The use of restraint requires expertise by staff members that is developed through initial and on-going crisis prevention and intervention content and skill-focused training. Hillcrest Educational Centers provides all new staff members with 28 hours of initial crisis prevention and intervention training before the staff are allowed to provide any direct care or service to students at any program site. All new staff receive behavior support training within the first 30 days of hire. Hillcrest Educational Centers utilizes Therapeutic Crisis Intervention as its crisis prevention and intervention model.

Additionally, any staff that provides direct care or service to students are required to attend annual refresher trainings in crisis prevention and intervention totaling at least 12 hours per year.

Written and practical post testing in crisis prevention and intervention is conducted during initial training, as well as once a year during annual refresher training. Staff are required to meet a competency rating of 70% on the initial post testing and 80% on the annual refresher post testing. Staff must demonstrate effective Life Space Interview skills, as well as the safe application of protective and physical intervention techniques in both initial and annual refresher practical post testing.

All restraint training emphasizes the use of individual crisis management plans, relationship building, skill development, verbal interventions, nonverbal communication, behavior support techniques, alternative interventions, and de-escalation techniques as the preferred methods of intervening with a student in crisis.

 

A. Policy
Hillcrest Educational Centers is committed to providing children and youth served with a safe environment and to address their treatment issues by using appropriate and effective therapeutic techniques in the most positive and the least restrictive and aversive manner possible.

Restraint is utilized only as an emergency intervention of last resort after other lawful and less intrusive alternatives have failed or been deemed inappropriate.

Restraint is only utilized when a student’s behavior presents the risk of assault or imminent, serious, physical harm or injury to self or others.

Staff will implement proper use of restraint to prevent or minimize any harm to the student as a result of the use of physical restraint.

If the use of restraint becomes necessary as an emergency intervention of last resort, it will be executed in a cautious manner consistent with the procedures defined within the crisis intervention system(s) in use by Hillcrest Educational Centers.

Prone Restraint shall not be used unless permitted pursuant to 603 CMR 46.03(1)(b) on an individual student basis and only under the following circumstances:

• The student has a documented history of repeatedly causing serious self-injuries and/or injuries to other students or staff;
• All other forms of physical restraints have failed to ensure the safety of the student and/or the safety of others;
• There are no medical contraindications as documented by a licensed physician;
• There is psychological or behavioral justification for the use of prone restraint and there are no psychological or behavioral contraindications, as documented by a licensed mental health professional;
• The program has obtained consent to use prone restraint in an emergency as set out in 603 CMR 46.03(1)(b), and such use has been approved in writing by the Program Director; and,
• The program has documented 603 CMR 46.03(1)(b) 1 – 5 in advance of the use of prone restraint and maintains the documentation.

 

This policy and these procedures are consistent with, and meet or exceed, all associated regulations of the Massachusetts Department of Early Education and Care (DEEC) and the Massachusetts Department of Elementary and Secondary Education (DESE), as well as associated standards promulgated by the Joint Commission.
Hillcrest defines restraint as direct physical contact that prevents or significantly restricts a student’s freedom of movement, in accordance with state regulations. Physical restraint does not include: brief physical contact to promote student safety, providing physical guidance or prompting when teaching a skill, redirecting attention, providing comfort, or a physical escort. Any restraint lasting more than 20 minutes is referred to as an “extended restraint”.
B. Restraint Oversight and Management; Performance Improvement
At all levels of the organization, Hillcrest takes steps to minimize and reduce the use of and duration of restraint while maintaining a safe environment for students and staff. Hillcrest’s Board of Directors and Senior Management Team, which includes the CEO/President, Executive Director and/or Senior Vice President, Program Director, and Department Heads, use the frequency of restraint as one indicator of quality of care and organizational performance.
Hillcrest’s management understands the potential risks associated with these interventions. Therefore, each Hillcrest program site maintains data on the use of all physical interventions on computer software designed by Hillcrest’s Information Services Department. This data describes the use of restraints by student, staff member, and time of day. The data are reviewed regularly by each program’s Improving Organizational Performance Committee and by the Senior Management Team of the agency. Analyses of this data are included in each program’s Improving Organizational Performance quarterly report to administration and the Board of Directors. The information is also analyzed quarterly by the agency’s Information Services department, and each quarter restraint data is submitted to the Massachusetts Department of Early Education and Care (DEEC), as required. Furthermore, use of restraint is reported to the Massachusetts Department of Elementary and Secondary Education (DESE) in accordance with state regulation.
Management staff at all levels review the data to ensure that proper procedures are followed, including the use of alternative interventions, and that the rights, dignity and well-being of students are maintained. Hillcrest staff are only authorized to use protective and physical interventions techniques that are part of the crisis prevention and intervention model that is endorsed for use. The current model in use is Therapeutic Crisis Intervention.
The Program Director/Program Manager/Program Manager of each Hillcrest program serves as the Restraint Coordinator for that site. He/she is ultimately responsible for leading efforts to minimize the use of restraint, and for ensuring that the use of restraint complies with both state regulations and Joint Commission standards. The agency Performance Improvement Coordinator coordinates the efforts at all program sites to reduce the use of restraint and monitor the safety and effectiveness of restraint techniques in compliance with Hillcrest restraint use policy.
The Improving Organizational Performance Committee (IOP) and the Student Treatment and Intervention Committee (STIC) for each site serve as Restraint Review Committees for that site. They share, with the Program Director, the responsibility for oversight and management of behavioral/ physical interventions. STIC membership generally includes, but is not limited to; agency Performance Improvement Coordinator, program administration, members of the clinical department, and direct care staff. Finally, Hillcrest’s Human Rights and Organizational Ethics Committee (HROE) monitors trends associated with possible violations of human rights or organizational ethics.
C. Restraint Authorization Procedures

Restraint is utilized only as an emergency intervention of last resort after other lawful and less intrusive alternatives have failed or been deemed inappropriate.

Restraint is only utilized when a student’s behavior presents the risk of assault or imminent, serious, physical harm or injury to self or others.

Staff will implement proper use of restraint to prevent or minimize any harm to the student as a result of the use of physical restraint.
1. Assessment at Admission

 

 

During the initial clinical assessment following admission to the agency, clinicians evaluate the potential for situations that could require the restraint of the student. Alternatives to restraints are outlined in detail. An Individualized Crisis Management Plan (ICMP) is developed for each student in care. Programs that use Applied Behavior Analysis will also develop comprehensive Behavior Support Plans for each student. These plans are used by staff to support students in behavioral crisis and identify how to effectively respond to meet the needs of the child. They focuses on the prevention of a crisis, as well as the physical techniques that are appropriate for use should the student exhibit behaviors that present a danger to themselves or others.
Any clinical plan to restrain the student as needed must be based on the reasonably anticipated and/or demonstrated behavior of the student within the Hillcrest environment. An LP order to restrain will not be based solely on the student’s restraint history or his/her history of dangerous behaviors. This initial assessment must be thoughtful and clear since it stands as clinical justification for emergency situations when a licensed practitioner may not be present. Additionally, the psychiatrist will evaluate the child’s risk of danger in the initial psychiatric report. When appropriate, this evaluation will include an LP order to restrain, as needed.

 

 

2. Restraint Prevention

 

 

Staff should utilize all individual treatment approaches, interventions and de-escalation techniques geared toward preventing or defusing volatile situations that may require the physical restraint of a student. The development of positive relationships between the student and staff, the recognition of staff own feelings in a crisis, the identification of the students’ needs, the focus on managing the environment, the teaching of skills, and the avoidance of conflict cycles created by staff to exert control are some of the effective ways to prevent a behavioral crisis and avoid the use of a restraint.
3. The Individualized Crisis Management Plan

 

 

Staff are required to utilize the Individualized Crisis Management Plan (ICMP) to effectively respond to the student’s needs in a behavioral crisis. The ICMP is an individualized plan specific to each student that is created at time of admission and updated minimally every three months as part of the treatment plan review process. The first section of the ICMP is a student-centered safety plan and the second section is a staff generated crisis prevention and intervention plan. The ICMP identifies specific student behaviors at each stage of their stress model of crisis and identifies how staff should respond at each stage to meet the needs of the students. The ICMP also contains information regarding the restraint techniques that could be utilized in an emergency should the student present an imminent danger of serious harm to themselves or others and all other interventions have failed. Restraint restrictions based on medical or psychological contraindications are also included. Input on the creation of the ICMP is obtained from the student, their family, and staff within the milieu.
4. Authorization to Initiate a Restraint; Ordering a Restraint

 

 

Only staff who have been trained in and successfully completed the initial 28 hour Therapeutic Crisis Intervention course and who have demonstrated competence in evaluating immediate danger and in applying restraint techniques in a safe and appropriate manner may initiate the restraint of a student.
The decision to initiate the restraint of a student by an authorized staff member is based on the emergent and immediate danger presented by the student to self or others. The order to restrain a student, or to continue a restraint that has been initiated, is made only by a licensed practitioner (LP). The Joint Commission defines a licensed practitioner as an individual who is permitted by law, and by the organization based on job description, to provide student care services within the scope of his/her license and job description.
Orders for restraint or for continuation of a restraint that has been initiated may be verbal or written. Verbal LP orders must be approved in writing within 24 hours. Licensed practitioners have the obligation to review the use of restraint as it relates to students for whom they are responsible.

