COA - Council On Accreditation

	Behavior Support and Management

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

Service Delivery Administration Narrative (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.

Include the full spectrum of behavioral support interventions that your organization utilizes (e.g., point programs, level systems, time out, manual restraint, etc.).
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…)

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.…)

3. Identify a part of your behavior support and management policies and practices that have been:

the most difficult to advance, and indicate the reasons why; and
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…)

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…)

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.

Attachments:

All COA-approved NA Requests.
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.


	Self-Study Documents	On-Site Documents	On-Site Activities
BSM 1 Philosophy and Organization Policy*	Provide a description of the organization's BSM philosophy in BSM Narrative Question 1 including: programmatic and preventive approaches the spectrum of BSM interventions 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	Documentation of clinical director notification of restrictive behavior management interventions Any applicable laws or regulations	Interview: Persons served Parents/legal guardians Clinical personnel Supervisory personnel
BSM 2 Behavior Support and Management Practices*	BSM philosophy and procedures given to persons served and parents/legal guardians at admission Parental/guardian notification protocol Criteria used to assess potential need/risk regarding behavior management	Procedures that address prohibition of harassment and violence	Interview: Parents/legal guardians Persons served Relevant personnel Case record review
BSM 3 Safety Training*	Table of contents for personnel and foster parent BSM training curriculum	List of personnel and foster parents required to receive competency based training, and the dates training was received Training curriculum for personnel and foster parents that addresses: recognizing and responding to behavior management issues de-escalation Personnel records Documentation of BSM training	Interview: Relevant personnel Foster parents required to participate in behavior support and management training
BSM 4 Restrictive Behavior Management Intervention Training*	Table of contents for personnel and foster parent restrictive behavior management training curriculum	Training curriculum that addresses BSM 4.01 Documentation of restrictive behavior management training provided	Interview: Relevant personnel Foster parents required to participate in restrictive behavior management training
BSM 5 Restrictive Behavior Management Interventions*	See policies and procedures under BSM 1 Authorization procedures (may be included in BSM policies and procedures)	Incident reports Behavior management logs	Interview: Authorizing personnel Direct service personnel Supervisory personnel Persons served Seclusion room observation
BSM 6 Documentation and Debriefing*	Debriefing protocol (may be included in BSM policies and procedures)	Behavior management/incident reporting form Aggregated behavior management incident reviews for the two most recent quarters Behavior management logs	Interview: Governing body Supervisory/management personnel Persons served Parents/legal guardians Case record review

Fundamental Practice Standards:


Essential Life and Safety	Health and Welfare	Client Rights
BSM 2.03, BSM 2.04, BSM 2.05, BSM 3.01, BSM 3.03, BSM 4.01, BSM 4.02, BSM 5.02, BSM 5.03, BSM 5.06, BSM 5.07	BSM 3.02, BSM 4.03, BSM 5.04, BSM 5.05, BSM 6.02, BSM 6.03, BSM 6.04	BSM 2.01

RELATED FILES


	BEHAVIOR SUPPORT AND MANAGEMENT The use of specialized interventions to guide, control, and redirect client behaviors. Examples of behavior management approaches used in residential treatment settings include mediation, time out, locked seclusion, and physical restraint.


	PRACTICE Established actions or ways of proceeding in the regular performance of organizational duties. Policies and procedures often guide practice.


	SERVICE RECIPIENT The individuals, groups, organizations, or communities that use, receive, or benefit from programs and services. Service recipients can include consumers, patients, family members, legal guardians, advocates, public/private organizations, employers, and purchasers. All are regarded as significant stakeholders served in a variety of agencies and practice settings.


	SERVICE One or more organization-operated programs or activities that have a common general objective and deploy the organization's material and human resources in a planned and systematic manner. An organization that publicly promotes or identifies itself in writing as offering a service, is licensed to deliver a service, assigns personnel and/or space to a service, or allocates financial resources to a service is considered to offer that service.


	ADMINISTRATION The personnel responsible for management functions of the organization, including fiscal management, human resources, and service delivery. Such personnel determine organizational goals, acquire and allocate resources to carry out a program, coordinate activities toward goal achievement, and monitor, evaluate, and make needed changes in processes and procedures to improve the likelihood of goal achievement. The term is synonymously used with MANAGEMENT.


	PERFORMANCE A measure of how well an organizational system provides services to consumers. Performance is often based on key indicators, such as rates of service, cost per consumer, degree of satisfaction with services, and extent of consumer access to services.


	PEER REVIEW An evaluation process in which professionals from similar backgrounds review the work of their associates.


