Transcript member rights - Community Care of Central Wisconsin

INDIVIDUAL RIGHTS
AND BEHAVIOR
SUPPORTS
JULY 29 & 30, 2010
Bob Mitchell, DHS, Contract Coordinator
ACRONYMS
MCO – Managed Care Organization (was CMO)
 BLTS - Bureau of Long Term Support, DHS
 DQA – Division of Quality Assurance
 DHS Department of Health Services,
 IDT – MCO Inter-Disciplinary Team
 OFCE –Office of Family Care Expansion
 ICF/MR Intermediate Care Facility for the
Mentally Retarded
 MCQS Member Care Quality Specialist

AUTHORITY
FEDERAL
Social Security Act - Collection of Federal
Laws that Describes How Assistance is Provided
to Those in Need.
 Title XIX – Grants to States for Medicaid
Assistance Programs
 Section 1915 – Creates Waiver to Support with
Medical Assistance home or community- based
services for individual that requires a level of
care provided in a hospital, nursing facility or
ICF/MR.

AUTHORITY FEDERAL
Section 1915(c) of the Social Security Act that
the state ensure the health, and welfare of all
individuals receiving services funded by Medicare
and/or Medicaid.
 Section 1932 – State Option to Use Managed
Care
 Section 1932(a.)(1)(A) In general subject to the
succeeding provisions of this section.

AUTHORITY

STATE
State Statute 51.61
Anyone receiving services for mental illness,
developmental disabilities or alcohol, or other
drugs has rights…
AUTHORITY 51.61(1) RIGHTS
(a) to be informed of rights
 (b) to refuse labor (not including personal
housekeeping)
 (cm) to send and receive sealed mail
 (d) to petition review of commitment order
 (e) to least restrictive environment
 (f) to receive prompt and adequate treatment
 (g) to refuse medication and treatment (only the
court can order medication compliance)

AUTHORITY 51.61(1) RIGHTS
(h) to be free from unnecessary or excessive
medication. Medication can not be used as
punishment, convenience of staff, or substitute
for a treatment program.
 (i) to be free from physical restraints and
isolation unless an emergency or part of a DHS
approved treatment program.
 (j) to not be subject to experimental research.
 (k) consent to treatment

AUTHORITY 51.61(1) RIGHTS
(l) to religious worship or “not”
 (m) to humane psychological and physical
environment
 (n) confidentiality of records, access, and
challenge accuracy.
 (o) to not be filmed or taped unless consent
 (p) to reasonable access to phone
 (q) to wear own clothing and laundry
 (r) access to reasonable storage

AUTHORITY 51.61(1) RIGHTS
(s) privacy
 (t) see visitors
 (u) present grievances without reprisal
 (v) use own money as chooses (amount can be
limited for security)
 (w) informed of cost of care
 (x) treated with respect and dignity

AUTHORITY 51.61(2) DENIAL OF
RIGHTS

Only for cause

that is well documented as
medically or therapeutically
contraindicated


Informed in writing

Review procedure available
AUTHORITY DHS 94

DHS 94

This is the Wisconsin Administrative Code that
describes how the Department of Health
Services will promote the rights as defined in
51.61
Available online at:
 http://nxt.legis.state.wi.us
 Look under Administrative Code Related, Health
Services

AUTHORITY DHS 94
Denial or Limitation of Rights – Summarized
from DHS 94 Subchapter II - Patient Rights
No rights can be denied except:
 Good cause for security
 Adverse effect on treatment
 Interfere with the rights of others
WORKING DEFINITIONS


Denial – No access to the right.
Limitation – Access to part of the right, or access
to the right when…

“when” must be described
PROCEDURE FOR DENIAL OR
LIMITATION OF RIGHTS –
SUMMARIZED FROM DHS 94
SUBCHAPTER II - PATIENT RIGHTS
 Documented
approach
as least restrictive
- no denial if a limitation would work
- no limitation more stringent then
necessary
PROCEDURE FOR DENIAL OR
LIMITATION OF RIGHTS –
SUMMARIZED FROM DHS 94
SUBCHAPTER II - PATIENT RIGHTS

