see below

2. Whether done by a staff person directly employed by (Agency) or by a TEA Agency engaged under contractual arrangement, (Agency) acknowledges having responsibility to oversee the timeliness, quality, appropriateness, and effectiveness of behavior supports and services provided.

3. A copy of the contract or agreement with the TEA shall be forwarded to DDD Behavioral Services.

D. When the agency has Clinical Responsibilities the following shall be included in these procedures: Comment by Clinical Services Unit: For Letter “D.1”- Please use this statement as it is written.

1. For individuals that have an identified need for Behavioral Supports and Service, this shall be accomplished in collaboration with the Planning Team and the individual’s Support Coordinator. Generally, when Behavioral Supports and Services for an individual are being sought or inquired about, the requests for this information would come from an individual’s Support Coordinator. When a request comes from someone other than the Support Coordinator, (Agency) will subsequently reach out to the Support Coordinator to ensure that there is Planning Team agreement with the service or support and coordination is taking place at that level.

a) Describe the agency procedure by which a point-of-contact and method of communication will be established and a procedure to respond definitively to inquiries within 5 business days. Comment by Clinical Services Unit: Please describe the process you have established related to the prompt. Please be sure to delineate the different processes for how you’ll work with the Support Coordinator and Planning Team when your agency is referred individuals who: 1. Have been assigned Acuity and your agency is responsible to meet both clinical and staffing needs of the individual. 2. Need SABS because they DO NOT have assigned Acuity and your agency is only responsible for meeting the clinical needs of the individual. We’ll specifically be looking for you to include the following: Who within your agency will be the point person? How do expect that the point person will receive referrals and communicate with the SC or family? (this could be prior to acceptance and admission (SABS) or while receiving services secondary to an acuity Differentiated Service) What process will you use to review potential referrals and make a decision related to whether you can meet the service needs of the individual? How will a decision related to services be communicated and is there a timeframe you expect to be done? (For SABS, we require this to be dome within 5 business days.)

2. Agency will not develop Behavior Plans that use personal control or any form of mechanical restraint as a behavior shaping technique without prior approval from DDD. Personal Control and Crisis Management are not to be incorporated into a behavior support plan or other behavior shaping strategies. Comment by Clinical Services Unit: For Letter “D.2” – “D.3”- Please use this statement as it is written.

3. All behavior supports will be developed with a consideration of the service recipient’s Human Rights and consistent with the NJ Developmentally Disabled Rights Act and NJ DHS/DDD personal rights statement, “Your Personal Rights” (6/2010).

E. For individuals with Behavioral Acuity, the provider of the Acuity Differentiated Service will establish procedures that utilize the Addressing Enhanced Needs Form (AENF). The AENF will be kept current and reflect the plan to address service needs. Comment by Clinical Services Unit: For Letter “E.1” - “E.2”: Please use this statement as it is written.

1. Identified behavior concerns, and the approaches used to address them, will be outlined in the AENF. These will be further developed into specific behavior plans / strategies which are trained to staff and instituted in the setting.

2. New behaviors, ineffectively addressed behaviors, or behaviors with health or safety implications are to be reported to the Support Coordinator. The AENF and the supports it identifies will be revised / updated to remain current.

F. Assessment and Plan Development – when provided as a Stand-Alone Behavior Support service (section 17.2) or when done to meet the behavior service needs of service recipient(s) with Behavioral Acuity (section 3.4), will adhere to these standards: Comment by Clinical Services Unit: For Letter “F.1” – “F.7”- Please use this statement as it is written.

1. “Assessment” refers to an investigation into the function of the identified behavior and what factors have a causal relationship to the behavior. The assessment, which may entail conducting a functional analysis of the behavior, will serve to inform the behavior-shaping methods and techniques to be used in the Behavior Support Plan / Strategy - the end product of “Plan Development” activities.

2. Assessment will be conducted using standard and accepted tools and methodologies. The assessment will either be incorporated into the behavior support / strategy or a summary of it will be shared with the Support Coordinator for Planning Team review.

3. Both the assessment and the resultant Behavior Support Plan / Strategy will conform to the terminology, required plan components, and approval criteria found in Division Circular #34.

4. Assessment/Plan Development activities will be initiated and completed as expeditiously as practicable, to assure effective supports are in place as needed. Assessment and Plan Development should typically be completed within no more than four to six weeks.

5. The Behavior Support Plan / Strategy will be shared with the Support Coordinator for dissemination, Planning Team review, and inclusion in the service recipient’s record.

6. (Agency), as a provider of Behavioral Supports and Services, will work both collaboratively and at the direction of the Planning Team.

