Sec. 14.31.06.15. Behavioral Interventions, Strategies, and Supports

A. General Policies.

(1) The licensee shall establish and follow written policies and procedures that:

(a) Are communicated to the child, the child’s parent or legal guardian, program personnel, licensing agency, and the placing agency;

(b) Incorporate the principles of positive behavioral interventions, strategies and supports, and trauma-informed care into all prevention and intervention strategies;

(c) Specify the approved procedures for the administration of prevention and intervention strategies and supports;

(d) Identify the program personnel authorized to administer each form of prevention and intervention strategies and supports;

(e) Include the procedures for training program personnel in the use and administration of each form of prevention and intervention strategies and supports that incorporate the principles listed in §A(1)(b) of this regulation; and

(f) Annually review the forms of prevention and intervention strategies and supports.

(2) A licensee may not use the following as disciplinary measures:

(a) Physical, mental, and verbal abuse, or corporal punishment;

(b) Assignment of physically strenuous exercise or work;

(c) The withholding of:

(i) Food;

(ii) Water;

(iii) Sleep;

(iv) Mail;

(v) Family visits; or

(vi) Program participation other than recreation or leisure activities;

(d) Forced feeding of a child;

(e) Chemical restraints, unless in compliance with State law and ordered by a physician;

(f) Mechanical restraints, except as permitted by other applicable State regulations or ordered by a court of competent jurisdiction; or

(g) Physical restraint, except when failure to do so would result in harm to others or to the child.

(3) A program may not delegate behavioral interventions, strategies, and supports of a child to another child or group of children.

B. Interventions Strategies.

(1) General Program Requirements. Program staff shall be encouraged to use an array of prevention and intervention strategies to increase adaptive behaviors or decrease targeted behaviors, as specified in the behavior intervention plan, that incorporate the following principles:

(a) Positive behavioral intervention strategies and supports;

(b) Trauma-informed care; and

(c) Individualized behavioral assessments and planning in accordance with COMAR 14.31.06.17.

(2) Program staff may use restraint only:

(a) After less restrictive or alternative approaches have been considered and:

(i) Attempted; or

(ii) Determined to be inappropriate;

(b) In a humane, safe, and effective manner;

(c) Without intent to harm or cause discomfort;

(d) When consistent with documented medical or psychological limitations and the child’s individual plan of care; and

(e) If the staff member performing the restraint has current certification in the use of restraint via the training program used by the licensee that has been approved by the State.

(3) Nothing in this chapter shall limit the responsibilities of law enforcement, judicial authorities, or security personnel.

C. Safe Environment Plan.

(1) General. The program shall develop a safe environment plan during intake and admission. The safe environment plan shall be reviewed and updated in conjunction with the child’s individual plan of care, or more frequently, as appropriate. The program shall partner with the child, the child’s parent or legal guardian, as applicable, and the custodial agency to develop a plan to create and maintain a nonviolent and healing environment and to prevent the use of restraint. The safe environment plan shall be easily accessible to program personnel at all times.

(2) Unless otherwise documented in a plan, the safe environment plan shall include the following:

(a) Physical space that the program shall provide to make the child feel safe, comforted, and in control of the child’s behavior;

(b) The triggers and situations that increase stress or fear and may cause the child to lose control of his or her behavior and how the child’s loss of control of his or her behavior is manifested;

(c) The methods for calming or soothing that the child prefers and has found to be successful;

(d) The child’s preferences regarding positive, nonphysical interventions, strategies, and supports if the child’s level of agitation increases;

(e) The medication that is appropriate clinically and agreed to and prescribed by the child’s treating physician that the child may choose to take voluntarily, if the child’s level of agitation increases despite the use of the alternative interventions identified in the safe environment plan;

(f) Any medical information that can affect the safety of a restrictive intervention;

(g) Any trauma history that the child has experienced;

(h) Any preferences or contraindications to the debriefing process; and

(i) The time frame in which law enforcement will be notified in the event of a child being absent without leave, not to exceed time limits as specified in COMAR 14.31.06.16.

(3) The program shall ensure that all program personnel working directly with the child:

(a) Are fully briefed on each child’s safe environment plan; and

(b) Honor the child’s requests and preferences identified in the plan, unless clinically contraindicated in a particular situation.

(4) The treatment team shall:

(a) Review the safe environment plan with the child following any post-restraint debriefing, and at other times consistent with the program’s policy, make any necessary changes identified by the child, staff, or both as appropriate; and

(b) Ensure that staff, the child’s parent or legal guardian, and the custodial agency are informed of any subsequent modifications made to safe environment and individual plan of care.

D. Use of Time Out.

(1) Program personnel may use time-out to address a child’s behavior if:

(a) The safe environment plan supports time-out;

(b) The child requests time-out;

(c) The child’s behavior unreasonably interferes with the program activities; or

(d) The child’s behavior constitutes an emergency, and time-out is necessary to protect a child or other person from imminent, serious, physical harm after other less intrusive interventions have failed or been determined to be inappropriate.

