Residental Treatment Facility Program Requirements in Pa.

[Guest guest]

I thought that some might be interested in the below letter. I believe

that letters to help restructure the residetnial treatment programs in Pa

to being more treatment focused is critical. Please feel free to pass on

to othersin Pa that you know might be interested in and encourage them to

write.

Joe

---------- Forwarded message ----------

Date: Thu, 6 Jun 2002 22:40:36 -0400 (EDT)

From: ph Cautilli <jcautill@...>

jbacker@...

Subject: Residental Treatment Facility Program Requirements

Backer

Beechmont Building

P.O. Box 2675

burg, Pa. 17105

RE: Residential Treatment Facility Program Requirements

Mr. Backer,

It was with great delight that I received the lastest draft of the Office

of Mental Health and Substance Abuse Service of program requirements for

residental treatment facilities. The goal was to correct the fact that the

3800 regulations do not " ..contain the specific program requirements

necessary to ensure appropriate mental health treatment occurs within a

RTF. " I was particularly glad to see that treatment plans should contain

" A brief narrative discussing the relationship ofthe treatment goals to

teh resident's discharge and reintegration into the community. " I am glad

to see the increased attention paid to caseconceptualization and rationale

for treatment intervetnions. It seemed like for along time, treatment in

Pa, was relagated to a tertiary role below operations/quality, and

finance. for along time, it felt like Pa wanted better service providers

but not necessarily treatment providers. Indeed, I began to wonder what

the service was that most agencies were providing and if it was

distinguishable from shlter and child care.

Thus, I was greatly pleased to see the increased focus on treatment and

the focus on reducing restraint. I believe that the required staff

trainign will be helpful in that regard. So I was pleased to see the

requirement for staff training, however, was disappointed to see that the

list was just basic ethics, operational, and adminstrative issues. Indeed,

only one mention of behavior management. I would like to see several

trainings added including (1) Functional Behavioral Assessment (an

intervention strategy which has demonstrated efficacy in reducing the use

of restrictive procedures- the efficacy is so great that the Indidivuals

with Disability Education Act, 1997 requires that all children with

behavioral and emotional disorders have one before these children are

suspended or removed from there current placement for disruption), (2)

using contingency management systems (The U.S. Surgeon General Report,

1999- has stated this is a well established and efficacious treatment for

children with behavioral disorders and Colvin, & Ramsey, 1995- has

shown that this procedure is critical to developing prosocial behavior and

getting children to utilize the skills that they have learned), and (3)

how to train children in social skills (another technique that has been

deemed to be successful, only if embedded into a contingency management

system- see , Colvin, and Ramsey, 1995).

Three additional comments on seclusion and restraint (1) Why are Pa

Licensed Practical Counselors and Marrage and Family therapist not allowed

to order seclusion and restraint and Clinical Social Workers are (the

State does now license counselors)? (2) I would like to suggest that it is

also time to move like Florida has toward having bachelor and master level

staff acquire credentals to demonstrate expertise in behavior

modification. The person who could speak directly to how this has

benifited Florida would be Gerald Shook <Shook@...> but this has led

to a state wide reduction in seclusion and restraint procedures. (3) Use

of seculsion and restraint should automatically be considered a treatment

failure and should lead to a clinical review of the treatment plan with

either an addenum written or a data based explaination as to why the

treatment was not changed.

Additionally, I would like to see an increase focus on clinical

accountability. I believe that one way to acheive this would be to

require programs to choose stanardize behavioral assessment instruments,

which focus not only on clinical sysmptoms but also adaptive behavior

(i.e., BASC, McConnel Scale, etc.) and have them to adminster the

instruments to children. Once these instruments were adminstered, then the

agencies should calculate the number or percent of children who made

reliable clinical change (see Seggar, Lambert, & Hassen, 2002 for

calculation of the reliable change index). Agencies should be required to

annouce the number or percent of children who make relaible change within

three months, six months and one year of entering the program.

Finally, I believe that the regulations do not relieve the department's

responsibility to create a best practice guideline for RTF programs. These

guidelines should focus on evidence based practices in residential

facilities. Some elements that the guidelines could highlight would be:

1. Evaluation does a comprehensive medical history 2. A comprehensive

BioPsychoSocial is completed 3. Assessment at least annually is

comprehensive 4. Treatment plans have evidence of a functional assessment

5. Assessment and treatment plan list and incorporate client strengths 6.

There is evidence in evaluation and treatment plan of an appropriate

diagnosis, including the identification of all comorbid conditions 7.

Identified strengths and needs are taken into account for an

individualized program._ 8. Discharge planning is initiated at admission

with the goal of returning the client to the least restrictive

environment. 9. There is evidence that admission and discharge planning is

conducted in cooperation with the family and agency involved with the

child/ adolescent. 10. There is evidence of multidisciplinary

participation in the program planning process. 11. There is evidence of

family involvement in developing of the individualized program plan 12.

The treatment plan includes measurable goals and clearly delineated

interventions. The Objectives in the treatment plan clearly state the (a)

person performing the behavior ( the conditions which the target

behavior is displayed (which is hte condition that you would want the

alternative behavior to be displayed in) © a behaviorally defined target

behavior (d) a criterion (what degree of accuracy for how long) to

determine when the objective is reached and (e) a target date for

completion 13. There is evidence of a clear focus on teaching alternative

skills rather than simply focusing on decelerating disruptive behavior 14.

All decelarative goals list corresponding acceleration goals (e.g.,

teaching prosocial skills, teaching other adaptive behavior to reduce

target). 15. Goals are linked to address expectations in the

post-discharge environment 16. When appropriate interventions addressing

suicidality are included in the treatment plan. 17. Goal mastery is

determined by objective criteria. 18. Progress monitoring data collection

occurs in a repeated fashion and used in program development. 19. There

is evidence of a consistent environment that includes a token system

(e.g., scheduled routines, point/level system, procedures for feedback

about behavior). 20. There is evidence of social skills training. 21.

There s evidence of promoting involvement of individuals with prosocial

peers (e.g., through community-based functions such as the YMCA)

References

Seggar, L.B., Lambert, M.J. & Hansen, N.B.(2002). Assessing clinical

significance: Application to the Beck Depression Inventory. Behavior

Therapy, 33, 253-269 (contact the author at micheal_lambert@...)

U.S. Health and Human Services (1999) A report of the U.S. Sergeon

General.

, H.M., Colvin, G., & Ramsey, E.(1995). Antisocial behavior in

schools: Strategies and best practices. s Cole.