7. The need for periodic reassessment of the function of the behavior and/or a revision of the Behavior Support Plan / Strategy will be a Planning Team determination, based upon collaborative input from (Agency). Criteria for reassessment or plan revision should be based upon the behavioral presentation of the service recipient and data-based indicators of progress toward the desired outcome.

G. Monitoring – when provided as a Stand-Alone Behavior Support service (section 17.2) and done in collaboration with the IDT/Planning Team, or when done to meet the behavior service needs of service recipient(s) with Behavioral Acuity in an embedded capacity (section 3.4), will adhere to these standards: Comment by Clinical Services Unit: For Letter “G.1” – “G.5”- Please use this statement as it is written.

1. Monitoring will be consistent with the examples provided in 17.2.

2. Monitoring is to be in accordance with the Service Delivery Report (SDR), if applicable.

3. Monitoring will result in written documentation compiling or summarizing data-based progress towards the intended behavioral outcomes. Monitoring reports will also note significant behavioral, training or implementation events.

4. At a minimum, these reports will be prepared and forwarded to the Support Coordinator every 90 days.

5. The frequency of reports shall be every 30 days when the behavior has significant health / safety implications, or when the Behavior Support Plan uses a Level III technique (per DC#34).

PROCEDURES - General Implementation Standards: Comment by Clinical Services Unit: This section applies to providers serving individuals with Behavioral Acuity, or having a NJCAT Level 3-4 behavioral assessment.

A. Describe the system by which (Agency) Director or designee will ensure all employees involved in the delivery of Embedded Behavior Supports in an Acuity Differentiated Service, are credentialed consistent with Waiver requirements. Comment by Clinical Services Unit: Please describe the process you have established related to the prompt.

B. Describe the system by which (Agency) Director or designee will ensure that prior to service delivery, all employees have completed applicable trainings consistent with Waiver requirements. Training documentation will be maintained for review. Comment by Clinical Services Unit: Please describe the process you have established related to the prompt.

1. Staff shall be trained in accordance with Waiver Appendix E., including Positive Behavior Supports (PBS) and all agency managed trainings. Note: PBS training has two levels, one for staff who have Implementer Responsibilities and an additional training for staff who have Clinical Responsibilities. Comment by Clinical Services Unit: Please identify the specific curriculum your agency will be using. Also note that Elizabeth Boggs Training is the default PBS training unless you have separate specific Division Approval to use an alternate training.

2. Describe the system by which staff shall be trained to understand the Behavior Support Plan / strategy, including their implementation and documentation responsibilities, the correct use of methods and techniques, and the limits of their permitted actions. Comment by Clinical Services Unit: Please describe the process you have established related to the prompt.

a) Such training is to be delivered directly by the credentialed individual that created the behavioral support / strategy, or by a designated proxy that they trained and is working under their direction. Comment by Clinical Services Unit: Please use the language as it is written.

C. Describe the agency’s system to maintain updated and accurate documentation verifying staff credentials and their completion of mandatory trainings. These will be maintained in the employee file and be available for inspection and review. Comment by Clinical Services Unit: Please describe the process you have established related to the prompt.

D. Describe the agency’s system by which when an individual, either directly or through a Support Coordinator, prospectively inquires about (Agency’s) provision of services, they will be provided with information about the range of behavioral needs the agency is prepared and approved to address. Comment by Clinical Services Unit: Please describe the process you have established related to the prompt.

1. Describe the agency’s process to communicate whether or not the agency has DDD approved behavior policy allowing them to provide “Stand-Alone Behavior Supports” as well as behavior services to individuals with Behavioral Acuity and / or assessed NJCAT behavior scores of 3-4. Comment by Clinical Services Unit: Please describe the process you have established related to the prompt.

a) Agency practice will be to not accept service recipients into their Acuity Differentiated Service(s) that the agency is not fully qualified and currently staffed to support; and they have attained and maintained corresponding Division approved behavior policy and procedure indicating Division approval to serve individuals with higher level behavioral needs (Behavioral Acuity and / or assessed NJCAT behavior scores of 3-4). Comment by Clinical Services Unit: For Letter “D.1.a.” and “D.1.a.i”- Please use this statement as written.

i. If (Agency) is not qualified to provide Behavioral Services to service recipients with Behavioral Acuity and / or NJCAT 3-4, and a current service recipient is newly assigned a Behavioral Acuity Factor, (Agency) will expeditiously revise their policy, procedure, availability of qualified staff, and trainings to meet this higher level of need.

2. Describe the system by which the (Agency) will supply information about any specific forms, processes, or practices (such as interviews and applications) that are required to initiate services. These will be shared with prospective service recipients at the time of initial inquiry and updates if revised. Comment by Clinical Services Unit: Please describe the process you have established related to the prompt.

