Facility Rules/Guidelines for Clients

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1 5-A Facility Rules/Guidelines for Clients I. Client Handbook: A. Upon admission, the Client Services Coordinator reviews the Client Handbook with clients and guardians and obtains signed consent from clients and guardians to the information in the handbook. B. During pre service orientation training, the Staff Development Specialist ensures that all new staff members receive training on how to implement handbook guidelines while helping clients exercise freedom of choice. C. Designated staff members teach a Treatment Mall class about the handbook to newly admitted clients. Electronics review with client: A. If a staff member observes a client with any device capable of internet access or photo, video, or file storage, then the Unit Coordinator and Residential Services Director meet with the client in the client s room during Treatment Mall hours. B. During this meeting, the Unit Coordinator and Residential Services Director ask the client to give them all electronic devices and electronic storage devices. C. The Unit Coordinator and Residential Services Director collect gaming devices, cell phones, cameras, and any other device capable of internet access or photo, video, or file storage. D. After receiving what the client provides, the Unit Coordinator and Residential Services Director inspect the room for any electronics not accounted for by the client. E. The Unit Coordinator and Residential Services Director ensure that the electronics that do not have internet capability or photo, video, or file storage are returned to the client within one week. F. The Unit Coordinator and Residential Services Director ensure that electronics deemed inappropriate are inventoried and sent to a designated person identified by the client. If the client has no one to send them to, then they make arrangements to store the items on campus. G. The Unit Coordinator and Residential Services Director document this review on the the Device Removal Form. H. The Shift Manager updates the client s personal property form on Therap to indicate items that have been removed from client s possession. I Other contraband: I. Staff members observe if clients obtain other contraband, including: 1

2 5-A 1. Firearms or weapons. 2. Knives, scissors, or other sharp objects. 3. Glass or ceramic items. 4. Alcohol or products that contain alcohol. 5. Tobacco products. 6. Bleach, cleaning wipes, or other cleaning products. 7. Recreational drugs. J. If a staff member observes a client with contraband, or has reason to suspect the client has contraband, then the staff member reports this concern to the Unit Coordinator. K. The Unit Coordinator and Residential Services Director meet with the client in the client s room during Treatment Mall hours to discuss if the client has contraband. L. During this meeting, the Unit Coordinator and Residential Services Director ask the client to give them all contraband. M. The Unit Coordinator and Residential Services Director collect contraband from the client. N. If the Unit Coordinator and Residential Services Director have reason to believe that the client has more contraband, then they inspect the room for any contraband not accounted for by the client. IV. References: Procedure 5 A. 2

3 5-B Behavior Management Programs I. Behavioral management program using the Behavioral Event Report (BER): A. Upon admission, the Behavioral Health Clinician conducts an assessment to determine the client s needs for a behavior management program. B. Based on the assessment results, the Behavioral Health Clinician develops the client s behavior management program. C. The Behavioral Health Clinician sends the behavior management program to the Behavioral Health Treatment Program Specialist (TPS). D. The Behavioral Health TPS develops the behavior plan in Therap. E. The Treatment Advisory Committee reviews the behavior plan and makes recommendations if needed. F. The Behavioral Health Clinician trains the Interdisciplinary Team (IDT) in how to use the BER. G. Unit Coordinators teach direct care staff how to use the BER. H. All staff members complete BERs for behaviors listed on the form, and any behaviors not listed on the form. I. Direct Support Professionals working in the Treatment Mall turn the BER into the Shift Manager located in the building they are working in. J. Direct Support Professionals who are working in the units send BERs to the Behavioral Health TPS by campus mail. K. Shift Managers turn collected BERs into the Behavioral Health TPS. L. All other staff turn completed BERs into the Behavioral Health TPS. M. The Behavioral Health TPS enters data from paper copies into Therap. N. Once each quarter, the Behavioral Health TPS prints three months of BER data and completes a Quarterly Progress Report. O. At the quarterly meeting, the IDT reviews and suggests revisions to the behavior management program along with the treatment plan. P. The Behavioral Health Clinician the revises the BER. Q. The Behavior Health Clinician re assesses the client for program modifications if needed. Fresh Start program: A. Upon admission, the Behavioral Health Clinician conducts an assessment to determine the client s needs for a behavior management program. B. If the assessment indicates that the client demonstrates high levels of physical aggression, property destruction, or self injurious behavior, then the Behavioral 1

