How Council on Accreditation (COA)—Behavior Support and Management Standards Align with the Nonviolent Crisis Intervention® Training Program.
COA—BSM Standards
|
The Nonviolent Crisis Intervention®
Training Program |
BSM 1: Philosophy and Organization Policy
The organization’s governing body and management promote a safe and therapeutic environment and provide necessary supports and resources to:
a. keep staff, foster parents, and service recipients safe; and
b. minimize the use of restrictive behavior management
interventions. |
The Crisis Prevention Institute, Inc.’s (CPI) Nonviolent Crisis Intervention® training program promotes a philosophyof Care, Welfare, Safety, and SecuritySM for both staff and clients. The focus of the program is on verbal de-escalation techniques. Restrictive behavior management interventions such as physical restraint are only taught as a last resort, when an individual is a danger to self or others and other less restrictive interventions have been tried and failed. |
BSM 1.01
The organization’s behavior support and management
policies and practices comply with federal, state, and local
legal and regulatory requirements. |
CPI recommends that each organization develop policies
and procedures that not only represent best practices
within the organization, but that also comply with all
federal, state, and local rules and regulations. CPI
provides a number of resources organizations can use to
assist them in establishing these policies and procedures. |
BSM 1.02
Behavior support and management policies cover:
a. practices used to maintain a safe environment and
prevent the need for restrictive behavior management
interventions;
b. whether isolation, manual or mechanical restraint, or locked seclusion are permitted as emergency safety measures;
c. other practices that may be used and under what circumstances; and
d. prohibited practices. |
BSM 1.03
The CEO and senior management conduct regular reviews of the use of behavior support and management interventions and:
a. review how organization practices compare with current information and research on effective practice;
b. use findings from quarterly risk management reviews of restrictive behavior management to inform staff about current practice and the need for change;
c. revise policies and procedures when necessary;
d. determine whether additional resources are needed; and
e. support efforts to minimize the use of restrictive behavior management interventions. |
Nonviolent Crisis Intervention® Certified Instructors receive
continuous updates on current information and best
practices in the field of crisis prevention and behavior
management through the Instructor Forum, CPI’s quarterly
newsletter, and through the Journal of Safe Management of
Disruptive and Assaultive Behavior, a professional journal
published by CPI. CPI offers a variety of additional
resources to Certified Instructors, including advanced
training courses, on-site consultations, free access to CPI’s
Professional Staff Instructors through a toll-free line, and
various print materials. |
BSM 1.04
The program or clinical director is notified following each use of locked seclusion or manual or mechanical restraint, and each incident is administratively reviewed no later than one working day following an incident. |
CPI provides a detailed model of procedures for staff to
utilize following an incident that requires the use of restraint
or seclusion. This model addresses the key components
necessary to properly review the events that occurred
before, during, and after the incident and encourages staff
to utilize this information to improve the organization’s
policies and procedures relating to such incidents. |
BSM 2: Behavior Support and Management Practices
A culture and structure exists within every facility and foster home that promotes respect, healing, and positive behavior and prevents the need for restrictive behavior management interventions. |
The philosophy of the Nonviolent Crisis Intervention®
training program is Care, Welfare, Safety, and SecuritySM
for all individuals affected by crisis—staff and client. One
of the program’s primary focuses is verbal de-escalation
strategies that are intended to defuse a situation from
escalating to the point where restrictive behavior
management interventions are required. |
BSM 2.01
The organization:
a. provides an explanation for and offers a copy of its
written behavior support and management philosophy
and procedures to service recipients or their parents or
legal guardians at admission;
b. informs service recipients or parents or legal guardians
of strategies used to maintain a safe environment and
prevent the need for restrictive behavior management
interventions;
c. has procedures that address harassment and violence
towards other service recipients, personnel, and, as
applicable, foster parents;
d. obtains the service recipient’s or parent’s or legal
guardian’s consent when restrictive behavior
management interventions are part of the treatment
modality; and
e. when the service recipient is a minor, notifies the parents
or legal guardians promptly when manual restraint,
mechanical restraint, or locked seclusion were used. |
CPI provides effective tools to Nonviolent Crisis Intervention® Certified Instructors for integrating these
requirements into organizational policies and procedures.
