Section 5.14 - Positive Behavior Supports(1)Policy. It is the purpose of the Department, reflected in M.G.L. c. 123B, § 2, and 115 CMR 5.14, "to establish procedures and the highest practicable professional standards" for the treatment of persons with intellectual and developmental disability, and to assure the dignity, health, safety, of its clients. System-wide PBS is a widely accepted and utilized framework for both systems change and individual treatment which supports individuals to grow and reach their maximum potential. PBS emerged from three major sources:(a) applied behavior analysis;(b) the normalization/inclusion movement; and(c) person-centered values. Journal of Positive Behavior Interventions, Positive Behavior Support: Evolution of an Applied Science," (Carr, Edward, Dunlap, Glen, Horner, Robert, et al.) Vol. 4, No. 1 (2002). PBS provides a means for selecting, organizing and implementing evidenced-based practices in the treatment of individuals. It focuses on clearly defined outcomes, data-based decision making and problem-solving processes that support practices with fidelity and durability. PBS emphasizes the use of positive behavior approaches and recognizes that behavior is often an individual's response or reaction to the environment and the need to communicate his or her preferences and wants to others. Therefore, PBS focuses on environmental modifications and antecedents. The strategies used to modify the behavior of individuals should involve PBS, which promote the dignity and respect of individuals, and should not be unduly restrictive or intrusive. It is both sound law and policy to use only procedures which have been determined to be the least restrictive or least intrusive alternatives.
(2)Required Elements of Positive Behavior Support for All Providers. All programs services or supports operated, certified, licensed, contracted for or otherwise funded by the Department, shall have the following elements to support the implementation of PBS: a PBS Leadership Team; a PBS Action Plan; Universal Supports, as defined in 115 CMR 5.14(3); and a system of data-based decision making for both individual treatment decisions and for system decisions.(3)Required Elements of Positive Behavior Supports for Providers with Individuals Needing Targeted or Intensive Supports. All programs proving supports to individuals needing Targeted or Intensive Supports shall have the following elements, in addition to those described in 115 CMR 5.14(2), to support the implementation of PBS: a referral plan for additional PBS support; a system to conduct functional behavior assessment, as described at 115 CMR 5.14(7), for each individual requiring Targeted or Intensive Supports; Targeted or Intensive Supports, based on individual needs; a PBSP for each individual requiring such supports; a PBS Qualified Clinician(s) to develop, implement, and monitor the PBSP; a system of coaching; and a systemic process for monitoring and quality improvement.(4)PBS Leadership Team. The PBS Leadership Team is the organizational entity providing governance for all PBS activities. All providers are required to have a PBS Leadership Team.(a) Membership of the PBS Leadership Team must include: an individual in an executive leadership position with authority to implement changes in management, content, resources and/or training, a Senior PBS qualified clinician, and other agency personnel representing different functional units within the organization, such as human rights, quality assurance or clinical staff.(b) In accordance with their organization's practices with regard to stakeholder participation, providers should invite one or more representatives of stakeholders, including individuals served by the organization, and or family members of individuals served, to participate and/or provide advice on PBS.(c) The responsibilities of the PBS Leadership Team shall include: 1. developing a written organization-wide PBS Action Plan;2. determining the configuration and number of PBS tiers based on population served and agency organizational structure, including Targeted or Intensive Team(s), as necessary;3. ensuring that the Universal Tier of PBS is implemented, and strategies have been identified to implement the Targeted or Intensive Tiers if they are needed by specific individuals;4. developing agency PBS goals and metrics to assess progress toward the goals;5. using ongoing data based decision making to:a. assess the implementation of the PBS Action Plan(s) on an ongoing basis,b. assess the treatment integrity of PBS across all three tiers, andc. assess the effectiveness of implementation of PBS plans across all three tiers;6. providing PBS training, coaching and oversight to staff within the organization.(5)Tiers of Support. All providers must maintain such systems of support as are necessary to meet the needs of the individuals they serve. These must include a Universal tier team, Universal tier of supports, and may include one or more tiers of support.(a)Universal Tier of Supports. Universal Supports are practices in place at all times supporting all individuals. Universal Supports ensure appropriate expectations are developed in all settings, socially appropriate behavior is reliably encouraged, and individuals are given choices and have opportunity to engage in preferred activities. Universal Supports include teaching individuals replacement skills and/or modifying physical or social environments to prevent challenging behavior. 