4 5-B Health Clinician develops a Fresh Start program for that client, in addition to the behavior management program described above. C. The Applied Behavioral Analysis Committee reviews the Fresh Start program and makes recommendation for revision to the behavioral health clinician. D. The Behavioral Health Clinician submits the completed Fresh Start program to the Treatment Advisory Committee. E. The Treatment Advisory Committee also reviews the Fresh Start program and makes recommendations if needed. F. The Behavioral Health Clinician sends the Fresh Start program via Scomm to the Administrative Support Staff. G. The Administrative Support Staff attaches the Fresh Start program to the Individual Data Page in Therap. H. The Shift Manager prints out the current Fresh Start data collection page daily for each client on the program. I. The client takes this Fresh Start data sheet to Treatment Mall activities and keeps it available to staff while in the unit. J. All staff members who serve the client document their interventions and positive client behaviors on the Fresh Start data sheet. K. Shift managers collect Fresh Start data sheets at the end of the day. L. Shift managers send data sheets to the Behavioral Health TPS. M. The Behavioral Health TPS tracks Fresh Start data and adds summary data to the Quarterly Progress Report. N. At the quarterly meeting, the IDT suggests revisions to the Fresh Start program along with the treatment plan. O. The Behavioral Health Clinician revises the Fresh Start program if needed. P. The Behavioral Health Clinician re assesses the client for Fresh Start program modifications, if needed. I References: Policy 5 B. 2

5 5 C 1 Restraints I. Physical holds: A. Staff members encourage the client to use coping skills when client begins to escalate. B. Staff members offer interventions from the coping plan. C. Staff members contact nurse if behaviors continue. D. Staff members follow MANDT protocol for holds if the client is at risk of harming self or others. E. Staff members ensure protection from harm during the hold. F. Staff release client when client is calm and contact the nurse for assessment. G. A nurse completes Part B of the Restraint/Seclusion Form as soon as possible (not to exceed one hour) after the client is released. H. Staff members complete Part A and Part C of the Restraint/Seclusion Form. I. Staff members send the completed Restraint/Seclusion Form to medical records. J. Shift Manager sends the completed Restraint/Seclusion Form to medical records. K. Staff members document the physical hold in on the General Event Report (GER) form in Therap. L. Staff members notify the Behavioral Health Clinician of the restraint. M. The Behavioral Health Clinician completes the Client Debriefing Form with client. N. The Behavioral Health Clinician sends the completed Client Debriefing Form to medical records. Restraint chair: A. If client does not become calm during a physical hold, a staff member contacts a Registered Nurse (RN), Qualified Intellectual Disabilities Professional (QIDP), or Behavioral Health Clinician for permission to place the client in the restraint chair. B. The contacted professional comes to the scene and assesses if the client is at risk of harm to self or others. C. The contacted professional gives staff permission to use the chair. D. Staff members place the client in the chair. E. Staff members inform the nursing department (if the contacted professional is not a nurse) that a client has been placed in the restraint chair. F. The contacted professional completes Part A of the Restraint/Seclusion Form. G. Staff members provide continuous visual supervision, documenting every 15 minutes on the Restraint/Seclusion Observation Flow Sheet. 1

