2024 Edition

Behavior Support and Management Introduction

Purpose

The agency’s behavior support and management policies and practices promote positive behavior and protect the safety of service recipients and staff.

Introduction

Effective behavior support and management practices center around preemptive interventions, such as identifying problem behaviors and working with the individual and their support systems to create practical solutions in order to minimize the need for restrictive interventions to the greatest extent possible. A culture that promotes respect, healing, and positive behavior, and provides service recipients with the support they need to manage their own behaviors, can help prevent crisis situations and the need for restrictive interventions. Involving the individual and appropriate family members or support systems early on in identifying triggers and previous successes in coping with escalating behaviors creates a collaborative approach to behavior support and management and helps provide personnel and the individual with early insight into aggressive, harassing, or self-injurious behaviors. Training prevents injuries and deaths in crisis situations, including those that warrant the use of restrictive interventions as a last resort. Agencies that maintain a process for reviewing incidents when they do occur have the opportunity to make changes in their practices to support the safest environment possible and further reduce the use of restrictive interventions.
Juvenile Justice

Interpretation

 Agencies serving youth involved with the juvenile justice system may be legally authorized to use restrictive interventions to prevent escapes, or protect property in order to maintain safety, security, and order. However, they should still only employ restrictive interventions when absolutely necessary, as referenced throughout these standards.

Additionally, some agencies serving youth involved with the juvenile justice system and accredited under COA's Juvenile Justice Residential Services (PA-JJR) standards may lock youth in their rooms for routine purposes (e.g., during sleep periods), as opposed to doing so in response to an incident. Although this practice does restrict a person's freedom of movement, it differs from the types of restrictive behavior management interventions addressed in this section insofar as it is utilized on a routine, ongoing, basis, rather than in response to a specific incident. Accordingly, this practice is addressed in PA-JJR 14, and the standards in this section do not apply to that practice.

NA The agency’s behavior support and management policy submitted as PA-ASE self-study evidence prohibits all use of restrictive behavior management interventions.

Note: Restrictive interventions are those that involuntarily restrict, limit, or curtail a person’s freedom of movement and include manual restraint, mechanical restraint, and seclusion. Federal guidelines consider any restriction of an individual’s movement a restrictive intervention. Related definitions can be found in COA’s glossary.


Timeout or isolation are colloquial terms that may or may not include restrictive interventions. For the purpose of these standards, any instance where an individual is placed in a room separate from others and they cannot voluntarily leave (whether the door is locked or personnel is preventing the individual from leaving) will be referred to as seclusion and considered a restrictive intervention.


Note: Agencies that work with populations with developmental delays and utilize protective clothing, such as protective helmets, will address those interventions in PA-PRG 5.02 and PA-PRG 6.03.


Note: Behavior Support and Management (BSM) will be NA when the policy referenced in PA-ASE 2 prohibits restrictive interventions.


Note: Please see PA-BSM Reference List for the research that informed the development of these standards.


Note: For information about changes made in the 2020 Edition, please see BSM Crosswalk.

2024 Edition

Behavior Support and Management (PA-BSM) 1: Oversight of Restrictive Behavior Management Interventions

The agency employs restrictive behavior management interventions under the oversight of its agency head and leadership.

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 
Fundamental Practice

PA-BSM 1.01

The agency's behavior support and management policies and practices comply with federal, state, and local legal and regulatory requirements.
Related Standards:

Examples: The Public Health Service Act, as amended by the Children's Health Act of 2000 and the Use of Restraint and Seclusion in Psychiatric Residential Treatment Facilities Providing Inpatient Psychiatric Services to Individuals Under Age 21 are federal regulations that govern the use of behavior management in the United States. Agencies serving youth involved with the juvenile justice system may be subject to different laws and regulations.

Note: The agency is required to comply with the more stringent standard or regulation. 

Note: COA recognizes that the laws or regulations governing agencies serving youth involved with the juvenile justice system may sometimes authorize practices that conflict with the standards to which COA holds other agencies, and has addressed some of the potential discrepancies throughout the standards in PA-BSM.
 
