***Insert Provider Logo*** - Inclusa



Behavior Health Positive Behavior Support Plan (BHPBSP)Member Name: Click here to enter text.DOB: Click here to enter text.Address: Click here to enter text.Provider Information: Click here to enter text.Guardianship/Activated POA: Choose an item.Protectively Placed: Choose an item.Chapter 51: Choose an item.If under Chapter 51, please list effective dates: FORMTEXT ?????County of Responsibility: Click here to enter text.County of Residence: Click here to enter text.PBSP Original Draft Date: Click here to enter a date.PBSP Review Dates: Click here to enter text. PhilosophyThe purpose of this support plan is to ensure that this individual is being supported in the most effective manner possible while understanding cultural and personality differences and maintaining self-worth, opportunity, and respect. This plan focuses on being mindful, person-centered, trauma informed, least restrictive, and integrated in the most effective manner. In order for this individual to attain and maintain the highest quality of life, the support team must provide the individual with positive, proactive, and consistent support, and understand the social, physiological, medical, and environmental influences to this behavior. Approaches outlined in this plan must be viewed as being flexible and incorporate, as appropriate, a full integration of social, emotional, environmental, occupational, intellectual, spiritual, and physical wellness. It is through this holistic and balanced plan that the individual and support team can maximize strengths, preserve rights, learn and enhance skills and tools, maintain resilience, and create positive social change to fit this individual’s needs, preferences, and outcomes.History (Please include member background, significant impacts of childhood/adulthood {where raised, family, living situation as a child/adult}, include any past legal involvement, and IQ if known).Click here to enter text.Current Status (Likes/dislikes, strengths, key relationships {negative/positive, natural/professional}, any current legal involvement).Click here to enter text.Current Diagnoses: Medical and Psychiatric (Please provide information as to how they may present in the individual)Click here to enter text.Working Effectively with the Member Building Rapport (What is the best way to get know this person?)Click here to enter text.Helping the Member Lead a Meaningful Life (How are staff helping achieve this and what does a meaningful life mean to this member?)Click here to enter text.Effective Communication (How does this person communicate? How do we effectively communicate with this person, including technology and other adaptations?)Click here to enter text.Structure/Routine (Include what choice is offered to this person in daily life)Click here to enter text.Environmental Considerations (i.e. home modifications, shatterproof glass/light bulbs, bolted furniture, food/water access, staffing, other residents in the home)Click here to enter text.Coping Skills and Staff Reinforcement of Coping SkillsClick here to enter text.Precursors and Strategies for Support STRESSORSSTRATEGIES FOR SUPPORTEx: Upcoming eventsMember has a history of showing anxiety over upcoming events. This anxiety has led destructive and maladaptive behaviors in the past.Staff should work out all details such as transportation, time of arrival, etc. to the event/activity prior to foreshadowing the event/activity with the member. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Behavioral Challenges and Interventions (Provide direction for staff as to what to and what not to do when challenges arise.)Behavior Definitions ChartBEHAVIOR DEFINITION #1INTERVENTIONSEx.: Property Destruction: Tipping, throwing, ripping, destroying or using objects to cause intentional damage to propertyStaff will remove other clients from the room or direct them to their bedroom for safetyStaff will alert other staff verballyEtc. (other member specific interventions FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Stages of Support STAGE OF CHALLENGING BEHAVIOR (INDIVIDUAL’S ACTIONS)SUPPORT STRATEGY (STAFF’S INTERACTION)ADAPTIVE: Ex.: Joking with staff, communicative, helpful, etc.REINFORCE: Ex.: Compliment on participation, joke around/have fun, participate in community activities, etc.TENSION: Ex.: Starts moving slower, won’t answer questions, face becomes drawn, etc.RESPOND: Ex.: Offer a chance to talk, give praise, switch staff if needed, etc.EMOTIONAL DISTRESS: Ex.: Begins swearing at staff, no eye contact, facial expressions tighten, etc.DIFFUSE: Ex.: Honor personal space, offer him a talk out, stay calm, etc.PHYSICAL DISTRESS: Ex.: Destroys house property, Physically aggresses on staff, bites, etc.SAFE BOUNDARIES: Ex.: Stay calm, move things/people out of the way, offer PRN, etc.RECOVERY: Ex.: May apologize, tears, willing to talk, etc.TALK OUT: Ex.: Explain details, let member apologize to you, focus on positives, etc. Data CollectionDescribe the data collection process for the adaptive coping and/or communication skills to be taught and the data collection process for any other positive and preventative interventions to be used (such as daily routine):Click here to enter text.Describe the data collection process for target behaviors exhibited: Click here to enter text.Describe how the data will be reviewed and who will review the data to monitor for safety, progress, and needed plan revisions:Click here to enter text. Staff Training (Describe the training frequency, identify the trainer, and where trainings are documented)Click here to enter text.Evaluation of Effectiveness/Review (Describe who is involved in the plan review, where the reviews of the plan are documented, objective benchmarks that will be used to evaluate plan effectiveness, review of plan when significant changes or new behaviors are identified)Click here to enter text.Plan Termination Criteria (if applicable)Click here to enter text.Signatures______________________________________________________________________Member SignatureDate_______________________________________________________________________Guardian SignatureDate_______________________________________________________________________Inclusa, Inc. CRC SignatureDate_______________________________________________________________________Inclusa, Inc. HWC SignatureDate_______________________________________________________________________Provider Staff SignatureDate________________________________________________________________________Other Support Signature Date ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download