The Nonviolent Crisis Intervention® training program
focuses on assisting staff in providing a safe
environment with the goal of preventing the need for
restrictive behavior management. This focus allows
organizational leadership to confidently present the
behavior management philosophy and procedures to
service recipients and parents/legal guardians as a safe
and effective method of behavior management. CPI also
provides tools designed to assist leadership in delivering
the appropriate message to caregivers. |
BSM 2.02
Personnel and foster parents support positive behavior by:
a. developing positive relationships with service recipients;
b. building on strengths and reinforcing positive behavior; and
c. responding consistently to all incidents of harassment
or violence. |
a., b. The Nonviolent Crisis Intervention® training
program includes positive behavior support
strategies and focuses on relationship building
with service recipients. The program also teaches
restrictive behavior management interventions
only as a last resort, when positive behavior
supports and verbal de-escalation do not work, or
the situation has escalated beyond circumstances
in which less restrictive interventions may be
safely used.
c. The Nonviolent Crisis Intervention® training
program teaches staff to consistently respond to
incidents of harassment, violence, and other
crisis situations by providing staff members with
the tools necessary to develop and implement
appropriate response procedures. |
BSM 2.03
The organization prohibits:
a. the use of restrictive behavior management
interventions by service recipients, peers, or any person
other than trained, qualified staff, or foster parents;
b. chemical restraint;
c. excessive or inappropriate use of behavior management
interventions as, for example, a form of discipline or
compliance, or for the convenience of staff or foster
parents; and
d. use of restrictive behavior management interventions in
response to property damage that does not involve
imminent danger to self or others. |
Because of the risks inherent in physical restraints used as
restrictive behavior management interventions, CPI advises
against using physical restraint in cases of discipline,
compliance, convenience, or property damage. The
Nonviolent Crisis Intervention® training program teaches
participants that physical restraints should only be used
when an individual is a threat to self or others. Nonviolent Crisis Intervention® Certified Instructors are taught to
safely and effectively administer physical restraint as a
form of restrictive behavior management intervention only
when other, less restrictive forms of behavior management
have been exhausted and when an individual is a danger
to self or others. |
BSM 2.04
Each service recipient participates in an assessment of the potential risk of harm to self or others to determine the need for behavior support and management interventions. |
CPI recommends that each of these factors be documented
in service recipients’ behavior management plans. These
factors affect the safety of the individual should restrictive
behavior interventions be necessary. The Nonviolent Crisis Intervention® training program teaches participants how to
recognize antecedents to harassing, violent, or out-ofcontrol
behavior, and psychological, social, and medical
factors that can limit the use of certain interventions on
particular individuals due to the increased risk for injury. |
BSM 2.05
Service recipients identified as being in need of restrictive behavior management interventions are assessed for:
a. antecedents to harassing, violent, or out-of-control behavior;
b. the effectiveness of previous uses of behavioral interventions;
c. psychological and social factors that can influence use of such interventions; and
d. medical conditions or factors that could put the person at risk. |
BSM 2.06
A behavior support and management plan is based on assessment results and:
a. identifies strategies that will help the person de-escalate their behavior and prevent harassing, violent, or out-ofcontrol behavior;
b. specifies interventions that may or may not be used;
c. is modified as necessary; and
d. is developed and signed by the person, his/her parent or legal guardian, and the foster parent or personnel, as appropriate. |
a. The CPI Crisis Development ModelSM provides a framework that matches different levels of crisis that an individual may experience with appropriate staff responses. This model, combined with staff members’ knowledge of the individuals in their care, will form the basis by which staff will create strategies to de-escalate the service user and prevent harassing, violent, and out-of-control behavior.
b. CPI recommends that staff review medical and
psychological conditions of all individuals in
their care to determine which interventions are
appropriate. The Nonviolent Crisis Intervention®
program covers the risks of restraints in great
detail and will assist staff members in
determining which positions may be unsafe
for individuals with certain conditions.