 

5. Maintaining Student and Program Safety

 

If a student is unwilling or unable to respond to verbal and/or less restrictive interventions and he/she demonstrates behaviors which constitute an immediate danger of serious harm to self or others, authorized staff may initiate a physical restraint as an emergency intervention, even if an LP is not available, and even if the student’s initial clinical assessment or psychiatric evaluation does not contain an order to restrain. Staff are so authorized in order to maintain safe conditions for students and staff.
6. Supervisor and LP Notification; LP Orders for Continuation of Restraint
If a restraint is initiated in response to an emergent and immediate danger presented by a student, the Supervisor or Assistant Supervisor on duty must be contacted as soon as possible and no longer within 5 minutes.
If the restraint must be continued for up to 20 minutes, the restraint then constitutes an extended restraint, and a Licensed Practitioner must be contacted, preferably by the supervisor/assistant supervisor. The LP will assess the situation to determine whether the physical restraint continues to be necessary and proper. If the LP determines that the restraint continues to be necessary and proper, he/she will order the restraint or the continuation of the restraint.
If the LP determines that continuation of the restraint is not necessary and proper, he/she will order the restraint to be discontinued immediately.
If, for any reason, a Licensed Practitioner cannot be reached at or near to the 20 minute point of the physical intervention, an LP must be contacted within 1 hour of the initiation of the restraint to authorize the restraint, and, if necessary, to authorize the continuation of the restraint. As noted, the Licensed Practitioner has the authority to immediately end the restraint should he/she find that the restraint, or its continuation, is unsafe, is not warranted, or that proper procedures are not being followed.
7. Time Limits on LP Orders to Restrain

 

LP Orders to restrain are time limited and are designated as such in the restraint order.
The restraint order for children under the age of 9 is limited to 1 hour.
For children age 9 to 17, the order is limited to 2 hours.
For children aged age 18 and older, the order is limited to 4 hours.

 

8. In-Person Evaluation of the Student

 

An LP will conduct an in-person evaluation of the student in restraint
• within 2 hours of the initiation of the restraint for children age 17 and under;
• within 4 hours of the initiation of the restraint for students age 18 and older.
During the evaluation the LP will work with the student and the staff to identify ways to help the student regain self-control, review alternative intervention approaches, and to provide a new order to restrain, if necessary.
If the student is no longer being restrained when the original verbal order expires, an LP will conduct an in-person evaluation of the student within 24 hours of the initiation of the restraint.

 

9. In-Person Reevaluations; Continuation of LP Orders to Restrain

 

If, for safety purposes, the restraint must extend beyond the original order, the student must receive an in-person reevaluation by a Licensed Practitioner before the LP authorizes the continuation of the restraint. Authorization to continue restraint is based on the student’s continued behavior that demonstrates the need for the restraint to be continued for safety purposes.
Reevaluation of the student in restraint will be conducted:
• every hour for students under the age of 9;
• every 2 hours for students aged 9 to 17;
• every 4 hours for students age 18 and older.
D. Conducting the Restraint; Maintaining Safety

 

1. Maintaining Safe and Appropriate Conditions

 

Hillcrest Educational Centers does not endorse the use of single person restraints. At least two staff members should be involved in restraining a student to maximize control, to maximize the ability to monitor the student for signs of distress and to ensure safety for all. When possible, the student should be restrained on a non-abrasive surface. Staff need to assess the student’s surroundings for safety. Staff must also try to ensure that the area in which the restraint is conducted is clean and that all issues of modesty, visibility to other children and maintaining a comfortable body temperature are addressed.
The restraint must be conducted utilizing the least restrictive technique possible and in as non-threatening and therapeutic a manner as possible, and as gently as possible while still maintaining control over the student’s movement. Care must be taken not to place undue pressure or weight on the student’s joints, the chest, the back, or abdomen. At no time shall the nose or the mouth of the student be obstructed. Only the protective and physical intervention techniques of the current crisis prevention and intervention model may be employed by staff.

 

2. Monitoring

The monitoring of a restraint for physical distress or injury is a conducted in order to ensure the student’s physical safety. Monitoring is conducted by a staff member who is directly involved in conducting the hold or restraint, and who is trained and competent to monitor restraints.
Effective monitoring requires that at least one staff involved in the restraint be able to see the student‘s face at all times during the restraint. Monitoring is conducted as an interim safety measure until a staff member outside of the restraint is able to function as the assessor of the restraint.

 

3. Continuous Assessment of Restraints

Continuous assessment of a restraint, like monitoring, is conducted in order to ensure the student’s safety and to minimize potential harm to a student. Continuous assessment is conducted as soon as possible after the initiation of the restraint and is continues until the restraint is discontinued. Continuous assessment of the restraint is performed by a trained and competent staff. Continuous assessment is conducted by a staff member who is not taking part in the restraint of the student. The assessor must be able to see the student’s face at all times during the restraint. The staff conducting the continuous assessment will assess, as indicated, the type of restraint being employed; signs of injury to student or involved staff; hydration; movement of the extremities; breathing; hygiene and elimination; physical and psychological status and comfort; and readiness for discontinuation of the restraint. The staff conducting the continuous assessment will also try to assist the student in meeting the behavioral criteria for the discontinuation of restraint and restoring safe conditions.
All Hillcrest Educational Centers staff that provide direct care or services to students must receive training in and demonstrate competence in conducting continuous assessments.
4. Discontinuing the Restraint

Restraint is discontinued as soon as it is safe to do so, when the student is no longer an immediate danger to self or others; if the student indicates that he or she cannot breath; or if the student is observed to be in severe distress, such as having difficulty breathing, or sustained or prolonged crying or coughing.
E. Disengaging and Processing
1. Disengaging

 

The procedure for disengaging from any physical intervention includes formally checking the student‘s physical condition.
a) Staff will clearly and directly ask the student if he/she has been injured or is experiencing any physical pain/discomfort.
b) Staff will also observe the student’s facial expressions, movement, and gait for signs of physical injury or pain/discomfort.
A restraint will be discontinued immediately if the student has visible bleeding, fluid coming out of their ears, seizure activity, vomiting, breathing difficulty, fracture or dislocation, is in an unconscious or unresponsive state, or any other indication of a medical emergency. If at any time during restraint a student states that they cannot breathe, staff will immediately discontinue the restraint.
2. Processing

 

Hillcrest Educational Centers endorses the use of processing aimed at understanding the incident, identifying supports that the student needs, identifying and practicing skills for the future, and making relationship repairs needed. The Skills for Life Treatment model and the Therapeutic Crisis Intervention model provide opportunities for processing that includes, but is not limited to the Life Space Interview, Situational Analysis, Collaborative Problem Solving, Skill Coaching Exercises, and the Student Incident Comment Form.
For students who are non-verbal or severely developmentally delayed verbal processing may not occur. Using behavioral momentum, returning the child to the previous activity, or offering alternative activities in accordance with ABA guidelines may be used as a means of addressing problematic behavior without re-escalating the student or providing inappropriate reinforcement for the problematic behavior.
3. Life Space Interview

 

