To understand behavior intervention, it helps to first understand behavior. The word behavior generally means the way we act. All day long we display a series of behaviors that are viewed by ourselves and others as positive, negative, or neutral. It is important to note that behaviors don’t just happen. A person’s behavior communicates a want or a need. We form beliefs and respond to people based on our view of their behavior. In simple terms, behavior intervention is to intervene or take action to prevent or change a behavior.
At Mains’l:
In the course of your time with Mains’l and in your personal life, you will be performing behavior interventions and people will be performing them on you. The procedures below provide definitions and examples of what we can’t do, what we can do, and what we should do when it comes to intervening in someone else’s behavior. Let’s start with the bad and end with the good.
The things we cannot do (also known as prohibited procedures)
The following are not allowed as a replacement for proper supervision or staffing, to reduce or stop a behavior, as punishment, or for staff convenience:
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In summary, we do not do these things. Not only do they make people unhappy, they generally do not work well to help people appropriately get their wants and needs met. Prohibited procedures may stop a behavior, but they do not teach a person what to do differently the next time. Prohibited procedures may also make a behavior worse. In addition, prohibited procedures can result in mental or physical injuries.
We have better options for you, so please keep reading. We will cover the things you can’t do first and end with the good stuff, positive supports.
Here are the simplified and technical definitions of prohibited procedures along with some and examples.
A chemical restraint is giving someone a drug or medication that has not been prescribed by their doctor to treat the behavior you are trying to avoid.
An example of chemical restraint is giving a person Xanax when they start yelling so they don’t become physically aggressive but Xanax is prescribed for the person to take when they have panic attacks. If Xanax is given for physical aggression and not a panic attack, this would be a chemical restraint.
Technical definition: The administration of a drug or medication to control the person’s behavior or restrict the person’s freedom of movement and is not a standard treatment or dosage for the person’s medical or psychological condition.
Mechanical restraint:
A mechanical restraint is using an object to limit or stop a person from freely moving a part of their body or have access to a part of their body
An example of a mechanical restraint is taping gloves onto a person’s hands so they cannot scratch themselves, but they would not choose to wear the gloves on their own.
Mechanical restraint does not include the following: (1) devices worn by the person that trigger electronic alarms to warn staff that a person is leaving a room or area, which do not, in and of themselves, restrict freedom of movement; or (2) the use of adaptive aids or equipment or orthotic devices ordered by a health care professional used to treat or manage a medical condition.
Technical definition: The use of devices, materials or equipment attached or adjacent to the person’s body, or the use of practices that are intended to restrict freedom of movement or normal access to one’s body, to prevent injury with a person who engages in self-injurious behaviors, such as head-banging, gouging, or other actions resulting in tissue damage that have or could cause medical problems resulting from the self-injury. Mechanical restraint also includes the use of practices that are intended to restrict freedom of movement or normal access to one’s body or body parts, or limits a person’s voluntary movement or holds a person immobile as an intervention precipitated by a person’s behavior.
A manual restraint is using your body to limit another person’s ability to move their own body.
An example of a manual restraint is pinning someone to the ground to stop them from going somewhere.
Technical definition: Physical intervention intended to hold a person immobile or limit a person’s voluntary movement by using body contact as the only source of physical restraint.
Basically, seclusion is making a person go somewhere or leave somewhere against their wishes and then not allowing them to leave.
An example of seclusion is forcing a person to be separated because they were pinching the staff by putting them in a locked room while attending a birthday party.
Technical definition: Removing a person involuntarily to a room from which exit is prohibited by a staff person or a mechanism such as a lock, a device, or an object positioned to hold the door closed or otherwise prevent the person from leaving the room; or otherwise involuntarily separating a person from an area, activity, situation, or social contact with others and blocking or preventing the person’s return.
Time out:
A time out is making someone go to an area and it is experienced as a negative consequence. It differs from seclusion in that the person is not stopped from leaving the area they were sent to, but it is still not allowable for a staff to tell a person receiving services that a consequence of their behavior/actions is that they have to go to a designated area.
Time out does not mean voluntary removal or self-removal for the purpose of calming, prevention of escalation, or de-escalation of behavior; nor does it mean taking a brief break or rest from an activity for the purpose of providing the person an opportunity to regain self-control.
An example of a time out is sending a person to their bedroom after an argument, when they do not want to go. Another example is requiring someone to sit on a chair for a specified amount of time, but not physically forcing them to stay in the chair.
Asking someone to ‘take a break’ to ‘cool down’, but not requiring them to do so, is not considered a time out.
Technical definition: The involuntary removal of a person for a period of time to a designated area from which the person is not prevented from leaving.
An example of an aversive procedure is to wash someone’s mouth out with soap if they swear in the hope that they will not swear again.
Technical definition: The application of an aversive stimulus based upon the occurrence of a behavior for the purposes of reducing or eliminating the behavior.
Examples of aversive stimulus are heat, cold, noise, a food or an event that is unwanted or unpleasant that is presented to stop someone or suppress a behavior.
Technical definition: An object, event, or situation that is presented immediately following a behavior in an attempt to suppress the behavior.
Deprivation procedure: A deprivation procedure involves taking away or not allowing someone to have something or do something they like, want, or need in order to get the person to stop or reduce the behavior.
An example of a deprivation procedure is to take away someone’s dinner because they hit someone or not allow the person to go to the dance because they hit themselves.
Technical definition: The removal of a positive reinforcer following a response resulting in, or intended to result in, a decrease in the frequency, duration, or intensity of that response. Often times the positive reinforcer available is goods, services, or activities to which the person is normally entitled. The removal is often in the form of a delay or postponement of the positive reinforcer.
The things we can only do in certain circumstance ( also known as restricted procedures)
A restricted procedure is something that should not normally be done, but may be allowed in very specific circumstances if it is done properly and for acceptable reasons. Some restricted procedures include:
Avoid the emergency use of manual restraint and
Prevent the person from physically harming self or others
Phase out any existing plans for the emergency or programmatic use of restrictive interventions that are prohibited.
Employees working with a person who has a positive support transition plan receive training before working unsupervised. In Minnesota, Mains’l develops a positive support transition plan on the forms and in the manner prescribed by the commissioner of DHS for a person who requires intervention in order to maintain safety when it is known that the person’s behavior poses an immediate risk of physical harm to self or others. The positive support transition plan forms and instructions will supersede the requirements in Minnesota Rules, parts 9525.2750; 9525.2760; and 9525.2780.
2. Emergency Use of a Manual Restraint:
Emergency physical intervention intended to hold a person immobile or limit a person’s voluntary movement by using body contact as the only source of physical restraint.
This means using a part of your body, such as your arms, hands, legs, or your entire body to stop the movement of another person.
An example of an emergency use of a manual restraint is to use a wrist side hug procedure to move a person away from someone they are trying to assault.
At Mainsl, we do not allow the emergencyuse of a manual restraint (EUMR) to be done to most people.
Employees who work with someone who has a support plan that allows EUMR are required to complete Behavior Basics and Emergency Use of Manual Restraint training before they can perform an emergency manual restraint.
A restricted procedure (one approved in a positive support transition plan or an emergency use of a manual restraint) cannot:
Be implemented in a manner that violates a person's rights.
Restrict a person's normal access to a nutritious diet, drinking water, adequate ventilation, necessary medical care, ordinary hygiene facilities, normal sleeping conditions, necessary clothing, or any protection required by state licensing standards or federal regulations governing the program;
Deny the person visitation or ordinary contact with legal counsel, a legal representative, or next of kin;
Be used for the convenience of staff, as punishment, as a substitute for adequate staffing, or as a consequence if the person refuses to participate in the treatment or services provided by the program;
Use prone restraint, which means the use of manual restraint that places a person in a face-down position. Prone restraint does not include brief physical holding of a person who, during an emergency use of manual restraint, rolls into a prone position, if the person is restored to a standing, sitting, or side-lying position as quickly as possible;
Apply back or chest pressure while a person is in a prone position;
Be implemented in a manner that should not be used (contraindicated) for any of the person's known medical or psychological limitations;
Be implemented by a staff that has not completed training on the proper techniques to do an emergency manual restraint.
The things that we can do (also known as permitted actions and procedures)
While these are not the first choice, or what we want to regularly have happen, the following can be used on an intermittent basis. Additionally, if addressed in a person service and support plan, these things can be done on a continuous basis. The reason for continuous use is to be included.
Physical contact
To calm or comfort a person by holding that person when they show no resistance to being held.
To protect a person known to be at risk of injury due to frequent falls as a result of a medical condition;
To facilitate the person's completion of a task or response when the person does not resist or the person's resistance is minimal in intensity and duration;
To block or redirect a person's limbs or body without holding the person or limiting the person's movement to interrupt the person's behavior that may result in injury to self or others with less than 60 seconds of physical contact by staff; or
To redirect a person's behavior when the behavior does not pose a serious threat to the person or others and the behavior is effectively redirected with less than 60 seconds of physical contact by staff.
2. Restraint may be used as an intervention procedure to:
To position a person with a physical disability in a manner specified in the person’s service and support plan.
Assist in the safe evacuation or redirection of a person in the event of an emergency and the person is at imminent risk of harm.
Allow a licensed health care professional to safely conduct a medical examination or to provide medical treatment ordered by a licensed health care professional that is necessary to promote healing or recovery from an acute, meaning short-term, medical condition.
3. Use of adaptive aids or equipment, orthotic devices, or other medical equipment ordered by a licensed health professional to treat a diagnosed medical condition do not in and of themselves constitute the use of mechanical restraint.
The things that you should do (positive supports)
Positive approaches should be used first and be the most commonly used approached to intervening in another person’s behavior. Positive support approaches include:
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By using positive support approaches, we show respect and honor the dignity of people. We are also more likely to see decreases in the behaviors we don’t want to see and increases in the behaviors we do want to see.
Responding to a challenging behavior
When a person begins to engage in escalating disruptive behavior and it becomes obvious that they may likely engage in continuous aggression, self-injury, or high level disruptive behaviors that also threaten the safety and well-being of self or others if not redirected, implement the following steps:
1. If appropriate or possible, remove all people, whose safety is threatened, from the immediate area of the threatening person.
2. Attempt de-escalation techniques. De-escalation techniques include restructuring the environment (noise, crowding, proximity), maintaining calm posture and body language, re-direction, positive verbal praise, active listening, and/or prompting (verbal and gestural).
3. If applicable, review the use of the person’s PRN (as needed) medication to address target mental health symptoms.
4. If the person’s behavior continues to be disruptive, ask the person to remove themselves from the ongoing activity to a location where they cannot observe the ongoing activity – this is a voluntary time out.
5. Follow through with the encouragement of the person’s absence from the ongoing activity with verbal prompts. Do not use physical intervention!
6. Monitor the person’s behaviors while they choose to be in a voluntary time out.
7. When the person stops the disruptive or threatening behavior, ask them if they want to return to normal activities.
8. If immediate intervention is needed to protect the person or others from physical injury or to prevent severe property damage that is an immediate threat to the physical safety of the individual or others, call 911.
9. If a behavior intervention that includes the police, PRN medication to stop a behavior, or , the staff who implemented the intervention:
• Notifies their manager immediately;
• Calls the on-call administrative personnel to report the incident as well as the on-call nurse (if they have one) if there is an injury;
• Completes the Behavior Intervention Reporting Form (BIRF), and submits it to the manager before they leave work;
• If a PRN medication is given for target behaviors rather than mental health symptoms, staff completes the BIRF.
10. If 911 was called, the staff responsible at the time of the incident:
• Completes an incident report and the BIRF.
• Calls the on-call administrative personnel to report the incident;
• Notifies the manager who notifies the case manager and the legal representative of the incident within 24 hours.
The procedures listed above are not used to respond to challenging behavior with a person when it has been determined by the person’s physician or mental health provider to be medically or psychologically contraindicated for a person. Mains’l will complete an assessment of whether the allowed procedures are contraindicated for each person receiving services as part of the service planning process.
