Behavior Supports

PURPOSE: This rule sets forth requirements for providers under contract with the Department of Mental Health to support individuals with intellectual and developmental disabilities and assure the rights of individuals to receive best practice behavior strategies that lead to greater independence and enhanced quality of life. This rule describes the division’s oversight of behavior supports, establishes and describes the role and function of behavior supports review committees. (1) Definitions— (A) Applied behavior analysis—The design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationships between environment and behavior, as established in section 337.300(1), RSMo; (B) Behavior analysis services—Use of applied behavior analysis principles and technology to assist support systems of individuals with challenging behaviors to prevent those behaviors as well as teach, promote, encourage, and reinforce alternative skills and behaviors; (C) Behavior support plan (BSP)—A part of the individual support plan that is comprised of behavior analytic procedures developed to systematically address behaviors to be reduced or eliminated and behavior skills to be learned; (D) Blocking—A staff person using a part of their body to prevent an individual from inflicting or incurring harm when an individual is attempting to hit, kick, or otherwise harm himself or herself, the staff, or another person. Use of pads, cushions, or pillows to soften or prevent impact to the individual or others is also considered blocking. Blocking does not involve grasping or holding any part of the individual’s body; (E) Challenging behaviors—Culturally undesirable behavior(s) likely to both limit access to the community and interfere with independence and autonomy; (F) Chemical restraint—Medications (prescribed or over-the-counter) administered with the primary intent of restraining an individual who presents a likelihood of serious physical injury to himself or others, not prescribed to treat a person’s medical condition (as defined in section 630.005, RSMo); (G) Due process—The right to be notified and heard on the limitation or restriction, the right to be assisted through external advocacy if an individual disagrees with the limitation or restriction, and the right to be informed of available options to restore the individual’s rights; (H) Emergency interventions—Reactive strategies that are not part of the individual’s plan used to maintain safety of the individual or others in the threat of imminent harm. These are strategies used for one (1) or two (2) incidents until a planned intervention is developed in the safety crisis plan and/or BSP. These emergency interventions may involve physical restraint strategies. These interventions must be least restrictive and comply with statutes, rules, regulations, and policies of the division; (I) Emergency intervention system—also called physical crisis management programs—A formal curriculum and training program to teach prevention, de-escalation, and physical restraint, also called manual holds, to maintain safety in emergency situations; (J) Exclusion time out—The temporary exclusion of an individual from access to reinforcement, as part of a formal BSP, in which, contingent upon the individual’s undesirable behavior(s), the individual is excluded from the potentially reinforcing situation but remains in the same area with others present; (K) Functional Behavior Assessment (FBA)—Information-gathering process used to understand the purpose of challenging behavior. The functional assessment must be designed and monitored by a licensed behavior analyst, or licensed psychologist, counselor, or social worker trained in behavior analysis; (L) Informed consent—Consent for treatment based on certain basic elements that include: an understandable explanation and purpose of the procedure to be followed, a description of physical, emotional, or mental discomfort or risk to be expected, an offer to answer any inquiries concerning the procedure, and an explanation that at any time consent can be rescinded. Informed consent must be obtained from the individual, or the guardian for individuals who have a guardian. Every effort should be made to obtain informed agreement from individuals with guardians; (M) Individual Support Plan (ISP)—A document that results from the person centered planning process, which identifies the strengths, capacities, preferences, needs, and personal outcomes of the individual. The ISP includes a personalized mix of paid and nonpaid services and supports that will assist the person to achieve personally defined outcomes; (N) ISP team—The individual, the individual’s designated representative(s), and the support coordinator. Providers of waiverfunded services may also participate in the ISP team if the individual or guardian requests such participation; (O) Least restrictive procedure—A procedure that maximizes an individual’s freedom of movement, access to personal property, and/or ability to refuse while maintaining safety. The degree of restrictiveness is based on a comparison of the various possible procedures that would maintain safety for the individual in a given situation; (P) Licensed behavioral support professional—individual licensed in the state of Missouri under section 337.315 (6) and (7), RSMo. (Q) Manual hold—also called physical restraint and manual restraint—Any physical hold involving a restriction of an individual’s voluntary movement. Physically