1. For individuals requiring interventions in addition to Universal Supports, providers must implement a standardized identification and referral process to refer an individual for Targeted or Intensive Supports.2. For individuals requiring additional support at the Targeted or Intensive Supports level, Universal Supports shall be maintained.3. Universal Supports include, but are not limited to, evidence-based practices such as praise, redirection, or use of schedules to provide structure to the environment.(b)Targeted Tier of Support.1. All Targeted PBSPs must be in compliance with 115 CMR 5.14(8).2. Targeted Supports are practices implemented fairly rapidly on an "as needed" basis for an individual or group of individuals at risk for developing challenging behavior and needing interventions in addition to Universal Supports. The initiation of Targeted Supports is a means to avoid serious challenging behavior. Targeted Supports are intended to support an individual(s) who is at risk for reduced quality of life due to his or her actions or the actions of another person. Reasons for initiating Targeted Supports may include responding to stressful life events or to address behaviors that are not immediately high risk.3. The Targeted Supports available for inclusion in a PBSP are determined by a provider's PBS Leadership Team.4. Targeted Supports include, but are not limited to, the least restrictive, evidence-based practices such as "check-in, check-out," self-monitoring, relaxation training, individualized schedule(s), positive-only token economies, or minimally intrusive decelerative consequences such as "planned ignoring" or voluntary time-out.5. Notwithstanding anything contained in 115 CMR 5.14(5), providers may develop individualized, targeted supports unique to an individual but that do not meet the criteria for the Targeted Tier of Support set forth in 115 CMR 5.14(5)(b)2. Such individualized or "targeted supports" must be expressed in written guidelines, but do not require an abbreviated or informal functional behavior assessment and do not require a PBSP. An example of an individualized or targeted support would be a unique approach to transitions to avoid the development of a challenging behavior.(c)Intensive Tier of Support. 1. All Intensive Support Plans must be in compliance with 115 CMR 5.14(8).2. Individuals are referred for Intensive Supports when there are concerns the health, safety, or emotional well-being of the individual, or others, is at risk, or the individual's quality of life is seriously impeded due to challenging behavior.3. An Intensive PBSP may include, but are not limited, to restrictive procedures identified at 115 CMR 5.14(14). A PBSP containing a restrictive procedure(s) requires an Intensive PBSP and must meet the requirements for the same.4. Intensive Supports typically are not implemented until Universal and Targeted Supports have been implemented with integrity and data have shown them to be insufficient to effect meaningful behavioral change. However, when there is danger of harm to an individual's self or others, Intensive Supports may be implemented immediately.5. Intensive Supports may include the use of de-escalation techniques contained in the CPRR curriculum as defined in 115 CMR 5.02.(6)General Principles of Positive Behavior Supports.(a) PBS should avoid the use of intrusive or restrictive interventions. There should be a focus on developing a comprehensive understanding of the individual, his or her life, health, and challenging behaviors through assessments including functional behavior assessment.(b) PBS require the use of evidence-based practices and peer-reviewed literature for interventions, the ongoing monitoring of individuals and ensuring treatment integrity, i.e. the use of practices that are effective and improve outcomes for individuals.(c) Targeted and Intensive Supports require a statement of the areas of concern, a functional behavior assessment (abbreviated or informal for Targeted Supports and formal for Intensive Supports) and a written PBSP. However, a PBSP is not required for "targeted supports" described at 115 CMR 5.14(5)(b)5.(7)Functional Behavior Assessment.(a) Functional behavior assessment (FBA) is the process of gathering and analyzing information about an individual's behavior in order to determine the purpose or intent of the actions. FBA should include an assessment of the antecedents and consequences, and consider the individual's history, paying special attention to factors that may have contributed to the behavior(s). As part of the initial steps in FBA, consideration of explanations for the behavior(s), including medical, medication or psychiatric issues is required.(b) FBA looks beyond the behavior itself for the cause of the behavior (the function). FBA seeks to understand what the individual is trying to communicate through his or her behavior, and what the function of the behavior is in the environmental context in which it occurs.(c) An FBA should include the elements consistent with guidance provided by the Department.(8)Positive Behavior Support Plans.