Staff Training
a. Before having unsupervised direct contact with a person receiving service and annually thereafter,
all employees who provide direct support receive instruction on prohibited procedures that address the following:
1. what constitutes the use of restraint, time out, seclusion, and chemical restraint;
2. staff responsibilities related to ensuring prohibited procedures are not used;
3. why such prohibited procedures are not effective for reducing or eliminating symptoms or undesired behavior;
4. why prohibited procedures are not safe
b. For the limited situations where the emergency use of a manual restraint may be allowed, before those staff may implement manual restraints on an emergency basis they must also be trained on the following within 60 days of hire:
1. alternatives to manual restraint procedures, including techniques to identify events and environmental factors that may escalate conduct that poses an imminent risk of physical harm to self or others;
2. de-escalation methods, positive support strategies, and how to avoid power struggles;
3. simulated experiences of administering and receiving manual restraint procedures allowed by the program on an emergency basis;
4. how to properly identify thresholds for implementing and ceasing restrictive procedures;
5. how to recognize, monitor, and respond to the person’s physical signs of distress, including positional asphyxia;
6. the physiological and psychological impact on the person and the staff when restrictive procedures are used;
7. the communicative intent of behaviors; and
8. relationship building.
9. the safe and correct use of manual restraint on an emergency basis
Training on any of these topics received from other sources may count toward these requirements if received in the 12 month period before the employee’s date of hire and valid documentation is provided to Mains’l.
In December 1991, the Occupational Safety and Health Administration (OSHA) published a new rule regarding exposure to blood borne pathogens. The purpose of this rule is to identify actions employers need to take for their employees who have potential occupational exposure to blood during performance of routine work duties.
The greatest risk of exposure to blood during the performance of routine work duties is found within the health care setting. Mains'l Services, Inc.'s workplace, a residential setting for people with developmental disabilities and related conditions does not pose the same type of exposures. The primary tasks of all employees of Mains'l Services is to offer training, assistance, and supervision to the people we serve. Only as a collateral or incidental duty are employees expected to render first aid or be exposed to blood or body fluids which may present possible exposure to a blood borne pathogen
Mains'l Services, Inc. is committed to providing a safe workplace and implements all OSHA recommended procedures that minimize occupational exposure. Mains'l Services also educates its employees about universal precautions that should be observed to prevent contact with blood or other potentially infectious materials. In addition to preventive measures and education, Mains'l also provides access to treatment following an exposure incident at no charge to employees.
The policies and procedures supporting this policy on Blood Borne Pathogens are designed to meet compliance with OSHA standards.
It is the responsibility of Mains’l Services to determine the specific policies and procedures used in each individual program and their compliance to rules and regulations. It is also the responsibility of Mains’l Services to make adjustments in the policies and procedures in the event rules and regulations are changed or reinterpreted.
The first step in determining work place exposure to blood borne pathogens is through the development of an Exposure Control Plan (see attached.) The Exposure Control Plan is designed to eliminate or minimize employee exposure to blood borne pathogens. The Exposure Control Plan must contain:
I. Exposure Determination
II. Schedule and Method of Implementation for:
III. Procedure for Evaluation of Circumstances Surrounding Exposure Incidents
The Exposure Determination (see Exposure Control Plan - Section I) is a site specific document completed by the Manager with the assistance of the Senior manager. Its purpose is to delineate all tasks and procedures which may present an occupational exposure. Because the primary tasks of all employees of Mains’l Services, Inc. is to offer training, assistance, and supervision to the people we serve, tasks posing an occupational exposure are considered collateral duties and are not regarded as primary job assignments. The completed Exposure Determination for each site is maintained in the policy manual at the site. The entire Exposure Control Plan, including the Exposure Determination, is reviewed and updated at least annually and whenever necessary to reflect new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure.The Exposure Control Plan also contains a Schedule and Methods of Implementation for A) the OSHA recommended methods of compliance including the concept of universal precautions, engineering and work practice controls, personal protective equipment and general housekeeping standards, B) Hepatitis B Vaccine and Post Exposure Follow Up, C) Communication of Hazards to Employees, and D) Record Keeping.
Using the Universal Precautions approach, Engineering and Work Practice Controls, Personal Protective Equipment and general housekeeping standards are in place in all sites as deemed necessary. (see Exposure Control Plan - Section IIA.) Information about the aforementioned topics is contained in the “Control of Infection and Communicable Disease” Training module and provided during the first 60 days of employment to new employees and immediately to current employees.
The Infection Control Plan is found within the Mains’l Policy Manual as an attachment to the Exposure Control Plan and incorporates related procedures addressing the universal precautions of hand washing, use of gloves, general cleaning procedures, and laundry procedure.
The Schedule and Methods of Implementation also pertain to the administration of the Hepatitis B vaccine and Post Exposure Evaluation and Follow Up. Pursuant to the OSHA modification of Hepatitis B vaccination requirements, employees who have occupational exposure as a “collateral duty” need not be offered the vaccine until an exposure incident has occurred. (An exposure incident is defined as a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral (skin piercing) contact with blood or other potentially infectious materials that results from the performance of an employee’s duties). Any unvaccinated person who has rendered assistance in any situation involving the presence of blood or other potentially infectious material, regardless of whether an actual exposure incident as defined by the OSHA standard has occurred, will be offered the vaccine. The procedure following an exposure incident is delineated in the Exposure Control Plan - Section IIB. New employees are instructed in the procedures during initial orientation and current employees are informed of the procedures during the training conducted by the Managers.
The Schedule and Methods of Implementation also pertain to the communication of hazards to employees. Warning labels and signs are not deemed necessary in the residential programs in which the employees of Mains’l work. Occupational exposures only occur as collateral duties of employees and training is provided in infection control, universal precautions, personal protective equipment including the use of gloves, general work practice controls such as hand washing, and general housekeeping standards.
As mentioned throughout this procedure, comprehensive training is provided to all employees of Mains’l Services, Inc. The training module includes all the elements recommended in the OSHA standard (see Exposure Control Plan - Section IIC.) New employees receive training within the first sixty days of employment and the training will be reviewed annually for all employees, within one year of previous training.
Finally, the Schedule and Method of Implementation applies to record keeping (see Exposure Control Plan - Section IID.) If an occupational exposure occurs, Mains’l Services will establish and maintain an accurate medical record for each employee with an occupational exposure. The medical records will be confidential and will include all information as stipulated in the OSHA regulations. Training records are maintained and contain all information as stipulated in the OSHA regulations.
The last component of the Exposure Control Plan is the procedure for evaluation of circumstances surrounding exposure incidents. Following an exposure incident, the senior manager will review all documentation of the route(s) of exposure and the circumstances under which the exposure occurred and make recommendations to prevent future exposure incidents (See Exposure Control Plan - Section III). The report will be reviewed by the Health Services Director who will make necessary changes or revisions to policy and procedure.
OSHA Rule on Blood Borne Pathogens: 1910.1030 of Title 29 of the Code of Federal Regulations
Mains'l respects and protects the data we receive and retain to promote service recipient rights. Access, release and duplication of private information are in accordance with federal and state statutes
Private data includes all information on a person that Mains’l has gathered for the purpose of offering supports.
Notice of Privacy Rights
Sharing Information: Mains’l employees are allowed to share information with only the following persons or entities without a release:
A person receiving services or their legal representative has a right to access and review the individual record and may request copies of pages in their record.
Besides the person receiving services and their legal representative, the people identified above do not automatically have access to private data about a person receiving services or about other staff or agency employees. Need-to-know basis means that the person must have a specific work reason requiring access to the information. Private data about a person is available only to those employees whose work assignments reasonably require access to the data; or who are authorized by law to have access to the data.
Any written or verbal exchanges about a person's private information by staff with other staff or any other persons will be done in such a way as to preserve confidentiality, protect data privacy, and respect the dignity of the person whose private data is being shared. As a general rule, if a person is unsure about sharing information regarding a person, they should contact their supervisor or reference this policy and procedure.
Sharing Information with Other Parties
Information regarding a person receiving service from Mains'l may be released to outside persons/agencies only after the person or their legal representative authorizes the release by signing the Consent to Exchange Information.
Obtaining Informed Consent and Authorization for Release of Information
Upon starting services and annually after that, the Mains’l manager or their designee will obtain informed consent and authorization to release information. There may be other times when a representative of Mains’l provides informed consent and requests authorization for release of information. The following procedures are to be followed at any time information is requested:
2. The manager maintains all informed consent documents in the person’s individual record.
The following will be observed when completing the Consent to Exchange Information:
Requesting Information from Other Licensed Caregivers or Primary Health Care Providers
Mains’l may need to request information about the person from other licensed providers. When this is needed, the manager will:
Release of Written Documents to Persons Receiving Service or Legal Representative
The following process is used when a person receiving supports or their legal representative wishes to obtain copies of written records:
Release of photographs or video to other parties: Photographs or video of people supported by Mains'l are displayed or released to outside persons/agencies only if the person receiving service or their legal representative has authorized the release by signing an Authorization for Release of Photographs.
The following is observed when completing the release of photographs form:
Minnesota Government Data Practices Act section 13.46
California Statute Title 17
HIPAA Standards of Privacy of Individually Identifiable Health Information 45 C.F.R. section 164
Consent to Exchange Information
Release of Information
Authorization for Release of Photographs
Notice of Privacy Practices for Person Receiving Service
Notice of Privacy Practices Acknowledgment of Receipt
Mains’l promotes the rights of the people we serve and protects their health and safety during the emergency use of manual restraints. “Emergency use of manual restraint” means using a manual restraint when a person poses an imminent risk of physical harm to self or others and it is the least restrictive intervention that would achieve safety. Property damage, verbal aggression, or a person’s refusal to receive or participate in treatment or programming on their own, do not constitute an emergency.
Mains’l employees will not perform an emergency use of manual restraint unless they have:
In addition to the behavior intervention policy and procedure, the following procedures are followed if and when it is necessary to perform the emergency use of a manual restraint.
Responding to Escalating Disruptive Behavior
When a person begins to engage in escalating disruptive behavior and it becomes apparent that they may likely engage in continuous aggression, self-injury, or high level disruptive behaviors that also threaten the safety and well-being of others if not redirected, implement the following steps:
8. If the person begins to engage in behavior that is continuous aggression, continuous self-injury, or high magnitude disruption that threatens the safety of themselves or others, emergency manual restraint may be implemented, as trained. When implementing an emergency use of manual restraint start with the least restrictive procedure necessary to keep the individual and others safe.
9. After implementing the manual restraint, attempt to release the person at the moment staff believe the person’s conduct no longer poses an imminent risk of physical harm to self or others and less restrictive strategies can be implemented to maintain safety.
Mains’l will not allow the use of a manual restraint procedure with a person when it has been determined by the person’s physician or mental health provider to be medically or psychologically contraindicated. Mains’l will complete an assessment of whether the allowed procedures are contraindicated for each person receiving services as part of the service planning required under section 245D.070, subdivision 2, for recipients of basic support services; or the assessment and initial service planning required under section 245D.071, subdivision 3, for recipients of intensive support services.
Manual Restraints Allowed in Emergencies
Below is a list of each of the manual restraints trained staff are allowed to use on an emergency basis when a person’s actions pose an imminent (it is about to happen) risk of physical harm to self or others and less restrictive strategies have not achieved safety. The list includes instructions for the safe and correct implementation of those procedures.
They are listed in order of least to most restrictive:
Conditions for Emergency Use of Manual Restraint
Emergency use of manual restraint must meet the following conditions:
Restrictions When Implementing Emergency Use of Manual Restraint
Emergency use of manual restraint must not:
1. be implemented with a child in a manner that constitutes sexual abuse, neglect, physical abuse, or mental injury;
2. be implemented with an adult in a manner that constitutes sexual abuse, neglect, physical abuse or mental injury;
3. be implemented in a manner that violates a person’s rights and protection;
4. be implemented in a manner that is medically or psychologically contraindicated for a person;
5. restrict a person’s normal access to a nutritious diet, drinking water, adequate ventilation, necessary medical care, ordinary hygiene facilities, normal sleeping conditions, or necessary clothing;
6. restrict a person’s normal access to any protection required by state licensing standards and federal regulations governing this program;
7. deny a person visitation or ordinary contact with legal counsel, a legal representative, or next of kin;
8. be used as a substitute for adequate staffing, for the convenience of staff, as punishment, or as a consequence if the person refuses to participate in the treatment or services provided by this program;
9. use prone restraint. “Prone restraint” means use of manual restraint that places a person in a face-down position. It does not include brief physical holding of a person who, during an emergency use of manual restraint, rolls into a prone position, and the person is restored to a standing, sitting, or side-lying position as quickly as possible; or
10. apply back or chest pressure while a person is in a prone position, supine (meaning a face-up) position, or side-lying position,
11. be implemented in a manner that is contraindicated for any of the person’s known medical or psychological limitations.