When the student has calmed and returned to baseline behavior, the staff involved in the incident will engage the student in the Life Space Interview process. This is used to support the student in processing through the incident and exploring their reactions to difficult situations as a way to help student gain insight into their feeling and behaviors. The Life Space Interview focuses the student on developing self-regulation skills. Staff and student work collaboratively through the Life Space Interview to connect the student’s feeling with behaviors, to strategies ways to respond to challenging situations in the future and to practice skills.
4. Student Incident Comment Form

 

Within 24 hours of a restraint, the incident will be thoroughly processed with the student through the use of the Student Incident Comment Form. During the processing, the student will be offered the opportunity to provide feedback and or register concerns in writing about the incident and the way it was managed, including but not limited to the restraint itself.
If the student chooses to provide such feedback or register concerns, he/she will do so in writing on a Student Incident Comment Form that will be attached to the original restraint report form. If the student is unable to write their concerns in a coherent or legible manner, a staff member can assist them in scribing the student’s comments on the form. If a student refuses to complete a Student Incident Comment form, a second attempt must be made by a supervisor to encourage the student to complete the form. The staff assisting the student in completing the Student Incident Comment Form may not be the staff member involved in the restraint that occurred in the incident.
Addressing the questions on the Student Incident Comment Form directly may not be possible in the case of severely developmentally delayed students. The forms will be completed, whenever possible, congruent with the student’s ability to process the content of the form.
5. Debriefing

 

Hillcrest believes that debriefing incidents is an important measure to gain insight into the cause of the incident and to identify prevention strategies to reduce future occurrences. Debriefings are conducted by supervisors and ideally should be conducted with individual staff member, but may also be conducted with groups of staff members. Debriefings serve as a post crisis response in which staff can assess their response to an incident and explore ways that they can improve their response and minimize frequency of behavioral crisis and the use of restraints.
Debriefings must be conducted for the following:
a) Any floor restraint.
b) Any restraint lasting 20 minutes or more (extended restraint)
c) Any intervention resulting in injury to student or staff.
d) Any critical incident including, but not limited to:
e) AWOL
f) Sexually intrusive behavior
g) Fire-related incidents
h) Major property destruction
i) Serious self-harm behaviors/statements
j) Any other significant event a supervisor or administrator deems appropriate.

 

All debriefings will be kept on file at a central location on campus so they can be tracked for type, frequency and result, and so they may be readily available for reference. Administrators must oversee debriefing to monitor volume, quality, progress, patterns of concerns, style of supervision, etc. IOP committees will utilize data from debriefing tracking to assess its overall effectiveness and impact on treatment and performance.
Debriefing offers us a unique opportunity to learn from negative behaviors or unsafe events, and if done properly, provides staff with a greater sense of insight, skill, and support. In essence, the benefits of debriefing improve our ability to help students and generally create a safer, calmer treatment environment.

If the Program Direction directly participated in the restraint, a duly qualified individual designated by the Execustive Director shall lead the review team’s discussion. The Program Director shall ensure that a record of each individual student review is maintained and made available for review by the Department or the parent, upon request.

 

F. Documenting Restraints

 

1. Restraint Reports

 

Physical Restraints are documented via written report on an approved Hillcrest . The contents of report, required by 603 CMR 46.06(2) and (3), shall include:

• The name of the student; the names and job titles of the staff who administered the restraint , and observers, if any; the date of the restraint; the time the restraint began and ended; and the name of the Program Director or designee who was verbally informed following the restraint; and, as applicable, the name of the LP who approved continuation of the restraint beyond 20 minutes pursuant to 603 CMR 46.05(5)(c).
• A description of the activity in which the restrained student and other students and staff in the same room or vicinity were engaged immediately preceding the use of physical restraint; the behavior that prompted the restraint; the efforts made to prevent escalation of behavior, including the specific de-escalation strategies used; alternatives to restraint that were attempted; and the justification for initiating physical restraint.
• A description of the administration of the restraint including the holds used and reasons such holds were necessary; the students behavior and reactions during the restraint; how the restraint ended; and documentation of injury to the student and/or staff, if any, during the restraint and any medical care provided.
• Information regarding any further action(s) that the school has taken or may take, including any consequences that may be imposed on the student.

A restraint under 20 minutes must be documented by the use of a Restraint Report Form by the staff member who initiated the restraint. Extended restraints (20 minutes or more) must be documented by the use of an Extended Restraint Report Form by the staff member who initiated the restraint. Restraint report forms contain the following information:

• Student name
• Name and title of all staff involved
• Name and title of all observers, if any
• Date of the Restraint
• Time the restraint began and ended
• Total number of minutes  in restraint
• Name of the Program Director, or designee, who was verbally informed following the restraint
• Name of the LP who approved continuation of restraint beyond 20 minutes and name of staff receiving the order for extended restraint
• Specific location
• A description of the activity in which the restrained student and other students and staff in the same room or vicinity were engaged immediately preceding the use of physical restraint
• The behavior that prompted the restraint
• The efforts made to prevent escalation of behavior, including the specific de-escalation strategies used; alternatives to restraint that were attempted
• Justification for initiating the physical restraint
• Description of the administration of the restraint including the holds used and reasons such holds were necessary
• The student’s behavior and reactions during the restraint
• How the restraint ended
• Documentation of injury to the student and/or staff, if any, during the restraint and any medical care provided
• Information/description regarding any further action(s) that the school may take, including any consequences that may be imposed on the student. (e.g. processing)
• Indication of completion of staff and student debriefing
• Documentation of the continuous assessments of a restraint. If the restraint is continued for more than 2 hours, an additional PI form must be attached for documentation of the assessments.
• Information regarding opportunities for the student’s parents to discuss with school officials the administration of the restraint, any consequences that may be imposed on the student, and any other related matter.

The Program Director, or designee, shall maintain an on-going record of all reported instances of physical restraint which shall be made available for review by the parent or the Department, upon request.

Each Hillcrest program site maintains data on the use of all physical interventions on computer software designed by Hillcrest’s Information Services Department. This data describes the use of restraints by student, staff member, and time of day.

2. Monitoring for Multiple Restraints

 

The Program Director, or designee, shall conduct a weekly review of restraint data to identify individual students who have been restrained multiple times during the week. If such students are identified, the Program Director, or designee, shall convene one or more review teams as they deem appropriate to assess each student’s progress and needs. The assessment shall include at least the following:

• review and discussion of the written reports submitted in accordance with 603 CMR 46.06 and any comments provided by the student and parent about such reports and the use of the restraint;
• analysis of the circumstances leading up to each restraint, including factors such as time of day, day of the week, antecedent events, and individuals involved;
• consideration of factors that may have contributed to escalation of behaviors, consideration of alternatives to restraint, including de-escalation techniques and possible interventions, and such other strategies and decisions as appropriate, with the goal of reducing or eliminating the use of restraint in the future;
• agreement on a written plan of action by the program.

The Program Director, or designee, shall conduct a monthly review of school-wide restraint data. This review shall consider patterns of use of restraints by similarities in the time of day, day of the week, or individuals involved; the number and duration of physical restraints school-wide and for individual students; the duration of restraints; and the number and type of injuries, if any, resulting from the use of restraint. The Program Director, or designee, shall determine whether it is necessary or appropriate to modify the school’s restraint prevention and management policy, conduct additional staff training on restraint reduction/prevention strategies, such as training on positive behavioral interventions and supports, or take such other action as necessary or appropriate to reduce or eliminate restraints.

 

On an ongoing basis, each program will identify a designee to monitor student restraints and determine which students have required 5 or more restraints in the last 7 day review period. If a student has required 5 or more separate instances of physical restraint during seven (7) consecutive days, the program designee will alert the program administrators. The administrators, along with other members of the treatment team as possible, will conduct a clinical and behavioral review of the student’s needs in order to determine whether the student’s treatment plan should be altered, and/or whether a Special Team meeting is indicated. The program designee will be responsible for inviting the student’s parent/guardian to this review. The results of this review, and any such changes in the treatment plan, must be documented in the case record accordingly.

 

Annual Restraint Data is submitted to DESE through WBMS.

 

3. Parent/Guardian Notification of Restraint

 

The Program Director, or designee, will make reasonable efforts to verbally inform the student’s parent/guardian of the restraint within 24 hours of the even and, within three working school days, shall notify the parent/guardian by written report sent either to an email address provided by the parent/guardian for communication about the student, or by regular mail postmarked no later than three school working days. If the school/program customarily provides a parent/guardian of a student with report cards and other necessary school-related information in a language other than English, the written restraint report shall be provided to the parent/guardian in that same language. The Program Director, or designee, shall provide the student and/or the parent/guardian an opportunity to comment on the use of the restraint and on information in the written report.