c., d. An important part of CPI’s discussion of
Postvention is debriefing. The recommended
debriefing process includes meeting with the
individual who was in crisis, the staff member(s)
involved in the crisis incident, and any other
individual who needs to be involved to discuss the
incident and ways to prevent similar incidents in
the future. The individual’s behavior support plan
should be modified if new intervention strategies
are established during the debriefing process. |
BSM 3: Safety Training
Personnel and foster parents receive behavior support training that promotes a safe work and service environment, and a reduction in emergency situations. |
The philosophy of the Nonviolent Crisis Intervention® training program is Care, Welfare, Safety, and SecuritySM. This philosophy is reflected in every aspect of the program to promote a safe work and service environment, which includes an effort to reduce the number of emergency situations. In addition, CPI promotes consistency in the application of Nonviolent Crisis Intervention® program standards for all caregivers of a particular individual. |
BSM 3.01
All personnel and foster parents receive initial and ongoing competency-based training, appropriate to their responsibilities, on the organization’s behavior support and management intervention policies, procedures, and practices. |
CPI recommends all staff receive training in accordance with their organizational responsibilities. CPI recommends staff attend an 8–16 hour initial competency-based training course and receive, at a minimum, an annual refresher training at least three hours in length. Resources for both initial and refresher training are available through CPI. |
BSM 3.02
Personnel and foster parents receive training that includes:
a. recognizing aggressive and out-of-control behavior, psychosocial issues, medical conditions, and other contributing factors that may lead to a crisis;
b. understanding how staff behavior can influence the behavior of service recipients; and
c. limitations on the use of physical techniques. |
The Nonviolent Crisis Intervention® program specifically addresses Precipitating Factors, Rational Detachment, and the Integrated Experience. These topics center around the factors that may lead to a crisis and understanding how staff behavior influences the behavior of the individual in crisis. In addition, the entire course addresses methods of de-escalation. |
BSM 3.03
Training addresses methods for de-escalating volatile situations, including:
a. listening and communication techniques, such as negotiation and mediation;
b. involving the person in regaining control and encouraging self-calming behaviors;
c. separation of individuals involved in an altercation;
d. offering a voluntary escort to guide the person to a safe location;
e. time out to allow the person to calm down; and
f. other non-restrictive ways of de-escalating and reducing episodes of aggressive and out-of-control behavior. |
a. Empathic listening is an important foundation of the Nonviolent Crisis Intervention® training program. Additional resources on topics such as mediation are available to Certified Instructors.
b. The CPI Crisis Development ModelSM and subsequent units expanding on that information provide staff with a number of strategies to assist the individual in regaining self-control.
c. CPI addresses strategies for separating individuals involved in an altercation in the Nonviolent Physical Crisis InterventionSM and Team Intervention unit. CPI also has a video/DVD specific to breaking up fights available for all Certified Instructors of the program.
d., e. Nonviolent Crisis Intervention® training can help facilities establish appropriate policies and procedures related to the use of time-out interventions within the context of the other inventions the organization employs.
f. Various verbal and nonverbal de-escalation strategies along with CPI Personal Safety TechniquesSM are taught in order to avoid restrictive behavior interventions. |
BSM 4: Restrictive Behavior Management Intervention Training
Personnel who use restrictive behavior management interventions, and foster parents who use manual restraint, are trained and evaluated on an annual basis. |
CPI recommends that those trained in the Nonviolent Crisis Intervention® program receive refresher training (including competency-based testing in administering physical restraints) every 6-12 months. |
BSM 4.01
Personnel designated to use restrictive behavior management interventions, and foster parents who use manual restraint, receive ongoing training on permitted interventions, including:
a. proper and safe use of interventions;
b. understanding the experience of being placed in seclusion or a restraint;
c. signs of distress; and
d. response techniques to prevent and reduce injury. |
In the Nonviolent Crisis Intervention® program all participants learn about the importance of team intervention, and the risks of restraint use. During the training staff are given the opportunity to take part in exercises both from the staff member and acting-out individual perspective.
The training also recommends that organizations create policies and procedures to address the following issues:
- What signs should staff look for?
- How will staff be trained to monitor these signs?
- What protocol is to be followed if signs of distress appear?
|
BSM 4.02
Training for personnel authorized to conduct assessment and evaluation of individuals undergoing a restrictive behavior management intervention covers recognizing and assessing:
a. physical and mental status, including signs of physical distress;
b. nutritional and hydration needs;
c. readiness to discontinue use of the intervention; and
d. when medical or other emergency personnel are needed. |
BSM 4.03
Personnel and foster parents who receive training on restrictive behavior management interventions receive a post-test and are observed in practice to ensure competency. |
Post-tests are included in all workbooks and must be graded by the Certified Instructor before completion cards can be issued. Additionally, competency-based testing tools are available to Certified Instructors to assist them in assessing the competency of their staff for all physical components taught within the program. |
BSM 5: Restrictive Behavior Management Interventions
Restrictive behavior management interventions are used only when less-restrictive measures have proven ineffective and in emergency or crisis situations to keep service recipients and personnel safe and protect individuals from harming themselves or others. |