Monitoring Emergency Use of Manual Restraint
Mains’l must monitor a person’s health and safety during an emergency use of a manual restraint. When possible, a staff person who is not implementing the emergency use of a manual restraint must monitor the procedure. The purpose of the monitoring is to ensure the following:
1. only manual restraints allowed in this policy are implemented;
2. manual restraints that have been determined to be contraindicated for a person are not implemented with that person;
3. allowed manual restraints are implemented only by staff trained in their use;
4. the restraint is being implemented properly as required; and
5. the mental, physical, and emotional condition of the person who is being manually restrained is being assessed and intervention is provided when necessary to maintain the person’s health and safety and prevent injury to the person, staff involved, or others involved.
Reporting Emergency Use of Manual Restraint
The staff who implemented any form of manual restraint procedure:
The manager/designated coordinator:
b. Within (5) working days of the behavior intervention, reviews and finalizes the Behavior Intervention Internal Review form.
Expanded Support Team Review of Emergency Use of Manual Restraint
Within 5 business days after the completion of the internal review, the manage or senior manager must consult with the expanded support team to:
1. Discuss the incident to:
a. define the antecedent or event that gave rise to the behavior resulting in the manual restraint; and
b. identify the perceived function the behavior served.
2. Determine whether the person’s service and support plan needs to be revised to:
a. positively and effectively help the person maintain stability; and
b. reduce or eliminate future occurrences of manual restraint.
3. Make the revisions to the person’s service and support plan when it is determined necessary.
The written summary of the expanded support team’ discussion and decisions will be documented on the Expanded Support Team Review Form and saved in the person’s plan file.
Internal Review of Emergency Use of Manual Restraint
a. Within 5 business days after the date of the emergency use of a manual restraint, the senior manager must complete and document an internal review of the report prepared by the staff member who implemented the emergency procedure. The internal review must include an evaluation of whether:
1. the person’s service and support strategies need to be revised;
2. related policies and procedures were followed;
3. the policies and procedures were adequate;
4. there is need for additional staff training;
5. the reported event is similar to past events with the persons, staff, or the services involved; and
6. there is a need for corrective action by the program to protect the health and safety of persons.
b. Based on the results of the internal review, the senior manager must develop, document, and implement a corrective action plan designed to correct current lapses and prevent future lapses in performance by individuals or Mains’l.
c. The corrective action plan, if any, must be implemented within 30 days of the internal review being completed
d. The original is filed in the person’s plan file and a copy is submitted to the director.
External Review and Reporting of Emergency Use of Manual Restraint
Within 5 business days after the completion of the expanded support team review, the senior manager must submit the following to DHS using the online behavior intervention reporting form which automatically routes the report to the Office of the Ombudsman for Mental Health and Developmental Disabilities:
1. report of the emergency use of a manual restraint;
2. the internal review and corrective action plan; and
3. the expanded support team review written summary.
Positive Support Transition Plan
If an individual uses a positive support transition plan, the plan will be written by a Board Certified Behavior Analyst. The plan will be written and phased out within 11 months form the date of plan implementation. The BCBA will use the DHS created and approved plan.
Behavior Intervention Policy and Procedure
Minnesota Statute 245D.06, subd. 5 to subd, 8; 245D.061 and Minnesota Positive Support Rule
PRN Use Protocol
Behavior Intervention Report Form (BIRF) and Incident Report Form
Behavior Intervention Report Form – Internal Review Form and External Review Form
Corrective Action Plan and Positive Support Transition Plan
Mains’l offers supports to people based on what is important to them, what is important for them, and the balance between important to/for the person. Getting to know someone is an ongoing process and we use a variety of ways to learn about the person and their support needs. Supports offered are person centered, aligned with the identified needs, interests, preferences, and desired outcomes of the person receiving services.
All supports and services are provided within the boundaries of what is legal, safe, ethical, and are authorized to provide through contracts and individual service agreements.
Once services have started, the person receiving services continues the discovery process with people they have chosen to support them. The process and procedure may vary, depending on the supports and needs of each person.
Mains’l employees are trained in offering person centered services. If at any time a Mains’l employee feels they do not have sufficient information regarding person centered practices, skills or tools, they are encouraged and expected to seek out a Person Centered coach. A list of coaches can be found on the Mains’l employee portal under Person Centered Thinking.
A variety of tools and skills are used to assist in recording the information learned, in order to develop a Support Plan. Tools/skills may include, but are not limited to: Matching Tools (to gain insight on what staff characteristics are preferred) and Discovery Tools (Important To, Importance For, Rituals and Routines, Relationship Map, Good Day/Bad Day, Communication Chart, Learning Log). These tools inform the person centered description (see Person Centered Description packet and forms.)
1. The person receiving services and Mains’l staff work together to develop a Personal Description of the person. Employees will document what they learned using the materials in the Person Centered Description packet within the first 30 days of starting services. Information discovered from this process creates the foundation of how supports will be offered. A one-page personal profile/description is created, based on the information learned (a snapshot of the person), and includes what’s important to the person, what others like and admire about them, and how to best support them.
2. The person receiving services and their support team, including Mains’l staff, work together to balance what is important to and for a person, and how to best support them. Information from existing support plans (i.e., Coordinated Service and Support Plan, Individual Service Plan, and Person Centered Plan, if available) is included in the Support Plan, which the manager will develop within the first 30-40 days of service. The Support Plan reflects what services and supports are offered, as well as how, when, and by whom the services will be provided.
3. Mains’l employees collaborate with the person receiving services when documenting information. This is to ensure the person has input into what is being recorded about them. The person has the right to not participate in this process, but it is recommended and is encouraged. This applies to all initial and ongoing recorded information gathered throughout the time the person receives supports from Mains’l.
4. If a Person Centered Plan is not already in place, the manager works with the support team to identify who is responsible to create the plan, as appropriate.
Throughout the year, the manager, along with direct support staff and other key people, collaborate on how to best meet the persons’ identified needs, interests, preferences and goals. The person’s Support Plan is updated when needed, at minimum annually, based on the discoveries from conversations and changes in what is important to and important for the person.
Ongoing Collaboration and Conversations
Mains’l values collaboration and partnerships when offering supports. We have ongoing conversations with the person receiving services and their support team, to continually learn about the person and their changing preferences, needs, and personal goals and outcomes. The process of “Nothing about the person, without the person” is maintained to the greatest extent possible.
Personal outcomes and goals are reviewed with the person receiving services on an ongoing basis, and at least every six (6) months. The Support Plan is updated as needed to reflect any changes, and support team members are notified as progress and changes occur, when applicable. Learning logs may be used to assist in using innovative, creative ways to overcome barriers or enhance the supports offered.
Meetings are scheduled throughout the year, as requested and/or needed. Meetings are scheduled by the manager and/or the person and their support team, and are held at the person’s home, or another place determined by the person and their support team.
1. Mains’l encourages a face to face meeting with the person receiving services and their support team within the first 30-45 days of starting services to review how things are going and to ensure all documentation Mains’l has created is acceptable to the person and their support team. While the person can choose to not have a face to face meeting, we strongly encourage this practice.
2.See Meeting Checklist (by service and meeting type) for a list of documents to be reviewed and/or completed prior to the meeting, at the meeting, and after the meeting.
3. The focus of all meetings is to continue to address what is important to and for the person. The person receiving services and the team talk about what’s working and what’s not working, what has been tried, and share ideas for better support delivery. The person receiving services is coached and encouraged to lead the meeting. They are also asked to assist in creating the agenda, including areas they want addressed (or do not want addressed) at the meeting. Person-centered skills and tools are used to assist the person in creating the agenda, as well as facilitating the meeting, as desired.
4. Meetings may begin by an opening round. A relevant positive question may be asked for all members to respond, i.e., “What is one highlight from the last year (week, month, etc.) you can share with the group?” or “What is one thing you like or admire about the person?”
5. If a person centered plan has been developed, the team reviews and updates as desired. If a plan has not been created, the manager works with the support team to identify who is responsible to create the plan, as appropriate.
6. The person receiving services, if so desired, follows the agenda and then reviews the most recent Support Plan, telling the group if changes are needed. The manager helps facilitate as needed.
7. The manager requests the person or appropriate team member to sign all documents, as required, listed on the Meeting Checklist.
8. A satisfaction survey is completed at each person’s Annual Meeting. A paper survey with a return envelope is offered, to consistently receive feedback on how we might improve our services.
9. The team identifies next meeting date/s and how often they want to receive written updates and reports, as appropriate.
Person Centered Description packet
Matching and Discovery Tools
Meeting Checklist (by service and meeting type)
Support Plan
Satisfaction Survey
We are committed to maintaining safe and comfortable environments where people live and work. All homes managed by Mainsl are led by the question, “Would I want to live here?”
We will make sure that services are provided in a safe and hazard free environment if we’re the owner, leaser, or tenant of the site.
We expect all service sites to be clean and well maintained and to pass inspections by the Maintenance Committee.
We maintain the exterior and interior of the sites we own and rent (depending upon the lease) which include walls, floors, ceilings fixtures, and equipment. We are responsible to keep these items in good repair, sanitary and safe.
We comply with applicable state, local fire, health, building and zoning codes at all times.
We also require that all sites are free of fire hazards like electric portable space heaters, cut fresh Christmas trees or lighted candles.
For people living in their own homes or apartments the manager will tell the person or their guardian and case manager about any environmental concerns so that they’re safe.
All new managers and support coordinators will receive training on this policy and procedure soon after being assigned to a new site.
Inspections and Code Compliance:
Physical Plant Requirements:
Common Areas:
Bedrooms:
Bedroom Furnishings:
For Service:
Service Contracts:
Emergencies – Gas Smells, Fires:
If you smell gas or spot/suspect a fire:
Emergencies – Extreme Temps:
Emergencies – Water Leaks:
Emergencies – Extreme Water Temps:
If the water heater is malfunctioning (too hot – in excess of 120F)
If the repair to the water heater will be delayed for more than 24 hours call the maintenance tech or vice president of administration to report the delay. Also call the manager and/or senior manager to develop a contingency plan (hotel) until the repair is made.
Power Outages:
Power Outages Numbers to Call:
Maintenance Requests – Phone App – this is being tested and will be finalized soon.
Non-Emergency – Service:
Whenever any service technician comes to the home to make a repair, always ask the tech for a copy of the work ticket and get that ticket to the maintenance tech.
Non-Emergency – Service Technicians:
Non-Emergency – Water Softener:
Licensing Preparation – Licensed Sites:
Fall/Winter Check Lists:
Support Coordinator’s Role in Maintenance:
Manager’s Role in Maintenance:
Maintenance Committee:
Landlords of Rental Properties:
Senior Manager Quarterly Site Visit Checklist
Fall/Winter Check Lists
Semi Annual Maintenance Inspection
Mains'l recognizes the rights of the individuals who choose our services; we value their opinions and welcome and encourage their input. Every person who receives service is encouraged to voice complaints and to recommend changes to Mains'l policies, procedures or services to any agency personnel or others of their choice without restraint, interference, coercion, discrimination, or punishment.
Upon request, Mains’l staff will provide assistance to the person receiving services and or their authorized representative with the complaint process. This assistance will include the name, address, and telephone number of outside agencies to assist the person and responding to the complaint in such a manner that the person’s concerns are resolved.