(a) A written PBSP is required for Targeted or Intensive Supports. The PBSP must be designed and written by a PBS qualified clinician. A PBSP should include the elements consistent with guidance provided by the Department. The PBSP should describe procedures for preventing a problem from occurring and ongoing monitoring of individuals to ensure treatment integrity.(b) PBSPs may include other assessments as needed and will seek to identify the strengths, preferences and interests of the individual.(c) PBSPs shall consist of the most efficient and the fewest interventions and support strategies coupled with reinforcement. Success will be measured by the increase of desired behaviors, a reduction of challenging behaviors, and improvements in quality of life.(d) PBSPs should focus on alternative strategies that address people's needs and provide meaningful choices. PBSPs should document such strategies, including that consideration was given to eliminating, reducing or minimizing antecedents or environmental conditions causing or exacerbating challenging behavior by making environmental modifications; emphasizing teaching or strengthening effective replacement behaviors and reinforcing incompatible behaviors serving the same function as and replace the identified challenging behavior(s); implementing a formal skill acquisition plan and data collection procedure in order to assess the effectiveness of skill acquisition activities; increasing monitoring of all aspects of the plan; and initiating more frequent or external reviews of data to ensure treatment integrity.(e) PBSPs that incorporate restrictive procedures must focus on alternative strategies contained in 115 CMR 5.14(8)(d).(9)Crisis Prevention, Response and Restraint Procedures. Crisis, Prevention, Response and Restraint (CPRR) procedures may be utilized as provided in 115 CMR 5.11 and may not be included in a PBSP. The goal of CPRR procedures is to ensure the safety of the individual and/or others. CPRR should terminate as quickly as possible.(10)PBS Qualified Clinician.(a) A PBS qualified clinician shall:1. be currently licensed in Massachusetts in accordance with applicable law as one of the following: b. an independent clinical social worker;c. an applied behavior analyst;d. a master's or doctorate level speech pathologist;f. a master's or doctorate level teacher with a certification in special education; org. a licensed mental health counselor (LMHC); or be a doctorate level special education teacher actively teaching the topics of positive behavior support or applied behavior analysis at the college or university level;2. have at least three years of training, including post graduate class work or formal training, and/or experience in function based behavioral assessment and treatment; and3. have at least three years of clinical experience in the treatment of individuals with developmental disabilities.(b) A Senior PBS qualified clinician serving on a leadership team under 115 CMR 5.14(4) shall: 1. be a PBS Qualified Clinician as described at 115 CMR 5.14(10)(a);2. have training in PBS, organizational strategies, and multi-tiered systems of support;3. have at least five years of training, including post-graduate class work or formal training, and/or experience in function based behavioral assessment and treatment;4. have at least five years of clinical experience in the treatment of individuals with developmental disabilities; and5. be able to perform all duties of a PBS qualified clinician under 115 CMR 5.14(10)(c).(c) A PBS qualified clinician's duties include:1. design and implementation of PBSPs, including making referrals to other clinicians;2. monitoring individuals and data to ensure treatment integrity and to determine effectiveness of the PBSP;3. making revisions to the PBSP as necessary; and4. providing supervision of: a. clinicians who meet the criteria described in 115 CMR 5.14(10)(a)1. and 2. who do not have a minimum of three years of experience as described at 115 CMR 5.14(10)(a)3., andb. personnel with a bachelor's degree in: iii. applied behavior analysis;iv. speech and language pathology; orv. education (teacher) and at least one year of post graduate experience working with individuals with developmental disabilities.(11)Quality Review and Monitoring.(a) All programs shall be responsible for implementing an internal quality review and monitoring process.(b) Quality review and monitoring processes should include the elements consistent with guidance provided by the Department.(c) The Department may periodically review a sample of PBS Action Plans, PBSPs and PBS internal monitoring plans to improve quality of systems and individual PBSPs.(12)Peer Consultation and Peer Review.(a)Peer Consultation. Peer consultation is provided in order to improve the quality and skill of the qualified clinician or author of the activities associated with the provision of PBS. Peer consultation is a voluntary activity designed to offer consultation and support from a peer.