(2) A setting used for time out shall:

(a) Provide program personnel with the ability to see the child at all times;

(b) Provide adequate lighting, ventilation, and furnishings; and

(c) Be unlocked and free of structural barriers to prevent egress.

(3) Program personnel shall supervise a child placed in time-out and provide a child in time-out with:

(a) An explanation of the behavior that resulted in the use of time-out; and

(b) Explanation and instruction on the behavioral expectations when the child returns to the milieu.

(4) Each period of time-out shall be appropriate to the developmental level of the child and the degree of severity of the behavior, and may not exceed 30 minutes.

(5) A child’s parent or legal guardian, the custodial agency, and program personnel may at any time request a meeting to address the use of time-out and to:

(a) Conduct a functional behavioral assessment; and

(b) Develop, review, or revise a child’s plan of care.

E. Restraint.

(1) Physical Restraint.

(a) The use of physical restraint must be in accordance with the approved behavior management system used by the licensee.

(b) The use of prone restraint is prohibited in residential child care facilities.

(c) The use of physical restraint is prohibited in residential child care facilities unless:

(i) The parent or legal guardian of a child has been notified before admission that the use of physical restraint may be necessary; and

(ii) There is an emergency situation and physical restraint is necessary to protect a child or other individuals from imminent, serious, physical harm after other less intrusive, nonphysical interventions have failed or been determined inappropriate.

(d) Physical restraint may be applied only by program personnel who have successfully completed State-approved training in the appropriate use of physical restraint consistent with §G of this regulation.

(e) In applying physical restraint, program personnel may only use the least amount of force necessary to protect a child or other person from imminent, serious physical harm.

(f) A physical restraint:

(i) Shall be removed as soon as the resident is calm; and

(ii) May not last longer than 30 minutes per occurrence or longer than the approved behavior management system used by the licensee.

(g) Trained staff shall constantly monitor the use of restraint for the following:

(i) Proper technique;

(ii) Level of consciousness of the youth being restrained;

(iii) Breathing; and

(iv) Other safety factors.

(h) The program administrator or designee shall be contacted immediately after the initiation of the restraint.

(2) Mechanical Restraint.

(a) The use of mechanical restraint is prohibited in residential child care facilities, except as permitted in COMAR 14.31.07.08.

(b) Program personnel are not prohibited from using a protective or stabilizing device prescribed by a health care professional.

(3) The use of seclusion is prohibited in Maryland residential child care facilities.

(4) Referral to Team.

(a) If restraint is used, and the child’s behavior intervention plan does not include the use of restraint, the team specified in Regulation .17A of this chapter shall meet within 5 business days of the incident to consider:

(i) The review of the safe environment plan;

(ii) The need for a functional behavioral assessment;

(iii) Reviewing or developing appropriate behavioral interventions; and

(iv) Revising or implementing a behavior intervention plan.

(b) If a child’s behavior intervention plan includes the use of restraint, it shall specify how often the team shall meet to review or revise, as appropriate, the child’s behavior intervention plan.

(c) When a team meets to review or revise a child’s behavior intervention plan, the team shall consider:

(i) Existing health, physical, psychological, and psychosocial information;

(ii) Information provided by the parent or legal guardian and the custodial agency; and

(iii) Observations by program personnel and related service providers.

(d) The program shall provide the parent or legal guardian, the child, the custodial agency, and the child’s attorney with written notice when a team proposes or refuses to initiate or change the child’s behavior intervention plan to include the use of restraint.

(e) A parent or legal guardian or child may request an appeal through the program's grievance process in accordance with Regulation .09E of this chapter if the parent or legal guardian or child disagrees with the team’s decision to propose, or refuse to initiate, or change the child’s behavior intervention plan to use restraint.

(5) Documentation Requirements for the Use of Restraint. Documentation of events surrounding the utilization of restraint in the child’s record shall include, but not be limited to:

(a) Type of restraint used;

(b) Rationale for the restraint and expected outcome of the intervention;

(c) The safe environment plan or other less restrictive interventions, de-escalation techniques, or all of these utilized prior to the implementation of restraint and the child’s response to each;

(d) The child’s response during and after the implementation of the restraint;

(e) The length of time in restraint;

(f) Description of the specific precipitating factors leading to the restraint, including:

(i) Description of observable behavioral, emotional, and physical characteristics of the child involved;

(ii) Degree of restriction or loss of privileges;

(iii) Any event, situation, or condition immediately preceding the behavior that prompted the use of restraint; and

(iv) The behavior that prompted the use of a restraint;

(g) Specific location where the restraint occurred, and general activity occurring within the environment before the incident;