3. Additionally, describe the system by which the (Agency) will advise of any usual or customary behavior shaping techniques or behavior management / interventions that are not used, either programmatically or in a behavioral “crisis,” as a matter of agency philosophy or business practice (refer to DC #19). This information will be shared with prospective service recipients prior to admission to service and updated if revised. Comment by Clinical Services Unit: Please describe the process you have established related to the prompt.

a) If (Agency) decides to use any unusual/non-customary behavior shaping techniques that DDD will be notified (refer to DC #34). Comment by Clinical Services Unit: Please use the language here as it is written.

E. Describe the agency’s system by which individuals and their representatives will be informed of the utilization of any electronic monitoring / recording equipment, or restrictive practices inherent to the program. Comment by Clinical Services Unit: Please describe the process you have established related to the prompt

F. Providers serving individuals with “Higher-Level Behavioral Needs” (Behavioral Acuity or a NJCAT Behavior score of 3-4), (Agency) shall acknowledge their responsibility to implement behavior supports using qualified staff trained in the methods and techniques contained within the behavior support(s) and, Behavior Supports will be instituted and implemented in line with the direction of the IDT / Planning Team. Comment by Clinical Services Unit: Please use the language provided as written in Letters “F” and “G”, with the exception of including your agency’s name as prompted.

G. Additionally, the following shall be addressed:

1. In order to meet the needs of these individuals, (Agency) will establish policy and procedures to train staff in Crisis Management. This requires the specific review and approval of the Division in accordance with DC #19. (See and complete Section 4 below, Crisis Recognition, De-escalation, and Management.)

2. When providing service to individuals requiring “Not Highly-Restrictive” devices (such as helmets, knee pads, splinting, etc.), to protect them from injury that would result from intentional behavioral actions, additional policy and procedure is required in accordance with DC #20. (See and complete Section 4 below Use of Not Highly-Restrictive Devices.)

H. Any behavior support to be implemented and instituted by (Agency) may need a level of review and approval consistent with DC #34. Behavior Supports with restrictive components that are implemented by (Agency) are subject to Human Rights Committee (HRC) and / or Behavior Management Committee (BMC) review.

1. (Agency) will identify whether they will operate their own HRC / BMC, for behavior supports and issues needing such review (see DC #34, DC #5 and DC #18). If an Agency opts to utilize their own HRC / BMC, (Agency) will forward meeting minutes to DDD (or make them available for review). Comment by Clinical Services Unit: Please be sure to state whether your agency will use an internal HRC and/or BMC or will be using the Division’s committee(s).

PROCEDURES - Crisis Recognition, De-escalation, and Management: Comment by Clinical Services Unit: Include all items “A” through “J” and provide enough detail to describe how the agency will operationalize and oversee the process steps included herein.

A. Please identify the comprehensive, commercially available, well-established training curriculum adequate for the population served. The agency’s choice will be subject to the Division’s agreement of suitability. Comment by Clinical Services Unit: Please state the name of the curriculum your agency has chosen to meet this requirement. NOTE: DDD must agree that the curriculum selected meets the needs of the individuals your agency intends to serve.

1. Curricula must contain robust content which includes:

a) Identifying early signs and triggers of pending crisis behavior

b) Methods to prevent and de-escalate crisis behavior

c) Non-contact techniques to defensively avoid injury from aggression

d) A hierarchy of personal control techniques (PCT) sufficient for the population served

e) Training to recognize signs and symptoms of physical distress or injury

2. A copy of all materials, both a Trainers Manual and the Trainee materials, must be forwarded along with this policy for Division review (unless the Division stipulates that it already has the materials / current versions). Comment by Clinical Services Unit: This statement is for informational purposes and can be removed.

a) Training materials must contain both narrative and graphic depiction of methods and techniques to be trained – clearly showing all points of interpersonal contact and body posture.

B. Please describe how (Agency) will institute requirements and training standards which address the following: Comment by Clinical Services Unit: Please clearly and concisely describe how your agency has organized the training of staff in your chosen PCT Curriculum. NOTE: This sections should not reflect how your clinical staff train DSP level staff in Behavior Plans as details related to the training of Behavior Plans was outlined in Section 2 of this document.

