There are five lesson in this course.
Lesson #5 Description: Record keeping and documentation are often part of providing services. The Positive Supports Rule has some specific requirements around documentation, reporting, and record keeping that all covered providers need to complete. These same requirements are part of 245D.
After completing this module, you will be able to:
Documentation and recordkeeping are often requirements of licensed services. Because they are requirements, providers can get focused on compliance rather than purpose. However, when people struggle with behavior that interferes with their ability to live well in their communities, documentation and recordkeeping can be a critical piece to making positive progress. Especially when people have communication barriers and multiple caregivers are involved, documentation may be the only way to clearly understand what is happening for the person.
Basic documentation and records include:
To learn more about general documentation requirements you can go to the following sections of 245D and the PSR:
EUMR should only be used in serious situations in which a person is at risk of harm or harming others and there are no other alternatives to protect people. Direct support professionals and other employees of the provider must have clear guidance on when, if, and how they may engage in these strategies. DHS requires license holders to have a policy. DHS provides a sample policy providers can use. You can use this to simplify the process and makes sure key components are attended to.
BIRFS must be filled out whenever there is an EUMR of a person receiving services. They must also be filled out when the following occurs:
You can review instructions for filling out the BIRF by clicking on the instructions button on the form. You may be asked to upload a copy of the person’s form. You can print the form.
When a person has been subjected to EUMR three times in 90 days or four times in 180 days, or when for any reason there is use of a limited, or restricted method of managing behavior, a Positive Support Transition Plan must be developed. In this situation, there should be strong evidence that other methods that are person-centered, positive supports have been used to support the person. A functional behavior assessment is necessary to inform the development of the Positive Support Transition Plan. There should be good indication that the new strategies are the least restrictive to the person as possible. It should be likely that the approaches will respectfully and humanely help the person develop necessary skills needed to enhance their quality of life and decrease the use of the target intervention. The person and their legal designees (as applicable) must sign consent for approaches in the plan. When a PSTP, it requires review every 90 days or more often as specified by the plan. The review must be documented on Form 6810A and the following will be reviewed:
Review the following to understand more about the forms that need to be completed for a PSTP.
Providers who allow emergency use of manual restraint must have a written policy that all employees know about and can follow. People receiving services need to receive written notice of this policy. Other appropriate legal designees or support team members should be notified as well. Providers who do not permit EUMR must also have a policy in place. The policy must state what alternatives will be used in lieu of EUMR.
The notice must clarify the person receiving service's rights in this process. The license holder must obtain a written acknowledgment that the person and others, as are required by the rule, have been notified of the policy and had a chance to review it. At minimum, notification must happen upon service initiation and whenever the policy is changed.
These procedures are prohibited without a PSTP in place. With a PSTP in place they must still be reported on a BIRF.
“Positive Support Transition Plan” is the plan required for development by the expanded support team to implement positive support strategies to:
Sometimes a provider initiates services with a person for whom a prohibited procedure was used regularly prior to services being initiated. Should the person and their team determine that immediately ending the use of the procedure may cause serious harm to the person or others, the procedure could be used for up to 11 months, if it is incorporated into a Positive Support Transition Plan. The team has 30 days after admission to develop the plan, and 11 months after the date the plan is active to phase out the use of the prohibited procedure.
If a person begins behaving consistently in a manner that has the potential to cause serious harm to themselves or others and the person and their team determines that the use a prohibited procedure may be necessary for a limited time a PSTP may be developed. Effective positive support strategies must be included to eliminate the need for the procedure and eliminate the target behavior as part of the plan.
In this situation, the team must submit a request to a committee, called the External Program Review Committee (EPRC), for the use of the procedure. The EPRC reviews these types of requests and makes a recommendation to the Commissioner of DHS to allow the procedure or not. Before the prohibited procedure may be used, the team must receive permission for the emergency use of the procedure.
Under the Positive Supports Rule there are conditions under which a PSTP must be developed. They include:
In all situations the person receiving services must be informed of any interventions and they need to understand the risks and benefits. If they have limits on their rights to consent, their legal representative acting only within the scope of their authority must provide consent.
Keep in mind that all members of expanded support team are encouraged to consider the person’s preferences and work to help develop strategies that are in their best interest.
There is a test linked to this lesson. You must take the test to receive credit for completing the lesson. Once you have finished reviewing this lesson, close the pop-up window and go back to your lesson assignment list. Then click on the title of the lesson you just completed, you will be taken to the welcome page again. A blue button "Take the Test" will have appeared. Click on it to take the test. Once you complete, submit, and pass the test, the lesson will be credited as complete.