The CPI Crisis Development ModelSM provides staff with verbal responses to acting-out behavior. Nonviolent Physical Crisis InterventionSM techniques should be used only as a last resort when an individual is a danger to self or others. This involves the use of safer, nonharmful control and restraint positions to safely control an individual until he/she can regain control of his/her behavior. |
BSM 5.01
Qualified personnel authorize each restrictive behavior management intervention in accordance with federal or state requirements. |
Because requirements on restrictive behavior management interventions vary from state to state, CPI recommends that each organization develop policies and procedures related to authorization of restrictive behavior management interventions that are in compliance with applicable federal, state, or provincial requirements, as well as with appropriate regulatory bodies such as COA. |
BSM 5.02
Service recipients are monitored continuously, face-to-face, and assessed at least every 15 minutes for any harmful health or psychological reactions. |
The Nonviolent Crisis Intervention® training program contains information about monitoring individuals being restrained and recommends individuals in restraint be assessed continuously for signs of distress. |
BSM 5.03
Procedures address safe methods for escorting individuals to seclusion rooms and placing them in seclusion. |
Nonviolent Physical Crisis InterventionSM techniques include the CPI Transport PositionSM which staff can use as a safer means of transporting individuals to a seclusion room. |
BSM 5.04
Isolation and seclusion rooms conform to existing licensing and/or fire safety requirements and are limited to one person at a time. |
CPI recommends writing isolation and seclusion room requirements into policies and procedures and ensuring the policies and procedures conform to licensing and fire safety requirements. |
BSM 5.05
During a restrictive behavior management intervention staff assess the service recipient’s need for food, water, and use of bathroom facilities and provide access when safe and appropriate. |
CPI strongly recommends that auxiliary team members provide ongoing observation and assessment of the physical and psychological status of the individual in crisis. The individual should be released from a restraint as soon as he/she is no longer a danger to self or others. |
BSM 5.06
Restrictive behavior management interventions are discontinued as soon as possible and are limited to the following maximum time periods per episode:
a. 15 minutes for children aged nine and younger, for all restrictive behavior management interventions;
b. 30 minutes for individuals aged ten and older, undergoing manual or mechanical restraint;
c. 30 minutes for individuals aged ten to thirteen in isolation or locked seclusion; and
d. one hour for individuals aged fourteen and older in isolation or locked seclusion. |
Nonviolent Crisis Intervention® training does not recommend time lengths for episodes of restraint. Restraint is viewed as an emergency situation, only used as a last resort when the individual is a danger to self or others, and only as long as that condition continues. When the person is no longer a danger, the restraint is discontinued. CPI recommends that time limits should not be used, but rather the length of restraint should be solely based on the response of the individual in restraint. |
BSM 5.07
Reauthorization by a physician or another qualified clinician is required for each instance of locked seclusion or mechanical restraint that exceeds the maximum time limit. |
CPI does not teach seclusion or mechanical restraint procedures, but recommends that an individual be released from seclusion or mechanical restraint as soon as he/she is no longer a risk to self or others. |
BSM 6: Documentation and Debriefing
The organization assesses restrictive behavior management incidents and effects to reduce future preventable occurrences and untoward consequences. |
After every crisis situation, CPI recommends that staff involved in the crisis situation hold a debriefing session. The CPI COPING ModelSM outlines the steps for this debriefing process, one of which is to discuss the incident and ways to prevent future occurrences from requiring restrictive behavioral interventions. |
BSM 6.01
The use of restrictive behavior management interventions is documented, including:
a. the clinical justification, use, circumstances, and length of application in the individual’s case record; and
b. names of the service recipient and personnel involved, reasons for the intervention, length of intervention, and verification of continuous visual observation in a log. |
CPI believes that it is important to thoroughly document every instance of restrictive behavior management and intervention. This documentation should be utilized when reviewing individualized behavior plans and should contain information required by federal, state, or provincial laws and information required by regulating bodies such as COA. |
BSM 6.02
Debriefing occurs in a safe, confidential setting within 24 hours of the incident and includes the service recipient, appropriate personnel, the foster parents, and parents or legal guardian to:
a. evaluate physical and emotional well-being;
b. identify the need for counseling or other services related to the incident;
c. identify antecedent behaviors and modify the service plan as appropriate; and
d. facilitate the person’s reentry into routine activities. |
The CPI COPING ModelSM of the Nonviolent Crisis Intervention® training program, incorporates all of these factors into the debriefing process. |
BSM 6.03
Personnel and foster parents involved in the incident are debriefed to assess:
a. their current physical and emotional status;
b. the precipitating events; and
c. how the incident was handled and necessary changes to procedures and/or training to avoid future incidents. |
The CPI COPING ModelSM has two different formats, one for staff debriefing and one for re-establishing Therapeutic Rapport with an individual after he/she has acted out. The CPI COPING ModelSM that is appropriate to the witness or other individuals involved in the incident can be used as a guide to incident debriefing. |
BSM 6.04
Any other person involved in or witness to the incident is debriefed to identify possible injuries and emotional reactions. |