 

4. Notification of Injury From Restraint

 

The Director of Quality Assurance, Program Director, or designee, shall report all restraint-related injuries to the Department. When a physical restraint has resulted in an injury to a student or program staff member, the program shall send a copy of the written report required by 603 CMR 46.06(4) to the Department postmarked no later than three school working days of the administration of the restraint. The program shall also send the Department a copy of the record of physical restraints maintained by the Program Director, or designee, pursuant to 603 CMR 46.06(2) for the 30-day period prior to the date of the reported restraint. The Department shall determine if additional  action by the program is warranted and, if so, shall notify the program of any required actions within 30 calendar days of receipt of the required written report(s).

Hillcrest Educational Centers conducts various types of agency trainings and development opportunities on an ongoing basis. These include, but are not limited to the following:

♦ New Staff Back:

Staff participate in New Staff Back after their third month of employment. The purpose of this training program is to provide ongoing learning opportunities, self-assess skill level in key areas, identify job challenges and potential strategies for dealing with them, and to evaluate their employment experience and the services provided by the campus/site at which they work. All direct care staff must participate in New Staff Back. Program Directors or their designee attend and participate in a portion of the training program. This program is conducted quarterly.

♦ Grand Rounds:

All staff are invited to participate in Ground Rounds training. The purpose of this training is to discuss in detail specific treatment programs on a case by case basis. Additionally, this forum is used to deliver in depth information on diagnoses related to the children served at Hillcrest Educational Centers.

♦ Quarterly Management Professional Development:

All management (Assistant Supervisors and above) are required to attend quarterly management professional development. These training sessions are utilized deliver organizational announcements (i.e. strategic planning information, core measurements, policy and procedure changes), campus/site updates, mandated training, and managerial professional development training.

♦ RCYCP Certification:

Hillcrest Educational Centers offers its Youth Development Professionals and Teacher Assistants an opportunity to earn a national credential in child and youth care work. The Residential Child and Youth Care Professional Certification is a national certification program developed by the University of Oklahoma. Obtaining certification requires 42 hours of instructional time, 3 hours of course review, and participating in an on line proctored examination in which a competency rating of 80% or better is required to obtain certification. This certification is optional for Youth Development Professionals and Teacher Assistants, but is a job requirement of all Assistant Supervisors and Supervisors.

♦ All Agency Training:

Hillcrest Educational Centers offers professional development opportunities to its staff in the form of All Agency Trainings. These events are held at least once per year and focus on current developments in the field of human services, education and treatment. Noted individuals in their respective fields facilitate these learning experiences.

 

 

 

 

A. Orientation Required Topics

The following topics are based on federal, state, accreditation, and agency requirements. These topics must be covered in the Hillcrest Education Centers orientation process in either New Staff Orientation or On Site Orientation.

1. Characteristics of Children Served
2. Symptoms and Behavioral Signs of Emotional Disturbances
3. Symptoms of Drug Overdose, Alcohol Intoxication, or Medical Emergency
4. Emergency and Evacuation Procedures
5. Preventing Abuse and Neglect/ Procedures for Reporting Abuse and Neglect
6. First Aid, CPR, and AED Initial Certification
7. Universal Precautions and Infection Control/Bloodborne Pathogens
8. Medication Policies/Side Effects and Special Precautions/Antipsychotic Medications (must be trained by an RN or MD)
9. Runaway Policy
10. Behavior Management Plans and Treatment Intervention Procedures
11. Therapeutic Crisis Intervention (must provide 28 hours of training and include skill demonstration post testing and written post testing with 70% accuracy)
12. The Organizations Mission and Goals
13. The Role of the Staff in the Growth and Development of the Student
14. The Relationship of the Staff and the IEP
15. Massachusetts Curriculum Frameworks
16. MCAS and Alternative Assessments
17. Transportation Safety
18. Student Records and Confidentiality
19. Civil Rights Responsibilities
20. Reporting of Safety and Quality of Care
21. Supervising and Monitoring Treatment Procedures and Plans
22. Performance Improvement and Safety Improvement Approaches and Methods
23. Fire Safety (response plan, use of extinguishers, drills, detection equipment, and secondary egress)
24. The Policies and Procedures of the Organization
25. Specific Job Duties and Responsibilities
26. Cultural Diversity and Sensitivity
27. Process Used to Address Ethical Aspects of Care
28. Knowledge of Growth and Development of Children and Youth
29. Hazardous Chemical in the Workplace
30. Harassment in the Workplace
31. Skills for Life
32. Professional Standards/Boundaries
33. Incident Report Writing
34. Physical Intervention Report Writing
35. Continuous Assessment of Physical Intervention
36. Bullying Prevention and Intervention
37. Child Development
38. Organizational Structure
39. Administrative Responsibilities at Program Sites

1. Annual Required Training Topics

All staff (including full time, part time, on call, new employees, interns, and volunteers) must participate in a minimum of 24 hours of training per calendar year.

The following topics are based on federal, state, accreditation, and agency requirements. These topics must be covered in the Hillcrest Education Centers’ on going mandatory training program:

1. First Aid, CPR, and AED Certification (every two years)
2. Therapeutic Crisis Intervention training for a total of 12 hours annually must be comprised of the following:

Therapeutic Crisis Intervention Recertification – must include written post testing with 80% accuracy, practical post testing in Life Space Interview, protective interventions, and restraint techniques and provide 6 hours of training in the following: needs and behaviors of students served, individualized crisis management planning, building relationships, avoiding power struggles, de-escalation techniques, alternatives to restraint, thresholds for restraint, physiological impact of restraint, protective and physical intervention techniques, debriefing procures, and conducting life space interviews)

Therapeutic Crisis Intervention Refresher Training- a minimum of three 2 hour refreshers must be attended for a total of 6 hours of annual refresher training in the following: needs and behaviors of students served, individualized crisis management planning, building relationships, avoiding power struggles, de-escalation techniques, alternatives to restraint, thresholds for restraint, physiological impact of restraint, protective and physical intervention techniques, debriefing procures, and conducting life space interviews)

Therapeutic Crisis Intervention (TCI) Training of Trainers (TxT) Program: This intensive five-day TCI train-the-trainer certification course provides organizations with the opportunity to develop an in-house training capacity in the TCI curriculum. Participants will develop knowledge, skills, and attitudes in the TCI curriculum necessary to deliver the training to staff in their organizations. Participants will have the chance to participate, practice, and receive feedback in conducting activities to gain immediate training experience. Training techniques such as role playing, leading small group discussions, using guided fantasies, conducting practice sessions, and using audiovisual aids will be demonstrated. Participants will receive all the necessary materials to conduct the TCI training program in their agency. Participants will be able to:

• Proactively prevent and/or de-escalate a potential crisis situation with a child or young person
• Manage a crisis situation in a therapeutic manner, and, if necessary, intervene physically in a manner that reduces the risk of harm to children and staff
• Process the crisis event with children and young people to help improve their coping strategies
• Effectively deliver TCI training in their agencies

3. Emergency Response (must include, but not limited to, training on emergency responses, power outages, severe weather conditions, evacuation procedures, staffing problems, must detail specific staff roles and responsibilities in emergency situations)
4. Fire Safety and Use of Extinguishers
5. Transportation Safety
6. Universal Precautions and Infection Control/Bloodborne Pathogens
7. Medication Policies/Side Effects and Special Precautions/Antipsychotic Medications (must be trained by an RN or MD)
8. Runaway Policy
9. Civil Rights Responsibilities
10. Preventing Abuse and Neglect/ Procedures for Reporting Abuse and Neglect
11. Needs of the Population Served
12. Knowledge of Growth and Development of Children and Youth
13. Cultural Diversity and Sensitivity
14. Student Records and Confidentiality
15. Behavior Management
16. Incident Report Writing
17. Physical Intervention Reporting
18. Continuous Assessment of Physical Interventions
19. Policies and Procedures
20. Professional Standards
21. Harassment in the Workplace
22. Skills for Life
23. Bullying Prevention and Intervention
24. Child Development

C. Other Required Training Topics

The following topics must be trained to individuals designated by specific job duties and responsibilities:

1. Medication Administration (must be completed prior to administering medications)
2. Screening, Assessing and Managing Pain
3. Massachusetts Curriculum Framework (annual training requirement for educational staff)
4. MCAS and Alternative Assessment (annual training requirements for educational staff)
5. Prohibited Abbreviations (annual training requirement for medically licensed staff and medical providers)
6. Training occurs when job duties change
7. Hazardous Chemical in the Workplace (whenever a new physical or health hazard is introduced into work environment)
8. Harassment in The Workplace (additional training must be provided to any person assuming a supervisory or managerial role)
9. Asbestos Awareness (maintenance and housekeeping staff)
10. Pool Supervisor Safety Training (requirement for staff designated as individuals in charge of supervision and safety of pool usage on site)

RATIONALE

Hillcrest Educational Centers Training and Staff Development program provides a learning and development process that promotes quality of programs, student and family successes, and professional and personal growth of staff. The training delivered meets or exceeds federal, state, and agency compliance requirements, as well as accreditation standards.

