SERVICE DELIVERY ADMINISTRATION NARRATIVE: BEHAVIOR SUPPORT AND
MANAGEMENT (BSM)
The Service Delivery Administration Narrative should provide an overview of key practices that contribute to the
performance and productivity of your organization. The Narrative supports, but should not duplicate, evidence
provided elsewhere in your self-study.
The Behavior Support and Management Service Delivery Administration Narrative should provide the Peer
Review Team with a clear, concise description of how your organization’s behavior support and management
policies and practices contribute to a safe service and work environment.
Purpose Standard: Behavior Support and Management (BSM)
The organization’s behavior support and management policies and practices promote positive
behavior and protect the safety of service recipients and staff.
Provide responses to the following questions that address your organization’s achievement of the Behavior
Support and Management Purpose Standard. Highlight applicable obstacles and innovations, if any, in each of
your responses.
1. Describe your organization’s overall approach to behavior support and management and how it is
implemented in practice to promote positive behavior.
a. Include the full spectrum of behavioral support interventions that your organization utilizes (e.g., point
programs, level systems, time out, manual restraint, etc.).
b. If your organization uses any restrictive interventions (e.g., isolation, manual restraint, locked seclusion,
and mechanical restraint), provide your organization’s rationale for their use.
(e.g., Our organization operates a residential treatment program for adjudicated youth who have a history
of violence and aggressive behavior. We have taken the following steps to promote a positive,
therapeutic environment and ensure the safety of our service recipients and staff…)
Organization’s Response:
2. Cite 2-3 examples of activities or decisions that your organization has undertaken to promote positive
behavior and a safe work and service environment.
(e.g., Over the last three quarters our quarterly risk management reviews have shown an increase in the
use of manual restraints in our residential treatment facilities. The CQI committee reviewed the data and
recommended we revise out BSM training curriculum. As a result, we designed and implemented a
revised training program to ensure that all current and incoming staff receive comprehensive, ongoing
training on how to recognize and respond to factors that may lead to a crisis. The first quarterly risk
management review following implementation of the revised curriculum has shown a reduction in the use
of manual restraints.…)
Organization’s Response:
3. Identify a part of your behavior support and management policies and practices that have been:
a. the most difficult to advance, and indicate the reasons why; and
b. the least difficult to advance, and indicate the reasons why.
(e.g., Changes in state regulations have increased the number of adolescents admitted with a history of
sexually acting out behavior. Consequently we’ve had to modify our behavior support and management
practices to include…)
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Organization’s Response:
4. Describe the data available to the CEO, senior management, and staff. Explain how it is used to minimize the
need for restrictive interventions. Specify any significant political, regulatory, cultural or economic changes
that have impacted the organization’s direction and/or ability to achieve its goals. (Please answer this
question only if your organization employs restrictive interventions. See BSM 5).
(e.g., Senior management reviews monthly reports on the use of restrictive interventions, and the data
from quarterly reviews of accidents, incidents, and grievances so that it can assess, in conjunction with
the CQI committee, the need for change in practice or additional resources, such as increased
supervision…)
Organization’s Response:
5. Provide any additional information about your organization’s behavior support and management polices and
procedures that would increase the Peer Team’s understanding of how the practice(s) support a safe
environment and reduce the need for restrictive interventions.
Organization’s Response:
Attachments:
a. All COA-approved NA Requests.
b. A list of all NAs applicable to your organization provided within the standards.
Note:
Organizations being accredited for the first time: Please provide information for the last year.
Organizations being reaccredited: Please provide information for the period since the last accreditation
review.
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TABLE OF EVIDENCE: BEHAVIOR SUPPORT AND MANAGEMENT (BSM)
Self-Study Documents On-Site Documents On-Site Activities
BSM 1 ? Provide a ? Documentation of ? Interview: Philosophy and description of the clinical director a. Persons served Organizational organization’s BSM notification of b. Parents/legal guardians Policy* philosophy in BSM restrictive behavior c. Clinical personnel
Narrative Question management ? Supervisory personnel
1 including: interventions
a. programmatic ? Any applicable laws
and preventive or regulations
approaches
b. the spectrum of
BSM
interventions
c. procedures/
interventions
prohibited by
the organization
? BSM policy and
procedures
? Incident review
procedures
? Aggregate of the
two most recent
quarterly reviews of
incidents requiring
restrictive behavior
management
interventions
BSM 2 ? BSM philosophy ? Procedures that ? Interview: Behavior and procedures address prohibition a. Parents/legal guardians Support and given to persons of harassment and b. Persons served Management served and violence c. Relevant personnel Practices* parents/legal ? Case record review
guardians at
admission
? Parental/guardian
notification protocol
? Criteria used to
assess potential
need/risk regarding
behavior
management
BSM 3 ? Table of contents ? List of personnel and ? Interview: Safety Training* for personnel and foster parents a. Relevant personnel
foster parent BSM required to receive b. Foster parents required to
training curriculum competency based participate in behavior
training, and the support and management
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Self-Study Documents On-Site Documents On-Site Activities
dates training was training.
received
? Training curriculum
for personnel and
foster parents that
addresses:
a. recognizing and
responding to
behavior
management
issues
b. de-escalation
? Personnel records
? Documentation of
BSM training
BSM 4 ? Table of contents ? Training curriculum ? Interview: Restrictive for personnel and that addresses BSM a. Relevant personnel Behavior foster parent 4.01 b. Foster parents required to Management restrictive behavior ? Documentation of participate in restrictive Intervention management restrictive behavior behavior management Training* training curriculum management training
training provided
BSM 5 ? See policies and ? Incident reports ? Interview: Restrictive procedures under ? Behavior a. Authorizing personnel Behavior BSM 1 management logs b. Direct service personnel Management ? Authorization c. Supervisory personnel Intervention* procedures (may be d. Persons served
included in BSM ? Seclusion room observation
policies and
procedures)
BSM 6 ? Debriefing protocol ? Behavior ? Interview: Debriefing and (may be included in management/incidena. Governing body Documentation* BSM policies and t reporting form b. Supervisory/management
procedures) ? Aggregated behavior personnel
management c. Persons served
incident reviews for d. Parents/legal guardians
the two most recent ? Case record review
quarters
? Behavior
management logs
FUNDAMENTAL PRACTICE STANDARDS:
Essential Life and Safety Health and Welfare Client Rights
BSM 2.03, BSM 2.04, BSM 2.05, BSM 3.02, BSM 4.03, BSM 5.04, BSM 2.01
BSM 3.01, BSM 3.03, BSM 4.01, BSM 5.05, BSM 6.02, BSM 6.03,
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BSM 4.02, BSM 5.02, BSM 5.03, BSM 6.04
BSM 5.06, BSM 5.07
Council on Accreditation • Copyright 2006