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2.0 Supporting People with Challenging Behaviour (continued)

Directive

Review Committee

Reviewing and monitoring the behaviour support plan are important steps in making sure that the plan is suitable for the person and his/her changing needs.

In addition to the requirements set out in section 18, “Behaviour support plan”, in Ontario Regulation 299/10, a service agency shall have access to a third party committee that reviews the behaviour support plans of person(s) with a developmental disability who have and/or may display challenging behaviour and who are receiving support from the agency, and provides advice as to whether the use of intrusive behavioural supports are:

  • Ethical and appropriate to the person’s needs and assessment results, based on professional guidelinesand best practices; and

  • In compliance with the ministry’s requirements outlined in Ontario Regulation 299/10 of the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, 2008 and this policy directive. 

A service agency shall have policies and procedures regarding the review committee, its membership, and its roles and responsibilities.

A service agency shall ensure that the review committee includes the involvement of a clinician with expertise in supporting adults with a developmental disability who have and/or may display challenging behaviour.

A service agency shall ensure that the review committee’s findings and any recommendations are documented and provided back to the clinician that oversees the behaviour support plan.

A service agency shall review the committee’s findings and recommendations and determine how the findings and recommendations may be implemented.

Support Provided by More than One Agency

A service agency shall develop a procedure (which may be formalized, as in a memorandum of understanding) to address situations where a person with a developmental disability who has challenging behaviour receives support from more than one agency, in order to ensure that the strategies outlined in the behaviour support plan are carried out in a consistent manner.

Behaviour Support Plan

The ministry recognizes that a clinician may recommend multiple strategies to address a person’s challenging behaviour, so that he/she may live as independently as possible and be included in the community.  It is expected that a behaviour support plan focuses on the least intrusive and most effective evidence-based practices (which would include positive behaviour intervention strategies). A behaviour support plan may also include intrusive behaviour intervention strategies. This policy directive sets requirements for the use of different types of intrusive behaviour intervention strategies. It is not suggested that a behavioursupport plan needs to include intrusive strategies.

In addition to the requirements for a behaviour support plan and approval of a behaviour support plan containing intrusive behaviour interventions strategies, as listed in section 18, “Behaviour support plan”, of Ontario Regulation 299/10, a service agency shall ensure the following:

  • The behaviour support plan is developed with the involvement of the person with a developmental disability who has challenging behaviour and/or, where applicable, persons acting on behalf of the person with a developmental disability, and the plan documents their involvement.
  • The person with a developmental disability who has challenging behaviour and/or, whereapplicable, persons acting on behalf of the person with a developmental disability, provides consent to the behaviour support plan and the strategies that it outlines.
  • The clinician(s) who approved the plan includes provision for the eventual fading or elimination of intrusive behaviour intervention strategies, which may be outlined in the behaviour support plan.
  • The agency has access to a review committee for all behaviour support plans that are developed for the person(s) with a developmental disability who have and/or may display challenging behaviour who are supported by the agency, and ensures that the behaviour support plans for the person(s) are reviewed by the committee. 

See also the requirements in the “Review Committee” section noted above and “Crisis Situations” section.

Debriefing Following Restraint or Secure Isolation/Confinement Time-Out

A debriefing is a time to learn from, and reflect on, the events that led up to the use of a restraint or secure isolation/confinement time-out.

In addition to the requirements set out in section 20, “Use of intrusive behaviour intervention”, in Ontario Regulation 299/10, a service agency shall adopt the following standards for debriefing after a physical restraint (including physical restraint in a crisis situation), mechanical restraint, or secure isolation/confinement time-out:

  • A debriefing process is conducted among all staff who were involved in the restraint or secure isolation/confinement time-out;
  • Staff inquire of others who were in the vicinity and witnessed the restraint or secure isolation/confinement time-out (e.g., other persons with a developmental disability who are supported in the same area, visitors) as to their well-being from having witnessed the restraint;

  • The supervisor or manager who oversees the behaviour support plan of the person with challenging behaviour who was restrained or in secure isolation/confinement time-out is made aware of the restraint or secure isolation/confinement time-out;

  • Other staff who support the person are made aware of the restraint or secure isolation/confinement time-out (e.g., in the event of a shift change shortly after the restraint or secure isolation/confinement time-out has taken place);

  • A debriefing process is conducted with the individual who was restrained or in secure isolation/confinement time-out (including individuals involved in a crisis situation), as soon as he/she is able to participate, and to the extent that he/she is willing to participate.  The debriefing must be structured to accommodate the person with a developmental disability’s psychological and emotional needs and cognitive capacity;