6 5 C 1 H. A nurse examines the client as soon as possible (not to exceed one hour from the time of placement in restraint), and completes Part B of the Restraint/Seclusion Form. I. Staff members offer range of motion exercises for at least 10 minutes, every 2 hours, and document this on the Restraint/Seclusion Observation Flow Sheet. J. The nurse conducts a follow up assessment once each shift while the client remains in the restraint, and completes Part B of the Restraint/Seclusion Form. K. If the client restraint is expected to last more than 12 hours, a nurse obtains physician order to authorize continuation of the restraint. L. When the client shows only Column 1 behaviors on the MDC Observation Flow Sheet for two consecutive 15 minute checks, staff contact a RN, QIDP, or Behavioral Health Clinician for permission to release the client from the restraint chair. M. The contacted professional arrives on the scene and determines if the client can be released from the restraint. N. Staff release client from the restraint. O. A nurse examines the client as soon as possible (not to exceed one hour from the time of release), and completes Part B of the Restraint/Seclusion Form. P. The contacted professional completes Part C of the Restraint/Seclusion Form. Q. The contacted professional sends the completed Restraint/Seclusion Form to medical records. R. After the client is released from the restraint, a staff member starts a GER Restraint Form in Therap. S. After the client is released from the restraint, the Behavioral Health Clinician completes the Client Debriefing Form. T. The Behavioral Health Clinician sends the completed Client Debriefing Form to medical records staff. I Considerations for restraining client behavior during a medical procedures: A. Staff members encourage the client to use coping skills when client begins to escalate during a medical procedure. B. Staff members offer interventions from the coping plan. C. If the client continues to escalate to the point of requiring protection from harm, then the physician prescribes the restraint for the medical procedure. D. Staff members initiate the restraint after the physician has authorized it. E. Staff members follow the procedure for physical holds or the restraint chair as outlined above. IV. References: Policy 5 C. 2

7 5 C 2 Spit Hood Spit hoods are restrictive devices that may be used by staff on the scene of an event with MDC clients as described in this procedure. I. Determination of need for use of a spit hood: A. The Qualified Intellectual Disabilities Professional (QIDP) ensures that clients who spit as a form of aggression have this problem and interventions for it on their Individual Treatment Plan (ITP). Use of a spit hood: A. Staff may use a spit hood if the client has the problem documented on the ITP. B. Staff may also use a spit hood if a client is spitting in the present situation. C. Staff may use a spit hood at any point only when they know it can be put on safely, such as when the client s arms are held in a physical hold or mechanical restraint. D. Staff talk to the client calmly when putting on the spit hood and explain the reason for it. E. Staff removes the spit hood when the client is calm or when the client is facing away from staff and cannot spit at them. F. Staff may use a spit hood only one time, and then must place it into a bio hazard container. G. Staff document each use of the spit hood, including the duration of the use of the hood, on the GER for the restraint event. H. Shift Managers ensure that spit hoods are stored in the pouch on the back of each restraint chair, and in the staff office in each residence. I. Shift Managers ensure that the brief spit hood instructions are stored in the pouch on the back of each restraint chair, and in the staff office in each residence. I Training A. Unit Coordinators ensure that staff employing the spit hood have received training in the use of the spit hood, and that documentation of this training is on file. IV. References: Policy 5 C, Spit Hood Use Instructions 1