Written Notice to the individual,/guardian,
record, and placing agency (MCO).
Right to a hearing
2. Conditions to restore the right
3. Duration of denial / limitation
4. Specific reason for denial/limitation
1.
OTHER ‘GEMS” FROM DHS 94

94.06 each service provider shall assist in the
exercise of all rights


No patient may be required to waive any rights as a
condition of admission or receipt of treatment
services.
94.52 The Department may investigate any
alleged violation.
STATE RIGHTS SPECIFIC TO FAMILY
CARE MEMBERS - DHS 10.51

Defined in Wis. Admin. Code DHS 10.51









Freedom from discrimination
Accuracy and confidentiality of information
Prompt decisions and assistance
Access to information
Enrollment choice
Information and access to ADRC
Support of rights, grievance and appeal
Support from MCO Outcomes, information,
participate in planning, service plan
implementation.
-AND-
STATE RIGHTS SPECIFIC TO FAMILY
CARE MEMBERS - DHS 10.51

DHS 10.51 specifically indicates members
receiving services for mental illness, a
developmental disability or substance abuse also
have all the rights under 51.61 Stats. And DHS
94. Wis. Admin. Code
WHAT ABOUT MEMBERS WHO ARE
FRAIL ELDER OR PHYSICALLY DISABLED?

Many MCOs have developed policies based on
DHS 94 defining member rights for frail elder
and physically disabled members.
WHAT ABOUT…
“PROGRAM OR HOUSE RULES?”
Rules that relate to basic health and safety
that are required for safe management of the
setting must be justifiable and on a safety and
security basis.
 Rules related to group living, work, or
program expectations to maintain “harmony”
must balance the rights of individuals
against those of peers and be the least
restrictive means of accomplishing the
objective.

WHAT ABOUT…
“PROGRAM OR HOUSE RULES?”


You should not have rules that make access to
basic rights, community, leisure, or recreational
opportunities contingent on a member’s
compliance.
Those issues must be in an individual treatment
program for the member needing that level of
support.

Source : DHS Clients Rights Office, Community
Programs Training, 2006
OTHER IMPACTS ON BEHAVIOR SUPPORTS
Access to addictive substances such as tobacco
should not be contingent on behavior.
 Individuals should not have to earn access to
items that have been purchased with their own
money. Reinforcers for behavior supports should
be paid as a portion of the service costs.
 An adult is an adult, is an adult, and should
always be treated as one.

WEBSITES AND CONTACTS
FOR MORE INFORMATION
Social Security Act
http://www.ssa.gov/OP_Home/ssact/comp-ssa.htm

Statute 51.61, DHS 94, and DHS 10.51
http://nxt.legis.state.wi.us
 51.61 Look under Statutes Related
 DHS 94 look under Administrative Code Related, Health
Services

Clients Rights Office
http://dhs.wisconsin.gov/clientrights/index.htm

Bob Mitchell, DHS, Contract Coordinator
[email protected]

RESTRICTIVE MEASURES
OVERVIEW
Presented by :
CCCW Behavior Support Oversight Committee
(BSOC)
WHAT WILL WE BE COVERING TODAY ?
Proactive and Behavior Support Plan overview.
 Definitions of Restrictive Measures per DHS 94.
 Emergency Restrictive Measures Plan.
 Roles of CCCW Interdisciplinary Teams, CCCW
Behavior Support Oversight Committee (BSOC),
and DHS/DLTS
 Restrictive Measures Approval Process (what
needs to be included).

RESOURCES AND INFORMATION FOR
TODAY’S TRAINING
DHS 94
 Guidelines And Requirements For The Use of
Restrictive Measures (DHS, DQA, DLTS)
(February 2009).
 Training on Restrictive Measures
DQA/DLTS/MCO Process (May 2009).
 CCCW Restrictive Measures Policy.