assisting someone who is unsteady, or blocking to prevent injury, is not considered a manual hold; (R) Mechanical restraints—Any device, instrument, or physical object used to confine or otherwise limit an individual’s freedom of movement that cannot be easily removed. Examples may include locking a wheelchair, taking crutches, taking power mechanism from wheelchairs, special seat belts that cannot be removed by the individual, or other ways of restricting an individual’s mobility. Mechanical restraints are prohibited from use in home and community based settings. The following are not considered mechanical restraints: 1. Medical protective equipment prescribed as part of medical treatment for a medical issue; 2. Physical equipment or orthopedic appliances, surgical dressings or bandages, or supportive body bands or other restraints necessary for medical treatment, routine physical examinations, or medical tests; 3. Devices used to support functional body position or proper balance, or to prevent a person from falling out of bed, or falling out of a wheelchair; 4. Typical equipment used for safety during transportation, such as seatbelts or wheelchair tie-downs; or 5. Mechanical supports or supportive devices used in normative situations to achieve proper body position and balance; (S) Person centered planning process—A process directed by the individual, with the inclusion of a circle of support created by or with the individual, a guardian, the responsible party or other person as freely chosen by the individual, who are able to serve as important contributors to the process. The person-centered planning process enables and assists the individual to access a personalized mix of paid and non-paid services and supports that will assist him/her to achieve personally defined outcomes. These trainings, supports, therapies, treatments and/or other services become part of the ISP; (T) Preventative strategies—Clearly defined protocols which describe knowledge and skill sets that providers and/or the individual must implement in order to prevent occurrences of undesirable behaviors or the use of restrictive supports while also creating increased opportunities for success. Preventative strategies are documented in the support section of the ISP; (U) PRN—A medical term meaning “when necessary”; (V) PRN Psychotropic medication for behavioral support—Medication (pharmacologic agent) that affects a person’s mental status and is prescribed to be given according to circumstance rather than at a scheduled time. If utilized, the BSP/ISP must include skill or responses to be developed to reduce the need for the PRN and must specifically describe strategies to address the situation prompting the PRN use. Use of PRN psychotropic medication is considered both a reactive strategy and a restrictive intervention; (W) Provider—Any entity or person under contract with the Department of Mental Health (DMH) to serve individuals with developmental disabilities funded by general revenue or through home and communitybased waivers administered by DMH; (X) Psychotropic/behavior control medications—Any medication that affects the person’s mental status or behaviors regardless of their diagnoses; (Y) Qualified personnel—Staff persons who have received training, demonstrated competency, and maintained required certification and understanding of the following: 1. The Physical Crisis Management System utilized at the agency in which they are employed; 2. The implementation of the individual’s safety crisis plan; 3. The implementation of the BSP and ISP; 4. All requirements as a service provider outlined in the most current service definitions for providers; (Z) Reactive strategies—Actions, responses, and planned and unplanned interventions in response to challenging behavior. Emergency interventions are types of reactive strategies. Reactive strategies have the aim of bringing about immediate change in an individual’s behavior or control over a situation so that risk associated with the behavior is minimized. Reactive strategies may take a number of forms and can include environmental, psychosocial, and restrictive interventions. Such procedures may be utilized as a first time response to an emergency situation. This also includes responses that are more delayed such as restricting access to the community or increased levels of supervision; (AA) Reactive strategy threshold—The use of five (5) or more reactive strategies within a one (1) month period. This threshold applies to the use of reactive strategies that also meet the definition of restrictive interventions; (BB) Regional Behavior Supports Committee (RBSC)—A committee consisting of a chairperson who is a Licensed Behavior Analyst, employed by the division and appointed by the division director or designee, along with qualified members, whose functions include meeting the expectations set forth in this rule; (CC) Regional Office (RO)—Local offices of the Division of Developmental Disabilities (referred to as “the division” throughout this document) serving a defined geographic region of the state; (DD) Restrictive interventions—The use of interventions that restrict movement, access to other individuals, locations or activities, restrict rights or employ aversive methods to modify behavior. These may also be called restrictive supports, procedures, or strategies; (EE) Safety assessment—An assessment by the planning team and a medical professional of an individual’s physical, and/or