SAMPLE - Intensive PBS Plan Template Massachusetts DDS - SAMPLE

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1 SAMPLE TEMPLATE FOR: INTENSIVE POSITIVE BEHAVIOR SUPPORT PLAN CHECKLIST & GUIDE File name = PBS Intensive Plan Template draft #3 SAMPLE - Intensive PBS Plan Template Massachusetts DDS - SAMPLE Person s name: Agency s qualified clinician leading intensive team: and; Agency s administrator addressing resource and systems issues: Date of plan: date of implementation: Date of Agency internal committee review: Introduction: This Checklist & Guide is intended to be a starting point for Agencies internal quality control efforts on their most complex PBS plans. The PBS Intensive plan is separate from the Functional Behavior Assessment (FBA). The FBA precedes and informs the PBS Intensive plan. All Intensive PBS plans must have the elements below; how the elements are put together (i.e., format) may be adapted and supplemented by the Agency that has developed and will oversee implementation and evaluation of the plan. The required elements and guidance below is based on the DDS PBS materials: PBS Intensive Support Plan Template and (to a lesser extent) PBS Functional Behavior Assessment. Both of these documents were released by DDS to the field in October, 2013 and revised in August, 2014 and both are on line at: NOTE Instead of completing section II. BACKGROUND (BASED ON FBA) below the full FBA may be attached. 1

2 Required Elements of Intensive Positive Behavior Support Treatment Plans: Reviewer please check Yes if required element is found in plan and No if it is not; comment at end of each section. Ia. IDENTIFYING INFORMATION About the Individual: A. Date of Birth B. Height & Weight C. Home address D. Day/Work Address E. HOW TO CONTACT PERSON / GUARDIAN COMPETENCY)STATUS,)CONSENT)&)OTHER)PROTECTIONS:) A. Statement on competence/guardianship B. State date and how informed consent for interventions was obtained and by whom C. ID others w/ protective roles e.g. HCP, Rep Payee. OTHER) A. Date report completed Ib. PROVIDER INFORMATION A. Author and treating clinician named and contact information e.g. mailing address and/or . B. Author and treating clinician credentials C. Agency administrator(s) sharing responsibility for plan. D. Briefly describe the process used to develop the P- BSP: input from individual and family; team meeting discussion; review of related concerns with PCP, etc E. Residential agency name and address. F. Day/work agency name and address COMMENTS on Identifying Information: 2

3 II. BACKGROUND (BASED ON FBA ETC.) YES NO A. Summary of Individual s relevant life history B. Brief summary of individual s strengths including accomplishments, relationships and coping skills C. Brief summary of individual s physical health history (issues, treatments, outcomes). D. Brief summary of individual s mental health history (issues, treatments, outcomes). E. Brief summary of individual s communication history. Id skills and method of communication. F. Describe individual s learning style and how best to encourage learning. G. Summarize (a) individual s beh l history; (b) current beh l concerns; and (c) history of treatment. H. Summarize individual s community and leisure activities. I. Summary of individual s current (a) behavioral treatment(s) (Universal supports, etc.) and (b) general living and work/day program supports and quality of life variables as noted in item D-2 of the FBA guide. J. Operationally define the problem behavior(s) & summarize available baseline and treatment data. K. Summarize indirect assessment methods e.g. record review, interview, etc. L. Summarize direct assessment methods e.g. observation, review of objective data, etc. M. Summarize any experimental FBA methods e.g. analogue conditions assessment, manipulation of antecedent or consequent conditions, etc. N. Summarize how individual s strengths or personal characteristics may be helpful in addressing the problem behavior(s) II. BACKGROUND (BASED ON FBA ) CONT. YES NO O. Individual s skill deficits that are relevant to the challenges being addressed by the PBS plan and what is being done to address those deficits. P. Environmental factors that are influencing the challenges being addressed by the PBS plan (positive and negative). Q. Safety concerns described and how they ll be addressed. R. Summary of reinforcers that may or will be used in the PBS Plan and that can be used to strengthen replacement behaviors. S. Findings of FBA i.e. hypotheses generated re: function of problem behaviors. COMMENTS III. COMPETING PATHWAY(S) YES NO A. Pathway(s) included and address all key behaviors. B. Competing Pathway(s) identifies alternate functional replacement behavior and if it needs to be taught strategy for teaching. C. Pathway(s) shows way to make problem behavior less needed and useful to individual by e.g. giving an alternate, easier route to the Consequence via a functional replacement behavior. D. Pathway(s) shows way to disconnect problem behavior and Consequence it previously produced. E. Strategy for reinforcing replacement behaviors - competing pathway 3

