A CRISIS PLAN
A. What is a crisis plan?
Crisis plans are used largely in the MH side of care. However, any individual who has the cognitive and verbal or expressive skills to describe how they feel and what helps
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them feel better or worse can develop a crisis plan. This can be accomplished independently or with the help and support of a professional.
Crisis plans are part of the Wellness Recovery Action Plan3 (WRAP Plan) that is developed by the individual. A professional may give guidance to assure the plan is well thought through, but the crisis plan should represent the individual’s work and their wishes.
Noticing and responding to symptoms BEFORE they are manifest as challenging behaviors reduces the chances that the individual will be in crisis. By writing a clear crisis plan when the individual is well, he or she can instruct others about care when he or she is not well. Thus the individual maintains responsibility for his or her own care.
The crisis plan portion of the WRAP Plan is different from the rest of the WRAP Plan in that other persons will use the crisis plan on behalf of the individual. Once the individual has completed their personal crisis plan, copies of the plan should be given to the people named in the plan as supporters.
B. What are the essential components of a crisis plan?
The essential components of a crisis plan are the following. Since the individual is writing their own plan, the components are described in first person language.
1. Describe what I’m like when I’m feeling well
2. List the symptoms the would indicate to others that they need to take over responsibility for my care and make decisions on my behalf
3. Identify my supporters or those people who I want to take over for me when the symptoms come up
a. There should be at least five people on the list of supporters
4. List all of the information about my medications
a. The name of my physician or physicians and phone numbers
b. My pharmacy and the number
c. My allergies
d. The medications I am currently on
3 Wellness Recovery Action Plan: A System for Monitoring, Reducing and Eliminating Uncomfortable or Dangerous Physical Symptoms and Emotional Feelings, Mary Ellen Copeland, MS, MA, Peach Press, Revised 2002
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i. Why I take these medications
e. The medications I prefer to take if medication becomes necessary
i. Additional medication I prefer to take if required
ii. Why I choose these medications
f. The medications that should be avoided
i. Why those medications should be avoided
5. List the treatments I would want in a crisis situation
a. Tell why the treatment is selected
b. Also list treatments that have negative connotations
i. Why those treatments feel bad or don’t work
6. Identify options for community care
a. Would you be able to stay at home?
i. If so, what supports would you need to make that happen
b. Is community care outside of the home an option as an alternative to hospitalization?
i. If so, identify what that is, where it is and how to access it
c. Is respite an option?
7. Specify where you would go if you need a safe facility outside the scope of community care
a. Where do you want to go?
b. Where do you want to avoid?
8. What do I need my supporters to do for me?
a. What could they do that would reduce symptoms?
b. What could they do that would help me relax?
c. What could they say to me that helps?
d. What could they do for me that MUST be done?
i. Get the mail
ii. Feed the pets
iii. Pick up the kids
iv. Pay my bills
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e. What do my supporters need to avoid because those things make me worse?
9. How do my supporters know when to back off or that I am feeling better?
The crisis plan should be updated whenever there is new information that needs to be shared or when a different decision is made that needs to be communicated. Remember that the supporters need to have copies when this information is updated.
Be sure that the individual signs the crisis plan in the presence of two witnesses. While crisis plans are not considered a legal document in Georgia in the way Living Wills or Durable Powers of Attorney are, if the plan is witnessed, the seriousness of the plan and its intent for use is emphasized.
APPROACH III B: DEVELOP A SAFETY PLAN
A. When should a safety plan be written?
In instances where challenging behaviors affect the health and safety of the individual or others, a safety plan should be developed.
Safety plans should begin with the use of interventions written in the PBSP, but should further specify additional steps to take in response to challenging behavior that is dangerous to the health and safety of the individual or others.
B. Where does the PBSP leave off and the safety plan begin?
A safety plan should be written when there are indications of challenging behavior(s) that may jeopardize the psychological or physical health and safety of individual or others. The safety plan should be constructed so that the individual AND staff are aware of how such challenging behaviors(s) are to be addressed.