NEW STAFF ORIENTATION

All staff (including full time, part time and on call staff) are required to attend and successfully complete New Staff Orientation prior to assuming their respective duties and responsibilities of their position at Hillcrest Educational Centers. Interns, volunteers and others who work in the program will attend all or portions of New Staff Orientation as determined by the extent of their interactions with students, as well as their respective roles within the agency.

Staff may not be assigned any direct care duties with students until they have participated in and successfully completed all aspects of the New Employee Orientation. Successful completion requires participation in New Staff Orientation in its entirety including being present for all training delivered, completion of all on line orientation coursework, and meeting all competency ratings on written and practical assessments given.

New Staff Orientation is intended to welcome the employee and provide them with an introduction to the organization and the services it provides, as well as comply with the training and development requirements of federal and state regulatory and licensing agencies and accreditation bodies.

New Staff Orientation is comprised of five main components including All About Hillcrest Educational Centers, Skills for Life Treatment Model Training or Introduction to Autism and Applied Behavior Analysis, Therapeutic Crisis Intervention Certification, First Aid, CPR, and AED Certification and New Staff Orientation On Line.

♦ All About Hillcrest Educational Centers: This component includes training on the mission, vision and values of the agency, a description of programs and services, an overview of employee related topics, as well as federal, state, accreditation, and agency compliance topics.

♦ Skills for Life Treatment Model Training: This component delivers 7 hours of training in the Skills for Life Treatment Model focusing on trauma informed care and collaborative problem solving including, but not limited to the philosophy of a trauma informed care and collaborative problem solving approach, the basics of trauma informed care, the basics of collaborative problem solving and tools for the trauma informed care and collaborative problem solving toolbox. All staff attending New Staff Orientation participate in this training with the exception of staff hired for the Autism Program.

 ♦ Introduction to Autism and Applied Behavior Analysis: This component delivers 7 hours of training focusing on, but not limited to an introduction to autism and Applied Behavior Analysis, communication skills of children with autism, data collection and reinforcement, educational programming with individuals with autism, prompting and errorless teaching, discrete trial, behavior chains and task analysis, and teaching activities of daily living. All staff hired for the Autism Program participate in this training.

 ♦ Therapeutic Crisis Intervention Certification: This component delivers 28 hours of training in Therapeutic Crisis Intervention including, but not limited to, individual crisis management plans, relationship building, skill developing, verbal interacting and intervention and physical interacting and intervention, de-escalation techniques, and alternatives to restraint. Certification requires staff to successfully complete all 28 hours of training, pass a written post test with a competency score of 70% or better and pass two practical post tests, one in the Life Space Interview process and one in all protective interventions and physical interventions.

♦ First Aid, CPR, and AED Certification: This component provides all new employees with an American Red Cross certification in 1^st Aid, CPR and AED. Staff must meet the minimum competency standards established by the American Red Cross for all written and practical assessments.

♦ New Staff Orientation On Line: This component provides all new employees with training in federal, state, accreditation, and agency compliance topics delivered through the agency’s Learning Management System via on line learning modules. All modules require post testing with a competency score of 80% or better.

♦Behavior Support Training: This takes place annually within the first month of the new school year.

 

ON SITE ORIENTATION

Following New Staff Orientation, all staff participate in an eight hour on site orientation program on the campus/site to which they are assigned. The purpose of onsite orientation is to acquaint the new staff with the physical setting of the site, introduce them to key on site personnel, review safety procedures specific to the site, provide a description of the programs and services, discuss the population served, review the routines and schedules of the site, deliver additional compliance training topics, and cover the specific duties and responsibilities of the new staff’s respective jobs.

ON SITE OBSERVATION

Following New Staff Orientation, all staff participates in an On Site Observation lasting the length of a normal workday or normal work shift. This On Site Observation is in addition to pre-employment on site observation that all staff participate in as part of the interview and hiring process. On Site Observation following New Staff Orientation, allows the new staff to observe their work environment after receiving the initial training, giving them an additional opportunity to observe and ask questions now that they have some background, knowledge, and skills and have been oriented to the organization.

 

At HEC we believe that people want to succeed and will do so if they can. We also believe then, that if they are not doing well there is something interfering in their ability to be successful.

At HEC we believe that a lack of skills (distress tolerance, relationship, mindfulness, emotional regulation), a lack of resources (community support, cognitive capacity, brain injury, etc.), and/or an environment that overwhelms the person’s skills and resources are what interfere with a person’s success. In order to create success, the incongruence between the person (skills and resources) and the environment (supports and demands) must be repaired.

As humans we are all in a developmental process, with strengths and limitations based on our unique developmental capacities. When the person and others in the environment know what skills, resources and limitations a person has, everyone involved can work together to overcome these limitations, and the environment can simultaneously modify its demands, supports, and expectations to help make success possible.

Hillcrest Educational Centers (HEC) is founded on the values of providing unwavering compassion, mobilizing second chances for children, and believing that change is always possible. Today’s intervention model builds upon this foundation, incorporating principles of Collaborative Problem Solving, Trauma Informed Treatment, and Applied Behavior Analytic services. The HEC treatment model also recognizes the parallel process at work between staff, students, and family, and incorporates this process in the model. We ask all citizens of the Hillcrest community, both staff and students, as well as families at home, to take part in this model, beginning with abiding by the HEC Community Values.

HEC Community Values 

Safety– At HEC we endeavor to maintain safety by creating an atmosphere of predictability, fairness, accountability, and peacefulness.

Respect– At HEC respect means recognizing what is important to us and to others, acknowledging how our actions and decisions affect our lives, the lives of others, and the community, and considering these in our decision making process.

Empathy– At HEC, we prioritize understanding others, what they need, and what gets in the way of their goals, so we can be better helpers, peers, coaches, employees, supervisors, friends, and community members.

Realistic Expectations– At HEC, we modify our expectations within the environment whenever possible based on the individual’s needs in order to create an environment in which they can be successful.

Self-care–

At HEC, we recognize that everyone gets overwhelmed at times. Through proactive self-care, identifying specific vulnerabilities, and building skills and supports, we can minimize our distress and better help others and ourselves through difficult times.

Collaboration/Teamwork- At HEC, the student, their family, support system, and the entire HEC community are committed to working together to bring the greatest success.

Personal Enrichment– At HEC, new opportunities to learn and grow are everywhere. No one is good at everything, but through trying new things, growth and eventually mastery can occur.

In order to ensure that the above values are clear and maintained in the campus environment, each campus may have a related set of expectations for its campus community.

On admission to HEC, students are assessed by all departments represented by the treatment team. Departments include, but are not limited to: clinical, residential, educational, vocational, and medical. Based on individual need, the treatment team will choose either a Skills for Life (SFL) or Applied Behavior Analysis (ABA) approach to student treatment. Regardless of the methodology, HEC treatment maintains the same core principles.

A. Core Principles of HEC Treatment 

Collaborative Problem-Solving (CPS) 

At the core of the HEC treatment model is the belief that problematic behaviors are displayed as adaptations to situations where coping skills and resources are overwhelmed. In order to intervene effectively, we must help individuals understand and recognize the impact of their own behavior, identify the related skill/support deficits, and assist the individual to develop needed skills and resources to manage the situation more effectively in the future.

