In addition to this chapter, a person who provides behavior support services to an individual shall comply with the following regulations of this subtitle: COMAR 10.22.01; COMAR 10.22.02; COMAR 10.22.03; COMAR 10.22.04; and COMAR 10.22.05. The Administration serves individuals who exhibit challenging behaviors and require a variety of supports to achieve success in exercising the individual's choices responsibly. Behavior support services are designed to assist individuals who exhibit challenging behaviors in acquiring skills, gaining social acceptance, and becoming full participants in the community. A licensee who provides services to an individual in the community or in an SRC whose record indicates a need for a behavior plan shall meet the requirements of this chapter. A licensee who contracts for behavior support services shall ensure that its contractor meets the requirements of this chapter and is knowledgeable about the Administration's service delivery system. Behavior support services include: Behavioral consultation; Temporary augmentation of staff; Behavioral training; and Behavioral respite services. In addition to the training requirements in COMAR 10.22.02.11A — D, the licensee shall ensure that staff who provide behavior support services, before being assigned independent duties, receive training in the: Principles of behavioral change; and Appropriate methods of preventing or managing challenging behaviors, which may include the use of mechanical restraints. A licensee shall ensure that a BP is developed for each individual for whom it is required. The licensee shall ensure the BP: Is developed, in conjunction with the team, by a licensed psychologist, psychology associate under the supervision of a licensed psychologist, licensed behavior analyst, licensed physician, licensed certified social worker, or licensed or certified professional counselor, who shall have training and experience in applied behavior analysis; Is based on and includes a functional analysis or assessment of each challenging behavior as identified in the IP; Specifies the behavioral objectives for the individual, and includes: A description of the hypothesized function of current behaviors including their frequency and severity; and Criteria for determining achievement of the objectives established; Takes into account the medical condition of the individual; Describes the treatment techniques and when the techniques are to be used; Specifies the emergency procedures to be implemented for the individual with a history of exhibiting behaviors that present a danger to self or serious bodily harm to others; Includes a description of the adaptive skills to be learned by the individual that serve as functional alternatives to the challenging behavior or behaviors to be decreased; Identifies the person or persons responsible for monitoring the BP; Specifies the data to be collected to assess progress towards meeting the BP's objectives; and Describes and documents each use of mechanical and physical restraint, the reason for its use, and the length of time used. Before implementation, the licensee shall ensure that each behavior plan which includes the use of restrictive techniques is: Approved by the standing committee as specified in COMAR 10.22.02.14E(1)(d); and Includes written informed consent of the: Individual; Individual's legal guardian; or Surrogate decision maker as defined n Health-General Article, §5-605, Annotated Code of Maryland. Before a licensee discontinues a behavior plan, the team and an individual appropriately licensed under Health Occupations Article with training and experience in applied behavior analysis shall recommend that the individual no longer needs a behavior plan. The licensee shall ensure that the use of restrictive techniques in any BP: Represents the least restrictive, effective alternative, or the lowest effective dose of a medication; and Is only implemented after other methods have been: Systematically tried, and Objectively determined to be ineffective. The licensee shall collect and present objective data to the authorizing licensed health care practitioner to indicate whether the restrictive technique being used is effective in reducing the individual's challenging behavior. The licensee shall: Convene the team within 5 calendar days after an emergency use of a restrictive technique to review the situation and action taken; Determine subsequent action include whether the development or modification of a BP is necessary; and Document that the requirements of this regulation have been met. The licensee shall ensure that staff do not use: Any method or technique prohibited by law, including aversive techniques; Any method or technique which deprives an individual of any basic right specified in Health-General Article, §§7-1002—7-1004, Annotated Code of Maryland, except as permitted in COMAR 10.22.04.03A; Seclusion; A room from which egress is prevented; or A program which results in a nutritionally inadequate diet. Staff may not use a restrictive technique: As a substitute for a treatment plan; As punishment; or For convenience. In addition to the requirements in Regulations .05 and .06 of this chapter, the licensee shall ensure that a BP which includes the use of medication includes: The specific medications that have been prescribed; The rationale for prescribing each medication; Any alternate methods of management being used to bring challenging behavior under control; and Objective data collected by staff and presented to the licensed health care practitioner to indicate that the medication being used is effective in reducing the individual's challenging behavior. The licensee shall ensure