IN ALL CASES, interventions found in ANY safety plan should begin with the least
restrictive intervention that would reduce or eliminate risk. Examples of issues to consider when making a safety plan follow.
1. Identify and document the challenging behavior(s) that represent risk to the psychological or physical health and safety of others.
2. Do contingency planning so that the individual and staff know “what to do if” or “what will happen if.”
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a. For each challenging behavior, document the interventions to be used, such as:
i. Specify verbal intervention strategies
ii. Opportunity for quiet music, exercise, or some other form of activity that would re-direct his or her attention and energy
iii. Offer the individual an opportunity to get away from stimulation
3. Determine what technological devices might offer extra supports for staff assistance, such as, but not limited to:
a. Warning devices
b. Staff cell phones
4. Determine whether more intensive supports in the form of staff presence is needed
a. Specify under what conditions the more intensive supports could be accessed
b. Specify how staff should access these supports
5. Specify the challenging behaviors that would trigger the use of a safety intervention of last resort:
a. The challenging behavior MUST be one that threatens the health or safety of the individual or others.
b. Only manual hold (also known as personal restraint) may be used. Refer to Section XIII for a full discussion of this safety intervention of last resort.
6. Specify the challenging behaviors or circumstances that would require the support of law enforcement
7. Specify the challenging behaviors or circumstances that would require professional emergency intervention, such as stabilization at an emergency receiving and evaluating facility
The safety plan must be developed under the direction and supervision of a QDDP
and must be incorporated by reference into the ISP, or for persons in MH care, the
plan must be developed under the direction and supervision of a QMHP and must be
incorporated by reference into the IRP. The rules set within each agency for the
monthly, quarterly, and annual review of ISP’s should also be made applicable to the
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safety plan.
Review and approval by all of the above stakeholders should occur when a safety plan is first developed. It should be reviewed and reauthorized more frequently if the PBSP undergoes a significant revision or if it is determined that it is not meeting the needs of the individual. Remember to obtain appropriate consents and authorizations from:
1. The individual or his or her representative
2. The interdisciplinary team
And to incorporate it into the ISP or IRP
C. Are there any particular processes that must occur when a safety plan is used?
When an emergency intervention of last resort is used, there are certain specific processes for documentation and debriefing that must be followed. Don’t forget that situations such as elopement or the use of an emergency intervention requires that an incident report be completed. Be sure to refer to your agency policies and procedures on these issues as well as policies and procedures of the Division of DBHDD, which are referenced in the Provider Manual for Georgia Department of Behavioral Health and Developmental Disabilities Providers Under Contract with the Georgia Department of Behavioral Health and Developmental Disabilities. Processes for documentation and debriefing after the use of an emergency safety intervention are discussed in Appendix E.2, “Processes for documentation and debriefing after the use of an emergency safety intervention.”
D. Can medication be used in a safety plan?
Did you notice that medication is NOT referenced as part of the equation of the safety plan? A group of physicians, psychiatrists and pediatricians who work with psychiatric and behavioral issues in public and private settings stated that medications should be used for targeted symptoms. Using this line of thinking, medication should be used within the safety plan ONLY if there are targeted symptoms that are addressed by the medication, such as:
1. Hallucinations
2. Impulsive thoughts, etc.
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You will find a full discussion regarding the use of medication for challenging behaviors in Section XII.
E. Should a safety plan be written when the health and safety of the individual or the health and safety of others is NOT affected?
A safety plan could be written when the health and safety of the individual or others is NOT affected. Examples of when this might occur are the following:
1. Verbal threats that do not result in physical harm to the person or to others
2. Destruction of property that does not affect the health and safety of the individual or of others
3. Challenging behaviors such as stealing, arson, vandalism, pulling fire alarms, etc.
You will need to give THOUGHTFUL consideration when you write plans for issues that, when put into action, are actually crimes. Incorporating legal responses to these behaviors needs to be carefully considered.