Fundamental Practice

PA-BSM 1.02

Behavior support and management policies address:
  1. safety measures to be taken when emergency situations arise, including which restrictive behavior management interventions may be used to protect service recipients from harming themselves or others;
  2. other practices that may be used and under what circumstances; and
  3. prohibited practices, including chemical restraint, corporal punishment, and behavior control methods that interfere with the indivdiual’s right to humane care.
Related Standards:
Interpretation: Medications are treatment for targeted symptomatology and should not be considered an intervention for challenging behaviors. In relation to element (c), chemical restraint does not include situations when a psychopharmacological drug:
  1. is used according to the requirements for treatment authorized by a court; 
  2. is provided using specified criteria in a person’s approved treatment plan as per a physician’s order to provide medical treatment for a specific diagnosis and known progression of symptoms, such as in cases of a PRN; or 
  3. is administered when necessary (PRN) to prevent immediate, substantial, and irreversible deterioration of a person’s mental status when prescribed by a physician or other qualified medical practitioner.

Examples: Refer to COA's definition of restrictive behavior management interventions at the beginning of this section for a list of interventions that may be included in the behavior support and management policy.

Note: Refer to COA's glossary for a definition of chemical restraint.
 
Fundamental Practice

PA-BSM 1.03

The agency prohibits the use of behavior management interventions:
  1. by any person other than trained, qualified personnel;
  2. as a substitute for appropriate staffing patterns, for the convenience of personnel or as punishment;
  3. in response to property damage that does not involve imminent danger to self or others; and
  4. when contraindicated in the individual's service or behavior plan. 
Related Standards:
Juvenile Justice Interpretation: Agencies serving youth involved with the juvenile justice system may be authorized to use restrictive interventions to prevent escapes, or protect property, in order to maintain safety, security, and order. However, they should still only employ restrictive interventions when absolutely necessary. 
 

PA-BSM 1.04

The agency head and leadership conduct regular reviews of the use of behavior support and management interventions and:
  1. compares agency practices to current information and research on effective practice;
  2. use findings from quarterly risk management reviews of restrictive behavior management to inform staff about current practice and the need for change;
  3. revise policies and procedures when necessary;
  4. determine whether additional resources are needed; and
  5. support efforts to minimize the use of restrictive behavior management interventions.
Related Standards:
 

PA-BSM 1.05

The program or clinical director is notified following each use of a restrictive behavior management intervention and each incident is administratively reviewed no later than one working day following an incident to:
  1. review any preemptive measures taken to avoid the intervention;
  2. determine whether or not the individual’s behavior support and management plan was followed; and
  3. assess the measures’ effectiveness.
2024 Edition

Behavior Support and Management (PA-BSM) 2: Behavior Support and Management Practices

Behavior support and management practices promote respect, healing, and positive behavior and prevent the need for restrictive behavior management interventions.

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VIEW THE STANDARDS

Related Standards:

Note: Please see the Case Record Checklist for additional guidance on this standard.

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 
Fundamental Practice

PA-BSM 2.01

The agency:
  1. provides an explanation for and offers a copy of its written restrictive behavior support and management philosophy and procedures to service recipients or their parents/legal guardians at admission;
  2. annually obtains the individual’s or parent’s/legal guardian’s consent when restrictive behavior management interventions are part of the treatment modality; 
  3. informs the individual or parent/legal guardian of the service implications, if any, of refusing to sign; and
  4. when the individual is a minor or has a legal guardian, notifies the parents/legal guardians promptly when the minor is involved in an incident involving a restrictive intervention.
Related Standards:
Juvenile Justice Interpretation: COA recognizes that it may be difficult for agencies providing residential juvenile justice services to involve youths' parents/legal guardians, especially when youth are placed outside of their communities and far from their families; however, agencies should still strive to involve families to the extent possible. When promptly notifying parents/legal guardians in the wake of an intervention proves difficult, the agency should document its efforts to initiate contact in the case record.

Additionally, when an agency provides involuntary services to youth involved with the juvenile justice system, obtaining consent may not be required.
 