4 IV. BEHAVIORS TO INCREASE A. Objective description of replacement behavior(s) expected to functionally replace. B. Rationale for replacement behaviors is based upon functional assessment. C. Replacement behavior(s) are found in Competing Pathways that are part of this Intensive PBS Plan. C. Method of measurement of all behaviors. D. Baseline data of all behaviors. V. BEHAVIORS TO DECREASE YES NO A. Objective description of behavior(s) to decrease; (note, if behaviors are grouped there should be data showing they are functionally related i.e. produce the same outcome). B. Rationale for targeting behaviors to decrease is based upon functional assessment and/or safety concerns. C. Method of measurement of all behaviors to decrease identified. D. Baseline data of all behaviors to decrease (or historical and current measure of behaviors if already under treatment). 4

5 VI. Preventative Interventions A. Antecedent intervention strategies identified (e.g. environmental modification, schedule change, procedures to address relevant establishing operations such as offering food to address hunger) B. Specific prevention strategies identified such as avoidance of triggering stimuli such as crowds or noise (NOTE may need to encourage work over time on coping strategies to help individual tolerate triggering stimuli) VII. TEACHING PROCEDURES YES NO A. Procedures that are or will be used to teach replacement behaviors such as modeling, shaping, etc. are identified. B. Teaching plan re: when, where and how often teaching efforts will occur. C. How teaching efforts will be tracked (i.e. fidelity with teaching procedures and teaching plan). D. How effect of teaching will be measured E. How effect of teaching will be evaluated 5

6 VII. CONSEQUENTIAL INTERVENTIONS YES NO A. All consequential procedures e.g. reinforcement, interruption are identified and step by step instructions guiding staff to implement accurately are included. B. Describe in detail the steps of each intervention designed to increase replacement behaviors. As needed address what skill will be taught, what behavior will be reinforced; and when and where the work will occur. C. Describe in detail the steps of each intervention designed to increase other desired behaviors including general coping skills, absence of problem behavior; be specific about what behaviors are being reinforced and how. D. Describe in detail the steps of each intervention designed to decrease the challenging behavior (s). Specify the e.g. reinforcement procedure(s) being used such as DRA, DRL. (Holds over resistance only can be Physical Restraint and are never part of a PBS Plan.) IX. Procedures for Measuring Key Behaviors and Evaluating Progress A. Method of measuring all key behaviors described; baseline data available for review (in graph or table). B. Up-to-date data provided on replacement behaviors to increase. C. Up-to-date data provided on behaviors to decrease. D. Up-to-date data provided on measures of program fidelity (procedures to increase alternate behaviors, procedures to decrease behaviors and teaching methods). E. Baseline data and a data recording sheet should be available for review. F. How progress will be evaluated (e.g. pre vs. post comparison of key data; input from individual, family and staff on progress). Evaluation of progress should have clear connection to person s quality of life. G. Graphs summarizing progress pre/post interventions and other key changes in person s life (e.g. new person moves into residence) are updated monthly and reviewed by Intensive Team to make decisions related to e.g. interventions, staff training, consultations sought etc. 6

7 X. Procedures for Training, Supervision, and Maintaining Integrity of Interventions A. Description of staff training and supervision to ensure plan implemented with integrity. (Qualified clinicians role in staff training should be clarified. Competency based training vs. exposure is to be preferred.) B. Description of staff monitoring to check and make sure staff understand program and thus can conduct it with fidelity. (May use checklist that is shared with staff so all can use as helpful guide.) C. Who will monitor plan implementation (position of that person) should be clear; also the frequency of that monitoring should be mentioned. D. How staff will be recognized and supported for accurately implementing plan should be clear. E. An abbreviated version of the plan exists for staff and it is part of the P-BSP and is consistent with overall plan and includes a summary of who the person is. COMMENT: Individual s Name: Reviewer s name(s): Date: Next review of plan: Date: Time: 7