emotional status. This includes history and current conditions that might affect safe usage of any reactive strategies, and identifies those reactive strategies that should not be used with the individual due to medical or psychological issues of safety. The safety assessment should be completed annually or on the occasion of any significant change; (FF) Safety crisis plan—An individualized plan outlining the reactive strategies designed to most safely address dangerous behaviors at the time of their occurrence or to prevent their imminent occurrence, included as part of a BSP or ISP; (GG) Seat belt guard—A safety device to prevent the release of the seat belt while the car is in motion. Seat belt guards are not mechanical restraints; (HH) Seclusion time-out—The involuntary confinement of an individual alone in a room or an area from which the individual is physically prevented from having contact with others or leaving. This is sometimes referred to as a safe room or calm room. Locked rooms (using a key lock or latch system not requiring staff directly holding the mechanism) are prohibited. (II) Significantly challenging behaviors— Actions of the individual which can be expected to result in issues described in paragraphs 1.—6. below. Services to address these behaviors may necessitate involvement of a licensed behavior analyst or other licensed professional with appropriate training and experience— 1. Have resulted in external or internal injury requiring medical attention or are expected to increase in frequency, duration, or intensity such that medical attention may be necessary without intervention by a licensed behavior support professional; 2. Have occurred or are expected to occur with sufficient frequency, duration, or intensity that a life-threatening situation might result because of self-injury, aggression, or property destruction. Examples include excessive eating or drinking, vomiting, ruminating, eating non-nutritive substances, refusing to eat, swallowing excessive amounts of air, or running into traffic; 3. Have resulted or are expected to result in major property damage or destruction, value of property more than two hundred dollars ($200); 4. Have resulted in or are expected to result in arrest and confinement by law enforcement personnel; 5. Have resulted in the need for additional staffing and/or behavioral/medical personal assistant services; or 6. Have resulted in the repeated use of emergency interventions and restrictive supports; and (JJ) Waiver assurances—As a condition of waiver approval by the Centers for Medicare and Medicaid Services, states collect and report performance data to measure compliance with assurances specified in the Code of Federal Regulations at 42 CFR 441.302. (2) Rights of individuals and assurances. (A) No individual shall experience restrictive supports without due process. Restrictive supports include, but are not limited to, any limitation of access to: 1. Communication with others; 2. Leisure activities; 3. The individual’s own money or personal property; 4. Goods or services per typical routines; 5. Access to parts of the home or the community; and 6. Privacy or independence via any direct observation and procedures such as continuous one-to-one staffing during times or places which would otherwise be considered private. (B) In addition to those rights described in and assured by federal and state law and 9 CSR 45-3.030, all individuals served by the division have the right to be treated with dignity and respect, to receive services in the least restrictive environment, and to be assured freedom from coercion and aversive stimuli. (C) All individuals served by the division have strategies that may prevent problem situations and challenging behaviors included in their ISPs. Preventive strategies shall meet the following conditions: 1. If there is a BSP, preventive strategies must be included; 2. Preventive strategies may be developed by non-licensed team members if the behavior of concern meets the following conditions: A. The behavior has not caused significant injury or danger to self, others, or property; and B. The behavior has not restricted the individual’s access to the community, and if the support strategies involved typically may be considered public domain by promoting a more positive environment, enriching the individual’s daily routine, and teaching more functional skills, but are not solely the practice of applied behavior analysis. (D) Individuals who are receiving paid supports who have experienced or are considered by the person centered planning team as likely to experience emergency interventions shall— 1. Have qualified personnel supporting them who have been competency trained in an emergency intervention system, who maintain current certification in the system; and 2. Have a safety assessment and a current safety crisis plan with all support providers. (3) Service delivery. (A) Individuals have the right to receive appropriate supports and services in accordance with their ISP and in accordance with (B) Individuals are integrated in and have access to the greater community in accordance with 42 CFR 441.301. The division ensures that services provided are of good quality and comparable to those provided to persons in the community without disabilities. (C) Providers comply with the terms and conditions of the home and community-based waivers approved by the Centers for Medicare and Medicaid Services and operated by the division and the