The primary intervention approaches guided by the CPS philosophy are skills assessment, skills development, and a collaborative problem solving process that leads to a mutually acceptable plan for working things out. HEC community members must practice the steps of collaborative problem solving in their interactions with others. This process involves three steps: 1) empathize, 2) define the problem, 3) invite the other person to problem-solve. Potential solutions  must be brought to interdisciplinary team meeting for discussion and approval prior to implementation.

In order for the collaborative treatment approach to work, the student, and as approved, the family or community members connected to the well-being of a student, as well as HEC staff, must understand behavior from a skills perspective, provide formal and informal opportunities to develop lagging skills, and have collaborative input into all aspects of the treatment and problem-solving process. Students should attend, or if unwilling/unable, have input into the CTP, special and emergency team meetings, as well as other venues when important decisions/problems are being considered.

Trauma Informed Care (TIC) 

When the environment is very overwhelming, as is often the case when a person experiences trauma, attachment disruption, loss, domestic violence or abuse, this can result insignificant impact on the development of the person’s skills and resources. Exposure to those who have experienced these events has impact on others in the community. A trauma informed environment requires an understanding of trauma and considers its effects, at the personal, individual, and societal levels.

As trauma and loss are, at their core, violations of interpersonal connection, the HEC community focuses on developing healthy relationships with others. Within these healthy relationships, motivation, healthy sense of self and connections to others and the community are developed. Other primary intervention approaches from the TIC philosophy include psycho-education about trauma/vicarious trauma and its effects, understanding the influence of individual trauma histories, making meaning from these difficult experiences, developing self-awareness, developing skills and resources to manage more effectively, and proactively planning for safety.

Applied Behavior Analysis 

When indicated, HEC uses Applied Behavior Analysis  as the method of treatment for individuals with developmental disabilities or behavioral difficulties associated with a number  other medical or psychiatric conditions.. Behavior analysis is the scientific study of behavior. Applied Behavior Analysis (ABA) is the application of the principles of learning and motivation, and the procedures and technology derived from those principles, to the solution of problems of social significance, including the education and treatment of individuals with .varying difficulties including Autism.   Applied Behavior Analysis has been empirically validated as an effective treatment for reducing challenging behavior and teaching adaptive skills. Educational and clinical programming relies on the principles of reinforcement, extinction, shaping, secondary and generalized reinforcement, and chaining, to teach appropriate skills in a variety of areas including communication, discrimination, daily living skills, academics, vocational skills and leisure skills.

Students appropriate for ABA services are those who have not benefited from traditional clinical interventions. Some students under an ABA treatment model may not have the insight, social skills, communication skills, or the developmental capabilities to engage in either individual or group therapies. Those students receiving ABA programming will have a Behavior Support Plan written in lieu of a Comprehensive Treatment Plan (CTP) and will receive their clinical services from a Board Certified Behavior Analyst (BCBA). All students who are capable will participate in the development of their educational and behavioral programs.

Integrated Treatment Domains 

HEC students’ treatment progress and resulting treatment phase are determined by accomplishing certain landmarks of growth and development in the areas of building connections with others, developing competency (utilizing skills), and becoming a good citizen, as well as other domains as determined by the specific campus. These core treatment goals for each treatment domain and phase are detailed and consistent across campuses. Progress in these domains is measured by specific task completion, as well as other meaningful measures as determined by the campus.

 

Skills Assessment and Development 

Developing a comprehensive understanding of each individual, their strengths and challenges, and the specific influences to their difficulties is a primary and ongoing component of treatment. The Assessment of Lagging Skills and Unsolved Problems (Greene & Ablon), along with supporting assessment tools, are utilized to facilitate this process, and to guide the treatment/intervention planning for each student. Through this process a thorough understanding of strengths, resources and limitations is acquired and a plan to help develop skills and resources while not overwhelming one’s resources can be initiated.

The core skills that are focused upon throughout all HEC campuses include: independent living/functional skills, academic skills, and the skills identified in Dialectical Behavioral Therapy (DBT) (Linehan): Mindfulness, Emotional Management, Distress Tolerance and Interpersonal Effectiveness.

Safety/Self-care Planning 

Each member of the HEC community completes a plan to help them and others recognize when they may be more vulnerable to getting overwhelmed and what to do about it if it occurs. The plan utilizes previous learning from skills assessment, trauma assessment, and the situational analysis processes, to communicate triggers, high risk situations, cues, coping skills and resources.

Accountability and Recognizing Successes 

The HEC Skills for Life model minimizes the use of reward and punishment as a means to gain compliance. Instead, the collaborative and respectful relationships between members of the community are seen as the primary change agents. Recognizing individual strengths and developing them into areas of ongoing success and competency lead to lasting change.

Consequences may be used to help create an environment of accountability. They may be used only when directly connected to a violation of the HEC Community Values or campus rules based on those values. They may be instituted when necessary to create or maintain safety or in effort to bring about internalization of a value or the development of skills. Consequences must therefore be meaningfully connected to the violation, should include a Life Space Interview to facilitate understanding, and a strategy to foster connections with others. Whenever possible, consequences should include the input of the person receiving them and any person affected by the act/event and includes an act of reparation for the effects on others. Consequences are not to be time or punishment-based (example: 72 Hour or “LOP” loss of privilege, restriction). Behavioral problems not related to the HEC Community Values must be managed through the relationship or more formally through Collaborative Problem Solving based interventions detailed previously.

Strengths and successes, even during times of problematic behavior, should be recognized and emphasized whenever possible. Strengths will be listed on each student’s treatment plan as well as their tracking logs. The students and their HEC community of support will be encouraged to recognize and indicate their use on the tracking log on an ongoing basis.

Rewards for good work, productivity and success are a wonderful part of life. Everyone works harder when a desirable outcome will be the result. Rewards are used in these ways within the HEC community as well. However, natural and relationship based (recognition from or time with a caring person, more options for recreational time) rewards should be prioritized. Rewards are never to be used as a means to coerce or bribe.

B. Cruel and Unusual Punishment 

HEC prohibits the use of all cruel and unusual punishment and coercion including, but not limited to, the following: 

1. Any type of physical hitting.

2. Excessive physical exercise or assignment of unduly physically strenuous or harsh work.

3. Causing a student to take an uncomfortable position or repeat physical movements.

4. Group punishments.

5. Ridicule, humiliation, verbal abuse, threatening statements or statements made to elicit fear.

6. Denial of essential program services.

7. Withholding of any meal, snack or earned reinforcement.

8. Denial of sleep or opportunities for exercise.

9. Denial of shelter, clothing, bedding or bathroom facilities.

10. Excessive withholding of emotional response or stimulation.

11. Use of non-approved physical or chemical restraint; or the use of any mechanical restraint.

12. Exclusion from entry to the residence.

C. Treatment Plan Components

The components of a Treatment Plan minimally include: 

1. Positive teaching strategies and programs intended to teach skills.

2. Individualized treatment with reasonable changes or accommodations in the environment to accommodate individual needs.

3. Strategies and techniques intended to extinguish maladaptive behaviors such as self-injury, aggression, excessive self-stimulation or non-compliance, emphasizing replacement behaviors and skills.

4. Interventions to promote change and growth of cognitive and emotional patterns.

5. A plan, with specific strategies, to aid the student toward moving to a less restrictive setting.

Assessment Policy for Residential Campuses 

Hillcrest utilizes an extensive assessment process during the admission process, during the diagnostic period (first 45 days of treatment), and ongoing. Throughout all of our assessments, the student, the student’s family and/or guardian, referring agencies, and the HEC treatment team are utilized in order to gather data and determine treatment interventions/services. The following is a summary of these processes.

Admission process 

Intake Assessment 

Before a student is admitted to an HEC program, an Intake Assessment and a Preliminary Treatment Plan (PTP) are completed by a member of the clinical staff and then distributed to the campus staff. The information gathered and relayed to staff includes information provided in the admission packet, information gathered through the Admissions Interview (see ICF), and when possible, direct communication with the family and referring agencies.