	PROGRAM A system of services offered by an organization. For example, an organization providing a mental health service may offer several mental health programs to different populations, e.g., a mental health program for adolescent teens. The word "program" can be used interchangeably with the word "service" or to describe specific programs.


	MANUAL RESTRAINT The practice of physically holding a person's arms, legs, or head to prevent harm to self and others.


	ISOLATION The practice of separating a person from others and placing him/her in a monitored, non-locked or "quiet" room in order to calm the person. A person in isolation is physically prevented from leaving the designated space or room where s/he is placed. For purposes of COA accreditation, isolation is distinguished from TIME-OUT.


	MANAGEMENT See ADMINISTRATION


	MECHANICAL RESTRAINT The use of any physical device to limit movement and prevent harm to self or others, not including devises such as prescribed orthopedic devices, surgical dressings or bandages, protective helmets, or any other methods that involve physical holding of an individual for the purpose of conducting routine physical examinations, conducting tests, protecting the child from falling out of bed, or to permit the child to participate in activities without the risk of physical harm.


	TRAINING Instruction so as to make fit, qualified, or proficient in a skill or body of knowledge.


	SENIOR MANAGEMENT Employees who assume administrative oversight for the organization's programs. Senior management positions may include vice presidents, chief operating officers, assistant commissioners, directors, or other positions that involve management of program administration. The term does not include supervisors of direct service workers.


	LOCKED SECLUSION The practice of placing a person in a locked room to prevent harm to self and others.


	RISK MANAGEMENT A systematic process of evaluating and reducing potential risks that may befall personnel, clients, an organization, or a facility. Risk management activities are directed toward reducing an organization's legal and financial exposure, especially to lawsuits.


	SUPERVISION Assumption of responsibility for directly overseeing and evaluating the work or work products of personnel within an organization. Also includes inspecting the act or process of accomplishing a function or activity.


	ACCREDITATION The formal evaluation of an organization against accepted criteria or standards. A professional society, non-governmental organization, or a governmental agency may conduct accreditation activities. A COA-accredited organization has undergone a period of rigorous self-study and is capable of providing programs and services that meet or exceed COA standards.


	RESTRICTIVE BEHAVIOR MANAGEMENT Interventions that restrict, limit, or curtail a person's freedom of movement to prevent harm to self or others. These interventions include isolation, manual or mechanical restraint, and locked isolation.


	CLINICAL The study, assessment, and diagnosis of the client situation followed by direct treatment to help the client achieve prescribed goals.


	PARENTS Parents can include: birth, foster, kinship, and adoptive parents. Please see service standards for more specific information about use of this term.


	LEGAL GUARDIAN A person who has legal responsibility for the care and management of a person incapable of administering his/her own affairs. In the case of a minor child, the guardian is charged with the legal responsibility for the care and management of the child and of the minor child's estate.


	CLINICAL PERSONNEL Qualified and trained professionals who provide the treatment services of an organization. Clinical personnel who assume case responsibilities must meet the applicable regulatory requirements and the minimum standards set by their respective professional organizations. Clinical personnel generally include clinical social workers (MSW or DSW/PhD in social work), clinical or counseling psychologists (PhD or PsyD), psychiatric nurses (MSN), certified marriage or family therapists, certified pastoral counselors, and board eligible or certified psychiatrists. Where additional disciplines or degrees are acceptable, it is stated in the standard for each service section. "Clinical personnel" and "mental health personnel" may be used interchangeably.


	PERSONNEL The body of employees and/or volunteers that carries out the organization's tasks under the organization's administration and/or supervision. This definition does not include foster parents who are specifically referenced in relevant standards


	CRITERIA Systematically developed, objective, and quantifiable statements used to assess the appropriateness of specific decisions, services, and outcomes.


	CASE RECORD A written compilation that describes the client and the services delivered. Records can be in hard copy and/or electronic format. The case record can be used as a source of information for quality improvement or other evaluation activities, for research purposes, or to demonstrate accountability to funding bodies.


	FOSTER PARENTS State- or county-licensed adults who provide a temporary home for children whose birth parents are unable to care for them. Foster parents are not considered employees or personnel and are specifically referenced in all relevant standards.


	INCIDENT REPORT A document describing a high risk event or an event at variance with policy, procedure, practice, or usual experience.


	GOVERNING BODY A person or persons with the legal authority and responsibility to set policy and oversee the operations of an organization. Generally, the governing body is a group, such as a board of directors or board of trustees. While the exact responsibilities of the governing body depend on the nature and character of the organization, the governing body has minimum fiduciary responsibilities to the organization set by statute, regulation, and case law, and typically assume responsibilities for long term planning, risk management, and evaluation and effectiveness of management.