For the purpose of this policy and procedure, the word grievance means an official statement of a complaint over something believed to be wrong or unfair. When a person applying for or receiving services from Mains'l wishes to submit a complaint or grievance the following procedure is available:
1. The person or their legal representative who wishes to file the complaint must provide a written account of the complaint to the Mains’l manager. Once the written complaint is received, the manager notifies the senior manager.
2. All complaints involving health and safety concerns must receive an initial response by the end of the next business day; all other complaints receive an initial response within 14 calendar days.
3. Every attempt is made by the manager and senior manager to resolve the complaint with the person and/or legal representative.
4. All complaints are expected to be resolved within (30) thirty calendar days of the manager receiving the written complaint.
5. If the grievance cannot be resolved by the manager and senior manager the person may bring the grievance to the highest authority in the program:
Minnesota California
Anne Roehl, Director of Services MN Anne Silcher, Director of Services CA
7000 78th Ave N 40 Landing Circle Suite 1
Brooklyn Park, MN 55445 Chico, CA 95973
Office: 763-494-4553 Office: 530-899-1907 ext.3
Toll Free: 800-441-6525 Toll Free: 888-899-4588
Fax: 763-416-9120 Fax: 530-899-1996
Legal Authority: Minn. Stat. § 245D.10, subd. 2 and 4
California Lanterman Act Section 4502 and Title 17 Section 50510
6. Once a complaint is received, the manager and senior manager complete a complaint review. The complaint review will include an evaluation of whether:
7.Based on this review, the manager and senior manager must develop, document, and implement a corrective action plan designed to correct current lapses and prevent future lapses in performance by staff or Mains’l, if any.
8. The senior manager will provide a written summary of the complaint and a notice of the complaint resolution to the person and case manager that:
9. The complaint summary and resolution notice are maintained in the person’s record.
10. At any time, the person who has the grievance may call, visit, or email an external agency to assist with making a complaint. Some resources include:
Minnesota
ARC – Minnesota
770 Transfer Road Suite 7A
St. Paul, MN 55114 Toll-Free: 1-800-582-5256
E-mail: mail@arcmn.org
Website: www.arcmn.org
Mid-Minnesota Legal Aid
430 1st Ave. North, Suite #300
Minneapolis, MN 55401
TDD: 612-334-5755
E-mail: none
Website: www.mylegalaid.org/mdc
Office of the Ombudsman for Mental Health and Developmental Disabilities
121 7th Place E, Suite 420
Metro Square Building
St. Paul, MN 55101
Metro: 651-757-1800
Toll-Free: 1-800-657-3506
E-mail: ombudsman.mhdd@state.mn.us
Website:www.ombudsmanmhmr.state.mn.us
Minnesota Department of Human Services
PO Box 64967
St Paul, MN 55164-0967
Phone: 651-431-2600
E-mail: dhsinfo@state.mn.us
Website: www.dhs.state.mn.us
California
Area 2 Developmental Disabilities Board
1367 East Lassen Avenue, Suite B-3
Chico, CA 95973
(530) 895-4027
Office of Clients’ Rights Advocacy
Kimberlee Candela
1280 East 9th St. Unit E
Chico, CA 95928
(530) 345-4113
People, who receive services and support from Mains’l, independently manage their personal finances and property to the fullest extent possible. Each person retains the use and availability of their personal funds and property, unless restrictions are justified and documented in the person’s service and support plan.
When part of the services being offered is support in managing finances, Mains’l maintains written authorization to manage funds from the person or the person’s legal representative and the case manager. Authorization is obtained within five working days of service initiation and renewed annually thereafter.
Mains’l employees may not accept power-of-attorney from a person receiving services from Mains’l for any purpose. Employees, volunteers or subcontractors of Mains'l may not borrow money or purchase personal items from persons served, sell items or personal services to a person served, or require them to purchase items for which Mains'l receives reimbursement.
All funds and/or related documentation are kept separate from the agency, program, staff or other individual funds and are stored in a secure location.
Personal Funds and Property when Starting and Ending of Service
When assigned responsibility to manage finances, Mains’l requests consent to authorize the Mains’l Financial Audit Team to audit checking accounts, savings accounts, and cash on hand to ensure financial integrity.
Cash Record
Consent to Manage/Audit Finances
Individual Financial Review
In MN 245D.06 Subd. 4 Funds and Property
Support Plan
Financial Review Summary/Work Plan
Financial Funds and Property When Starting/Ending Services
Requests for service are accepted from people requesting supports for themselves, their caregivers, family members and guardians, other providers, and social service agencies. Mains’l accepts referrals from people without regard to race, gender, age, disability, spirituality, or sexual orientation, and our practices are consistent with a person’s service recipient rights.
Mains’l uses a person centered approach to discover if the person requesting services and Mains’l are a good fit, based on needs, alignment with Mains’l values, and our ability to meet the person’s level of care. We do not refuse to offer services to a person based solely on the type of services the person is currently receiving, the degree of their emotional, physical or intellectual abilities, type of communication style, personal routines, or past success rate. If we cannot meet a person’s service needs, documentation regarding the reason will be provided to the person, the person’s legal representative, and case manager, upon request.
Referrals
Mains’l engages in conversations with the person requesting services and their support team to help identify what’s important to and important for the person. We are committed to a collaborative approach when developing services for people, and a team of Mains’l employees work together to determine if service needs can be met. Team members may consist of a customer service specialist, navigator, senior manager and/or manager.
When a person contacts Mains’l about our services:
The information gathered is used to assist with the development of the person’s support plan.
Enrollment
When the person requesting services and Mains’l agree that we are a good match, the process of starting services begins. This procedure may vary, depending on the supports and needs of each person.
References
Getting to Know You
Person Centered Description packets
Enrollment Meeting Checklist
How We Offer Supports and Services Policy and Procedure
Mains’l Guidebook to Supports
Starting Services/Change of Service form
Most of the services Mains’l provides are funded by Medicaid. So, you play a vital role in protecting the integrity of the Medicaid Program. To reduce waste, abuse, and fraud you need to know what to watch for and when to report if you suspect that waste, abuse, or fraud is occurring.
Although the terms Medicaid and Medicare fraud and abuse have slightly different meanings, depending on individual state law, they generally mean the same thing: any violations of the state and federal requirements related to the delivery of services to Medicaid or Medicare recipients.
Waste is a broad term that refers to care that is not effective or that is not delivered efficiently.
Abuse is when a provider does not follow good medical practices, resulting in unnecessary costs, improper payment, or services that are not medically necessary.
Fraud is when Medicaid or other insurance is billed for services or supplies a client never received. It is when a person knowingly cheats or is dishonest. The dishonesty results in a benefit such as payment or coverage that the person would not have been entitled to otherwise.
Examples of Fraud, Abuse and Waste include but are not limited to:
Multiple state and federal laws make it illegal for a person to bill Medicaid, Medicare or other insurance providers for goods or services that he or she knows are false.
Any person who submits a claim to Mains’l that he or she knows, or should know is false will be held responsible and his or her action may be punishable by law.
Suspected fraud, abuse, and violations of this policy is immediately reported. Any report of fraud or abuse, received by Mains’l will be investigated. Suspected waste should also be reported to reduce or prevent waste from continuing.
Failure of an employee to report suspected fraud, abuse or a violation of this policy will result in employee discipline, up to and including separation.
Any suspicions of fraud, abuse, and waste should be directly reported to our Public Funds Compliance Officer, the Director of Administration.
The Public Funds Compliance Officer will conduct an internal investigation. In the event that our Public Funds Compliance Officer, the Director Administration is suspected or alleged to be involved in fraud, the National Director of Human Resources will complete the investigation. The investigation will include at least the following:
If it is determined after a thorough investigation that any employee has committed fraud, their employment will be terminated immediately.
If it is determined that a vendor, person receiving services, or other business partner has committed fraud, Mains’l reserves the right to end the relationship.
While Mains’l prefers that reports of suspected fraud and abuse are made internally, you have the right to report suspicions of Medicaid abuse or fraud to a state agency.
In California: Department of Health Care Services/Health Care Programs at 800-822-6222 or
http://www.dhcs.ca.gov/individuals/pages/stopmedi-calfraud.aspx
Office of the Attorney General 800-722-0432
http://www.ag.ca.gov/bmfea/medical.htm
In Minnesota: Department of Human Services Provider Fraud: 800-657-3750 Recipient Fraud: 800-627-9977
http://mn.gov/dhs/general-public/licensing/report-fraud/index.jsp
Mains’l will not discharge, discipline, threaten, or discriminate against, or penalize an employee, who in good faith reports or participates in an investigation of fraud, abuse, or waste internally or externally. However, failure to report suspicions of fraud, abuse, and waste will result in disciplinary action, up to and including termination.
(Rev.5/24/2019 CJ)
Requests for service are accepted from people requesting supports for themselves, their caregivers, family members and guardians, other providers, and social service agencies. Mains’l accepts referrals from people without regard to race, gender, age, disability, spirituality, or sexual orientation, and our practices are consistent with a person’s service recipient rights.
Mains’l uses a person centered approach to discover if the person requesting services and Mains’l are a good fit, based on needs, alignment with Mains’l values, and our ability to meet the person’s level of care. We do not refuse to offer services to a person based solely on the type of services the person is currently receiving, the degree of their emotional, physical or intellectual abilities, type of communication style, personal routines, or past success rate. If we cannot meet a person’s service needs, documentation regarding the reason will be provided to the person, the person’s legal representative, and case manager, upon request.
Referrals
Mains’l engages in conversations with the person requesting services and their support team to help identify what’s important to and important for the person. We are committed to a collaborative approach when developing services for people, and a team of Mains’l employees work together to determine if service needs can be met. Team members may consist of a customer service specialist, navigator, senior manager and/or manager.
When a person contacts Mains’l about our services:
1. We gather basic information about the person, including service needs, funding type, personal information, preferred characteristics of support staff, and the type of housing or roommate preferences, as applicable.
2. We will ask if a person centered description and/or Person Centered Plan have been created. If so, we request the information. If not, we offer resources to assist the person in this process. The process may involve an outside person centered planner.
3. We meet with the person and their circle of support (those invited by the person they want involved) about what is important to and for them. Most often we have a “meet and greet” at a place designated by the person and/or at a place with potential roommates. “A Getting To Know You” form can be used to begin recording information about the person.
4. If during these conversations/introductions it is determined that Mains’l is a good fit for the person and/or their circle of support, information sharing continues. Mains’l asks for the following, as applicable/available:
a. Important to the person:
o Person Centered Plan (Picture of a Life, MAP, Essential Lifestyle Plan, etc.)
o Personal Description and/or Personal Profile
o Support/program plan (i.e., Coordinated Service and Support Plan or Individual Program Plan)
b. Important for the person
o Personal Safety Plan (Individual Abuse Prevention Plan, Support/Program Plan)
o Individualized Education Program Plan – completed by school professional
o Medical and health care related information and/or assessments (psychological and/or psychiatric evaluation, behavior assessment, physical therapy, dental, occupational therapy, audiology, etc.)
o Positive Support Transition Plan
5. If there are concerns regarding potential risk to the agency, the assigned manager meets with the Vice President of Administration to determine if the referral process can continue. Certain medical needs or behavioral or criminal histories may pose too great a risk for the person or Mains’l. History of arson, assault, and sexual offenses, for example, require special consideration and may not match Mains’l’s ability to provide supports. When there appears to be a mismatch between Mains’l’s ability to provide supports and the supports that are likely needed, the referral must be reviewed and approved by the executive leadership team.
6. If it is determined that the person and Mains’l are not a good fit and we are not going to provide services, the manager will provide documentation of the reason to the person, the person’s legal representative, and case manager, upon request.
7. When the person requesting services and Mains’l agree that we are a good match, the manager negotiates the service agreement with the case manager. Upon receiving the service agreement, (or authorization that the agreement is in process), the manager begins developing services.
8. The manager meets with additional Mains’l staff when the supports requested require resources that extend beyond our current support options. Members may include the following: services director, human resources representative, nurse, therapeutic specialist, finance representative, and/or a housing representative. The development team works together to ensure the person’s support needs can be met, and within the expected timeframe(s). The team meets on a regular basis to communicate updates on progress to the person and their support team, as needed.