8 5 D Seclusion ICF DD only I. Procedure: A. If client does not become calm during a physical hold, a staff member contacts a Registered Nurse (RN), Qualified Intellectual Disabilities Professional (QIDP), or Behavioral Health Clinician for permission to place the client in the restraint chair. B. The contacted professional comes to the scene and assesses if the client is at risk of harm to self or others. C. The contacted professional gives staff permission to use the seclusion room. D. Staff members place the client in the seclusion room; no other location can be used for seclusion. E. Staff members inform the nursing department (if the contacted professional is not a RN) that the client has been placed in seclusion. F. The contacted professional completes Part A of the Restraint/Seclusion Form. G. Staff members provide continuous visual supervision, documenting every 15 minutes on the Restraint/Seclusion Observation Flow Sheet. H. The nurse examines the client as soon as possible (not to exceed one hour from time of placement in seclusion) and completes Part B of the Restraint/Seclusion Form. I. The nurse conducts a follow up assessment once per shift while the client remains in seclusion, and completes Part B of the Restraint/Seclusion Form. J. If the seclusion is expected to last more than 12 hours, a nurse obtains physician order to authorize continued seclusion. K. When the client shows only Column 1 behaviors on the Observation Flow Sheet for two consecutive 15 minute checks, staff contact a RN, QIDP, or Behavioral Health Clinician for permission to release the client. L. The contacted professional arrives on the scene and determines if staff can release client from the seclusion room. M. Staff release client from the seclusion room. N. A nurse examines the client as soon as possible (not to exceed one hour from the time of release), and completes Part B of the Restraint/Seclusion Form. O. The contacted professional completes Part C of the Restraint/Seclusion Form and sends the completed Restraint/Seclusion Form to medical records staff. P. After the client is released from seclusion, a designated staff member documents a General Event Report (GER) Form in Therap. Q. After the client is released from seclusion, the Behavioral Health Clinician completes the Client Debriefing Form with the client and sends the completed Client Debriefing Form to medical records staff. References: Policy 5 D. 1

9 5-E Psychotropic Medication Usage I. Procedure: A. The Psychiatrist meets quarterly with each client to review scheduled and PRN psychotropic medications. B. The Psychiatrist meets quarterly with the Clinical Director to review scheduled and PRN psychotropic medications for all clients, to evaluate for efficacy and, if indicated, possible dose reduction. C. The Psychiatrist meets with the interdisciplinary team quarterly to provide status updates on clients receiving psychotropic medications, as well as a report indicating what side effects or changes to watch for in the client. D. The interdisciplinary team reports efficacy and any potential side effects of such medications to nursing department. E. The nursing department provides reports to the Psychiatrist. References: Policy 5 E. 1

10 5 F Working with Law Enforcement I. Procedure when a client s unsafe behavior has exceeded MDC staff ability to manage, and an emergency exists: A. The supervisor most knowledgeable about the situation contacts the Montana Developmental Center (MDC) Administrator or designee. B. The Administrator or designee calls law enforcement, describes the situation, and requests assistance. When law enforcement assistance is needed after business hours, the designee consults with the Human Services Specialist or the Administrator on call. C. When law enforcement arrives, the Administrator or designee reviews the situation with law enforcement. The Administrator or designee and law enforcement mutually decide the type of assistance needed. D. When the type of assistance needed is decided, law enforcement takes control of the situation, i.e., law enforcement decides what interventions are necessary to bring the situation under control and intervenes accordingly. E. When Law Enforcement interventions have stabilized the situation and the MDC staff are able to manage the client s behavior in a manner that ensures everyone s safety, the Administrator or designee re takes control from Law Enforcement. Procedure when it appears that a client has committed a crime, or a crime has been committed against a client: A. The supervisor most knowledgeable about the situation contacts the Administrator or designee. B. The Administrator or designee calls law enforcement, reports the alleged crime, and requests assistance. C. When law enforcement arrives, the role of the Administrator or designee is to ensure the safety of clients; the role of the Police Officer is to take action relative to the alleged crime. I Procedure when a client has left MDC grounds, and MDC staff efforts have not resulted in the client s return: A. The supervisor most knowledgeable about the situation contacts the Administrator or designee

11 5 F B. The Administrator or designee calls law enforcement, reports that a client has left the grounds of MDC and has not responded to MDC staff efforts to return the client to MDC, and requests assistance. C. When law enforcement arrives, the Administrator or designee reviews the situation with Law Enforcement and mutually decide what the Police will do and what the MDC staff will do to return the client to MDC. D. When the roles of Law Enforcement and MDC staff in returning the client to MDC have been determined, Law Enforcement takes control of the situation, i.e., Law Enforcement decides what interventions are necessary to bring the client back to MDC and intervenes accordingly. E. When Law Enforcement has returned the client to MDC, and staff members are able to manage the client s behavior in a manner that ensures everyone s safety, the Administrator or designee re takes control from law enforcement. IV. References: Policy 5 F

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