When writing a safety plan that addresses challenging behaviors that DO NOT affect the health and safety of the individual or of others, the interventions written MAY NOT include using a safety intervention of last resort. A discussion of safety interventions of last resort will follow in Section XIII.
XII. USING MEDICATIONS FOR CHALLENGING BEHAVIORS
Unfortunately it has been noted from time to time that medication is periodically used to “control” challenging and not so challenging behaviors. The worst case discovered in a provider setting was one in which ALL individuals in the care of the provider (20 plus people) were prescribed some form of major tranquilizer such as Haldol, Mellaril or Thorazine; benzodiazepine such as Ativan, Xanex or Valium; AND medication ordinarily given for extra pyramidal symptoms that was given in such amounts that it was causing sedation, such as Benadryl or Cogentin.
This is an extreme example, but variations of this example are periodically found in the community.
A. Is it ok to give medication for challenging behaviors?
We have talked about the fact that behavior is something you can see. It is something you can count. Behavior is NOT a mood, an attitude, or the fact that someone has an unbounded amount of energy.
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So is it ok to give medication for challenging behaviors? No, it is NOT ok to give medication for challenging behaviors. A group of physicians, psychiatrists and pediatricians who work with psychiatric and behavioral issues in public and private settings said, “NO…behaviors are best treated with specific behavioral solutions”. They went on to say that medications should be used to treat ILLNESSES and their symptoms.
What follows are the points these physicians made about behavior and how to intervene with challenging behaviors. If you have read the other chapters that precede this one, these comments sound VERY familiar.
1. The overall goal when caring for individuals is that we support them with a safe and satisfying quality of life.
2. Many times we try to modify a behavior that is not really that big of a deal. Maybe it is OK for them to do something that we see as inappropriate. The behavior may be obnoxious but it is not hurting anyone.
a. An example is that of an individual who sits down in the floor and will not move. How important is it that they move at that time?
3. BEWARE OF POWER STRUGGLES! Many times the only winning move is not to play!
4. There is not a behavior that does not have an antecedent. We may not understand what that is, but there is definitely an antecedent behind that behavior.
5. Staff needs to be trained in how to look at a challenging behavior and figure out what might be happening that affects that behavior or the meaning of the behavior. All staff working with individuals needs to be more aware of antecedents.
6. Not every behavioral intervention will successfully address the challenging behavior. Sometimes you must go through series of changes in the plan in order to figure out how best to address the behavior.
7. It is very important to prioritize which challenging behavior to address and to work on one behavior at a time.
8. Think of behavior plans in terms of baby steps, not huge giant steps.
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9. People have to see plans as fluid in nature. If the positive reinforcer is not working, it is not a positive reinforcer.
10. Staff’s interventions are only as good as the plan that is developed.
a. A behavior plan is only as good as the trained person developing it
b. A behavior plan is only as good as the consistency with which it is carried out
11. If the recommendations made are not followed, there is no chance that the intervention will work. Recommendations MUST be followed!
12. Decisions about the effectiveness of behavioral interventions need to be DATA DRIVEN.
13. It is very important to know what has been tried in the past.
14. Behavior plans need to be individualized to include choice and preferences of the individual. Homogenized plans (what is good for one is good for another) don’t work!
15. It comes back to identifying the cause of challenging behaviors.
16. Interventions recommended may be more difficult or time consuming to do, but the result is more positively life-changing in the long run.
Additionally, the physicians recommended that staff be trained in non-physical means of intervening with individuals, and that the training should emphasize maintaining the dignity of and respect for the person.
B. Are medications EVER appropriate to give to someone with challenging behaviors?
The answer is “yes,” but ONLY if the medication is used to treat symptoms of an
illness. The group of physicians discussing these issues made the following points.
