Service Narrative Counseling, Support, and Education Services CSE

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…)

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.

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

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,

BSM 4.02, BSM 5.02, BSM 5.03, BSM 6.04

BSM 5.06, BSM 5.07

DOCSFORD

Service Narrative Counseling, Support, and Education Services CSE