LifeWays Operating Procedure
Clinical serviceS
SUBJECT: 05.02.02 Behavior Risk Management Committee
PURPOSE: The purpose of this operating procedure is to outline the committee structure,
committee scheduling process, and case reviews for the Behavior Risk
Management Committee of LifeWays. This procedure will also define prohibited
interventions.
GOVERNING AGENCY POLICY: 05.02 Clinical Risk Management
DEFINITIONS:
Aversive Techniques: Techniques that require the deliberate infliction of unpleasant stimulation
(stimuli which would be unpleasant to the average person or stimuli that would have a specific
unpleasant effect on a particular person) to achieve the management, control, or extinction of
seriously aggressive, self-injurious or other behaviors that place the individual or others at risk
of physical harm.
Crisis Prevention Institute (CPI): A series of approved physical techniques used defensively or
to control the behavior of a individual. The approved techniques are designed to protect the
individual and others from harm and to avoid substantial property damage, while using the least
restrictive intervention necessary. Utilizing the physical management component of CPI is one
of the two emergency interventions approved by LifeWays for use in crisis situations when all
other supports and interventions fail. Each LifeWays contracted provider is responsible for
implementing protocol specifying when CPI is to be utilized.
Freedom of Movement: A recipient shall not be restricted more than is necessary to provide
mental health services to him/her, to prevent injury to him/her, or to others, or to prevent
substantial property damage, except that security precautions appropriate to the condition and
circumstances of an individual admitted by order of a criminal court or transferred as a
sentence-serving convict from a penal institution may be taken. A restriction of a recipient's
freedom of movement adopted under this authority must include the date it expires and
justification for its adoption shall be promptly noted in the record of the recipient. Additionally,
the restriction shall be removed when the circumstances that justified its adoption ceases to
exist.
Functional Behavioral Assessment (FBA): an approach that incorporates a variety of techniques
and strategies to determine the pattern and purpose, or “function” of a particular behavior and
guide the development of an effective and efficient behavior plan. The focus of an FBA is to
identify social, affective, environmental, and trauma-based factors or events that initiate,
sustain, or end a behavior. A physical examination must be done by a MD or DO to identify
biological or medical factors related to the behavior. The FBA should integrate medical
conclusions and recommendations. This assessment provides insight into the function of a
behavior, rather than just focusing on the behavior itself so that a new behavior or skill will be
substituted to provide the same function or meet the identify need. Functional assessments
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should also identify situations and events that precede positive behavior to provide more
information for a positive behavior support plan.
Imminent Risk: an event/action that is about to occur that will likely result in the potential harm to
self or others.
Intrusive Techniques: Techniques that encroach upon the bodily integrity or the personal space
of the individual for the purpose of achieving management or control, of a seriously aggressive,
self-injurious or other behavior that places the individual or others at risk of physical harm.
Physical management: Techniques used by staff as an emergency intervention to restrict the
movement of an individual by continued direct physical contact in spite of the individual’s
resistance in order to prevent him or her from physically harming themselves or others. The
term “physical management” does not include briefly holding an individual in order to comfort
them or to demonstrate affection.
 Manually guiding down the hand/fists of an individual who is striking their own face
repeatedly causing risk of harm IS considered physical management if they resist the
physical contact and continues to try and strike. However, it is NOT physical
management if the individual stops the behavior without resistance.
 When a caregiver places his hands on an individual’s arms to prevent him or her
from running out the door and the individual resists and continues to try and get out
the door, it IS considered physical management. However, if the individual no longer
attempts to run out the door, it is NOT considered physical management.
 Physical management involving prone immobilization of an individual, as well as any
physical management that restricts a person’s respiratory process, for behavioral
control purposes is prohibited under any circumstances. Prone immobilization is
extended physical management of an individual in a prone (face down) position,
usually on the floor, where force is applied to their body in a manner that prevents
him or her from moving out of the prone position.
Positive Behavior Support: A set of research-based strategies used to increase opportunities for
an enhanced quality of life and decrease seriously aggressive, self-injurious or other behaviors
that place the individual or others at risk of physical harm by conducting a functional
assessment, and teaching new skills and making changes in a person’s environment. Positive
behavior support combines valued outcomes, behavioral, and biomedical science, validated
procedures; and systems change to enhance quality of life and reduce behaviors such as selfinjury, aggression, property destruction, and pica. Positive Behavior Supports are most
effective when they are implemented across all environments, such as home, school, work, and
in the community.