MO HealthNet DD Waiver Provider Manual. (4) Contracted providers shall monitor and implement positive proactive strategies to reduce the likelihood that an individual will require reactive strategies or restrictive interventions. Providers shall develop processes to review the problem situations when the reactive strategy threshold is reached. (A) Individuals reaching the reactive strategy threshold trigger the planning team’s extensive review and analysis of the problem situations. The planning team should— 1. Convene within five (5) business days to complete the review and any restrictions of the supports, environment, training for staff, medications, or other issues that might affect the individual; 2. Identify triggers, preventative strategies, and barriers to using the least restrictive strategies; 3. Consider the need for a functional behavior assessment, and development of a formal BSP or revision of an existing BSP; and 4. Develop new or revised proactive strategies and strategies to prevent situations that are likely to result in use of reactive strategies. (B) Any individual meeting the reactive strategy threshold for three (3) consecutive quarters should be referred to the Regional Behavior Support Review Committee for consultation. If an individual meets the reactive strategy threshold of five (5) or more in a one (1) month period, the planning team should request the support coordinator submit a request for behavioral services. (5) Restrictive Interventions other than approved physical crisis management procedures shall not be used as an emergency or crisis intervention. (A) Use of restrictive procedures that meet the definition of reportable events must be reported in accordance with 9 CSR 10-5.206. (B) Restrictive interventions are utilized only as alternatives to more restrictive placements and only as a means to maintain safety and allow the teaching of alternative skills that the individual can utilize to more successfully live in the community. (C) The ISP must include justification for any restrictions. The following requirements must be documented in the ISP: 1. Identification of a specific and individualized assessed need; 2. Documentation that the positive interventions and supports used prior to any modifications to the ISP; 3. Documentation that less intrusive interventions were tried but were not successful; 4. Regular collection and review of data to measure the ongoing effectiveness of the intervention; 5. Established time limits for periodic reviews to determine if the intervention is still necessary or can be terminated; 6. Informed consent of the individual or their legal guardian; and 7. Assurances that interventions and supports will cause no harm to the individual as described in 42 CFR 441.301(c)(2)(xiii). (D) Prohibited procedures—The following interventions are prohibited by the division and are considered at high risk for causing harm: 1. Any technique that interferes with breathing or any strategy in which a pillow, blanket, or other item is used to cover the individual’s face; 2. Prone restraints (on stomach); restraints positioning the individual on their back supine; or restraints against a wall or object; 3. Restraints which involve staff lying/sitting on top of an individual; 4. Restraints that use the hyperextension of joints; 5. Any technique or modification of a technique which has not been approved by the division, and/or for which the person implementing the technique has not received division-approved training; 6. Mechanical restraints; 7. Any strategy that may exacerbate a known medical or physical condition, or endanger the individual’s life, or is otherwise contraindicated for the individual by medical or professional evaluation; 8. Use of any reactive strategy or restrictive intervention on a “PRN” or “as needed” basis; 9. Standing orders for use of restraint procedures not part of a comprehensive safety crisis plan that delineates prevention, deescalation, and least restrictive procedures to attempt prior to use of restraint; 10. Any procedure used as punishment, for staff convenience, or as a substitute for engagement, active treatment, or behavior support services; 11. Use of law enforcement or emergency departments cannot be incorporated into ISPs or BSPs as “PRN” procedures or as contingencies to eliminate or reduce problem behaviors; 12. Reactive strategy techniques administered by other individuals who are being supported by the agency; 13. Corporal punishment or use of aversive conditioning—Applying painful stimuli as a penalty for certain behavior, or as a behavior modification technique; 14. Overcorrection strategies— Requiring the performance of repetitive behavior as a consequence of undesirable behavior designed to produce a reduction of the frequency of the behavior; 15. Placing persons in totally enclosed cribs or barred enclosures other than cribs; and 16. Any treatment, procedure, technique, or process prohibited by federal or state statute. (E) Procedures that may be conditionally approved in writing by the division— 1. Any modification to a physical crisis management technique or any non-nationally recognized physical crisis management system; 2. Seclusion time-out placement of a person alone in a secured room or area which the person cannot leave at will shall only be utilized as part of an approved BSP. The use of seclusion time-out requires ongoing services from a licensed behavioral service provider and prior review and approval by