9. Mains’l support team members and the person requesting services continue the discovery process to learn as much as possible about each other. Mains’l uses a variety of person centered practices to assist in documenting the information learned. These tools/skills may include, but are not limited to: Matching Tools (to gain insight on what staff characteristics are preferred) and Discovery Tools (Important To/For, Rituals and Routines, Relationship Map, Good Day/Bad Day, Communication Chart, Learning Log). Many of these tools are contained in the Person Centered Description materials packet.
The information gathered is used to assist with the development of the person’s support plan.
Enrollment
When the person requesting services and Mains’l agree that we are a good match, the process of starting services begins. This procedure may vary, depending on the supports and needs of each person.
1. When new staff are needed, Mains’l partners with the person and their support team to recruit employees who are the right fit for the person and Mains’l.
2. If during the referral process it has been determined that the person requesting services is looking for a new place to live, the support team members determine the roles and responsibilities of each member in locating housing. Depending on the supports identified, different levels of supports will be needed.
a. In some cases, Mains’l may have an established home that provides up to 24 hours of support. If a roommate is desired by existing tenants of the established home, and this level of support is requested by the person, the manager will make arrangements for the people to meet and get to know each other.
b. If the person has a criminal background which may affect roommates, the manager notifies the roommates and/or their guardians and case managers (i.e., is on a sexual predator registry.) Also, the manager notifies the person requesting supports if one of the potential roommates is on a sexual predator registry.
c. If everyone agrees the living arrangement is a good match for all, a move in date is scheduled by the manager, the person, and their support team.
d. When new housing must be arranged before supports start, a move-in date is set when the person’s home has been secured (lease signed, roommates identified if needed, etc.) The roles and responsibilities are assigned by the person and their support team, depending on the level of support requested.
e. Once staffing and housing is established, as needed, an enrollment meeting can be scheduled.
3. An enrollment meeting is scheduled by the manager, and/or the person and their support team. Meetings are held at a place agreed upon by the person and their circle of support.
4. At the meeting, conversations continue to address what is important to and for the person. These conversations help the manager record information that will inform the person’s Support Plan.
a. If a Person Centered Plan has not been created by/for the person, the team addresses who will be responsible to develop the plan, as appropriate.
b. All documents listed on the Enrollment Checklist will be reviewed and/or signed by the person and/or their guardian.
c. The manager offers a Mains’l Guidebook to Supports. The handbook includes policies and procedures on how we offer services.
d. A date when services will actually begin will be determined by the person and the support team.
5. The manager completes a Starting Services form to notify other Mains’l departments when services are starting.
6. The manager begins the process of developing the person centered Support Plan (see How We Offer Supports and Services Policy and Procedure). This document is developed as soon as possible (best practice 15 days but no later than 30 days after the initial starting services meeting) and is sent to the person and their identified support team
Getting to Know You
Person Centered Description packets
Enrollment Meeting Checklist
How We Offer Supports and Services Policy and Procedure
Mains’l Guidebook to Supports
Starting Services/Change of Service form
Mains’l provides representative payee services in accordance with the rules and regulations of the Social Security Administration. Mains’l only offers representative payee services to individuals who receive other services from the agency.
A representative payee can be appointed by the Social Security Administration to receive the Social Security or SSI benefits for a person who can’t manage or direct the management of his or her benefits. Mains’l does not charge a monthly fee from Social Security benefits and/or Supplemental Security Income (SSI) benefits, but charges may apply depending on the business relationship between Mains’l and the person requesting representative payee services.
A representative payee’s main duties are to use the benefits to pay for the current and future needs of the beneficiary, and properly save any benefits not needed to meet current needs. A payee must also keep records of expenses.
Establishing Mains’l as a Representative Payee
The following steps are to be followed to establish Mains’l as Representative Payee:
Fulfilling Representative Payee Responsibilities
It is the policy of Mains’l to ensure our procedures for temporary suspension and termination of services promote continuity of care and service coordination for people receiving services.
This policy is in alignment with state statutes (see References at end of document.)
Suspending Services
a. Reasons for temporary suspension of services:
1. A person may suspend services with Mains’l at any time. Some reasons a person might choose to suspend services are:
2. Mains’l may also choose to suspend services. Temporary service suspension by Mains’l is limited to the following situations:
a. positive support strategies have been implemented to resolve the issues leading to the temporary service suspension, but have not been effective and additional positive support strategies would not achieve and maintain safety; OR
b. less restrictive measures would not resolve the issues leading to the suspension.
a. This includes non-payment of waiver obligations, spenddowns, private pay, GRH, Medicaid and any other funding sources.
b. Medicaid or other funding being inactive or person is no longer eligible for services.
b. Actions taken before services are suspended: Mains’l requests that we be notified in writing if a person chooses to suspend their services. Before Mains’l gives notice of temporary service suspension, the manager documents actions taken to minimize or eliminate the need for suspension.
1. Action taken by Mains’l must include, at a minimum:
If, based on the best interests of the person, the circumstances at the time of the notice were such that the manager was unable to consult with the person’s team or request interventions services; the manager must document the specific circumstances and the reason for being unable to do so.
c. Actions taken when suspending services:
1. The manager notifies the person or the person’s legal representative and the case manager in writing of the intended temporary service suspension by completing a Notice of Temporary Suspension of Services.
2. If the temporary service suspension is from supported living services or community residential services:
a. In Minnesota, the senior manager must notify the DHS Commissioner in writing. DHS notification will be provided by fax at 651-431-7406.
b. In California, the senior manager must notify the Case Management Supervisor in writing.
3. The Notice of Temporary Service Suspension is given on the first day of the service suspension.
4. The written notice of service suspension must include the following elements:
5. During the temporary suspension period the manager must:
d. Returning to services after suspension: A person has the right to return to receiving services during or following a service suspension with the following conditions:
1. Based on a review by the person’s support team or expanded support team, the person no longer poses an imminent risk of physical harm to self or others, the person has a right to return to receiving services.
2. If the support team or expanded support team makes a determination that is different than the recommendation of a licensed professional treating the person for the reason services were suspended, the manager must document the specific reasons why a different decision was made.
Ending Services
a. Reasons for ending services:
1. A person may end services with Mains’l at any time. Some reasons a person might choose to end services are:
2. Mains’l may also choose to end services. Termination of service by Mains’l is limited to the following situations:
b. Actions taken before services are terminated: Mains’l requests to be notified in writing if a person chooses to end their services. Before Mains’l gives notice of service termination, the manager will document the actions taken to minimize or eliminate the need for termination.
Actions taken will include, at a minimum:
If, based on the best interests of the person, the circumstances at the time of the notice were such that the manager was unable to consult with the person’s team or request interventions services; the manager must document the specific circumstances and the reason for being unable to do so.
c. Actions taken when terminating services:
1. A written notice of an intended service termination, including those situations which began with a temporary service suspension, must be completed on the Notice of Service Termination form and given to the person, their legal representative, and the case manager before the proposed effective date of service termination.
a. For California services, and for intensive services in Minnesota, the notice must be provided at least 60 days before the proposed effective date of service termination.
b. For all other services, the notice must be provided at least 30 days before the proposed effective date of service termination.
c. If the service termination is from supported living services or community residential services:
2. This notice may be given in conjunction with a notice of temporary service suspension.
3. The written notice of a proposed service termination must include all of the following elements:
4. During the service termination notice period, the manager must:
Minnesota Statute 245D.10, subdivision 3 and subdivision 3a.
California Statute Title 17, division 2, chapter 3
Notice of Temporary Suspension of Services
(Revised 8/16/2022; LM)
The following incidents and emergencies need to be reported as soon as possible, and no longer than 24 hours from when it occurs, or from the time you find out about it:
a. Any serious injury of a person defined as:
b. A person's death
c. Any medical emergency, unexpected serious illness, or significant unexpected change in an illness or medical condition of a person that requires a Mains’l staff to call 911, requires physician treatment, or hospitalization;
d. Any mental health crisis that requires Mains’l staff to call 911 or a mental health crisis intervention team, or similar mental health response team;
e. An act or situation involving a person that requires Mains’l staff to call 911, law enforcement, or the fire department;
f. A person’s unauthorized or unexplained absence (as determined by the individual’s support team):
g. Conduct by a person receiving services against another person receiving services that:
h. Any sexual activity between persons receiving services involving force or coercion;
i. Any emergency use of manual restraint;
j. A report of alleged or suspected maltreatment of a child or vulnerable adult.
Incidents that involve maltreatment or an unexplained physical injury are reported immediately to MAARC (Minnesota Adult Abuse Reporting Center) or the local child welfare agency, in accordance with agency maltreatment reporting procedures. (See Responding to and Reporting Maltreatment Policy and Procedure.)
Responding to All Incidents
When an incident as defined above occurs:
An employee who is working at the time of the incident:
4. Call and report the incident to the on-call administrative personnel: 612-598-5700
5. As soon as possible and before leaving the shift notify the assigned manager or senior manager
6. Complete an Incident Report and any other related documentation
7. When an incident involves more than one person receiving services, employees do not disclose personally identifiable information about the other person involved when reporting to the legal representative and case manager, unless we have their consent.
8. Medical emergencies require a direct call to the on call nurse 612-644-0615
Additional procedures for responding to specific incidents and emergencies are provided on the following pages. In addition, you will receive customized training, based on the unique needs of the person or people you will be working with.
Responding to a Power Outage
Responding to Fire
Depending on where you are at:
1. Follow the site evacuation plan/evacuate the home.
2. Lead people to the designated safe place, using the nearest exit away from the fire.
3. The designated meeting place for this person’s home is _____________________________________
(at least 75 feet away from the home)
4. Call 911
5. Location of fire extinguishers at this person’s home is _______________________
Do not attempt to use extinguishers on any fire larger than a small wastebasket.
6. Call to report to on-call administrative person: 612-598-5700.
They will assist if relocation is necessary.
7. The employee working at the time of the fire completes an incident report
Fire Drills: When we support people in community residential settings the manager initiates/assigns completion of fire drills according to the printed agency schedule and based on the services being provided. The schedule is designed to vary the staff participating and the times of day the drill is conducted. Actual simulation of a variety of fire locations and responses are practiced. Following the completion of a drill, the Fire Drill Report is completed and submitted to the assigned senior manager who evaluates the response and makes recommendations for additional safeguards as needed.
Responding to a Carbon Monoxide Alert
a. When the carbon monoxide detector sounds, and people are showing symptoms* associated with carbon monoxide poisoning:
1. Immediately evacuate the building as quickly as possible. The designated safe place is: ___________________________________________________________________________
2. Call 911. Do not reenter the building until it has been aired out and the problem has been corrected.
3. Call the on-call administrative person for assistance and to report: 612-598-5700; call again to report when you are allowed to re-enter the home.
b. When the carbon monoxide detector sounds, and people are not
Showing symptoms associated with carbon monoxide poisoning:
1. Press the test/reset button.
Note: If dangerous levels are present, the unit will re-sound.
2. If unit does not re-sound, you may remain in the home, but
watch for any signs that the monitor is faulty or for other symptoms
of carbon monoxide (above).
3. If the unit does re-sound:
Evacuate the individuals from the home
Turn off all appliances, vehicles, or other sources of combustion immediately. These could include a furnace, water heater, vehicles, and other sources
Immediately get fresh air into the home by opening doors and windows
Call your service provider to make a report
Do not restart appliances until the service provider, or maintenance personnel, has stated the problem has been corrected
4. Call the administrative on-call person for assistance: 612-598-5700.
Responding to Severe Weather/Tornado
a. National Weather Service alerts to possible tornado or severe storm developments.
Tornado or severe storm Watch - (Conditions are right for a tonrnado over the next 12 hours)
Tornado Warning - (an actual tornado has been sighted inthe area)
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b. The designated safe area for severe weather/tornado at this home is:_______________________
Severe Weather/Tornado Drills: When we support people in community residential settings, during tornado season, at least two practice drills in response to severe weather/tornado occur. The drills are initiated/assigned by the manager, according to the printed agency schedule. Following the completion of the drill, a Tornado Drill report is completed and submitted to the assigned senior manager who evaluates the response and makes recommendations for additional safeguards as needed.