  • Debriefings are documented;

  • The debriefing process is conducted within a reasonable time period (i.e., within two business days) after the restraint or secure isolation/confinement time-out is carried out (including crisis situations).If circumstances do not permit a debriefing process to be conducted within a reasonable time period, the debriefing process should be conducted as soon as possible after the reasonable time period, and a record must be kept of the circumstances that prevented the debriefing process from being conducted within the reasonable time period; and

  • A serious occurrence report is filed with the Ministry of Community and Social Services, as may be appropriate and as per the serious occurrence reporting procedure.

Crisis Situations

In addition to the requirements set out in section 21, “Crisis intervention, use of physical restraint”, of Ontario Regulation 299/10, if a person with a developmental disability experiences three crisis situations within a 12 month period, the service agency shall investigate the potential causes of the behaviour and factors that may have led to the crisis situations. This investigation may lead to a functional assessment of the individual and the development of a behaviour support plan for him/her.

Definition:

“Functional assessment” is referenced in the definition of a “behaviour support plan”, which is defined in Ontario Regulation 299/10 as “a document that is based on a written functional assessment of the person that considers historical and current, biological and medical, psychological, social and environmental factors (a bio-psycho-social model) of the person with a developmental disability that outlines intervention strategies designed to focus on the development of positive behaviour, communication and adaptive skills”.

Contacting the Police

A service agency may wish to contact their local police department to discuss how the agency and the police can work together to best respond to situations that may engage law enforcement in a safe and effective manner. For example:

  • To have preliminary discussions to plan and develop protocols that may be used to respond to adults with a developmental disability in certain situations. Agencies may be able to provide information on strategies to engage with the individual, how best to communicate, and how police can keep persons with a developmental disability and themselves safe;
  • To request police assistance during a crisis where the physical safety of agency staff and/or others in the vicinity is at immediate risk and attempts at de-escalation and other means to address the person with challenging behaviour and/or the situation have been ineffective.

The ministry would expect that a service agency’s policies, procedures and practices concerning how to respond to people with a developmental disability who have and/or may display challenging behaviour in a crisis situation would not rely exclusively on involving the police.

The ministry understands that the police may, in some cases, be called upon to respond to complex situations that may be non-criminal in nature.  It is important that a service agency explore efficient and effective ways of supporting adults with a developmental disability who have and/or display challenging behaviour, including front-line incident response, to ensure that individuals who are in crisis are receiving support and assistance from the most appropriate parties and the service provider(s).  A service agency should also be mindful of the potential impact of involving the police in a crisis situation (e.g., possibly criminalizing the adult with a developmental disability who has/is displaying challenging behaviour).

Training for Staff

Seeking to ensure that staff are properly trained and enhancing the safety of all people who receive support from the agency, regardless of whether they have and/or  display challenging behaviour (either currently or in the past), , is important to the security that any person would want to feel in their home, recreational space, or workspace.

Further to the requirements to train direct care staff on the use of physical restraint, as set out in section 17(2), “General behaviour intervention strategies, training”, of Ontario Regulation 299/10,

A service agency shall ensure that it selects a training package from the identified list of training packages and providers, which was reviewed by the Community Networks of Specialized Care Ontario5. During this review, it was determined that the curriculum of these training packages, in their entirety, allow for compliance with requirements outlined in Ontario Regulation 299/10 and could enable direct care staff to respond appropriately to emergency situations involving adults with a developmental disability who are displaying challenging behaviour.  A service agency shall therefore ensure that all components of the curriculum within a selected training package (both theory and practice of all physical restraint holds outlined in the curriculum) are taught to and successfully completed by all direct care staff at the agency.   

Section 19 of Ontario Regulation 299/10 concerns “Behaviour intervention, strategies, policies and procedures” and requires that a service agency have policies and procedures regarding the use of behaviour intervention strategies for persons with developmental disabilities who have challenging behaviour.  As part of these policies and procedures, a service agency must identify strategies and means for direct care staff to respond in a crisis situation.  These policies and procedures could include a section that sets out the physical restraint holds covered in the training with staff which may be used by direct care staff during a crisis situation.  These policies and procedures may be based on the profile of the individuals supported and the agency’s own philosophy of support.  Regardless of a service agency’s policies and procedures, however, a service agency must ensure that all components of the training package curriculum (both theory and practice of all physical restraint holds outlined in the curriculum) are taught to and successfully completed by all direct care staff.

