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Behavioral Support Strategies

Sometimes people with disabilities may act in a way that poses a direct and serious risk of harm to their physical safety or the safety of others. Or their actions increase the likelihood that they will be legally sanctioned, which could include items such as eviction, arrest, or being incarcerated. 

Restrictive Measures are used as a method of last resort by people providing specialized services to keep people safe from a risk of harm or legal sanction per the Ohio Administrative Code 5123-2-06 and always used with positive measures.

This rule is designed to ensure people with disabilities are supported in a caring way that promotes dignity, respect, and trust and with recognition that they are equal citizens with the same rights and personal freedoms granted to Ohioans without developmental disabilities.

Considering Restrictive Measures

The focus of a behavioral support strategy is proactive creation of supportive environments that enhance the person’s quality of life by respecting their needs and expanding their opportunities to exercise choice, voice, and control through positive measures. Positive measures may include:

  • Alternative ways to communicate needs and have needs met;
  • Adjusting the physical or social environment;
  • Addressing sensory stimuli;
  • Adjusting schedules; and
  • Establishing trusting relationships.

Development of a behavioral support strategy that includes restrictive measures requires:

  • Documentation that positive measures have been tried and failed;
  • An assessment conducted in the past 12 months that shows:
    • The behavior poses risk of harm or likelihood of legal sanction or the individual’s engagement in a precisely-defined pattern of behavior that is very likely to result in risk of harm;
    • The level of harm or type of legal sanction that could be expected within the behavior;
    • When the behavior is likely to occur;
    • The individual’s needs, diagnosis, life history including traumatic experiences to gain insight into origins and patterns of the person’s actions; and
    • The nature and degree of risk to the person if a restrictive measure is implemented.
  • A description on how to mitigate risk of harm or legal sanction;
  • A plan of action on reducing and eliminating the need for restrictive measures; and
  • Ensure the person has access to preferred activities in all environments the person accesses to prevent unsafe actions due to boredom, frustration, lack of effective communication, or unrecognized health problems.

Risk of harm means there is a direct and serious risk of physical harm to the person or to someone else. The person must be causing or are very likely to begin causing physical harm. They must also be capable of causing physical harm. 

Likelihood of legal sanction includes the risk of eviction, arrest, or incarceration.

Restrictive measures are used only when necessary to keep people safe and always with positive measures and shall never include prohibited measures. 

Behavioral support strategies that include restrictive measures shall be designed in a trauma-informed manner that promotes healing, recovery, and resilience, and is based on understanding the person’s trauma history. 

Service plans shall include positive non-restrictive measures such as de-escalation techniques, problem solving, coping skills, and emotional regulation skills. At times, these positive non-restrictive measures may not work, and additional intervention is warranted through a restrictive measure.

Documentation that includes the justification of the proposed measure and the nature and degree of risk to the person if the restrictive measure is implemented shall be submitted to the human rights committee for review.

Restrictive measures may include manual, mechanical, and chemical restraints, time-outs, and rights restrictions.

A behavioral support strategy that includes chemical restraint, manual restraint, or time-out will need to specify when and how the provider will notify the person’s guardian when such a restraint is used.

Before Implementing a Restrictive Measure

Before implementing a restrictive measure, the team should ensure that: 

  • There is a single person-centered plan, meaning the person's individual service plan includes behavioral support strategies with no separate behavioral support plan;
  • The proposed restrictive measure is the least restrictive option;
  • They have obtained informed consent to use an agreed upon restrictive measure from the person or their guardian;
  • The team has obtained the approval of the Human Rights Committee (HRC);
  • The team has notified DODD using the Restrictive Measure Notification (RMN) process;
  • Providers have been trained on using the restrictive measure; and 
  • Any other restrictive measure requirements have been met. 

90-Day Reviews (or more frequently if specified by the HRC)

Once a behavioral support strategy with restrictive measures has been approved, the Human Rights Committee will determine how often a strategy will be reviewed, whether it is at least every 90 calendar days or more frequently.

This review will be to determine and document the effectiveness of the strategy and whether or not the strategy will be continued, discontinued, or revised. The review shall consider:

  • Data and documentation for the effectiveness of strategies;
  • The individual's self-report and the observations by paid staff regarding the individual's achievement of desired outcomes and pursuit of interests;
  • Up-to-date information indicating the risk of harm or likelihood of legal sanction is still present;
  • Any new skills that have been developed that may reduce or eliminate threats to safety or wellbeing; and 
  • If a Manual restraint was implemented, did the review include the person's perspective and at least one staff member's perspective on why the restraint occurred and what could have been done differently to avoid the restraint. 

A decision to continue the strategy shall be based upon a review of up-to-date information justifying the continuation of the strategy.