Fundamental Practice

PA-BSM 2.02

The agency collaborates with the individual and/or parent/legal guardian to screen or assess for:
  1. the individual’s perception of emotional and physical safety;
  2. past experiences with restrictive behavior management interventions;
  3. antecedents or emotional triggers and the resulting behaviors; 
  4. previous successes in utilizing strategies and coping skills to mitigate the need for restrictive behavior management interventions;
  5. psychological and social factors that can influence use of such interventions, including trauma history; and 
  6. medical conditions or factors that could put the person at risk.
Related Standards:
Interpretion: When the screening or assessment is conducted by an outside provider the agency should maintain a copy in the case record.

Examples: Medical factors can include issues related to use of medications, such as an insulin imbalance. Psychological and social factors may include psychosis or claustrophobia.
 
Fundamental Practice

PA-BSM 2.03

A behavior support and management plan is based on assessment results and:
  1. identifies proactive, strengths-based strategies that will help the person de-escalate their behavior and prevent harassing, violent, or out-of-control behavior; 
  2. specifies interventions that may or may not be used, taking the individual’s trauma history into account; 
  3. is modified as necessary; and 
  4. is developed in collaboration with the individual and signed by the person, their parent/legal guardian, and personnel, as appropriate. 
Related Standards:

Note: The behavior support plan, sometimes called a crisis plan, can be part of, and reviewed with, the overall service or treatment plan.
2024 Edition

Behavior Support and Management (PA-BSM) 3: Restrictive Behavior Management Intervention Training

Personnel who use restrictive behavior management interventions are trained and evaluated on an annual basis using a nationally recognized curriculum.
Related Standards:

Examples: Training on restrictive behavior management interventions can include:
  1. proper and safe use of interventions, including when it is appropriate to use a restrictive intervention and time limits for use;
  2. understanding the experience of being placed in seclusion or a restraint, including the medical and therapeutic risks related to restrictive interventions and the resulting consequences of the misuse of restrictive interventions, including trauma and re-traumatization;
  3. response techniques to prevent and reduce injury;
  4. evaluating and assessing physical and mental status, including signs of physical distress, vital indicators, and nutrition, hydration, and hygiene needs;
  5. readiness to discontinue use of the intervention;
  6. when medical or other emergency personnel are needed; and
  7. documentation and debriefing.

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
2024 Edition

Behavior Support and Management (PA-BSM) 4: Restrictive Behavior Management Interventions

Restrictive behavior management interventions are used in a manner that protects the safety and well-being of service recipients and personnel in crisis situations when less-restrictive measures have proven ineffective.
Related Standards:

Note: The use of mechanical restraints is prohibited for public or private non-medical, community-based facilities that serve children and youth according to the Public Health Service Act, as amended by the Children's Health Act of 2000. As referenced in PA-BSM 1.01, agencies serving youth involved with the juvenile justice system may be subject to different laws and regulations, and should familiarize themselves with any laws and regulations addressing the behavior management interventions they are permitted to employ. 

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 

PA-BSM 4.01

Personnel qualified through annual training and evaluation authorize each restrictive behavior management intervention in accordance with any applicable federal or state requirements.
 
Fundamental Practice

PA-BSM 4.02

Individuals are monitored continuously, face-to-face, and:
  1. assessed at least every 15 minutes for any harmful health or psychological reactions; and 
  2. interventions are discontinued immediately if they produce adverse side effects such as illness, severe emotional or physical stress, or physical injury.
 
Fundamental Practice

PA-BSM 4.03

Procedures address safe methods for involuntarily escorting individuals.
NA The agency does not escort individuals or use seclusion.
 

Examples: This includes methods such as the backwards escort.
 
Fundamental Practice

PA-BSM 4.04

Seclusion rooms:
  1. conform to existing licensing and/or fire safety requirements;
  2. are outfitted with a door that easily opens in case of emergency (e.g. spring lock door); and
  3. are limited to one person at a time.
NA The agency does not use seclusion.

Note: Please see the Facility Observation Checklist for additional guidance on this standard.