Responding to Severe Winter Weather
a. During the cold winter months, remain alert to changing weather conditions. Regularly check the weather reports on TV, radio, or internet. Also, advisories may be issued internally across e-mail.
b. When the National Weather Service announces an extreme cold or blizzard warning it means that these conditions will occur within 12 hours of the initial advisory.
c. During actual blizzard warnings, no unnecessary transportation is permitted. Necessary travel i.e., medical appointments, may occur only with the approval of the manager after consultation with the senior manager.
d. Be aware and prepared for other closing that may affect the
Schedule of the person you support and make necessary arrangements.
e. Call 911 and report your position if there is an accident or the vehicle goes off the road during the winter months. Stay in the vehicle unless it is not safe to do so.
f. The location of flashlight and battery radio is_________________
g. If structural damage or extended power outage occurs, call the on-call administrative personnel at 612-598-5700. They work with the senior manager to coordinate alternative housing if
relocation is necessary. Maintenance personnel will assess the reported damages, as necessary.
Also call to notify the on-call administrative person when power is restored.
h. If services need to be relocated for more than 24 hours, an incident report is completed and submitted by the manager. The manager or their designee notifies the person’s legal representative or emergency contact and case manager within 24 hours of the incident. They also notify licensing personnel as appropriate.
Emergency Evacuation and Emergency Sheltering/Relocation of Services
People may need to be relocated due to structural damage after a storm or fire, furnace malfunction (including carbon monoxide), gas explosion, power outage, or other physical plant concerns.
When there are concerns for the health and/or safety of the persons who live there the following steps should be taken:
1. If additional staff is needed to meet the emergency, staff on duty should call the manager, senior manager, and/or on-call administrative personnel for assistance at 612-598-5700.
2. If relocation is necessary, call the manager, senior manager and the on-call administrative personnel. They will work together to determine where the individuals can go most immediately, as well as assist with a long term plan, if that is needed. If relocation exceeds 24 hours, the manager completes an incident report.
3. The on-call administrative personnel works with the manager and senior manager to notify all employees, agency maintenance personnel, insurance company, parents, guardians, case managers, and county satellite and state licensors.
4. Maintenance personnel work with law enforcement to secure the property and assess damage and, if possible, complete needed repairs so people may return to their home as soon as possible.
Responding to a Mental Health Crisis
You have a few options:
1. Call 911 if the concern is life threatening.
2. Call a mental health crisis intervention team or
line that you can search on the internet.
3. A person can also call their individual therapist,
when the situation does not require an immediate
911 emergency response.
Responding to a Missing Person
No two missing people are the same. Consequently, it is vital to find out as much about the missing person as possible before initiating a particular response.
1. If a person is suspected missing, note the time and location
when and where the person is expected to be.
2. Check the persons Community Supports and Services Plan
(Support Plan) and/or Personal Safety Plan for guidance and the
length of time the person can be on their own.
3. Attempt to locate the person by calling people or agencies
he/she may be with, and search the immediate area and
nearby areas of potential interest to the person.
4. If the person cannot be located, immediately call the on-call administrative personnel at 612-598-5700. The on-call administrative personnel provides direction for notifying the person’s legal representative or designated emergency contact, case manager, and police.
5. The employee working at the time the person was determined missing completes an Incident Report and any related documentation, i.e., Health Care Progress Notes, communication notes, police report, etc.
6. The manager or their designee follows up with the case manager and the person’s legal representative or designated emergency contact within 24 hours of the incident. They also notify licensing personnel as appropriate.
Responding to Physical Aggression between People Receiving Services
1. Follow the approaches you have learned in Behavior Intervention Policy and Procedure and your individualized training and seek assistance from other staff if available.
2. If injury to an individual has occurred or there is imminent possibility of injury to another person and:
a. you have been trained in the emergency use of manual restraint, immediately implement emergency use of a physical intervention, likely a manual restraint. (Refer to Emergency Use of Manual Restraint Policy and Procedure).
b. you have not been trained in the emergency use of manual restraint or it isn’t effective and you cannot make the situation safe for people, immediately call 911.
3. After the situation is under control, question the people as to any injuries and look for any signs of injury. If injuries are noted, provide necessary treatment, contacting medical personnel if needed.
4. Notify the manager and administrative on-call person (612-598-5700) as soon as everyone is safe and the individuals’ immediate needs have been met.
5. The staff that was most directly involved at the time of the incident completes an incident report before completing their shift. If the incident involved emergency use of a manual restraint, a call to law enforcement or other first responders, emergency psychiatric hospitalization, or a prn psychotropic medication was administered, this staff completes a Behavior Intervention Reporting Form (BIRF) and submits it to the site manager prior to leaving the shift.
6. The manager or their designee notifies the case manager and the person’s legal representative or designated emergency contact within 24 hours of the incident. They also notify licensing personnel as appropriate.
Responding to Sexual Exploitation or Assault
1. If you witness what you think is sexual exploitation or sexual assault, talk to the persons involved in a calm manner and ask them to separate. If there has been obvious force or intimidation, based on your knowledge of the individuals, physically intervene or call 911 if necessary. If the individuals are unclothed, provide them with a robe or other clothing, but they should not redress in the clothing they were wearing and they should not bathe or shower.
2. Talk to each of them separately, to the extent possible, to determine what led to the interaction and what happened. Assess whether the person is experiencing any physical or emotional discomfort. Ask what, when, where, and how questions. Do not ask “why” questions. Document your initial observations and the information provided by the persons as soon as possible after talking with them.
3. In a respectful manner, look for any signs of physical injury (e.g. bruising, bleeding, etc.) and document your observations as soon as possible.
4. If medical personnel and/or law enforcement have been contacted, follow all instructions they provide.
5. If it is determined unnecessary to involve medical and/or law enforcement personnel, the person(s) may resume their normal activities.
6. Call the manager and the on-call administrative person at 612-598-5700 as soon as appropriate arrangements have been made to meet the person(s) needs.
7. The staff most directly involved at the time of the incident completes an incident report before completing their shift. If the incident involved emergency use of a manual restraint, a call to law enforcement or other first responders, emergency psychiatric hospitalization, or a prn psychotropic medication was administered, this staff completes a Behavior Intervention Reporting Form (BIRF) and submits it to the manager, before the end of the work day.
8. The manager or their designee will notify the case manager and the person’s legal representative or designated emergency contact within 24 hours of the incident. They also notify licensing personnel as appropriate.
When Law Enforcement is Requested
1. In the event staff have summoned law enforcement or fire department to the home (e.g. due to possible criminal activity, security/safety concerns, individual’s behavior, fire etc.) or to the site of an incident or emergency, staff will explain, in detail the reason for requesting them, upon their arrival. Answer all questions asked of you and follow any instructions provided. Document the event on an incident report as soon as possible after the fact, and notify the on-call administrative personnel immediately.
2. If law enforcement was requested for security/safety concerns or behavior this staff also completes a Behavior Intervention Reporting form (BIRF) and submits it to the site manager prior to leaving the shift.
3. The manager or their designee notifies the case manager and the person’s legal representative or designated emergency contact within 24 hours.
Unannounced Law Enforcement
1. If law enforcement officers arrives unannounced to the home or the site of an incident or emergency, staff first ask for proper identifications as warranted (i.e., non-uniformed officer). Ask how you can be of assistance and be cooperative with the official. Answer all questions asked of you; offer additional information after the officer’s questions have been answered. Before they leave, ask the official for his/her business card and a case number if one is being assigned.
2. Document the event on an incident report as soon as possible after the fact.
3. Call the manager and on-call administrative person immediately.
4. The manager or their designee notifies the case manager and the person’s legal representative or designated emergency contact within 24 hours.
5. Submit a photo or the front and back of the officer business card if a case number is being assigned to the vice president of administration.
Vehicle Crash
1. If involved in a vehicle crash, provide all information requested of you and provide officials with the necessary insurance information. Also, be sure to obtain insurance information from the other drivers involved. (See Accident Protocol posted at the site). Always call the police- never leave the scene until given permission by law enforcement.
2. Document the event on an incident report as soon as possible after the fact. Notify the manager and on-call administrative personnel immediately.
3. The manager or their designee notifies the case manager and the person’s legal representative or designated emergency contact within 24 hours.
Contact with Law Enforcement in the Community
1. If you have contact with law enforcement or the fire department while in the community, as a part of your work, follow the procedures described in “Requested Law Enforcement” or “Unannounced Law Enforcement” above, depending on who initiates the contact.
2. Document the event on an incident report as soon as possible after the fact. Notify the manager and on-call administrative personnel immediately.
3. The manager or their designee notifies the case manager and the person’s legal representative or designated emergency contact within 24 hours.
Reporting Incidents and Emergencies
When an incident occurs:
a. The employee who is supervising at the time of the incident:
o Immediately calls 911 if there is a medical emergency or a physical or sexual assault in progress;
o Immediately (before leaving the shift) notifies:
The assigned manager or senior manager;
The on-call RN, if the incident resulted in an injury to the individual; and
The administrative on-call personnel
o Completes an Incident Report and any other related documentation, i.e., Health Care Progress Notes, Entry Notes, communication book, and a BIRF, if applicable
b. The manager:
o Reviews each incident report and related documents the next working day for accuracy and thoroughness, to identify any patterns and to determine corrective action. The manager will ask for the incident report to be rewritten if the content is not accurate or not written factually or professionally.
o The manager is responsible for completing the incident report and for any follow-up related to the incident, i.e. retraining, disciplinary action, etc.
o Faxes or brings the incident report to the senior manager the next working day following the incident
c. The senior manager:
o Reviews the incident report for accuracy and thoroughness, returning it to the manager if changes or additions are needed.
o They sign/initial the report, below the designated coordinator’s signature
o Scans or e-mails the incident report to the “Incident Reports” e-mail address at Mains’l
d. The manager, or senior manager in their absence, reports the incident to the person’s legal representative or designated emergency contact and case manager within 24 hours of:
o An incident occurring while services are being provided
o Within 24 hours of discovery or receipt of information that an incident occurred, unless we have reason to know that the incident has already been reported, or
o As otherwise directed in a person’s Coordinated Services and Support Plan (Support Plan) or Coordinated Services and Support Plan Addendum
o A copy of the incident report is sent to these persons, if requested
o The senior manager sends a copy of the incident report to the county satellite licensor for any incident that involves serious injury, death, or change in health status that may affect continuation of services
e. When the on-call administrative personnel receives the call from the employee:
o They must verify whether the employee has reached the manager or senior manager to provide the notice to the legal representative or designated emergency contact and case manager, within 24 hours of the incident
o Notify the following agencies as appropriate, within 24 hours:
Death or Serious injury Office of Ombudsman for Mental Health and
Developmental Disabilities FAX 651-797-1950
AND
Department of Human Services, Division of Licensing FAX 651-431-7673
Maltreatment Minnesota Adult Abuse Reporting Center
(MAARC) at 1-844-880-1574 or online at mn.gov/dhs/reportadultabuse/ or for minors call law enforcement of the county Child Protection Agency Death, Serious Injury, or fire County Satellite Licensor that causes structural damage or requires the fire department
f. All employees receive ongoing training regarding emergency response procedures and responding and reporting incidents and emergencies.
g. When reporting a maltreatment incident, specifically, the person’s legal representative and case manager must be notified unless there is a reason to believe that either party is involved in the suspected maltreatment. The information that must be disclosed is the nature of the activity or occurrence reported and the agency that received the report.
h. The on-call administrative personnel notifies Chuck Jakway, vice president of administration, about any incidents report to MAARC, death, serious injury, police or fire rescue. In the absence of the vice president of administration, John Jakway, shall be notified. The vice president of administration, or his designee, initiates an internal review of incident reports of death and serious injuries that occurred while services were being provided and those that were reported by the program as alleged or suspected maltreatment, for identification of incident patterns, and implementation of corrective action as necessary to reduce occurrences. The internal review will include an evaluation of whether:
1. The policies and procedures were adequate
2. Related policies and procedures were followed
3. There is need for additional staff training
4. The reported event is similar to past events with the persons or the services involve to identify incident patterns
5. There is need for corrective action by the program to protect the health and safety of the persons receiving services and to reduce future occurrences
i. Based on the results of this review, a corrective action plan is developed, documented, and implemented to correct current lapses and prevent future lapses in performance by staff or the agency, if any. Internal Reviews are completed within 30 calendar days of the report.