the RBSC; and 3. Use of physical crisis management procedures when part of a comprehensive safety crisis plan that delineates prevention, de-escalation, and least restrictive procedures to attempt prior to use of restraint. (6) BSPs are developed by a licensed behavioral service provider in collaboration with the individual’s support system. The techniques included in the plan are based on a functional assessment of the target behaviors. The techniques meet the requirements for the practice of applied behavior analysis under sections 337.300 through 337.345, RSMo. The BSP includes the following information: (A) Alternative behaviors for reduction and replacement of target behaviors, defined in observable and measurable terms. They are specifically related to the individual and relevant environmental variables based on FBA; (B) Goals and objectives for acquisition of appropriate alternative behaviors; (C) Interventions aligned with positive functional relationships described in FBA including strategies to address establishing operations, contextual factors, antecedent stimuli, contributing and controlling consequences, and physiological and medical variables; (D) Data collected must include antecedents/triggers, description of events, duration, consequence/result, and effects of interventions; (E) If physical restraint or seclusion timeout are used, health status is monitored and data documented for one (1) hour after the event in fifteen (15) minute intervals. Health status data includes monitoring of vital signs including pulse, visual observations of energy/lethargy level, engagement with others, and other observed reactions; (F) Description of specific data collection methods for target behaviors to assess the effectiveness of the strategies and data collection methods to assess the fidelity of implementation strategies; (G) Data displayed in graphic format in the monthly progress reports, with indications for the environmental conditions and changes relevant to target behaviors; (H) Proactive strategies to prevent challenging behaviors, improve quality of life, promote desirable behaviors, and teach skills, that are specifically described for consistent implementation by family and/or staff; (I) Specific strategies with detailed instructions for reinforcement of desirable target behaviors; (J) Specific strategies to generalize and maintain the desired effects of the BSP, including strategies for fading contrived contingencies to natural contingencies to support system changes and maintain these strategies after BSP is faded; (K) A safety crisis plan if it is necessary to have strategies to intervene with at risk behaviors to maintain safety; (L) If a plan includes physical restraint or seclusion time-out, specific criteria and procedures are identified; (M) Target behavior(s) related to the symptoms for which psychotropic medications were prescribed and when they should be administered and the process for communicating data with the prescribing physician; (N) Description of less restrictive methods attempted in the past, their effectiveness, and rationale that proposed BSP strategies are the least restrictive and most likely to be effective as demonstrated by research or history of individual; (O) The method of performance based training to competency for caregivers and staff providing oversight; (P) The qualified behavioral service provider reviews data at least monthly; and (Q) Description of how the plan will be communicated to all supports and services including the frequency with which the ISP team will receive updates. (7) A safety crisis plan is developed by the support team after the first use of any reactive strategy or when the personal history of the individual indicates there is a likelihood that reactive strategies may be needed in the future, or where the individual’s support team plans to use reactive strategies. (A) If reactive strategies are considered likely and necessary, the team should be proactive and consider the need for more specialized support strategies in the ISP and services such as Person Centered Strategies Consultant or Behavior Analysis Services (see Medicaid Waiver service definitions). (B) Procedures identified are least restrictive and within safety parameters of the safety assessment. These are used as a last resort after implementation of proactive, positive approaches. (C) If a safety crisis plan includes physical restraint, exclusion time-out, or seclusion time-out, specific criteria and procedures are identified. (D) The plan includes the informed consent of the person, their parent, or guardian. (E) The safety crisis plan is a part of the ISP. (F) Safety crisis plans are part of any BSP. (8) If a safety crisis plan includes the use of physical restraint, the name of the approved or nationally recognized crisis management program must be included in the individual’s safety crisis plan (as per section 630.175.1, RSMo). Restraints are only used in situations of imminent harm to prevent an individual from injuring self or others. Less restrictive crisis management procedures, including deescalation techniques and environmental management, should be attempted prior to use of any type of restraint. Use of physical restraints are documented in a safety crisis plan. (A) Physical Restraints. Techniques used to physically restrain individuals are limited to those from nationally recognized physical crisis management programs or internally developed programs approved by the division. 