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Service Narrative Counseling, Support, and Education Services CSE

By Tim Olson,2014-05-17 20:02
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Documentation of BSM training. Interview: Relevant personnel. Foster parents required to participate in behavior support and management training.

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…)

    Council on Accreditation • Copyright 2006

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.

    Council on Accreditation • Copyright 2006

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

    Council on Accreditation • Copyright 2006

     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,

    Council on Accreditation • Copyright 2006

BSM 4.02, BSM 5.02, BSM 5.03, BSM 6.04

BSM 5.06, BSM 5.07

Council on Accreditation • Copyright 2006

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