(b)Peer Review. Peer review is provided in order to ensure compliance with regulatory standards applicable to PBS contained in 115 CMR 5.14. A PBSP containing restrictive procedures shall, in addition to the other requirements set forth at 115 CMR 5.14, be reviewed by a Peer Review Committee appointed by the program head or designee or, at the election of the provider, by a Peer Review Committee convened by the Department. Except in an emergency, such review shall occur and the comments of the Peer Review Committee, if any, shall be addressed by the treating clinician(s) prior to the implementation of the PBSP. 1. For each such review, the Peer Review Committee shall be composed of three or more PBS Qualified Clinicians with combined expertise in the care and treatment of individuals with needs similar to those served by the facility or program and in behavior analysis and behavioral treatment, at least one of whom shall be a licensed psychologist.2. The Peer Review Committee shall be specially constituted so as to exclude any clinician responsible for the development or implementation of the Intensive PBSP.3. The Peer Review Committee shall review an Intensive PBSP to determine if it conforms to the requirements for appropriate treatment established by 115 CMR 5.14.4. The Peer Review Committee's review of an Intensive PBSP may include such record reviews, interviews, inspections, and other activity as the Peer Review Committee may in its discretion deem necessary, and may include requests that the Intensive PBSP be resubmitted for such periodic review as the Peer Review Committee may deem appropriate.5. In the event that the Peer Review Committee concludes the Intensive PBPS or a part of the Intensive PBSP violates the requirements for appropriate treatment established by 115 CMR 5.14, the Intensive PBSP, or part thereof, shall not be implemented, unless the issue is resolved by the PBS qualified clinician responsible for the development or implementation of the Intensive PBSP.6. The provider, and the Peer Review Committee, shall maintain a written record of the Intensive PBSPs reviewed at each Peer Review Committee meeting, and the results of each individual review. The records of changes, if any, to the Individual PBSP shall be available to Peer Review Committee members at each meeting.(13)Human Rights Committee Review.(a)Positive Behavior Support Plan Review. New PBSPs containing restrictive procedures shall be submitted to the program's human rights committee established in accordance with 115 CMR 3.09: Protection of Human Rights/Human Rights Committees. The human rights committee shall monitor and review PBSPs containing restrictive procedures.(b)Frequency of Review. The human rights committee review of a new PBSP shall occur no later than the next meeting following the meeting at which the PBSP was first presented to the committee. However, provided the committee shall further expedite such review on request of the program head or designee for cases where the program head or designee determines immediate consideration of the proposed PBSP is necessary to protect the individual's health and safety. Except in an emergency, such review shall occur and the comments (if any) of the human rights committee shall be addressed by the treating clinician(s) prior to implementation of the PBSP.(c)PBSP Review. The human rights committee's review of an existing PBSP containing restrictive procedures shall occur:1. upon the introduction of a new restrictive procedure; or(14)Restrictive Procedures. PBSPs incorporating restrictive procedures must focus on alternative strategies and the elements contained in 115 CMR 5.14(8)(d). Restrictive procedures may be permitted only after positive approaches have been utilized and only in conjunction with an Intensive PBSP. Such restrictive procedures may include, but are not limited to: (a) "Time out" requiring physical removal over the individual's active resistance to the time out;(d) Response blocking; and(e) Protective devices as described at 115 CMR 5.12(1)(b)2.(15)Prohibited Practices. (a) The following procedures are prohibited: 2. any noxious, unpleasant, uncomfortable or distasteful stimuli;6. the locking of exits from buildings, except in accordance with 115 CMR 5.04 and 42 CFR 441.301(c)(4);7. prone restraint; and any physical restraint which causes pressure or weight on the lungs, diaphragm or sternum causing chest compression or restricting the airway, or basket hold in a seated position on the floor;8. removing, withholding, or taking away money;9. denial of a nutritionally sound diet including withholding of a meal;10. denial of adequate bedding or clothing; and11. mechanical restraint.(b) A limited, short-term waiver of the prohibition on prone restraint for use in an emergency may be available from the Department Office of Policy and Planning on an individualized basis.(16)Emergency Procedures. Nothing in 115 CMR 5.14 prohibits the use of emergency restraint, confiscation of any item used in a threatening manner, or removal from the environment for the purpose of protecting the individual and others around him or her. This includes the use of restraint procedures in the course of an established program, when the individual becomes a danger to him or herself or others, prior to staff being able to implement a lesser restrictive hierarchy. However, it is emphasized that emergency procedures may not be used at frequent intervals, becoming a routine method of intervention. If emergency procedures are utilized three times in a six-month period, the PBS qualified clinician will conduct a FBA and develop an appropriate plan of action. Amended by Mass Register Issue 1411, eff. 2/21/2020.