1. Medications should be used to treat ILLNESSES and their symptoms. Medications should NOT be used for challenging behaviors that are not a product of illnesses and their symptoms.
2. You may see self-hurtful or injurious behaviors with psychiatric disorders; HOWEVER the medication used in these situations is treating psychiatric symptoms.
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3. Symptoms should be treated even though it may not be totally clear what the diagnosis is.
4. When you cannot clearly explain that you are giving medication for particular symptoms, the line has been crossed.
5. The line has been crossed when medication effects interfere in daily life.
6. The purpose of medication is to improve the quality of life for the individual. If you are doing anything else with medication, it is not appropriate.
7. Medication should be used for specific symptoms only research supports the use of that medication for those symptoms.
8. It is important to know what medications have been tried in the past.
9. It is important for staff to understand that most psychiatric medications take a while to work. Some take up to a month or so to get a therapeutic level in the body.
10. It is VERY important to add only one medication at a time.
11. Decisions about medications and their effectiveness on targeted symptoms need to be DATA DRIVEN.
12. It is important that staff understand that any of us might have idiosyncratic reactions to medication (reactions that are opposite or different from the intended effect). This is ESPECIALLY true for individuals who have MR/DD disabilities AND with children.
C. Are PRN medications ever OK to use for individuals living in the community?
On this topic, the group of physicians was very clear: PRN medication should be to treat specific symptoms of illness, NOT challenging behaviors. Additionally, PRN medications are very appropriately used for psychiatric symptoms as a part of a WRAP or relapse plan.
PRN medications should be used ONLY in this way:
1. For specific targeted symptoms
2. The frequency of use should be tracked
a. How often is the PRN medication used?
b. What are the circumstances when the PRN medication is used?
3. What symptom was the PRN medication used for?
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a. How effective was the medication for that symptom?
Orders for PRN medications should be written in this way:
1. Use X medication
2. Given or taken in X way
3. For X symptom
4. Not to exceed X amount in X times
D. When we take an individual to the doctor, what does the doctor need to know?
It is VERY important to both TAKE and BRING BACK the right information when seeing a physician. The physicians gave VERY SPECIFIC suggestions about what a doctor needs to know in order to make their best determination about how best help the individual.
REMEMBER, physicians see literally hundreds of people a month in their practice,
regardless of whether it is a public or private practice. The more detail you can have available for the doctor at the time of the visit, the better able the doctor will be to properly treat the individual. Here is what the physician group said.
1. Physicians need a good description of the symptoms or challenging behavior. They need to understand as clearly as possible exactly:
a. What is going on
b. When it is occurring, and
c. What is going on within the environment when these symptoms, issues or challenging behaviors occur?
2. They need to understand exactly what supports are in place so that the individual can live in the community
Additionally, they suggested having a more objective person make observations about the symptoms, challenging behavior or other issues going on…someone who is not as closely involved on a day-to-day basis.
E. How should we prepare for a visit to the doctor?
These are specific points that were made about HOW TO PREPARE FOR A VISIT TO THE DOCTOR.
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1. Come to the physician with a brief but succinct and accurate description of the individual’s medical history to include
a. A history of illnesses, surgeries, etc.
b. A list of chronic and ongoing medical issues for the individual
i. Include how each chronic and ongoing medical issue affects the life of the individual
c. A list of allergies and sensitivities
2. Bring a GOOD description of the symptoms or challenging behavior that is the concern, including
a. Exactly what is going on
b. Exactly when it is occurring
c. Exactly what is going on within the environment when these symptoms, issues or behaviors occur
d. Bring any data or tracking sheets that relate to the reason for the visit
3. Bring a complete list of the current medications that the individual is on, including
a. The name, dose, route and frequency of each medication
b. The purpose of each medication
c. Who ordered each medication
d. The original date the medication was ordered
4. Be able to clearly describe the community supports that are in place, which would include the individual’s
a. Living situation
b. Work situation or other daytime activities
c. Who is available to support the individual (who is important to the person)
5. It is VERY important to have someone accompanying the individual who knows the person’s story.
a. It is equally important that the person accompanying the individual be someone who can connect with and relate to the person.