1. Identify who will train staff (may be listed by job title), and note their qualifications / authorization to be a trainer of this specific material

2. Identify agency staff to be trained (may be listed by job title / location)

a) Specify the timeframe for the initial staff training (typically before working with individuals with demonstrated need)

b) Specify the routine staff retraining cycle

i. Minimally, the agency must document having staff demonstrate their proficiency in all PCT techniques at least annually

c) Specify any other retraining process

i. Agency policy / timeframe for full retraining

ii. Agency policy for retraining based on concerns or issues

aa Staff must be retrained if a prior utilization resulted in injury or distress. In this situation, staff may not use any personal control technique before being successfully retrained.

C. Describe your process to meet these requirements, which must occur prior to use of PCT on any service recipient. Comment by Clinical Services Unit: Please describe how you will obtain Medical Review.

1. Medical review prior to use:

a) Prior to use, and on an annual basis, the IDT will conduct and document a review of the client record, noting any identified health concerns

b) A physician will review / identify any contraindicated techniques, if the IDT have noted any questions or concerns

D. Describe your authorization process / approval requirements for each utilization of PCT, which must include, at a minimum, the following: Comment by Clinical Services Unit: Please describe who the Authorizing Entity for PCT is and the approval requirements for each PCT use.

1. Approval may only be granted by the agency Chief Executive Officer (CEO) or their qualified designee

a) Designee must be Qualified Intellectual Disability Professional (QIDP).

2. Each application of PCT requires an express approval supported by written documentation

a) Approval is limited to one-hour limit; a unique, discreet written reauthorization is needed for continued use.

E. Describe your process / procedures to ensure that authorization of CEO or designee is obtained. Comment by Clinical Services Unit: Please clearly and concisely describe the process staff will follow to obtain Authorization for PCT use.

1. Provide comprehensive written procedures for obtaining authorization which includes the process by which each request for authorization is made.

F. Describe your process/ procedures to document and track each authorized use of PCT, to include: Comment by Clinical Services Unit: We will need to review the forms your agency will be using to document the authorization and use of PCT, as well as the required condition checks. Please use the information in this section to guide you developing these form. When we review these forms, we will need to ensure all that is written here is included.

1. Name / Title of the individual making the request to utilize PCT, the nature of the emergency, and the time the request was made. This should be completed by the staff who is making the request.

2. Name / Title and time the request was responded to by the CEO or designee.

a) Indication of whether or not approval was granted

b) Note any conditions, limitations or special instructions made with the approval or denial of the request

3. Approval of the CEO or designee shall constitute a “written order” authorizing the PCT and must be placed in the client record within 24 hours of the occurrence.

4. When PCT in in use, the service recipient shall remain under continuous observation by all involved staff.

5. The following will be documented contemporaneously by the staff during the implementation of PCT:

a) Date / time: application & release

b) PCT technique and duration

c) Documented checks, every 15 minutes, on the condition of the individual relative to:

i. any signs of distress

ii. whether their behavior necessitates continuation of the PCT

d) In the case of distress or injury, staff will document in the client’s medical record:

i. the time and nature of any distress or injury

ii. the immediate cessation of the PCT

iii. the provision of medical attention, as needed

G. Reference the agency’s requirement for appropriate action if distress / injury falls under Danielle’s Law. Comment by Clinical Services Unit: Since your general operating procedures will include a section that speaks directly to Danielle’s Law, we ask that you only reference here that your agency will follow the provisions outlined within the statute.

H. Describe your process whereby, whenever PCT is authorized, the family / guardian shall be notified and provided a summary within 24 hours of the event. Additionally, the Support Coordinator (or planning team leader) will be notified and provided a summary. Comment by Clinical Services Unit: Please describe the process for notifications when PCT occurs. Who will be notified? Who is responsible for making the notifications? When will notifications occur?

I. Describe and include the following items in your policy and procedure: Comment by Clinical Services Unit: Since your general operating procedures will include a section that speaks directly to the reporting of UIRs, we ask that you generally describe how you will adhere to the provisions outlined within Circular #14.

1. Unusual Incident Reporting (UIR) of accident, injury, distress or misuse / unauthorized / unapproved use of PCT - in accordance with DC#14.

2. Agency procedure for disciplinary action if PCT is used without authorization, under false pretense, or if an unapproved technique is used.

J. Describe the agency system of Quality Assurance - Methods to limit overuse and monitor for patterns of utilization.

1. The agency will establish a quality assurance methodology for usage review & to identify patterns of use. Comment by Clinical Services Unit: Please describe your Quality Assurance Plan to review the use of PCT across all setting within your agency. The goal here should be to look at trends and patterns across different settings, different individuals, staffing patterns, times of day, etc., to identify patterns of use and limit overuse. We will specifically be looking for you to describe the following: What metrics will you use to look for patterns and trends? Who will gather these metrics and how often? How will the aggregated data be reviewed? What will happen to the data that is reviewed? Will recommendations be made? Who, on the Executive Level, will receive the information or recommendations and what will happen when it’s received?