 
Fundamental Practice

PA-BSM 4.05

During a restrictive behavior management intervention staff assess the service recipient’s need for food, water, and use of bathroom facilities and provide access when safe and appropriate. 
 
Fundamental Practice

PA-BSM 4.06

Restrictive behavior management interventions are discontinued as soon as possible, and are limited to the following maximum time periods per episode:
  1. 15 minutes for children aged nine and younger, for all restrictive behavior management interventions; 
  2. 30 minutes for individuals aged ten and older, undergoing manual or mechanical restraint; 
  3. 30 minutes for individuals aged ten to thirteen in seclusion; and 
  4. one hour for individuals aged fourteen and older in seclusion. 
Juvenile Justice Interpretation: Although agencies serving youth involved with the juvenile justice system may be authorized to use time limits that exceed those listed in the standard, COA expects these agencies to meet the timeframes outlined in the standard whenever possible. When it is necessary to extend timeframes in order to maintain safety, security, and order (for example, when youth must be transported greater than 30 minutes in mechanical restraints in order to prevent escape), qualified personnel must approve the extension, and the intervention should be discontinued as soon as possible.
 
 
Fundamental Practice

PA-BSM 4.07

Reauthorization by qualified personnel is required for each instance of a restrictive intervention that exceeds the maximum time limit. 
 

PA-BSM 4.08

The agency has procedures to address the safe removal of individuals in seclusion or mechanical restraint in the event of an emergency evacuation.
NA The agency does not use seclusion or mechanical restraint. 
2024 Edition

Behavior Support and Management (PA-BSM) 5: Documentation and Debriefing

The agency assesses restrictive behavior management incidents and effects to reduce future preventable occurrences and untoward consequences.
Juvenile Justice Interpretation: When agencies serving youth in the juvenile justice system use mechanical restraints to prevent escape during transport, rather than in response to an incident, some elements of the BSM 5 practice standards may not apply.   

Note: Please see the Case Record Checklist for additional guidance on this standard.

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 
Fundamental Practice

PA-BSM 5.01

The use of restrictive behavior management interventions is documented, including:
  1. the justification, use, circumstances, and length of application in the individual’s case record; 
  2. all attempts made prior to the use of a restrictive behavior management intervention in order to preempt it, including the strategies identified in the individual’s behavior management plan; and
  3. names of the service recipient and personnel involved, reasons for the intervention, length of intervention, and verification of continuous visual observation in a log.
Juvenile Justice Interpretation: Element (b) may not apply when a juvenile justice program uses mechanical restraints to prevent escape during transport. 
 
Fundamental Practice

PA-BSM 5.02

Debriefing occurs in a safe, confidential setting within 24 hours of the incident and includes the service recipient, frontline and clincal personnel, other appropriate personnel, and parents/legal guardians to:
  1. evaluate physical and emotional well-being; 
  2. identify the need for counseling, medical care, or other services related to the incident; 
  3. identify antecedent behaviors and modify the service plan as appropriate; and 
  4. facilitate the person’s reentry into routine activities.
Related Standards:
Interpretation: The agency ensures the service recipient’s participation in the debriefing process. In situations where the individual initially refuses to participate, the agency should make continued attempts to involve the individual.

Interpretation: If the parent or legal guardian is unable to be reached within the 24 hour period, all attempts to reach them should be documented and there should be continued outreach attempts past the 24 hour period to notify them of the incident.

Juvenile Justice Interpretation: Element (c) may not apply when a juvenile justice program uses mechanical restraints to prevent escape during transport.  
 

PA-BSM 5.03

Personnel involved in the incident are debriefed to assess:
  1. their current physical and emotional status; 
  2. the precipitating events; and
  3. how the incident was handled and necessary changes to procedures and/or training to avoid future incidents.
Juvenile Justice Interpretation: Element (b) and the second half of element (c) (regarding changes to avoid future incidents) may not apply when a juvenile justice program uses mechanical restraints to prevent escape during transport.
 

PA-BSM 5.04

Any other person involved in or witness to the incident is debriefed to assess their current physical and emotional status. 
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