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b. Encourage family to come if possible or appropriate
6. Staff accompanying the individual need to make it clear that the purpose of the visit is to seek help for the individual, and to be specific about
a. The description of the behavior, issue or symptom
b. Exactly what we have attempted to do
c. And that we are willing to come back for additional visits if necessary to resolve the illness, issues or symptoms
F. What information needs to GO BACK to best support the individual?
It is important that good and accurate information GO BACK WITH the individual and staff so that care given to the individual is EXACTLY what the physician orders. The physician’s suggested this list of questions that the PROVIDER staff should ask.
1. Exactly what is being treated?
2. Ask for explicit instructions about the interventions or care that is ordered by the physician
a. Staff might consider using a tape recorder to help remember what gets said
3. If medications are ordered, be sure the individual AND staff understands
a. What are risks, benefits and alternatives to medication?
i. Say “the team wants to know”
4. Ask for explicit instructions about use of medications (this information could also come from a pharmacist)
a. How does the medication interact with food?
b. Are there any issues about taking this medication with other medications?
c. Are there any issues about the time of day the medication is ordered for?
d. What should be done if a dose is missed?
e. Are there any symptoms that would indicate that the medication is causing a problem?
f. Are there any lab requirements with the use of this medication?
NOTE: Use same pharmacy to fill ALL prescriptions so that the pharmacist is
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WELL AWARE of ALL medications used by the individual and so adverse interactions between medications can be prevented
5. How long will medication take to effect a change in the symptom or illness?
6. If the medication is stopped, how long will it take to wear out of the person’s system
7. Be certain that staff understand the instructions given. If the use of a tape recorder was not an option
a. Ask for copy of physician’s note for the person’s record
b. If you have an agency form, the physician might be willing to make these notes on your form
8. Ask the physician if it is possible to e-mail questions to him or her (or some other form of written communication) if questions arise.
b. In regard to communication, the physician group also said that it is INCUMBENT upon the service provider, advocates, etc. to be a link for person served. It is CRITICAL that each person in our system of care have someone who can support him or her in his or her story being heard.
G. In Summary
The physician group summarized the work of the day with these thoughts. When individuals have challenging behaviors:
1. First, look for medical issues that might be going on.
a. Refer to Appendix B.2, B.3 and B.4 for many ideas of things to look for
2. Second, determine if the environment or persons in that environment is having an impact on the individual’s behavior.
a. Refer to Appendix B.1 for ideas.
3. Last, medication used for the purpose of behavior modification or chemical restraint is NEVER an option.
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XIII. EMERGENCY SAFETY INTERVENTIONS OF LAST RESORT
There is only ONE emergency safety intervention of last resort that may be used within community settings, and that is personal (manual) restraint. The definition of personal (manual) restraint is: The application of physical force, without the use of any device, for the purpose of restricting the free movement of a person’s body.
Personal restraint does not include briefly holding a person without undue force in order to calm or comfort the person or holding the person’s hand to safely escort the person from one place to another.
Personal or manual restraint IS permitted within all community settings associated with the Division of DBHDD EXCEPT in homes operated under a Personal Care Home license. Personal Care Home rules DO NOT permit the use of any safety intervention of last resort.
The use of personal or manual restraint as an emergency safety intervention of last resort MUST be incorporated into a crisis plan or a safety plan.
Training of staff in the use of personal or manual restraint must be done using procedures and techniques taught by nationally benchmarked emergency safety intervention training programs.
There are other emergency safety interventions of last resort that you may have heard about, HOWEVER NONE are permitted under any circumstance in community outpatient, day habilitation or residential settings. Of course there is one exception. Crisis Stabilization Programs, which are residential Emergency Receiving and Evaluation Facilities whose mission it is to provide psychiatric stabilization or detoxification, may use the other emergency safety interventions of last resort which are listed in Appendix F.