DISCLAIMER
We are putting the cart before the horse.
 Prior to even thinking about restrictive
measures, we need to have a behavior support
plan in place.
 Data documenting effectiveness or
ineffectiveness.
 Restrictive measures are the last resort option.

PROACTIVE SUPPORT PLANS



Designed to prevent the likelihood of negative,
maladaptive behaviors from emerging, and places focus
on positive behaviors, one’s strengths, and abilities.
Create an environment that is conducive of safe learning
and expression, residents feel more comfortable and are
more likely to respond favorably to staff support.
Evolve with the individual and are updated routinely as
we learn more about each person’s abilities, improvement
in certain life areas, and effective interventions and
interactions.
PROACTIVE SUPPORT PLANS
Is the big picture plan.
 How do we support the individual throughout the
day - not just during crisis?
 More importantly, how do we assist the
individual in being more independent, by
assisting in modifying behaviors?
 Very clear step-by-step for consistency.

BEHAVIOR SUPPORT PLANS

Specific to each individual behavior.
Define the behavior (what does it look like).
 Precursors, onset, severity, how often it occurs, how
long will it last - conclusion of the behaviors.
 Identified function of the behavior.
 Proactive prevention of behavior.
 Management of the behavior.

EFFECTIVENESS OF A PLAN
Data collection, Data collection, Data collection.
 Review, Review, Review, Review.
 Team approach and input.

RELATIONSHIP OF INDIVIDUAL RIGHTS AND
RESTRICTIVE MEASURES
Mail
Access to Phone
Prompt
Treatment
Restraint
Isolation
Seclusion
Least Restrictive
Treatment and
Conditions
Visitors
Storage
Access to Funds
Religion
Voting
Medications and
Treatment
WHAT IS A RESTRICTIVE MEASURE?

The definition of Restrictive Measures applies to
the forms of restraint, isolation, and protective
equipment identified below:






Manual Restraints
Mechanical Restraint
Medical Restraint
Isolation/Seclusion
Protective Equipment
Mechanical Support
WHAT IS A RESTRAINT?

Any device, garment or physical hold that

Restricts the voluntary movement of a person’s
body or access to any part of the body

And cannot be easily removed by the individual
MANUAL RESTRAINTS
“Hands on,” holding limbs or body contingent
upon behavior
 Restricting or preventing movement
 Not longer than 15 continuous minutes

Examples:
MANUAL RESTRAINT DOES NOT INCLUDE:
Medical restraints.
 Holding limbs or body to provide functional
movement and positioning.
 Holding limbs or body to prevent falling.
 Self-protective blocking or passive redirecting
aggressive behavior.
 Graduated guidance as part of an approved
intervention.

MECHANICAL RESTRAINT
A device applied to any part of a person’s body
contingent upon behavior
 Restricts or prevents movement or normal
use/functioning of the body part
 Cannot be easily removed by the individual
 Cannot impair hearing, vision, or speech (DHS)

Examples:
MEDICAL RESTRAINT
Apparatus or procedure that restricts voluntary free
movement
 Cannot be easily removed by the individual
 Used prior to, during, or subsequent to a medical
procedure
 Or to protect during the time a medical condition exists

Examples:
MEDICAL RESTRAINT CONT. –
SHORT-TERM USE
MD writes an order for use during the first 10
days. Guardian is notified.
 If restraint continues past the initial 10 days,
then guardian consent is required.
 If this occurs regularly or becomes long-term,
then application for use is required.

ISOLATION/SECLUSION
Involuntary physical or social separation from
others by actions of staff
 Contingent upon behavior

Examples:
PROTECTIVE EQUIPMENT
Device that does not restrict movement but does
prevent access
 Applied to any part of a person’s body to prevent
tissue damage as a result of behavior
 Cannot be easily removed by the individual

Examples:
MECHANICAL SUPPORT
An apparatus
 Properly aligns a person’s body or helps maintain
balance
 Designed by a qualified professional in
accordance with principles of good body
mechanics, concern for circulation, and allow for
change in position.
 Generally not a restraint, but could be if it meets
the definition.