Proactive Strategies in a Culture of Gentleness: Strategies within a positive behavior support
plan used to prevent seriously aggressive, self-injurious or other behaviors that place th
individual or others at risk of physical harm from occurring, or for reducing their frequency,
intensity, or duration. Supporting individuals in a culture of gentleness is an ongoing process
that requires patience and consistency. As such, no precise strategy can be applied to all
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situations. Some examples of proactive strategies include: unconditional valuing, precursor
behaviors, redirection, stimulus control, and validating feelings.
Reactive Strategies in a Culture of Gentleness: Strategies within a Positive Behavior Support
Plan used to respond when individuals begin feeling unsafe, insecure, anxious or frustrated.
Some examples of reactive strategies include: reducing demanding interactions, increasing
warm interactions, redirection, giving space, and blocking.
Request for Law Enforcement Intervention: Calling 911 and requesting law enforcement
assistance as a result of an individual exhibiting a seriously aggressive, self-injurious or other
behavior that places the individual or others at risk of physical harm. Law enforcement should
be called for assistance only when: caregivers are unable to remove other individuals from the
hazardous situation to assure their safety and protection, safe implementation of physical
management is impractical, and/or approved physical management techniques have been
attempted but have been unsuccessful in reducing or eliminating the imminent risk of harm to
the individual or others. Involving law enforcement is one of the two emergency interventions
approved by LifeWays for use in a crisis situation when all other supportive interventions have
failed.
Restraint – The use of a physical or mechanical device to restrict an individual’s movement at
the order of a physician. The use of physical or mechanical devices used as restraint is
prohibited except in a state-operated facility or a licensed hospital. This definition excludes:
 Anatomical or physical supports that are ordered by a physician, physical therapist or
occupational therapist for the purpose of maintaining or improving an individual’s
physical functioning.
 Protective devices, which are defined as devices or physical barriers to prevent the
individual from causing serious self-injury associated with documented and frequent
incidents of the behavior and which are incorporated in the written individual plan of
service through a behavior treatment plan, which has been reviewed and approved by
the Committee and received special consent from the individual or his/her legal
representative.
 Medical restraint, i.e. the use of mechanical restraint or drug-induced restraint ordered
by a physician or dentist to render the individual quiescent for medical or dental
procedures. Medical restraint shall only be used as specified in the individual written
plan of service for medical or dental procedures.
 Safety devices required by law, such as car seat belts or child car seats used while
riding in vehicles.
Restrictive Techniques: Techniques that will result in the limitation of the individual’s rights as
specified in the Michigan Mental Health Code and the federal Balanced Budget Act. Examples
of such techniques used for the purposes of management, control, or extinction of seriously
aggressive, self-injurious or other behaviors that place the individual or others at risk of physical
harm, include: limiting or prohibiting communication with others when that communication would
be harmful to the individual; prohibiting unlimited access to food when that access would be
harmful to the individual (excluding dietary restrictions for weight control or medical purposes);
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using the Craig (or veiled) bed, or any other limitation of the freedom of movement of an
individual. Use of restrictive techniques require the review and approval of the Committee.
Seclusion – The placement of an individual in a room alone where egress is prevented by any
means, Seclusion is prohibited except in a hospital or center operated by the Michigan
Department of Community Health (MDCH), a hospital licensed by the department, or a licensed
child caring institution licensed under 1973 PA 116, MCL 722.111 to 722.128. Seclusion does
not include involuntary confinement for legally mandated non-clinical purposes such as
confining a person facing serious criminal charges or serving a criminal sentence in a locked
room.
Therapeutic De-escalation – An intervention, the implementation of which is incorporated in the
individualized written plan of service, wherein the recipient is placed in an area or room,
accompanied by staff who shall therapeutically engage the recipient in behavioral de-escalation
techniques and debriefing as to the cause and future prevention of the target behavior.
Time Out – A voluntary response to the therapeutic suggestion to a recipient to remove
him/herself from a stressful situation in order to prevent a potentially hazardous outcome.