(h) Staffing level, types of program personnel (male, female, unlicensed, licensed);

(i) Unit capacity and unit population;

(j) The names of the program personnel who observed the behavior that prompted the use of restraint;

(k) The names and signatures of the program personnel implementing, observing, and monitoring the use of restraint;

(l) A description of the restraint event, including:

(i) The child’s behavior and reaction during the restraint; and

(ii) The name and signature of the administrator informed of the use of restraint;

(m) Physical condition, including any observable or reportable injuries of the child during and after the restraint, including:

(i) Description of any injuries sustained;

(ii) On-site first aid intervention; and

(iii) Off-site medical treatment;

(n) Medication, as identified in the child’s safe environment plan, administered before, during, or after the restraint;

(o) Date and time of the restraint; and

(p) Notification:

(i) To the program administrator or designee;

(ii) To the parent or legal guardian;

(iii) To the placement agency; and

(iv) To the licensing agency in writing, the information described in Regulation .18D of this chapter.

F. Debriefing.

(1) Staff.

(a) Within 24 hours of the incident, program personnel involved in the incident and the clinical coordinator, supervisor, or designee shall discuss and document the management of the incident by addressing the following:

(i) The precipitating factors of the incident;

(ii) Program personnel response to the incident;

(iii) De-escalation techniques or less restrictive interventions attempted, or both, and the child’s response to each;

(iv) Timeliness of program personnel intervention;

(v) Program personnel's ability to function as a team and improvements that could be made;

(vi) Adequacy of program personnel response and need for additional staff;

(vii) Aspects of the incident that should be the focus for discussion for the team; and

(viii) Other interventions that could have been used to prevent the restraint.

(2) Child.

(a) Within 24 hours of the incident, unless contraindicated by the safe environment plan, the child involved in the incident and the program administrator or designee shall discuss and document the management of the incident by addressing the following:

(i) The precipitating factors of the incident;

(ii) Program personnel response to the incident;

(iii) De-escalation techniques or less restrictive interventions attempted, or both, and the child’s response to each;

(iv) Timeliness of program personnel intervention;

(v) Program personnel's ability to function as a team, and improvements that could be made;

(vi) Adequacy of program personnel response, and need for additional staff;

(vii) Aspects of the incident that should be the focus for discussion for the team; and

(viii) Other interventions that could have been used to prevent the restraint.

(b) If the child declines to participate in the debriefing:

(i) Program personnel shall document efforts to conduct the debriefing, efforts to engage the child in the process, and the reasons the child declined to participate; and

(ii) Negative consequences may not be imposed upon the child for nonparticipation.

G. Administrative Procedures.

(1) Each residential child care facility shall develop policies and procedures to address:

(a) A continuum of prevention and intervention strategies that incorporate the principles of positive behavioral interventions, strategies and supports, and trauma-informed care;

(b) The prevention of self-injurious behaviors;

(c) Methods for identifying and defusing potentially dangerous behavior;

(d) The use and documentation of time-out consistent with Regulation .15D of this chapter; and

(e) The use of restraint consistent with Regulation .15E of this chapter.

(2) Quality Assurance. Each residential child care facility shall develop a quality assurance process to:

(a) Ensure that each child’s needs are addressed;

(b) Monitor and address the incident management findings, frequency, and types of restraints utilized;

(c) Implement measures to reduce the use of restraint; and

(d) Annually review policies and procedures, and provide them to program personnel and the parent or legal guardian.

(3) Training.

(a) Each residential child care facility shall provide training to program personnel on this chapter and the appropriate implementation of policies and procedures developed in accordance with §A of this regulation.

(b) The program personnel shall receive training on current professionally accepted practices and standards from a vendor whose training program has been approved by the State and which includes all of the following:

(i) Positive behavioral intervention strategies and supports;

(ii) Trauma-informed care; and

(iii) Restraint.

(c) Training shall be required:

(i) Before program personnel may work with children independently; and

(ii) At least annually.

(d) Each residential child care facility shall identify program personnel authorized to serve as a program wide resource to:

(i) Assist with training on de-escalation techniques; and

(ii) Ensure proper administration of time out and restraint.

(4) Monitoring and Compliance.

(a) Each residential child care facility shall develop policies and procedures on:

(i) Monitoring the use of time out and restraint; and

(ii) Receiving and investigating complaints regarding time out and restraint practices.

(b) The residential child care facility shall report the use of restraint to:

(i) The parent or legal guardian within 24 hours of the incident unless otherwise specified in the safe environment plan by the parent or legal guardian;

(ii) The placement agency;

(iii) The licensing agency in writing, information described in Regulation .18D of this chapter; and

(iv) Child Protective Services, as required by Regulation .14 of this chapter.

(c) The licensing agency may monitor and request any information regarding any matter related to time-out or restraint implemented by a residential child care facility.