Required Behavior Support Plan (BSP Components)
All the necessary steps for getting a BSP in place and implementing the program should have occurred before the request for the Level of Need (LON) increase (one level of need higher than Inventory for Client and Agency Planning [ICAP] service level or LON 9).
- A baseline of the frequency and severity of the behavior that adequately reflects the individual's behavioral issues during a set time. There should be data sheets or observation notes documenting the frequency of targeted behaviors during the baseline period of at least one month, unless the behavior frequency is extremely high, thereby permitting a shorter baseline. Severity rankings should meet the criteria specified by the Texas Department of Aging and Disability Services (DADS) ICAP training materials.
- A functional assessment (analysis) of the targeted behavior to identify the history of behavioral interventions that have been used, all attempts at less intrusive interventions, and when and under what conditions the behavior occurs. This assessment should describe the hypothesized function of the behavior, which is the basis for the BSP interventions.
- A specific objective to decrease or eliminate the targeted behavior must have been implemented, including a detailed description of specific interventions for the specific behavior. The BSP must clearly identify the undesirable behavior and target its decrease or elimination. Exactly how staff are to respond to the targeted behavior must be clear and simple enough that staff can verbally describe the procedure. Although positive reinforcement techniques are an essential component of all behavior programs, a program that focuses simply on teaching social behaviors is not sufficient if it does not give staff clear directions on what to do if the undesirable behavior occurs.
- Progress notes must be based on data recorded about the defined behaviors and the interventions used in the BSP. There must be data sheets or progress notes that document every occurrence of the target behavior, unless otherwise specified in the program. The specifics regarding the incidents should be recorded (i.e., if the planned intervention was carried out or not and why, the individual's actions and the staff actions).
- The team must have approved the BSP.
- Per Texas Administrative Code (TAC), Title 40, Part 1, Chapter 9, Subchapter D, §9.178 (v), any behavior management techniques involving intrusive interventions or restriction of the individual's rights are required to be developed by a behavioral support service provider with input from the individual, his or her legally authorized representative (LAR), the program provider and any actively involved persons.
- All appropriate consents must be obtained. Anyone who receives one-to-one (1:1) supervision is considered to be in a highly restrictive and intrusive program; therefore, the individual or his or her LAR must have signed consent before implementing the program.
- For the Intermediate Care Facilities for Persons with an Intellectual Disability (ICF/IID) program only, the specially constituted committee must have approved the BSP.
- If the LON increase (one level of need higher than ICAP service level or a LON 9) is requested for another year, there must be evidence of progress or program modification. If the program is effective, the rate and/or severity of the behavior should decrease over time. In cases where the intervention primarily involves preventive actions by staff, the frequency of these preventive actions also should decrease over time. Note: the actual frequency of the behavior may be low throughout because of successful prevention. If such decreases are not observed, the behavior needs to be re-analyzed through a functional assessment and the BSP must be modified as indicated. Regular evaluation of the BSP's effectiveness should occur at intervals specified in the plan. This evaluation must be more frequent than annually and consistent with progress of the individual as well a problems in implementing the plan. This information is not required to be submitted to Program Enrollment/Utilization Review (PE/UR) annually for renewal, but it must be maintained by the program provider and be made available for review by PE/UR staff, upon request.
NOTE: Before implementing a plan designed to decrease undesirable behaviors, attempts should have been made to determine the effectiveness of other, less restrictive, less intrusive approaches. This could include such activities as modifying the environment, redirecting the behavior, ignoring the behavior (extinction), etc.
If such approaches prove ineffective, a functional assessment should be completed. This involves careful data collection and analysis of the conditions (time, location, during which activities, etc.) under which the targeted behavior occurs. Such an analysis might lead to a less intrusive method for managing the behavior. In addition, purely positive reinforcement techniques might be attempted. These activities are most effective if done under professional consultation from a psychologist or behavior analyst. However, the term consultation does not imply that a contract with an outside consultant is required. Agency staff, if properly qualified, can perform this function. Refer to the Home and Community-based Services (HCS) rules and principles regarding behavior management techniques involving restriction of individual rights or intrusive techniques [§Section 9.178 (v)].
Fading Plan Expectations
Because there appears to be some misunderstanding regarding the fading plan for 1:1 supervision reflecting a step-by-step plan that, if and when completed successfully, results in the individual no longer receiving 1:1 supervision, the following guidance is provided. Including a statement indicating the team will consider fading when "such and such" criteria are met is not a sufficient fading plan.
DADS expectations for a reasonable LON 9 fading plan are as follows:
- The plan to fade 1:1 should be part of the BSP. The fading plan is specific to the individual and based upon the life-threatening behavior(s) for which 1:1 supervision (restrictive/intrusive procedure) is required. The criteria for implementing fading should be tied specifically to the life-threatening behavior(s) for which the LON 9 (1:1 supervision) is authorized and, if determined by percentages, tied to the baseline rate (rates before implementation of any behavior plan — if known). Alternatively, a specific number of episodes/instances of the behavior could be set as criteria. The fading plan should have the best possible chance of being successful based on the teams' knowledge of the individual.
- The fading plan should be a gradual process that gives the individual time to adjust to the changes in supervision and enables him or her to experience the success he or she is achieving. Alternatively, fading can be set to be attempted routinely at a specific time and/or place and then expanded to other times/places. Said in another way: The actual fading plan needs to be described in a step-by-step fashion that ends up with 1:1 supervision being discontinued. To be successful, these should be small steps and designed by the team and psychologist.
- Criteria are identified for expanding or generalizing fading to other times and or places. Alternatively, fading can be indefinite and only tied to criteria for beginning 1:1 supervision (e.g., start the day with the 1:1 staff providing "line-of-sight" supervision unless and until the individual exhibits the [or one of the] behaviors for which the 1:1 supervision was authorized).
- Criteria for abandoning the fading plan or going back one step also should be specified. The criteria for going back to 1:1 supervision are operationally defined or identified (i.e., what constitutes failure on a specific fading attempt). This also should include direction on where or on what step to resume the fading schedule and for how long, if it is different than the original fading plan.
- The completion of the fading plan from constant 1:1 supervision to a less restrictive level (e.g., "line-of-sight" or "general") supervision can be accomplished within one year if fading progresses without the individual exhibiting the life-threatening behavior(s).
If a provider or his or her staff psychologist needs clarification of the above, they may contact:
Texas Department of Aging and Disability Services
Access & Intake
IDD Waivers Program Enrollment/Utilization Review
Mail Code W551
P. O. Box 149030
Austin, Texas 78714-9030
PE/UR Message Line: 512-438-5055