that a licensed health care practitioner documents that: Any potential side effect from the medication outweighs the behavior that will occur without the use of the medication; and Attempts are being made to gradually decrease the dosage or discontinue the medication when clinically indicated. A licensed health care practitioner shall review any medication that has been prescribed to modify behavior at a minimum of every 90 days. PRN orders for medications to modify behavior are prohibited. Medications to modify behavior may not be used in quantities that interfere with an individual's ability to participate in daily living activities. Physical restraint may only be used when the individual's behavior presents a danger to self or serious bodily harm to others. The licensee shall ensure that only staff who have been trained in the management of disruptive behavior, or other curriculum approved by the Administration, may use a physical restraint and may only do so as specified in the curriculum. In addition to the requirements in Regulation .06 of this chapter, the licensee shall document in the individual's record each use of a physical restraint, including the reason for its use. Use of Mechanical Restraint for Behavioral Purposes. A mechanical restraint may only be used: To prevent an individual from engaging in self-injurious behaviors such as head banging, teeth gnashing, and similar behavior; To prevent serious bodily harm to others; or As required by an individual's treating licensed health care practitioner to allow an individual to recuperate from surgery or injury. The licensee shall ensure that a mechanical restraint is designed and used: In a humane, safe, and effective manner; and Without intent to harm or create undue discomfort. If a mechanical restraint is being used for the purpose of §A(1)(a) and (b) of this regulation, the licensee shall: Meet the requirements in Regulations .05 and 06 of this chapter; Obtain written authorization from a licensed health care practitioner trained in applied behavior analysis for the use of the mechanical restraint, including the duration of its use and the circumstances under which the restraint is authorized; Document in the individual's record each use of mechanical restraint, including the reason for its use; and Require staff to check on the individual every 15 minutes. When a mechanical restraint is being used for the purpose of §A(1)(a) and (b) of this regulation, the licensee shall afford the individual the opportunity: To be escorted to the bathroom and offered fluids at least every 2 hours; For motion and exercise for a period of not less than 10 minutes during each 2 hours in which the restraint is used; and To be provided meals at regularly scheduled hours. A licensed health care practitioner who authorized the use of the mechanical restraint shall review the authorization at a minimum of every 90 days, and document its effectiveness and whether continuation is indicated. Use of Mechanical Restraint for Medical Purposes. If a mechanical restraint is being used for the purpose of §A(1)(c) of this regulation, the licensee shall: Obtain written authorization from the individual's treating licensed health care practitioner; and Document in the individual's record the reason and guidelines for the use of the restraint, including the time frame the mechanical restraint is to be used. Use of a Mechanical Support. A mechanical support may only be used if authorized by a licensed health care practitioner. The licensee shall ensure that a mechanical support is designed and used: In a humane, safe, and effective manner; and Without intent to harm or create undue discomfort. The licensee shall document in the individual's record the reason for use of the mechanical support, when it is to be used, and the directions for its use. The licensed health care practitioner who authorized the use of the mechanical support shall document its effectiveness and whether continuation is indicated, at least, on an annual basis. Chemical restraint may only be used when the individual's behavior presents a danger to self or serious bodily harm to others. A licensee may only use a chemical restraint in a behavioral emergency when: Ordered by a licensed health care practitioner; and Administered and monitored by a licensed health care practitioner. In addition to the requirements in Regulation .06 of this chapter, the licensee shall document in the individual's record the use of any chemical restraint, including the reason for its use. The licensee shall monitor the use of restrictive techniques through its internal quality assurance process as required by COMAR 10.22.02.14B(4). After the effective date of this chapter, a licensee providing residential services which specializes in behavior support services shall comply with the requirements of this chapter and COMAR 10.22.08. Health-General Article, §§7-904; Health Occupations Article, §17-6A-01 et seq.; Annotated Code of Maryland Effective date: July 29, 1985 (12:15 Md. R. 1517) Regulations .01 — .10 repealed effective January 23, 1989 (16:1 Md. R. 70) Regulations .01 — .11 adopted effective January 23, 1989 (16:1 Md. R. 70) Regulation .09B amended as an emergency provision effective May 3, 1989 (16:10 Md. R. 1102); adopted permanently effective October 30, 1989 (16:21 Md. R. 2261) Regulation .09G amended effective January 6, 1992 (18:26 Md. R. 2830) Chapter, Intensive Behavior Management and Other Programs Utilizing Behavior Management Techniques, repealed and new chapter, Behavior Support Services Program Service Plan, adopted effective July 26, 1999 (26:15 Md. R. 1148) Regulation .05B amended effective January 30, 2017 (44:2 Md. R. 85)