Overview of Rule 65G-8
 Establishes procedure for approval of crisis
intervention curricula
 Requires providers to establish policy and procedures
for the use of reactive strategies
 Requires periodic review and analysis
 Requires assessment to rule out medical
contraindications for use of reactive strategies
 Establishes procedures for authorizing use of reactive
strategies
 Establishes limits on the use of reactive strategies
Overview of Rule 65G-8 (cont’d)
Includes prohibited procedures
Documentation and reporting
mechanisms
Establishes procedure for
enforcement of rule
In the Name Of Treatment
A Little History…..
 Formerly called “Emergency Procedures”
 HRSM 160-4 Appendix G
 HRSM 205-1
 Hartford Courant Article: “Deadly Restraint”
1998
 ACT memo 1999
 Children’s Mental Health Act of 2000
 Title V of Public Health Services Act
 Public Advisory from Advocacy Center
Change is good…
 F.A.C. 65G-8
 applies to all providers
 applies to any consumer who is funded under FS 393
 Requires curriculum that is approved by central office
in Tallahassee
 Each consumer must have initial assessment by
physician upon admission
 Use of authorizing agents per type of strategy used
 “Use of any reactive strategy on a ‘PRN’ or ‘as needed ‘
basis is prohibited
Authorizing Agents
 For any strategy, staff must notify highest level supervisor
 For seclusion and restraint, the authorizing agent may be the staff
directly involved in procedure
Strategy Used
Medical Protective
Equipment
Chemical Restraint
Behavioral protective Device
Mechanical Restraint
Authorizing Agent
Licensed physician
Seclusion
Staff with bachelor’s degree, two years experience
with DD, and certified in approved curriculum
Staff certified in approved curriculum
Manual Restraint
Licensed physician
BCBA, FL-CBA, person licensed under 490 or 491
BCBA, FL-CBA, person licensed under 490 or 491,
Licensed physician
Types of Reactive Strategies
Seclusion
Manual Restraint
Mechanical Restraint
Chemical Restraint
Behavioral Protective Equipment
Manual Restraint
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Definition: “Use of hands or body to immobilize a person’s
freedom of movement or normal access to his or her body for
more than fifteen continuous seconds”
Does not include physically guiding individual during transport or
skill training for up to 2 minutes.
Authorizing Agent must be certified in its use through Agencyapproved curriculum
Only used if sufficient number of staff available for safe
implementation
Staff must attempt to redirect first!
Requires continuous monitoring especially respiration rate
Requires reapproval if exceeds one hour
Requires Visual inspection (by authorizing agent of on-site
designee) if longer than 2 hrs.
Seclusion
Definition: “enforced isolation or confinement of an individual in a
room or area”
 Not Time out or medical isolation
 Authorizing Agent must have Bachelor’s degree, two years experience
in D.D., and certified in reactive strategies
 Only used if sufficient number of staff available for safe implementation
 Staff must attempt to redirect first!
 Requires continuous monitoring especially respiration rate
 Room must have:
 Sufficient lighting
 Proper ventilation
 Room for person to lie down comfortably
 Room must be inspected for safety and unsafe objects removed before
use
 Door is not locked; may be held shut by spring bolt or magnetic hold that
releases if staff stops holding
 Requires reapproval if exceeds one hour
 Requires Visual inspection (by authorizing agent of on-site designee) if
longer than 2 hrs.
Time Out (Not a Reactive Strategy)
Definition: “procedure designed to interrupt a
specific behavior of an individual by temporarily
removing that individual to a separate area or
room, or by screening him or her from others, or by
signaling that the individual is in “time out.
 Short for Time Out from Positive Reinforcement
 Not a reactive strategy defined by this rule
 Must be short in duration
 Never more than 20 min. (or considered
seclusion)
Time Out (cont’d)
 Part of a written behavior plan, that includes a
functional assessment and approve by LRC
 Plan is implemented by BCBA, FL-CBA or
licensed under 490 or 491
 Implemented in response to a specific behavior
 Includes requirement that individual returns to
previous activity at end of time out
 Time out data must be collected and analyzed
 Must include termination criteria (e.g. “one minute of
calm”)
Mechanical Restraint
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Definition: “a physical device used to restrict an individual’s movement
or restrict the normal function of the individual’s body
Does not include:
 Physical equipment or orthopedic appliances, surgical dressings or
bandages, or supportive body bands or other restraints necessary for
medical treatment, routine physical examinations, or medical tests
 Support Devices
 Equipment used for safety during transportation
 Medical protective equipment (see next slide)
Authorizing Agent must be BCBA, FL CBA, Physician, or licensed
under 490 or 491
Requires continuous monitoring, monitor respiration
Reauthorization if longer than 1 hr.
Staff must attempt to redirect first!
Requires Visual inspection (by authorizing agent of on-site designee) if
longer than 2 hrs.