2. The IDT must meet within 5 work days if ever 3 or more “emergency” PCT events occur in a rolling 6-month period.

K. Agency documentation forms for PCT request / approval, and condition checks shall be submitted for Division review. Comment by Clinical Services Unit: This statement is for informational purposes and can be removed.

PROCEDURES - Use of “Not Highly-Restrictive” Devices : Comment by Clinical Services Unit: This section applies when the use of certain protective devices (like helmets, knee pads and jumpsuits) are indicated, approved, and used consistent with an individual behavior support plan. Typically, this level of need would be limited to particular individuals with behavioral acuity, or having a NJCAT Level 3-4 behavioral assessment. For Letters “A” – “I”- Please use these statements as they are written.

A. “Not Highly-Restrictive” devices are described in Division Circular #20. (Agency) will obtain approval from DDD if it is determined that “Not Highly-Restrictive” devices will be utilized. Each service provider requesting approval to utilize them shall submit to the Division of Developmental Disabilities (Behavior Policy Review Committee) a set of comprehensive written procedures governing their use.

B. “Not Highly-Restrictive” devices will not be used as the primary behavior shaping technique to address the underlying behavior that results in the need for behavioral intervention. Criteria for use of the device including instructions for the application of the device; which shall only be consistent with an approved Behavior Support Plan. The Behavior Support Plan will be subject to all review and approval as a Level III plan. The plan should include the following:

1. A statement specifically identifying the form(s) of device to be used and describes staff titles / positions that will be trained to use the device.

2. Certification by a physician that the device is not medically contra-indicated for the individual;

3. Identified recordkeeping and review requirements.

4. Inclusion of a curriculum for training staff which shall include, but not be limited to, training in the proper use and application of each device to be employed as well as the recognition of the signs of physical distress.

a) “Physical distress” means the individual is exhibiting one or more of the following: difficulty breathing; choking; vomiting; bleeding; fainting; unconsciousness; discoloration; swelling at points of restraint; appearance of pain; cold extremities or similar manifestations.

C. Primary reliance on punishment, physical or mechanical restraints or aversive techniques to decrease undesirable behavior is contrary to Division policy.

D. Devices used for control purposes are considered to be appropriate only when absolutely necessary and their use shall be minimized in favor of other, more positive interventions.

E. The device will only be used as part of an approved behavior modification program and for the purpose of protecting the individual from accidental self-injury.

F. These devices shall only be applied by staff trained in their use and application.

G. The need for the particular device to be used for behavioral intervention shall be documented in the Service Plan and re-evaluated no less than annually as a part of the plan review or as specified by the Planning Team / IDT.

H. Only commercially produced devices shall be employed.

I. Devices shall be inspected prior to each use to ensure that they remain in good repair and free from tears or protrusions which may cause injury.

PROCEDURES – Quality Review- Oversight and Monitoring:

A. Consistent with (Agency’s) Quality Improvement Plan, (Agency) will establish a system of administrative oversight to verify that behavioral supports and services are appropriate, effective and timely. Comment by Clinical Services Unit: Please describe your Quality Assurance Plan for the delivery of the Behavior Supports and Services your agency is providing. The goal here should be to review whether you are delivering Behavior Supports and Services in a timely way, and that those supports and services are appropriate and effective. We will specifically be looking for you to describe the following: What metrics will you use to review how services are delivered? Who will gather these metrics and how often? How will the aggregated data be reviewed? What will happen to the data that is reviewed? Will recommendations be made? Who, on the Executive Level, will receive the information or recommendations and what will happen when it’s received?

1. These reviews will focus on behavior support timeframes for creation and dissemination, effectiveness as measured by progress towards behavioral outcomes, and satisfaction survey data of family/guardian.

2. Reviews shall be specific and applicable to the Behavioral Services addressed within this policy and procedure to include:

a) Acuity (Clinical) Responsibilities

b) (General) Implementation Standards Responsibilities

c) Crisis Recognition De-escalation and Management Standards

d) The use of Not Highly-Restrictive Devices

3. The system of administrative oversight and monitoring will describe how this information will be aggregated, presented, and reviewed at an agency executive level.

Name and Title of the Author of this Document: Comment by Clinical Services Unit: Please include the name and title of the person who developed this document

Agency CEO/Authorized Representative: Comment by Clinical Services Unit: The Authorized Representative, if not the CEO, should have authority to approve and assure implementation of the content noted within this document.

Signature: Date:

1. (Agency-Insert Page Number and Version/Date in this footer section)