PROCEDURE
COMMITTEE MEMBERSHIP
Committee composition shall be comprised of at least three (3) individuals and be consistent
with current policy and Department of Community Health requirements, and shall include the
following:
1.
2.
3.
4.
5.
At least one (1) licensed psychologist with specific training in behavioral analysis.
At least one (1) licensed Physician/Psychiatrist;
At least one (1) licensed Registered Nurse;
LifeWays’ Recipient Rights Officer (Ex-Officio)
When appropriate, a LifeWays’ Certified Peer Support (Ex-Officio)
Members must complete at least four (4) hours of training annually. Continued education or
professional development must be in the area of Applied Behavior Analysis for those members
designated as having experience in this area.
The Committee, and Committee chair, shall be appointed by the Leadership Council for a term
of not more than two years. Members may be reappointed to consecutive terms.
COMMITTEE STRUCTURE
The Committee shall meet no less than monthly and as often as necessary to meet the needs of
the individuals. The Committee chairperson shall distribute an agenda outlining the cases
scheduled for review and any committee business prior to the meeting. The Committee
chairperson shall ensure the Committee composition is appropriate and in accordance with
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LifeWays policy prior to conducting a vote. Members shall not participate in voting when a
conflict of interest exists relative to a case being presented. It is the responsibility of the
Committee member to disclose such a conflict. A decision shall be based on a majority vote.
All meetings shall be documented in minutes (Attachment 1), which clearly delineate the actions
of the committee. Minutes shall be maintained in a secure location for a minimum of 7 years.
COMMITTEE REVIEWS
The Committee Chairperson or designee shall maintain a calendar of cases for regularly
scheduled ongoing reviews. For all case reviews, the primary clinician will complete a
Medication/Behavior Plan Review Report Form, (Attachment 2).
EXPEDITED REFERRALS/CASE REVIEWS
The BRMC recognizes the consequence of time relative to this service and has established a
mechanism for the expedited review of behavior treatment plans. In the event a primary
clinician, individual, or advocate, the Behavior Psychologist contacts the Committee
Chairperson requesting an immediate review of a proposed behavior treatment plan. The
Chairperson may pull the Committee together via telephone or impromptu meeting for review of
the proposed plan or schedule the case during the next regularly scheduled committee meeting.
Expedited reviews must occur within 48 hours of the request. Recipient Rights must be
informed of the proposed plan to assure that any potential rights issues are addressed prior to
implementation of the plan. Upon approval, the plan may be implemented. All plans approved
in this manner must be subject to full review at the next regular meeting of the Committee.
CASE REVIEWS
The BRMC shall review cases that require monitoring due to risk potential or problem resolution
for high-risk potential. Case consultation is available at the request of the individual or any
advocate on behalf of the individual when treatment circumstances create potential risk (ie.
problems with diagnosis, unimproved outcomes, adverse reactions to treatment, or when
person-centered desires are likely to result in a risk to the individual’s health and safety).
Examples include but are not limited to:
A) Cases involving the use of psychotropic medications for behavior control purposes
where the target behavior is not due to an active psychotic process.
B) Review of all provider case closings or referrals to less restrictive service when the
individual has received intensive services (inpatient, crisis residential) within the past
year, and/or has not successfully completed the treatment being closed. Provider shall
complete Medication/Behavior Plan Review Report form (Attachment 2).
C) Any restrictions on movement as a result of therapeutic indications, not including devices
customarily used during medical procedures or for postural support.
D) Individual has required physical intervention.
E) Children placed in residential facilities.
F) Persons placed in state hospitals.
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LifeWays does not permit interventions that use seclusion or restraint or aversive techniques.
However, in the rare instance where a technique not permitted may be medically necessary.
LifeWays BRMC will refer the Behavior Treatment Plan to MDCH for approval (See Attachment
6: Hierarchy of Behavior Modification Techniques). All cases that propose the use of intrusive
or restrictive techniques will be expeditiously reviewed by the BRMC.
PROHIBITED PROCEDURES
The following procedures are specifically prohibited by any provider in the treatment of any
individual receiving services through LifeWays:
 Denial of a nutritionally adequate diet;
 Physical restraint and/or seclusion (including non-voluntary time out), except in inpatient
facilities under physicians’ orders;
 Prone Immobilization;
 Aversive behavior modification procedures or procedures involving painful stimuli;
 Use of unusual medications or experimental drugs;
 Prescription of drugs with high abuse potential;
 Research projects that involve inconvenience or risk to the individual;
 Corporal punishment; and
 Implementation of an individual’s behavior management plan by other recipients of
service.