Must have opportunity for movement, exercise for at least 10 minutes
per hour
Behavioral Protective Equipment
Definition: “a device used as a means of interfering
with or preventing specific results of a targeted
behavior as part of a behavior program approved by
the Local Review Committee”
 Used to prevent target behavior or results
 Part of LRC-approved program
 Authorizing Agent must be BCBA, FL CBA, or
licensed under 490 or 491
Medical Protective Equipment
 Health-related
protective devices
 Prescribed by a physician or
dentist for use during specific
medical or surgical procedures, or
 Client protection in response to
an existing medical condition
Chemical Restraint
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Definition: “use of medication to effect immediate control of an
individual’s behavior. It does not include the medication administered as
treatment for a medical or psychiatric condition”
Use of meds. for immediate behavioral control – not routine meds. for
treatment
Authorizing Agent is physician
Only on written order by physician
Physician must be on-site or provide phone consultation to authorized
person who is there and who has seen person
If physician is not onsite, then they must dictate order to on-site licensed
medical professional
Order kept in records with:
 Date issued
 Expected results
 Detailed description of behavior justifying order
 Monitoring at least every ½ hour and record effects in record
 No standing order PRN’s
Approved Emergency Procedure Curriculum
 All providers and facilities that use reactive
strategies must have an approved
curriculum
 Emergency procedure training curriculum
must be approved by APD
 Staff certification in approved curriculum is
valid for one year only
Initial Assessment
 Completed upon admission, annually, change in
condition
 Physician’s report: Medical conditions, physical
limitations that place at risk and/or preclude specific
procedures
 Document any trauma relevant to use of reactive
strategies
Conditions that might increase risk
 Obesity
 Blindness
 Cardiac conditions
 Limited range of motion
 Pregnancy
 Osteoporosis/
 Asthma/respiratory
Osteopenia
 Hemophilia
 Other
 Impaired gag reflex
 Back/Spinal cond.
 Seizure disorders
 Deafness
All Reactive Strategies
 Require authorization by authorizing agent
with clear rationale
 Authorizing agent notified of conditions
leading up to use of strategy
 Agent is responsible for terminating procedure not in compliance
with rule
 Requires continuous monitoring
 Must be least restrictive
 Terminate as soon as emergency ends
 Within 5 minutes after calm criteria is met
 Not used as punishment
All Reactive Strategies (cont’d)
 Greatest possible comfort and
protection from injury for client
 Limit 1 hour unless reauthorized
 Episode more than 15 minutes after
release requires new authorization
Prohibited Procedures
 Noxious or painful stimuli,
 Untested or experimental procedures
 Procedures that might restrict or obstruct an individual’s
airway or impair breathing
 including techniques whereby staff persons use their hands
or body to place pressure on the client’s head, neck, back,
chest, abdomen, or joints (which causes pain);
 Restraint of an individual’s hands, with or without a
mechanical device, behind his or her back
 Physical holds relying on the inducement of pain for
behavioral control
 Movement, hyperextension, or twisting of body parts
 Any maneuver that causes a loss of balance without
physical support (such as tripping or pushing)
Prohibited Procedures (cont’d)
 Using a pillow, blanket, or other item is used to cover the
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individual’s face as part of the restraint process
Any reactive strategy that may exacerbate a known medical
or physical condition, or endanger the individual’s life
Use of any containment technique medically
contraindicated for an individual
Containment without continuous monitoring and
documentation of vital signs and status with respect to
release criteria
Use of any reactive strategy on a “PRN” or “as required”
basis.
Important things to remember
 The Agency may disapprove the use of any emergency
procedure, system, strategy, or program that does not
meet the above requirements or that contains
procedures the Agency determines to be unsafe.
 Reactive strategies occurring
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More than 2 x in 30 day period
6 x in 12 month period
 Need to request for behavior analysis services
 Provider must have
 written behavioral criteria for termination of a reactive
strategy, to all staff trained in those techniques.
Reactive Strategies Reporting
 Report on “Reactive Strategy Report” form
 Submit Monthly to Area APD Office – due by 5th
working day of month
 APD Submits Combined Report Monthly to Central
Office – due by 10th calendar day of month
Documentation
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No later than end of work shift
Behavior requiring use
Strategy used
Date, Start and End time
Person who Initiated, Used, Authorized, Ended
strategy
 Signed by Authorizing Agent within 24 hrs.
Reactive Strategy Policy and Procedures:
Provider responsibilities
 Approved emergency procedure curriculum
 only the reactive strategies provided in the Agencyapproved curriculum
 Appropriate staff training,
 Record maintenance,
 Reporting and recording the use of any reactive
strategy,
 Training in the provisions of this rule chapter,
 Data collection,
 Reactive strategy consent information in client records
Reactive Strategy Policy and Procedures: Provider
responsibilities (cont’d)
 All staff implementing reactive strategies must be certified
 A variation of a specific reactive strategy
 if it is designed for a specific client with documented evidence of need and
benefit,
 only if evaluated and approved in advance of implementation by the Local
Review Committee and the Agency’s Senior Behavior Analyst.
 Must conduct an internal review at least annually with a written evaluation that
addresses the following issues:
 Proposed methods of reducing the use of reactive strategies;
 Evaluations to ensure:
 Reactive strategies are being conducted in accordance with the Agencyapproved emergency procedure curriculum and
 Administered in a safe manner
 Compliance with this rule chapter, including appropriate records and
reports of reactive strategies.
 The facility or provider must maintain this written evaluation for a
minimum of five years and make it available to the Agency upon request.
The Following Do Not Take Effect Until
February 1, 2009:
 65G-8.002: Agency-approved Curriculum
 65G-8.003: Policies and Procedures
 65G-8.004: Initial Assessments
Sample Scenarios
Questions and Answers
Contact Information
 Ken Winn, SunCoast Region Area Behavior Analyst
Phone: 813-233-4356
Fax: 813-233-4307
Email: Ken_Winn@apd.state.fl.us
 Diana Geller, SunCoast Region Quality Assurance
Phone: 813-233-4358
Fax: 813-233-4307
Email: Diana_Geller@apd.state.fl.us