When the initial reporter believes the incident was maltreatment, the on-call administrative personnel sends a Status of Report of Suspected Maltreatment letter to the initial reporter at their home address, with two working days.
j. The person conducting an internal review of maltreatment follows the Reporting and Responding to Maltreatment Policy and Procedure.
k. The person conducting a review of emergency use of manual restraints follows the Emergency Use of Manual Restraint Policy and Procedure.
Record Keeping:
1. The review of an incident will be documented on the incident reporting form and will include identifying trends or patterns and corrective action, if needed.
2. Incident reports will be maintained in the person’s record. They will also be e-mailed/scanned into the incident report e-mail address ireport@mainsl.com. Incident reports and corresponding documentation (MAARC reports, Internal Reviews, DHS determination letters, Status of Maltreatment Status Letters and Ombudsman Reports will be stored in this e-mail box.
Critical Incidents
A critical incident is any incident that: involves illegal activity, results in significant injury to a person receiving services or staff, the death of a person or staff, has significant negative impact on a member of the neighborhood or community or is judged to potentially have a high level of risk/exposure for the agency.
The procedure for managing critical incidents is as follows:
1. Call 911 if appropriate.
2. The staff present and most immediately involved in the incident calls the administrative on-call personnel.
3. The administrative on-call personnel call the assigned senior manager; together they determine whether this is a critical incident. If it is determined to be a critical incident, the senior manager contacts one of the persons listed below in #4. If the senior manager is not available, the administrative personnel will proceed to step # 4.
4. Critical Incident Lead- Notify one of the following in the order listed:
In Minnesota:
Anne Roehl 612-597-9486 (c)
John Jakway 612-240-7642 (c)
In California:
Anne Silcher 530-723-2901 (c) Jamie Markey 530-723-0322 (c)
5. When one of the above persons is contacted, they become the critical incident lead and the primary contact. It is this person’s responsibility to direct all agency activity to the incident until it has been resolved.
6. Media Lead- When there is request or potential requests for comment from any external stakeholders or media agencies, only the following people should provide comments, in the order listed:
Corporate (Minnesota, California)
Tracy Hinkemeyer 612-987-3910 (c)
Anne Roehl 612-597-9486 (c)
The media lead will work, together with the critical incident lead and senior leadership team, to respond to any media requests or questions.
7. No other staff should initiate or respond to any contact from external stakeholders or the media unless specifically requested to do so by a member of the Executive Team. Any written reports or correspondence are to be reviewed by the critical incident lead and media lead prior to release.
8. Critical incidents could occur at the Mains’l offices. The Mains’l offices will keep a current emergency response contacts list of whom to call in case of specific kinds of emergencies such as damage (internal or external), disturbances, fire alarms, gas interruption, etc. This list will be reviewed and updated at least annually by the vice president of administration.
References
Safety Drill Calendar
Fire Drill Report
Tornado Drill Report
Incident Report
Emergency Contact Poster
Emergency Evacuation Plan
Office of Ombudsman Serious Injury Report
Office of Ombudsman Death Report
Death or Serious Injury Report Fax Cover Sheet
Emergency Response Contacts
Mains’l endeavors to protect people who receive services from maltreatment through education and clear expectations of what to do when you suspect a person is experiencing a form of maltreatment such as abuse, neglect or financial exploitation. Minnesota has multiple laws about the maltreatment of vulnerable adults and minors that are used to inform our action
If you suspect, witness, or become aware of maltreatment of a vulnerable adult or a child, report immediately!
Where to report maltreatment:
To Report to Mainsl, call the administrative on-call phone at 612-598-5700
If you choose to report outside Mainsl:
For Adults: call 1-844-880-1574 or go to:mn.gov/dhs/reportadultabuse/ to report
For Children: Contact Law enforcement or locate the local child welfare agency phone number by going to: http://mn.gov/dhs/people-we-serve/children-and-families/services/child-p... or for a child living in foster care call 651-431-6600
If you choose not to call the Mains’l administrative on-call person, you need to report directly to the Minnesota Adult Abuse Reporting Center (MAARC-for adults) or the local child welfare agency (for children) if you suspect maltreatment;
Suspected maltreatment must be reported.
You do not need to have proof that maltreatment has occurred.
How people learn about responding to and reporting maltreatment
Mains’l provides awareness and education to our employees and the people we support on responding to and reporting maltreatment.
The who, what, where, why, and how for responding to and reporting maltreatment
Who is considered a vulnerable individual? In general, any person who needs assistance to adequately care for him or herself, and is therefore at a greater risk of maltreatment, is considered a vulnerable individual. Based on Minnesota laws, any person receiving services from Mains’l is considered either a vulnerable adult or child. The definition of a child for maltreatment reporting is a person who has not reached age 18.
Who is considered a caregiver? "Caregiver" means and individual or facility who has responsibility for all or a portion of the care of a vulnerable adult voluntarily, by contract, or by agreeement. Caregiver does not inlcude an unpaid caregiver who provides incidental care.
What is maltreatment? For vulnerable adults, maltreatment is defined as abuse, neglect, or financial exploitation. For children, maltreatment is defined as physical abuse, sexual abuse, and neglect. Definitions of each type of maltreatment are provided below in the definitions section. For complete definitions, please see the Minnesota Statutes listed above.
Who is required to report maltreatment? While anyone can report, many people are required by law to report, including you. A complete list of who is required to report can be found in the Statutes listed above. Some professionals who are mandated reporters are people who work in the following areas:
IF YOU SEE SOMTHETHING.....
What is required to be reported? Suspected maltreatment and any injury that cannot be explained must be reported within 24 hours of finding out. Definitions of maltreatment are listed in this document.
For children, if you know or have reason to believe a child is being or has been neglected or physically or sexually abused within the past three years, you must immediately make a report to the child protection unit of the local social service agency.
Who do I report to? For the suspected maltreatment of a vulnerable adult, report to the Minnesota Adult Abuse Reporting Center (MAARC). For suspected maltreatment of a child, report to law enforcement or the local child welfare agency. We also ask that you contact the Mains’l administrative on-call personnel.
What happens at Mains’l after a report is made? When Mains’l has reason to believe that an internal or external report of alleged or suspected maltreatment has been made, we also report and respond.
Internal reviews are completed by Chuck Jakway, Vice President of Administration or a designated Senior Manager. Mains’l documents completion of the internal review and will provide a copy to the commissioner immediately upon request.
What is the Minnesota Adult Abuse Reporting Center? The Minnesota Adult Abuse Reporting Center was established on 7/1/15 to replace the county based Common Entry Point system. MAARC is the central location for receiving reports of vulnerable adult maltreatment.
What are local child welfare agencies? Each county in the state has a local child protection/welfare agency responsible for taking reports and investigating. The number for your local child welfare agencies can be found online and is included in orientation materials.
Who is the Mains’l administrative on-call personnel? The administrative on-call personnel is a group of employees at Mains’l who are extensively trained in maltreatment reporting. This team rotates an administrative cell phone for one week at a time in addition to their regular job duties. They are expected to answer the phone or return phone calls as soon as they can. With the caller, they walk through the steps required to complete maltreatment reporting and ensure the health and safety of the person who may have been maltreated.
How much time does a mandated reporter have to make a report? No longer than 24 hours from the time you believe or know that witnessed or suspected matreatment occured
Any person making a good faith report in a timely manner is protected from any civil or criminal liability that might otherwise result from their actions.
What happens if I do not report suspected maltreatment? There are many things that can happen if you do not report including:
If you are asked to not report something, you can explain to the person that you are required by law to report. You also do not have to inform the person that you are making a report, go ahead and make the report if you suspect maltreatment has occurred.
Will I be protected from retaliation if I make a report? Yes, Mains’l will not retaliate against anyone for making a report in good faith (an honest report) and takes action to protect people who report. There are also laws in place to protect people who make good faith reports.
A person who intentionally makes a false report may be found liable in a civil suit for any actual damages suffered by the reported facility, person or persons and any punitive damages up to $10,000.00 and attorney’s fees.
What is therapeutic conduct? Some of the definitions reference therapeutic conduct. It refers to services and caregiver responsibilities that are provided in good faith and in the interests of the vulnerable individual where an accident or injury might occur that was not intended to harm.
What is considered an accident? A sudden, unforeseen, and unexpected occurrence or event which is not likely to occur, and which could not have been prevented by exercise of due care. It is also considered an accident if the occurrence or event happens when an employee or the person providing services is in compliance with the laws and rules relevant to the occurrence or event.
What is considered serious harm? An injury that requires medical treatment that cannot be immediately provided by the present caregiver may be considered serious harm. The act of going to the doctor when no medical treatment is received is not considered serious harm.
How do I know how to protect the person receiving services? Before you perform any caregiver responsibilities, you should review the person’s Service Questionnaire and Safety Plan that was written specifically for the person receiving services that addresses the vulnerable individual’s susceptibility to abuse, neglect, and financial exploitation, as well as other vulnerabilities. Review this document before services are provided so you are prepared. The individual receiving services participates in the development of this plan to the fullest extent possible. The plan is reviewed and if necessary, revised at least annually. If after reading the plan you have questions, please make sure to ask the person responsible for training you.
Maltreatment definitions for adults (See MN Statutes for complete definition and additional information)
https://www.revisor.mn.gov/laws/2022/0/Session+Law/Chapter/98/2022-08-01...
Abuse: Abuse can be physical, emotional, verbal, or sexual. This includes but is not limited to:
1. An act against a vulnerable individual that includes:
a. assault
b. the use of drugs to injure or facilitate crime
c. the solicitation, inducement, and promotion of prostitution
d. criminal sexual conduct
2. Conduct which is not an accident or therapeutic, which produces or could reasonably be expected to produce physical pain or injury or emotional distress, including, but not limited to the following:
a. hitting, slapping, kicking, pinching, biting, or corporal punishment
b. use of repeated or malicious oral, written, or gestured language or the treatment of a vulnerable individual which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing or threatening;
c. use of any aversive or deprivation procedure, unreasonable confinement, or involuntary seclusion, including the forced separation of the vulnerable individual from other persons against their will.
3. Sexual contact or penetration between a person providing services and a vulnerable individual.
NOTE: It is not considered abuse when a vulnerable adult, who is not impaired in judgment or capacity by mental or emotional dysfunction or undue influence, engages in consensual sexual contact with a person providing services, when a consensual sexual relationship exists; or for a person, including a facility staff person, when a consensual sexual personal relationship existed prior to the care giving relationship.
4. The act of forcing, compelling, coercing, or enticing a vulnerable adult against the vulnerable adult’s services will to perform services for the advantage of another.
Caregiver: Means an individual or facility who has responsibility for all or a portion of the care of a vulnerable adult voluntarily, by contract, or by agreement. Caregiver does not include an unpaid caregiver who provides incidental care.
Neglect: Neglect means neglect by a caregiver or self-neglect.
1. “Caregiver neglect” means the failure or omission to supply a vulnerable individual with care or services, including but not limited to food, clothing, shelter, health care, or supervision, which is reasonable and necessary to obtain or maintain the person’s physical or mental health or safety, and is not the result of an accident or therapeutic conduct.
2. “Self-neglect “ means neglect by a vulnerable adult of the vulnerable adult’s own food, clothing, shelter, health care, or other services that are not the responsibility of a caregiver which a reasonable person would deem essential to obtain or maintain the vulnerable adults’ health, safety, or comfort.