The training packages identified through the review process led by the Community Networks of Specialized Care Ontario would include information on understanding human behaviour, how to effectively support a person in a manner that allows the individual to feel safe, engaged and respected, as well as early warning signs of, and means to prevent, a crisis situation.  Training packages would also include information on early intervention techniques, strategies to assist a person to calm him/herself and de-escalate a situation, ways to promote personal safety (for staff and for the individual), should a crisis situation arise , as well as post care, follow-up and debriefing, subsequent to experiencing a crisis situation.  The topics covered in these training modules may provide insight and important information that may be relevant to all direct care staff in various aspects of their work. 

A service agency shall ensure that staff who work directly with persons with developmental disabilities receive and successfully complete all components of the refresher training, including theory and practice of all physical restraint holds , according to a retraining or recertification schedule developed by the training provider or as recommended by the training provider (e.g., a schedule identified as a best practice).

Note that the requirements above are separate from those outlined in sections 17(3), 17(4), 17(5) and 17(6) of Ontario Regulation 299/10.  These sections identify requirements for a service agency concerning training for staff members and volunteers on the behaviour support plan(s) of the individuals whom the staff and volunteers will be supporting.

Feedback to Staff on Behaviour Intervention

In order to ensure that the strategies contained in a behaviour support plan are effective, it is important that the supporting staff person(s) carry out the strategies as they have been outlined in the plan.

In addition to the requirements set out in section 17, “General behaviour intervention strategies, training”, of Ontario Regulation 299/10, a service agency shall ensure that:

  • Supervisors monitor the application and use of behaviour intervention strategies (both positive and intrusive strategies), to see that the strategies are carried out as outlined in the behaviour support plan and in accordance with best practices in the field.

  • Supervisors ensure that feedback is provided on a regular basis to their staff on the application of behaviour intervention techniques with people who have a developmental disability with challenging behaviour, and as part of the staff person’s performance plan (e.g., the discussion about the staff person’s overall performance, held on an annual basis).

Use of Restraint or Secure Isolation/Confinement Time-Out – General

The ministry recognizes that restraint, secure isolation/confinement time-out, and prescribed medications are used in some situations with adults with a developmental disability who have challenging behaviour , as part of their behaviour support plan.  The remaining sections of this directive focus on the ministry’s expectations for the use of intrusive behaviour strategies, which are aimed at ensuring a person’s safety and well-being during the use of restraint, secure isolation/confinement time-out, or with prescribed medication.

Definitions:

“Mechanical restraint”, as an example of a type of intrusive behaviour intervention in Ontario regulation 299/10, is “a means of controlling behaviour that involves the use of devices and equipment to restrict movement, but does not include any restraint or device
i) that is worn most of the time to prevent personal injury, such as a helmet to prevent head injury resulting from seizures or a device to safely transport a person in a motor vehicle,

ii) that helps to position balance, such as straps to hold a person upright in a wheelchair, or

iii) that is prescribed by a physician to aid in medical treatment, such as straps used to prevent a person from removing an intravenous tube”.

Further to the above definition, a mechanical restraint is not a device that is worn or used at points in time for protective purposes, such as mittens.

“Secure isolation or confinement time-out”, as an example of a type of intrusive behaviour intervention in Ontario regulation 299/10, is “a designated, secure space that is used to separate or isolate the person from others and which the person is not voluntarily able to leave.”  Secure isolation or confinement time-out does not refer to a space that a person may use to “cool down” when he/she feels anxious or angry, and where the person may leave freely, or to an apartment where the person may live on his/her own”.

“Prescribed medication”, as an example of an intrusive procedure or action in Ontario regulation 299/10, is medication that is prescribed “to assist the person in calming themself, with a clearly defined protocol developed by a physician as to when to administer the medication and how it is to be monitored and reviewed”.

In addition to the requirements set out in section 20, “Use of intrusive behaviour intervention”, of Ontario Regulation 299/10, a service agency shall ensure that the use of physical restraint, mechanical restraint, and secure isolation or confinement time-out is stopped when there may be a risk that the intervention itself will endanger the health or safety of the individual ; or the supporting staff person(s) have assessed the individual and situation and have determined that there is no longer a clear and imminent risk that the individual will injure him/herself or others.


This list is available on the MCSS website. Further detail on the training packages is available in the “Summary of Findings” document on http://www.qamtraining.net/files_english.html.