To ensure that staff are adequately prepared to work with the student, the following information is included in the Intake Assessment:

• Student identification, legal guardian, relevant family information, and current intellectual functioning
• Student Strengths
• Reason for Referral
• Significant Behavior Problems:
  • Physical Aggression
  • Verbal Aggression
  • Sexual Behaviors
  • Firesetting Issues
  • Self-Harm Behaviors
  • Elopement/Runaway
• Substance Abuse
• Delinquent/Status Offenses
• Significant Medical Problems
• Current Medications
• Current Diagnosis

Preliminary Treatment Plan 

To ensure the safety of the student, the safety of others, and for developmentally and culturally appropriate treatment during the assessment process, the Preliminary Treatment Plan includes goals that focus on the following areas:

• participation in the assessment and orientation process
• participation in counseling/mental health services
• participation in individual and group therapies
• participation in medical/health assessments
• completing a family contact plan
• participation in recreational activities
• developing and practicing age appropriate social skills
• reducing the occurrence of high risk behaviors

Each goal has treatment objectives that are appropriate for the student and his/her specific needs. Specific to reducing high risk behaviors, the high risk behaviors identified in the Intake Assessment, basic parameters for the use of therapeutic physical intervention are included in the Preliminary Treatment Plan. These parameters include articulating that physical intervention may only be used after all other interventions have been attempted and are ineffective, when a student is presenting an imminent risk to self or others, or when by evading staff, a risk to self or others is imminent.

It should be noted that participation in this process is program specific and that not all students may possess the skills to participate as articulated above. Students having significant cognitive impairments may not be skilled enough to participate in verbal therapies. In such cases functionally appropriate alternative behaviors are taught proactively as a means of providing students with alternative behaviors that can be prompted and reinforced when used in crisis situations.  

Individualized Crisis Management Plan 

Additionally, a very detailed plan for ensuring the safety of the student and managing high risk behaviors is completed upon admission. This plan, entitled the Individualized Crisis Management Plan or ICMP, is rooted in utilizing a trauma informed approach to treatment. The ICMP is a component of Therapeutic Crisis Intervention (TCI). Hillcrest’s ICMP is a 2 page document that incorporates input from the student, the student’s family, guardian, funding agencies, and the HEC treatment team developed within the first 24 hours after admission. All parts of this process will utilize the input of the family, guardian, and funding agencies as well as student records as current interactions with the student.

The goal of the first page of the ICMP is to ensure the student’s input is immediately utilized in his/her treatment. It utilizes questions posed to the student to identify the student’s goals, strengths, and interests. It includes questions posed to the student that help identify the student’s triggers, sore spots, and situations that overwhelm their coping skills. Page 1 also identifies skills, resources, and interventions that the student finds helpful or not helpful.

The second page of the ICMP provides important information about the student’s current and historical high risk behaviors and high risk situations. Important safety information such as medical concerns, trauma triggers, current diagnoses, and current medications is included. This page then identifies individualized interventions to utilize when the child presents at different stages in the stress model of crisis. Page 2 also identifies very specific parameters for the use of physical intervention and what types of physical intervention are permitted.

Behavior Support Plans

Treatments based on upon the results of FBA’s  referred to as the Behavior support plan will employ strategies designed to increase functionally appropriate alternative responses, using the least restrictive procedures possible. All such procedures should be reinforcement based, using known preferences of the child.A behavior support plan is a very detailed intervention plan designed to render the most challenging behaviors exhibited by the child useless. Behaviors targeted for intervention are those that present the most risk to child and staff, or those responses that are significant enough that they hinder learning or further stigmatize the child.  This document is split into two main sections each providing specific instruction on how to teach, reinforce, and redirect student behavior.  

The Pro-active section of the BSP is designed to inform staff on what appropriate replacement behaviors should be prompted and reinforced when exhibited by the child.   Following this process will establish new patterns of behavior for the child, teaching them that exhibiting these behaviors will serve the same purpose as their previously inappropriate behavior, and also teach them that they will receive positive attention and reinforcement when these desirable behaviors are exhibited.

The Reactive portion of the behavior support plan is a supportive process designed to tell staff how to redirect the child when precursor behavior is observed that may lead to more challenging behavior.  If the child accepts redirection they are praised for their appropriate behavior and staff encourages the child to re-engage in their regularly scheduled activities.  If redirection is not successful and the child continues to escalate, the staff are instructed in how they should proceed if the need to interrupt the behavior, or if staff must intervene to keep the child and others in the environment safe.

Mental Status Exam and Risk Assessment 

Within 24 hours of admission, the student’s clinician completes a mental status exam and risk assessment, gathering important information about the student’s current mental status, including assessing for any current risks of harm to self or others as well as protective factors.

Diagnostic Period 

Diagnostic Tools 

Within the first 45 of days of treatment, students, their families, referring agencies, and treatment team members participate in a wide variety of interviews, assessments, and diagnostic tools that culminate in the Comprehensive Treatment Plan (CTP) or Behavior Support Plan, and the Diagnostic Psychosocial Assessment Report (DPSA). The following is a list of assessments/tools that are completed. A timeline of all documents, the departments responsible for ensuring their completion, and the dates by which they are due in the chart can be found under separate cover.The following is a list of assessments/tools that are completed:

• Trauma Assessment
• High Risk Behavior Assessments as deemed appropriate (Firesetting, Sexual Behavior)
• Substance Abuse Assessment
• Psychiatric Evaluation
• Other Diagnostic Scales as deemed appropriate (i.e. ADHD scale, Depression Inventory, Trauma Symptom Checklist, Family/Developmental Questionnaires)
• Academic Assessments
• Recreational Assessment (Leisure Scope Assessment)
• Life Skills Assessment (Ansell Casey, Youth Readiness Assessment)
• Spirituality Assessment
• Treatment Map (completed during Diagnostic Assessment Team Meeting)

Diagnostic Assessment Team Meeting 

By day 45 of a student’s placement, the Diagnostic Assessment Team Meeting is held in order for all departments to share their findings. The goals of this meeting include (1) examining all assessment information in preparation of the CTP and (2) for inclusion in the Diagnostic Psychosocial Assessment (DPSA). The following is a brief outline of the meeting agenda/process:

• Identifying the treatment team’s diagnostic and treatment planning questions
• Identifying data: distribute genogram, providing brief identifying data for student, family, and presenting problem, including strengths, resources, areas of needed support
• Historical data & formulation: distribute DPSA draft; review family, behavior, and placement history; provide summary of developmental & family questionnaires; summary of trauma assessment, summary of high risk assessments
• Current functioning w/ focus on connections between current behavior & trauma
  • Student self report of functioning, insight, treatment needs, and goals
  • Identify strengths & resources of the student and family. Include spiritual and cultural practices, traditions, and resources.
  • Intellectual functioning- academic reports & summary of psychological testing including assessments of intellectual functioning, projectives, any other testing, and recommendations of the psychologist
  • Medical functioning – nursing report
  • Social functioning – residential report
• Answering diagnostic & treatment planning questions
  • Discuss identified sore spots, triggers, and quick relief behaviors
  • Brainstorming treatment goals & interventions, utilizing all of the above
  • Recommendations for any further assessments

In the ABA program completing a preliminary Functional Behavior Assessment with parents or caregivers may occur as a means of identifying the previously known variables that may reinforce challenging behaviors. Functional assessment interview forms are brief in nature and help guide future assessment directions.   

Diagnostic Psychosocial Assessment Report (DPSA) 

As noted above, the DPSA is completed by the clinician within 45 days of intake and provides staff with important information to utilize in the treatment of the student. The following is a list of information provided in the DPSA:

• Presenting Problems
• Strengths/Resources
• Developmental and Medical History
• Educational History
• Placement and Treatment History
• Family Situation, Past and Present
• Trauma History
• High Risk Behaviors:
  • Substance abuse
  • Sexual aggression
  • Physical aggression
  • Firesetting
  • Self-Harm
  • Elopement/Runaway
• Criminal involvement (legal disposition)
• Religious Affiliation, Spirituality
• Psychological Evaluation Results
• Medications and Physical Intervention History
• Current DSM Diagnosis
• Clinical Impressions
• Clinical Formulation
• Recommendations for Intervention

Ongoing Assessment 

Assessment does not end at day 45 of a student’s placement. Assessment of treatment needs, interventions, risk levels, are progress in treatment are ongoing.