Financial exploitation/abuse: Occurs when a person misuses funds, assets, or property of a vulnerable individual. This includes but is not limited to:
1. Failure to use the vulnerable individual’s financial resources to provide food, clothing, shelter, health care, therapeutic conduct or supervision for the vulnerable individual, and the failure results in or is likely to result in detriment to the vulnerable individual;
2. Willfully using, withholding, or disposing of funds or property of a vulnerable individual without legal
authority;
3. Obtaining performance of services by a third person/party for the wrongful profit or advantage of the actor or another to the detriment of the vulnerable individual;
4. Acquiring possession of, control of, or an interest in, funds or property of a vulnerable individual through the
use of undue influence, harassment, duress, deception, or fraud;
5. Forcing, compelling, coercing, or enticing a vulnerable adult against his or her will to perform services for the profit or advantage of another.
Maltreatment definitions for children
Physical abuse: Any physical injury, mental injury, or threatened injury, inflicted by a person responsible for the child’s care on a child other than by accidental means, or any physical or mental injury that cannot reasonably be explained by the child’s history of injuries, or any aversive or deprivation procedures, or regulated interventions, that have not been authorized under section 121A.67 or 245.825.
Abuse does not include:
1. Reasonable and moderate physical discipline of a child administered by a parent or guardian which does not result in injury. Unintentional injury resulting from physical discipline is physical abuse.
2. The use of reasonable force by a teacher, principal, or school employee as allowed in section 121A.582.
Actions which are not reasonable and moderate (so NOT allowed) include, but are not limited to any of the following that are done in anger or without regard to the safety of the child:
Sexual abuse: Is when a person who has a significant relationship to the child or is in a position of authority controls or forces a child into any act considered by law to be criminal sexual conduct. Sexual abuse also includes any act which involves a minor which constitutes a violation of prostitution offenses. Sexual abuse also includes threatened sexual abuse. Sexual contact includes fondling, touching intimate parts and sexual intercourse.
Neglect: Occurs when a child’s health and safety needs are not being met. This includes;
1. Failure by a person responsible for a child’s care to supply a child with necessary food, clothing, shelter, health, medical or other care required for the child’s physical or mental health when reasonably able to do so;
2. failure to protect a child from conditions or actions that seriously endanger the child’s physical or mental health when reasonably able to do so, including growth delay, which may be referred to as failure to thrive, that has been diagnosed by a physician and is due to parental neglect;
3. failure to provide for necessary supervision or child care arrangements appropriate for a child considering factors as the child’s age, mental ability, physical condition, length of absence, or environment, when the child is unable to care for the child’s’ own basic needs or safety, or the basic needs or safety of another child in their care;
4. failure to ensure that the child is educated;
5. prenatal exposure to a controlled substance;
6. medical neglect:
a. nothing in this section shall be construed to mean that a child is neglected solely because the child’s parents, guardian, or other persons responsible for the child’s care in good faith selects and depends upon spiritual means or prayer for treatment or care of the disease or remedial care of the child in lieu of medical care; except that a parent, guardian, or caretaker, or a person mandated to report pursuant to subdivision 3, has a duty to report if a lack of medical care may cause serious danger to the child’s health. This section does not impose upon persons, not otherwise legally responsible for providing a child with necessary food, clothing, shelter, education, or medical care, a duty to provide that care;
7. chronic and severe use of alcohol or a controlled substance by a parent or person responsible for the care of the child that adversely affects the child’s basic needs and safety; or
8. emotional harm from a pattern of behavior which contributes to impaired emotional functioning of the child which may be demonstrated by a substantial and observable effect in the child’s behavior, emotional response, or cognition that is not within the normal range for the child’s age and stage of development, with due regard to the child’s culture.
Remember… Respond immediately if you suspect, see, or hear about maltreatment!
Thank you for helping to protect people from harm.
To view Minnesota statutes please go to: https://www.revisor.mn.gov/laws/2022/0/Session+Law/Chapter/98/
Minnesota Statute 245A.65 Maltreatment of Vulnerable Adults
1. Minnesota Statute 245A.66 Maltreatment of Minors
2. Minnesota Statute 626.556 Mandatory Reporting of Maltreatment of Minor
3. Minnesota Statute 626.557 Mandatory Reporting of Maltreatment of Vulnerable Adults
(Revised 8/16/2022; LM)
Mains’l is committed to a safe and healthy working environment for all employees, persons receiving services and stakeholders.
Mains’l will comply with occupational safety and health standards or rules as stipulated by 29 CFR 1910 OSHA Federal General Industry Regulations and Department of Labor and Industry OSHA state laws and rules.
(Right to Know) Mains’l neither manufactures, stores, transfers or disposes of any hazardous materials.
Mains’l has policies and procedures on blood borne pathogens which provide for infection control through procedures for cleaning and disinfecting, glove use, use of protective barriers, medical sharps, hand washing and laundry.
The agency’s infection control plan is designed to prevent illness and disease through universal precautions and availing HBV vaccine to any new or current employee at no cost to the employee.
Mains’l also has an exposure control plan for its employees which include testing by a medical provider.
For occupational safety Mains’l follows the basic tenants of the AWAIR program. AWAIR is an acronym for A Workplace Accident and Injury Reduction Program. This program is designed to identify potential causes of injuries and accidents and to eliminate those from the workplace wherever possible.
Occupational safety is everyone’s responsibility. According to OSHA, an overwhelming majority of workplace accidents are due to unsafe acts and workplace conditions. Each employee is responsible for:
The AWAIR Program is intended to:
Strategies to reduce workplace accidents and injuries:
Once each year; CRS sites will conduct an exercise to list together 3-4 workplace conditions or behaviors that can cause accidents and/or injuries. In turn the supervisor will elicit solutions from the participants to address these conditions or behaviors. The results will be sent to the vice president of administration for review and any follow up action necessary.
Inspections of Work Sites:
Home Safety Inspection Checklists will be used by CRS site staff to identify potential conditions that might also cause accidents or injuries. These checklists are to be completed once every two months and sent to the vice president of administration for review and any follow up actions necessary.
Enforcement Strategies:
Employees who fail to follow safety rules or requirements will be subject to employee discipline as described in HR policies.
Training:
The primary training for safety in the workplace is blood borne pathogens. Otherwise CRS sites will acquaint employees with local safekeeping practices.
Assessment and Control of Hazards:
Mains’l prohibits use and storage of hazardous materials.
Safety Coordinator:
The safety coordinator for Mains’l is the vice president of administration.
Food and Food Safety:
The manager of each home is responsible for the coordination of:
Goods Provided by the Agency:
The manager of each home is also responsible to ensure that:
The senior manager for each home checks to verify that each person has clean and adequate supply of linens in good condition during their scheduled quarterly site visits and documents such on the Site Visit Checklist.
Personal Items:
The manager for each home is responsible to assure that:
Pets and Service Animals:
The manager of each home is responsible to assure that:
Control of Pests and Vermin:
All staff will remain vigilant keeping an eye open for any signs of insects or vermin. If sighted or suspected, staff will immediately report that information to their supervisor. The supervisor will evaluate the report, gather any additional information needed, conduct a site visit and report their findings to the senior manager or maintenance.
The senior manager with consultation with the vice president of administration will immediately summon an exterminator to report to the site within 24 hours. Exterminators have protocols on treating homes and sites on addressing furnishings, furniture and household structures and environments. This includes the extermination of bed bugs for which there is a specific protocol.
29 CFR 1910 OSHA General Industry Regulations
Department of Labor and Industry OSHA Laws and Rules (MSA Chap. 182)
Infection Control Plan
Exposure Control Plan
Cleaning and Disinfectant Procedures
Glove Procedures
Handwashing Procedures
Laundry Procedures
Protective Barrier Procedures
Sharps Procedures
Risk Exercise
Home Safety Checklist
Home Safety Checklist Calendar
Site Visit Checklist
Bed Bugs Protocol
Training PowerPoint
Mains’l retains all records related to people receiving services and programs in a secure location for the period of time required by law.
When services are provided in a licensed home, the access to the current records is maintained at the home either on paper or electronically. For services provided in the person’s own home, records are maintained at the program services office either on paper or electronically. Mains’l protects service recipient and program records against loss, tampering, and unauthorized disclosure.
The following people have access to the information in a person’s record, in accordance with applicable state and federal laws, regulations, or rules:
1. the person, the person's legal representative, and anyone properly authorized by the person;
2. the person's case manager;
3. Mains’l’s employees providing services to the person, unless the information is not relevant to carrying out the coordinated service and support plan or coordinated service and support plan addendum;
4. the county child or adult foster care licensor, when services are also licensed as child or adult foster care; and
5. the DHS licensor or investigator as required under the Human Services Licensing Act, Minnesota Statutes, Chapterand Chapter 245A.
The following documents are in each service recipient record per 245D.095:
2. Service information, including:
3. Health information, including medical history, special dietary needs, and allergies.
4. When Mains’l is assigned responsibility for meeting the person's health service needs, documentation of:
5. A copy of the person’s current coordinated service and support plan or the portion assigned to
Mains’l.
6. A copy of the individual abuse prevention plan/safety plan.
7. Copies of service planning assessments required under section 245D.071, subdivisions 2 and 3
8. A record of other service providers, including: contact person, telephone number, services being
provided, and names of staff responsible for coordination of services.
9. Documentation of orientation to service recipient rights and maltreatment reporting policies and
procedures.
10. Copies of authorizations to handle a person’s funds.
11. Documentation of complaints received and grievance resolutions.
12. When requested by the person, legal representative, case manager or team: copies of written
reports regarding the person including: progress review reports, progress or daily log notes recorded by the program, and reports received from other agencies involved in providing services or care of the person.
13. Summary of ending services, if applicable.
14. Service suspension/termination and related documentation, if applicable.
Retention guidelines are as follows:
Category | Longest Retention Period |
Laws/Regulations Requiring Retention |
Service Recipient Records Program Records
|
All records related to a person who is currently receiving services, are maintained for the duration of their services. Once a person’s services have ended, records are retained for seven (7) years. Program incident reports, BIRFS, contracts, and licensing documents are retained for seven (7) years. Program policies and procedures are maintained until no longer required or until the policy and procedure is replaced by a new policy or procedure |
MN Statute 145.30, 145.32 MN Rule 9505.2190 MN Rule 4658.0470 MN Rule 245D.095 |
Service Recipient Records
Documents that are created or received by Mains’l that pertain to a person receiving services are saved in the person’s secure electronic record or paper file.
For paper files, after a County Foster licensing review, information is removed from the individual’s medical and plan file and scanned into the Mains’l document management system. At this time, information that has been summarized into another format (e.g. data into a progress review) may be discarded. Managers organize the information to be scanned as follows:
1. Separate the documents into the categories of:
2. Incorporate all documents from work books into the primary file and remove pages that are duplicates or are general in nature and not specific to the individual.
3. Prepare all documents for scanning:
4. Scan documents into the appropriate category within the Fortis system.
5. Once scanning is complete, verify that all pages have been scanned and are readable before destroying the original.
Program Records
1. The program services, support services and human resources departments are responsible for scanning these documents:
2. Prepare all documents for scanning as follows:
3. Scan documents into the appropriate category within the document management system
4. Once scanning is complete, verify that all pages have been scanned and are readable before destroying the original.
(Rev. 1/8/19; SR
Mains'l ensures the exercise and protection of each person’s rights in the services and supports provided.
These rights are established for the benefit of persons receiving services. Mains’l will not require a person to surrender these rights as a condition of receiving services. A guardian or legal representative or, when there is no guardian or legal representative, a designated person, may seek to enforce these rights.
Informing people about rights
Implementing a rights restriction
Restriction of a person’s rights is allowed only if determined necessary to assure the health, safety, and well-being of the person. Any restriction of these rights is documented in the person’s coordinated service and support plan. Mains’l support plan and must be approved by the person or their legal representative before the restriction is implemented. Approval may be withdrawn at any time, at which time the right must be immediately and fully restored. Restrictions are reviewed, minimally, semiannually and more frequently if requested by the person or their legal representative if any, and case manager.
Service Recipient Rights
Rights Restriction Summary