Examples:
EXCEPTIONAL MEASURES
Specific forms of restraint that are considered
highly restrictive and present a higher level of
risk
 Requires an additional level of review - Oversight
Committee
 Waiving or modifying any process requirement is
considered an exceptional measure, as well

EXCEPTIONAL FORMS OF …
MANUAL RESTRAINT

Any form of horizontal restraint


Physically forcing a person to lay in a
horizontal position
Takedowns

Physically forcing a person to a prone position
on the ground, floor, or mat
EXCEPTIONAL FORMS OF …
MECHANICAL RESTRAINT
Restraint vests, jackets, body wraps
 Seclusion
 Wrist or ankle restraints
 Removal of mobility aids
 Restraint chairs
 Bed enclosures

EXCEPTIONAL FORM OF …
ISOLATION
Seclusion
 Person is physically set apart from others
 Use of locked doors

EMERGENCY USE OF RESTRICTIVE MEASURES

Emergency is defined as:
Sudden, unexpected behavior that places the person
or others in some danger of injury or
 onset of signs/symptoms known to be precursors of
such behavior
 After two incidents within 6 months no longer
unanticipated

EMERGENCY USE OF
RESTRICTIVE MEASURES POLICY
 Requirements
that must be addressed for
a provider to be able to use emergency
restrictive measures:





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Written Policy
Release Criteria
Reauthorization of Use
Time limits and Physician orders
Trained Staff
Measure employed must be monitored
EMERGENCY USE OF
RESTRICTIVE MEASURES POLICY CONT.:
Involve Law enforcement when necessary
 Critical Incident reporting
 DHS notification

EXAMPLE


Frank is non-ambulatory and uses a highly modified
wheelchair for proper body alignment. He often kicks
his legs out, moves them off the foot rests, or lets them
hang behind the foot rests. This has been resolved by
providing a strap around each ankle that is, in turn,
strapped down to the footrest holding his foot securely
to the rest. The Physical Therapist has written into
their evaluation, “ankle straps secured to footrests for
safety during transportation.” This is repeated in his
support plan.
Is this a restraint?
WHAT CAN BE EXPECTED OF CCCW IDT’S
ROLES WITH RESTRICTIVE MEASURES?
IDTs will monitor for the use of Restrictive
Measures.
 Assist providers/families with the development of
Behavior Support Plans and/or Restrictive
Measures applications.
 IDTs to submit Restrictive Measures applications
and/or Behavior Support Plans to their direct
supervisor for review when received from
providers .
 IDTs will complete quarterly reviews of BSP
and/or Restrictive Measures Plan for consistency,
accuracy, and proper utilization with provider.

IDT ROLES, CONTINUED:
For members with approved Restrictive
Measures, request and obtain monthly reports
from providers on the frequency of use of
Restrictive Measures and/or other interventions.
 Meet monthly with IDT to discuss frequency
report.
 Any unplanned or emergency use of restrictive
measures must be reported through the Critical
Incident process, and to IDT Supervisor within
24 hours of the event.

WHAT IS THE ROLE OF CCCW BSOC?
Once the IDT has brought back the information
and/or waiver application, what is the next step?
 BSOC will review the information received by the
IDT to determine if there is a restrictive measure
being utilized, and what type. This will all be
communicated to the IDT.
 A letter will be drafted and sent to the provider
with what is needed to move the process along.

WHAT IS THE ROLE OF CCCW BSOC?

For Restrictive Measures waiver applications, the
BSOC will:
Review initial applications for restrictive measures and
rights restrictions.
 Provide written feedback and support to providers and/or
IDTs and supervisors in the development of plans.
 Offer assistance when appropriate to the provider and IDT
through the process.
 Provide the initial approval and submit to DHS/DLTS for
individuals with developmental disabilities.