Individualized Crisis Management Plan (ICMP) 

The ICMP is distributed to staff and staff and is reviewed quarterly at the student’s CTP meeting. In addition, students and staff sometimes identify new goals, strengths, interventions, triggers, sore spots, or safety concerns during the quarter. In these cases, students and staff are expected to communicate these findings with the clinician or in team meeting so that the changes can be made to the ICMP immediately. The updated ICMP is then redistributed.

The Behavior Support Plan (BSP) is available to staff at all times through the electronic data collection system on the ASD Unit.  BSP’s are stored on IPADs carried by staff and are available to staff through Catalyst.   Staff are encouraged to review and consult the BSP’s frequently because they are extensive and offer a wide range of strategies to increase positive behavior and student success. Each BSP is a fluid document that changes frequently.  When changes are made to BSP’s they are announced at team meetings, community meetings, and shift stand up meetings.  Additionally clinicians will email all staff to announce changes and encourage review of the procedures prior to working with the child again.   BSP changes are made based upon changing acuity levels of student behavior, having new behavior targets added, and when behaviors have improved and targets are removed.   

High Risk Behavior Assessments 

Hillcrest Educational Centers is committed to the careful assessment and appropriate treatment of students with high risk behaviors.Students  with histories or clinical presentations of sexualized behavior or fire setting require specialized assessment.

Students who present with either sexualized behaviors or firesetting/fire related behaviors may require a  risk management assessment being completed by their clinician in conjunction with the clinical administrator and/or staff psychologist. If a student is admitted to Hillcrest Educational Centers with a current risk assessment specific to their high risk behavior (within the last 12 months) a new one will not be completed during the diagnostic period. It would be completed one year from the date of the existing evaluation. It is appropriate to summarize the current evaluation and treatment recommendations  in the student’s diagnostic psychosocial assessment.

The  risk management assessment gathers information in the following areas: social, emotional and developmental background, family history and current functioning, trauma history and current functioning, history and course of treatment of the problematic behavior, current attitudes and behaviors related to the high risk area. It also identifies current high risk indicators (both static and dynamic) and protective factors as well as a determination of risk management needs. The assessment will also outline a safety and prevention plan as well as treatment recommendations for the student. This assessment will be shared with the student’s treatment team and redone on an annual basis, if a new disclosure occurs or if there is a notable change in the student’s functioning related to this behavior.

When these special assessments of sexualized behaviors, sexually abusive behaviors, and fire setting behaviors suggest that these problems continue to represent active risks in the clinical profile of the child, the high risk behavior must be addressed both in the treatment milieu and in the CTP treatment objectives. These special assessments may be built into formal psychological evaluations when psychological testing is required for the identified student. Updated high risk assessments must be done on at least a yearly basis as part of the CTP process or whenever a child shifts dramatically in the risk management needs, e.g. when new information surfaces that suggests the child should be considered at higher or lower risk. High risk assessment outcomes should be included as part of the discharge summaries, either in the form of the screening tools provided by HEC or in the narrative section of the discharge summary.

Functional Behavior Assessments

Functional Behavior Assessment is a varying set of procedures used to determine the purpose/function of challenging behavior.  Predicting behavior occurrence, identifying the purpose/function/ motivation of challenging behavior, and identifying those variables that maintain such responses allow for the development of effective function based treatments.

Function based treatments are those treatments implemented using the hypothesized functions of behavior derived from assessment. These procedures will focus on the use of positive approaches to develop functionally appropriate alternatives to the challenging behavior evaluated.  The final goal of assessment and treatment will be to make meaningful (socially significant) measurable changes to student behavior that will improve the individual’s quality of life. Treatment based upon these assessments are included in Behavior Support Plans (BSP), and Daily Management plans (DMP).  

The assessment process follows a general course which includes screening and general disposition, definition and quantification of a target response, identifying target responses to teach, program development (BSP), progress monitoring, and follow-up as deemed necessary by data analysis.

Comprehensive Treatment Plan (CTP) 

Comprehensive Treatment plans are reviewed regularly by the treatment team.  Each program has specific timelines identified for these review meetings and updated documents.  Further information about the specific contents of the CTP can be found in Chapter 4 Hillcrest Educational Centers Policies and Procedures.

Program Timelines are as follows:

Hillcrest Academy:  45 days, annually

Highpoint:  45 days, quarterly

Brookside ITU: 30 days, 90 days, quarterly

ASD Behavior Support Plans: 45 days, quarterly

Intake Assessment and Treatment Planning Policy for Housatonic Academy

Housatonic Academy completes an assessment of youth at admission as part of it’s treatment planning process. Throughout all of our assessments, the student, the student’s family and/or guardian, referring agencies, and the HEC treatment team are utilized in order to gather data and determine treatment interventions/services. The following is a summary of these processes.

Comprehensive Intake Assessment: Beginning at the time of acceptance, information will be gathered in order to complete a Comprehensive Intake Assessment document on the day of admission. To ensure that staff are adequately prepared to work with the student, the following information is included in the Comprehensive Intake Assessment:

• Client identification, legal guardian, relevant family information, and current intellectual functioning
• Client Strengths, Resources, Preferences, and Recreational Interests
• Reason for Referral
• Educational History
• Placement History
• Behaviors of Risk: Suicide, Non-Suicidal Self Injury, Substance Abuse, Agression, Sexual Behaviors, Sexual Exploitation, Fire Setting Issues, Elopement, Poor Judgement/Impulsivity, Potential Risk for Victimization, Delinquent/Status Offenses
• Medical and Developmental History
• Family History
• Spiritual, Cultural, and Communication Needs
• Significant Medical Problems
• Current Medications
• Current Diagnosis
• Current Treatment Needs and Services

Mental Status Exam: The Mental Status Exam is completed by a clinician as part of an initial interview with the student on the day of admission. It gathers important information about the student’s current mental status, including assessing for any current risks of harm to self or others.

Trauma Screening: The trauma screening is completed by the clinician as part of an initial interview with the student on the day of admission. It is a questionnaire designed to identify past trauma experiences that staff may need to be aware of in their work with the youth.

Substance Abuse Screening: The substance abuse screening is completed by the clinician as part of an initial interview with the student on the day of admission. This is designed to assess any current risk for substance abuse and potential needs for treatment referrals.

Individualized Crisis Management Plan (ICMP): The ICMP is completed in 2 parts, and is finalized within 7 business days of admission. Whenever possible, direct communication with the family and referring agencies will be utilized in this process.

The ICMP is a detailed plan for ensuring the safety of the child and managing high risk behaviors. This plan is rooted in utilizing a trauma informed approach to treatment. The ICMP is a plan mandated by Therapeutic Crisis Intervention (TCI). Hillcrest’s ICMP is a 2 page document that allows for input from the student, the student’s family, guardian, funding agencies, and the HEC treatment team. The first page is completed with the student and clinician within 24 hours of admission. The second page is completed by the campus management team and/or the treatment team within 7 business days of the student’s admission utilizing the input of the family, guardian, and funding agencies as well.

The goal of the first page of the ICMP is to ensure the student’s input is immediately utilized in his/her treatment. It utilizes questions posed to the student to identify the student’s goals, strengths, and interests in their treatment. It includes questions posed to the student that help identify the student’s triggers, sore spots, and situations that overwhelm their coping skills. Page 1 also identifies skills, resources, and intervention that the student finds helpful or not helpful.

The second page of the ICMP provides important information about the student’s current and historical high risk behaviors and high risk situations. Important safety information such as medical concerns, trauma triggers, current diagnoses, and current medications is included. This page then identifies individualized interventions to utilize when the child presents at different stages in the stress model of crisis. Page 2 also identifies safety measures. The ICMP is updated whenever an addition or change is determined by the treatment team.

Spirituality Assessment: The Spirituality Assessment is completed within 15 days of admission with the family. It is designed to identify any spiritual supports the student may need or request at the Housatonic Academy.

Comprehensive Treatment Plan: Within 45 days of admission, the treatment team will complete a treatment plan during the IEP meeting to address the treatment needs and goals of a student. HA will make every effort, unless contra-indicated, to have the student and family participate in this meeting and the final treatment plan. The treatment plan utilizes goals identified in the IEP. Measurable objectives and school services/interventions are designed to address school interfering behaviors and to support the discharge goal of the student. This plan will be reviewed annually during the student’s annual IEP meeting.