REVIEW PROCESS AND DOCUMENTATION
Initial Review: The Behavioral Psychologist will submit to the BRMC a functional behavioral
assessment based on the individual’s full chart, including historical information.
The Committee shall not approve any plans that have not conducted an analysis of the causes
of the behavior or determined whether positive behavioral supports and interventions have been
adequately pursued and unsuccessful.
The BRMC shall consider the benefits of a procedure in comparison to the possible risks. In all
cases, a positive approach and an alternative behavior should be identified. It should be
demonstrated that the least restrictive intervention is being utilized. The treatment plans must
be supported by the Crisis Prevention Institute (CPI) approved techniques to drive the Network
toward a culture of gentleness. The individual and/or guardian must give specific informed
consent for the medication or intervention and that appropriate staff training has been
implemented.
When psychotropic medications are prescribed for behavior control with no active psychotic
process present, the treatment plan must address a plan to improve positive alternative
behaviors, thus decreasing the need for medication over time. Any restrictions on movement as
a result of therapeutic indications are to be reviewed by the Office of Recipient Rights; the
Committee shall ensure and document that such review has occurred. In all situations wherein
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a restriction of individual rights or a special treatment procedure is utilized, the intervention shall
terminate whenever the circumstances that justified its use cease to exist.
The Committee discussion, rationale, recommendations, next scheduled review, and decision
will be documented on the review form, and the committee will sign the BRMC Review Minutes
form. Both will be forwarded to the primary clinician for communication to the secondary
providers (residential staff) and to be included in the medical record. The BRMC chairperson
shall keep a copy of all meeting minutes.
Each plan will be reviewed in full by the Committee as determined by the level of intensity and
frequency of the intervention or as requested by an individual, guardian, or treatment team as
part of the person-centered planning process but no less than quarterly.
INTERVENTION MONITORING
The following data shall be collected on individual plans through data sheet monitoring
 Dates and numbers of interventions used
 Settings where behaviors and interventions occurred
 Behaviors that initiated the techniques
 Documentation of the analysis performed to determine the cause of the behaviors that
precipitated the interventions
 Attempts to use positive behavioral supports
 Behaviors that resulted in termination of the interventions
 Length of time of each intervention
 Staff development and training and supervisory guidance to reduce the use of these
interventions
The BRMC will review the intervention frequency and severity in an aggregated format
quarterly. The data will be reported quarterly to the Quality Management Council. The Quality
Management Team will include this as a part of the Organization’s Quality Assessment
Performance Improvement Program.
CRISIS PREVENTION INSTITUTE (CPI) EMERGENCY PHYSICAL MANAGEMENT
Any use of emergency physical management on an individual with or without a behavior
treatment plan must be approved CPI techniques and reported to the LifeWays Office of
Recipient Rights through the incident report process. The Office of Recipient Rights shall
forward all incident report involving CPI to the Behavior Risk Management Committee for
review. An analysis of physical management throughout the network will be reported to both the
BRMC and the Organization’s Quality Management Council.
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REFERENCE
MDCH/CMHSP Managed Mental Health Supports and Services Contract FY 12 Attachment
C6.8.3.1
MDCH Companion Guide to the Technical Requirement for Behavior Treatment Plan Review
Committees
MDCH Guide to Prevention & Positive Behavior Supports in a Culture of Gentleness
Procedure 05-02.04
Attachments/Forms
Attachment 1: BRMC Review Minutes
Attachment 2: BRMC Medication/Behavior Plan Review Report
HISTORY
*Formerly Policy 06.07 Behavior Risk Management Committee - Adopted: September 17, 1997
Reviewed: 12/08/98, 01/03/00
Revised:
11/14/01, 09/09/03
Reviewed: 09/06/04, 10/10/05, 10/18/06
Revised:
08/15/07
Deleted:
02/20/08
*As Procedure 05.02.02 Behavior Risk Management Committee - Effective date: February 20, 2008
Revised:
11/19/09, 08/17/12
Reviewed:
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Attachment 1
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Attachment 2
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