WHAT IS THE ROLE OF DHS/DLTS FOR
DEVELOPMENTALLY DISABLED POPULATION?
DHS/DLTS restrictive measures review panel will
review waiver application once it is approved by the
MCO.
 DHS/DLTS will inform applicants of decisions/
feedback within 15 working days of the receipt of the
application (complex case may take longer).
 DHS/DLTS restrictive measures review panel will
verbally communicate concerns as early as they are
indentified and work with the MCO and provider to
identify more appropriate interventions.
 DHS/DLTS restrictive measures review panel will
provide input, advice, and technical assistance.

WHAT IS THE ROLE OF DQA?
For the Physically Disabled, and Elderly
Populations.
 Within CBRF, AFH, RCAC, and Adult Day Care.
 Waiver variance are submitted to both MCO and
DQA Regional Director.
 DQA (WAVE Committee)reviews and
approves/denies waiver of variance request.
 Review usually occurs concurrently with CCCW
BSOC.

THE APPROVAL PROCESS FOR …
INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES
THE APPROVAL PROCESS FOR …
ELDERLY AND PHYSICALLY DISABLED
APPLICATION PROCESS

What needs to be included in the submitted
application for restrictive measures as part of a
behavior plan:




2607 Application (D. D. population)
Behavior Support Plan/ Proactive
Support Plan
Restrictive Measures Plan
Pictures of Interventions
APPLICATION PROCESS





Staff Training Plan
Documentation Plan
Reduction /Elimination Plan
Physician order/support letter
Proper signatures
APPLICATION PROCESS
 What
needs to be included in the submitted
application for use of a medical restraint:
2608 Application (D.D. population)
 Description of Medical Condition Requiring
Restraint
 Proposed Medical Restraint and Description
(when, where, for how long)
 Picture of Intervention
 Written Authorization by Physician (type of
restraint ordered, indications for use, time
period recommended, etc.)

APPLICATION PROCESS CONT.



Training Description
Reduction /Elimination Plan
Proper Signatures
CRITERIA FOR APPROVAL OF
RESTRICTIVE MEASURES
The individual's behavior presents an imminent
danger to self or other persons.
 The restrictive measure proposed is the least
restrictive approach available to achieve an
acceptable level of safety for the individual.
 There is documentation that less restrictive
interventions have been tried and were not
effective.
 The measure is adequately supported by the
training provided to all staff involved in use or
monitoring of the measure.

CRITERIA FOR APPROVAL OF
RESTRICTIVE MEASURES
The supervision, monitoring plan and back-up
arrangements are adequate to ensure effective
responses to unanticipated reactions to the
measures that might arise.
 With the use of the measure, the health, safety,
welfare, dignity, and other rights of the
individual are adequately ensured.
 The application contains a reasonable plan for
reducing and/or eliminating the need for using
the measure.

CRITERIA FOR APPROVAL OF
RESTRICTIVE MEASURES
The restrictive measure is used only for the
duration necessary to ensure the individual's
safety or that of others.
 The restrictive measure are not used in lieu of
adequate staffing.

DECISION TYPE
Unconditional approval (usually for one year)
 Approval with conditions
 Denial (with written reason why)
 Denial letters also come with description of
appeal rights.

CONTACTS

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
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

Kris Kubnick: (715) 301-1889
CCCW Behavior Support Oversight Committee Chair
Julie Strenn: (715) 204-1768
CCCW Provider Network Director
Social Security Act
http://www.ssa.gov/OP_Home/ssact/comp-ssa.htm
Statute 51.61, DHS 94, and DHS 10.51
http://nxt.legis.state.wi.us
 51.61 Look under Statutes Related
 DHS 94 look under Administrative Code Related, Health Services
Clients Rights Office
http://dhs.wisconsin.gov/clientrights/index.htm
Bob Mitchell, DHS Contract Coordinator
[email protected]
Glenn Lamping, DHS Member Care Quality Specialist
[email protected]