Finally, the use of medication to modify behavior or for the purpose of chemical restraint is NEVER permitted. Refer also to Appendix F for additional information.
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XIV. AFFORDING RESPECT TO THE INDIVIDUAL, OBSERVING CLIENTS RIGHTS, FEDERAL AND STATE LAWS AND DEPARTMENTAL RULES
A. Afford respect to persons served
As you think about how you will work with person(s) with challenging behaviors, special care must be given to the protection of the dignity of the individual and to each person’s unique needs. Remember to afford the person with the same respect you would want for yourself. Always remember that the most effective teaching tool you have is how you behave.
B. Know the story of the person you serve
Spending time with people and getting to know their stories will tell you most of what you want or need to know. Also remember that you may be the only voice for the person that you serve. Being known is strategic to the individual over their lifetime. Vulnerability and isolation can lead to serious trouble.
C. Informed consent
Every person has a right to consent to or deny services, unless a court has taken that right from the person or a licensed psychologist, physician, licensed clinical social worker or clinical nurse specialist believes that he or she is an imminent danger to self or others and signs an emergency document indicating the same.
In order for an individual to give his or her consent, he or she must be informed both of the potential risk and benefit associated with the proposed treatment. It can be a difficult process to explain potential risk and benefit to someone who has difficulty understanding words or to someone who has trouble verbally communicating. However the risk and benefit MUST be explained to each person using means that they can best understand.
While full family participation should always be encouraged, do not automatically conclude that the person wishes family or friends to participate or that a parent is authorized to give consent. In Georgia, persons who are adults must consent BEFORE any other person who is NOT a professional can be given any information about the individual, their treatment or care. Unless the person has a guardian, or has in some other way been adjudicated incompetent, an adult person is the only one who can legally give consent for his or her treatment. However, it would be advisable to have a client representative participate in this process when the individual has difficulty understanding
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or communicating.
D. Laws and regulations
Special care must be taken to ensure that all services, treatment and care take place in full compliance with applicable laws and regulations. The Official Code of Georgia Annotated (O.C.G.A.) makes it very clear in Chapters 33, 34 and 37 that persons will be served in the least restrictive environment [least restrictive way] that meets the needs of the person served. This is further emphasized in the Rules and Regulations for Clients’ Rights Chapter 290-4-9.
The Division’s “Core Requirements for All Providers” found in the Provider Manual for Georgia Department of Behavioral Health and Developmental Disabilities Providers Under Contract with the Georgia Department of Behavioral Health and Developmental Disabilities provide additional detail about how these ideas must be implemented. For additional information, refer to the source documents mentioned.
XV. STRATEGIES THAT MAINTAIN RESILIENCE IN CAREGIVERS
Someone who takes care of him or her self takes better care of another person’s needs. If we don’t take the time to take care of ourselves, we behave in ways much like the challenging behaviors of the person that we serve. In other words, our thoughts and feelings about what is not tended to in our lives will often easily manifest in ways we do not want or plan.
Having the tools to do the work required is imperative! In the business of working with people, some of the tools required are likely to be: 1) knowing our personal story including our strengths and limitations; 2) knowing the story of the person; 3) knowing something about characteristics of the issues the person struggles with; 4) knowing what is expected in the work setting; and 5) knowing how to access support and clarification when needed.
There are two metaphors that can apply to those of us who take care of others:
1.The first is to remember that before taking off in a plane, you are taught to put the oxygen mask on yourself before helping anyone else. If you pass out from lack of oxygen while trying to help someone else, you have done neither of you any good.
2.The second is for you to imagine that your job is to jump into the water to rescue someone who is drowning. You may know that if you swim directly toward a drowning
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person, that person will grab on to you and try to keep from going under the water by holding on to your neck or literally trying to climb on top of you.