1. Requests for use of physical crisis management systems other than those that are nationally recognized must be made, in writing, to the Chief Behavior Analyst of the division. If internally developed systems are approved and utilized, a quarterly analysis of the use of the restraint procedures and strategies to eliminate the need is completed and submitted to the Chief Behavior Analyst. 2. The physical restraint techniques are used only in the manner designed, are formally trained to competency, and staff maintain certification as specified by the physical crisis management system. 3. Physical restraint techniques are only employed for situations of imminent harm to self or others and not to protect property. 4. Any improper or unauthorized use of a physical restraints or excessive application of force may be considered abuse and may prompt an investigation. 5. Blocking is not considered a physical restraint procedure if used as defined in this rule. (B) Chemical restraints include prescription and over the counter medications and require the approval of the division director or his/her designee prior to implementation of these restraints. Any use of a chemical restraint must be included in an approved safety crisis plan meeting the following criteria: 1. Identification of chemical restraints to be used; 2. Written physician orders for any chemical restraints are time limited and for no longer than three (3) hours; 3. Written physician orders are placed in the individual's record and contain at least the following information: A. Brief description of the imminent harm situation including ongoing activities, staff actions, and the individual’s actions that relate to the imminent harm; B. Type of chemical restraint used; C. The time when the order was written; D. The time when the chemical restraint was first administered; 4. Ongoing visual observation and safety checks during the time that the chemical restraint is affecting the individual; 5. Standing or PRN orders for chemical restraints shall not be used. Specification in a safety crisis plan or reactive strategies deemed safe for an individual and/or recommended as the most likely to be effective will not be considered as PRN orders; 6. The authorized medical professional designated by the physician writing the order observes the individual and evaluates the situation within thirty (30) minutes from the time chemical restraints were initiated; and 7. In an emergency in which an on-site authorized physician is not available, only a registered nurse or a qualified licensed practical nurse may administer chemical restraints to an individual and only after receiving an oral order from an authorized physician. A. The documentation of such oral orders include the following: (I) Name of physician who gave the order; (II) Name of nurse who received the order; (III) Name of nurse who actually administered the chemical restraint—identify behaviors requiring the chemical restraint in specific terms that allow measurement; (IV) Anticipated effects of the medication and time frame related to the effects. B. The person administering the chemical restraints documents the information required and the physician's oral order in the individual’s record or equivalent record. C. The oral order is signed by a physician as soon as possible after the initial administration of the chemical restraint. (C) Mechanical restraints are prohibited. (9) Utilization of a seclusion time-out (or safe-room) procedure requires prior approval from the Chief Behavior Analyst. Request for such approval must include a functional assessment of the target behavior, a BSP, the rationale for the use of the procedure, and data supporting the need for the procedure and that less restrictive interventions were ineffective. The Chief Behavior Analyst must also approve of the designated time-out area or room. (A) Seclusion time-out will become a prohibited procedure as of July 1, 2021. (B) Behavioral services remain active during the time period in which the BSP (seclusion time-out intervention) is in place. (C) The BSP with a seclusion time-out procedure includes all elements identified in section (6) of this rule as well as the following: 1. Specification that only qualified personnel may use seclusion time-out for an individual under conditions set out in an approved BSP; 2. If the BSP includes time-out, it is reviewed and approved by the following: A. RBSC; B. The individual or the family, or legal guardian as appropriate; and C. The Chief Behavior Analyst or designee; 3. Target behaviors, operationally defined, and consistent with the function identified in the functional assessment for the target behavior; 4. Description of strategies to ensure high rates of positive reinforcement and engaging activities are available for the individual making “time in” an enriched situation; 5. Criteria for release from seclusion time-out and discontinuation of a seclusion time-out episode— A. Release from seclusion time-out criteria is limited to no more than five (5) minutes of calm behavior; B. Total duration for the seclusion time-out episode is no more than one (1) hour except in extraordinary instances (during initial stage of program) that are personally approved at the time of occurrence by the behavior analyst and reviewed within one (1) business day by the region’s assigned area behavior analyst; C. Continuous observation of the person in time-out; D. Seclusion time-out will be discontinued if there are any signs of injury or medical emergency and the person will be assessed by appropriate medical personnel; and E. The date, time, and duration of each seclusion time-out intervention is documented on a data sheet and on an event management form. (D) Time-out areas or rooms shall meet the following safety and comfort requirements: 1. Areas and rooms to be utilized for seclusion time-out and the procedures for the use of seclusion time-out are reviewed and approved by the Chief Behavior Analyst or designee; 2. Continuous observation of the individual in the area is maintained at all times; 3. Adequate lighting and ventilation is used at all times; 4. The area or room is void of objects and fixtures such as light switches, electrical outlets, door handles, wire, glass, and any other objects that could pose a potential danger to the individual in time-out; 5. If there is a door to the room or area, it will open in the direction of egress such that the individual in the room is not able to bar the door to prevent entry; 6. The door is void of any locks or latches that could allow the door to be locked without continuous engagement by a staff person; and 7. The room or area will be at least six (6) feet by six (6) feet in size or large enough for any individual who will utilize the room to lie on the floor without head or feet hitting walls or door. (10) The division provides oversight for services provided to individuals with significantly challenging behaviors through RBSCs. The division establishes at least two (2) RBSCs. Additional RBSCs may be established depending upon need and staff capacity. (A) Members of the RBSC are appointed by the division director or designee. (B) The RBSC consists of three (3) to five (5) members including: 1. A chairperson who is a licensed behavior analysis employed by the division; 2. A member or members of the provider community licensed to practice applied behavior analysis or who provided behavior therapy under contract with DMH prior to January, 2012 or who are working towards Board Certified Behavior Analyst (BCBA) or Board Certified Assistant Behavior Analyst (BCaBA) certification under the supervision of a licensed behavior analysis; and 3. A medical consultant or other professionals as indicated by the information under review or requested by the chairperson. (C) The RBSC meets at least once every three (3) months, and may meet as often as needed to fulfill responsibilities. (D) The purpose of RBSCs is to promote the implementation of best practice strategies that lead to greater independence and enhanced quality of life for individuals experiencing challenging behaviors. RBSCs ensure the following: 1. That waiver assurances are met; 2. That best practice behavioral services are followed; 3. That ethical guidelines are followed; 4. That behavioral strategies are least restrictive; and 5. That implementation of strategies documented in the ISPs and BSPs support progress toward greater independence and enhanced quality of life. (E) The division establishes RBSC review criteria to prioritize the individuals with significantly challenging behaviors and those individuals whose supports include restrictive interventions. 1. Individuals experiencing significantly challenging behaviors reaching threshold criteria for reactive strategies, or who have been prescribed psychotropic/behavior control medications, or who have PRN psychotropic medication for behavioral support. 2. A BSP may be reviewed based on a request by the members of the ISP, including, but not limited to, the parent/guardian, support coordinator, or Regional Director (or designee) to provide technical assistance. 3. The Regional Director and the RBSC prioritize reviews to ensure appropriate representation based upon issues that represent regional challenges to meet identified objectives. 4. The RBSC shall respond to requests for review within thirty (30) calendar days of receipt of the request. 5. The support coordinator and provider of BSPs and ISPs reviewed by the RBSC will receive written summary of the RBSC's recommendations within five (5) working days of the RBSC's review of the BSPs or ISPs. (11) If use of prohibited or unauthorized procedures is discovered, the following occurs: (A) Regional Director is notified of the use of prohibited procedures, the agency involved, persons for whom the procedures were utilized, and reasons for use; (B) Regional Director directs regional staff and Area Behavior Analyst to conduct a focused review of the agency; (C) If the focused review confirms that prohibited or unauthorized procedures were used, the Regional Director will be informed and notify the provider and support coordinator; (D) Area Behavior Analyst works with planning teams to determine appropriateness of strategies and need for additional services to assist the provider to address the situations positively, proactively, and preventatively; (E) Area Behavior Analyst refers supports of individuals, for whom the prohibited practices have been used, to the RBSC; and (F) Follow up reviews of the provider will occur to ensure that appropriate procedures and supports are utilized and prohibited practices have been discontinued for a duration determined by the Chief Behavior Analyst. AUTHORITY: sections 630.050 and 630.175, RSMo Supp 2019.* Original rule filed Sept. 20, 2019, effective March 30, 2020. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.175, RSMo 1980, amended 1996, 2008, 2014, 2016, 2019.