In both of these examples, you must first know what to do. And you must have the skills through training to do the job! It simply won’t work any other way.
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APPENDIX C
Procedures for Billing and Documenting Personal Assistance Retainer
A personal assistance retainer is a component of Community Living Support Services. The personal assistance retainer allows for continued payment for Community Living Support services while a participant is hospitalized or otherwise away from the home in order to ensure stability and continuity of care. This retainer allows continued payment to personal caregivers under the waiver for up to thirty (30) days per calendar year for absences of participant from his or her home.
Personal Assistance Retainer Documentation: Providers, except for providers of participant-directed services, must document the following in the record of each participant for whom a personal assistance retainer is a component of Community Living Support Services:
1. Beginning and end date of absence.
2. Reason for absence.
3. Scheduled days and units per day for Community Living Support Services as specified in the ISP.
4. Scheduled staff was not deployed to work at any other provider location.
The Co-Employer agency of any participant/representative who opts for participant-direction through a Co-Employer Agency must document the personal assistance retainer as above. The participant/representative who opts for participant-direction through a Financial Support Services Provider must maintain copies of CLS Personal Assistance Retainer Timesheet for any claims of this retainer for Community Living Support Services.
Personal Assistance Retainer Allowances and Exclusions:
A. Personal Assistance Retainer Allowances
The personal assistance retainer allows continued payment to personal caregivers under the waiver for the following:
 Up to thirty (30) days per year for absences of the participant from his or her home, per calendar year.
 Only for the scheduled days and amounts of Community Living Support services as indicated in the ISP (e.g., if a participant receives CLS services
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only on Tuesday, Wednesday, and Thursday for a total of 16 units per day, the personal assistance retainer may only be claimed for Tuesday, Wednesday, and Thursday for 16 units per day for any week for which the retainer provides continued payment). The provider must document specific days and units billed under the personal assistance retainer.
B. Personal Assistance Retainer Exclusions
The following exclusions apply to the personal assistance retainer:
 Payment is not made for Personal Assistance Retainer outside of scheduled days and units per day for Community Living Support Services as specified in the Individual Service Plan.
 Payment of Personal Assistance retainer is not allowable for absences due to services that are reimbursable as other waiver and Medicaid State Plan services except for admissions to a general hospital or nursing facility as indicated below.
 Payment of Personal Assistance retainer beyond allowable days indicated below.
Personal Assistance Retainer Billing:
Providers must submit claims as follows for the personal assistance retainer:
A. Claims During Hospital Stays
1) Providers submit claims for each admission to a general hospital or nursing facility, including ICF/MR and skilled nursing facilities;
2) Providers submit claims for only scheduled days and units as specified in the participant’s Individual Service Plan;
3) Providers bill a separate line for each day claimed during the hospital stay;
4) Providers list place of service on the claim as follows:
 31 for Skilled Nursing Facility
 32 for Nursing Facility
 54 for Intermediate Care Facility/MR
 21 for Inpatient Hospital
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Providers submit claims for only scheduled days and units as specified in the participant’s Individual Service Plan;
B. Claims for Other Absences
1) Providers submit claims up to the allowable thirty (30) days per calendar year for all absences of the participant from his or home, including hospital stays as in Section A. above, and other absences of the participant from his or her home, such as vacations and family/relative visit, per calendar year;
2) Providers submit claims for only scheduled days and units as specified in the participant’s Individual Service Plan;
3) Providers may submit claims for other absences as standard (that is, in weekly, bi-weekly, or monthly spans)
Note: For personal assistance retainer claims during hospital stays, the provider must bill a separate line for each day claimed during the hospital stay up to the allowable thirty (30) days per calendar year for all absences of the participant from his or her home.
absences of the participant from his or her home.
Note: For personal assistance retainer claims during hospital stays, the provider must bill a separate line for each day claimed during the hospital stay up to the allowable seven (7) days per admission.
Rev. 01 2013

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