DSP Protocol Evaluation p.

1 of 4
Terrace ICF, MHANC

DSP Evaluation on Targeted Protocols

Pursuant to the March 2019 Audit of Terrace ICF by OPWDD, DOH & Fire Marshal
Terrace ICF Management Oversight Committee, MHANC

DSP: ____________________ Evaluator: ____________________ Date: __________

Directions:
1. In the boxes placed before each item, put a:
a. Check mark “✓” for sufficient knowledge;
b. “X” mark for insufficient knowledge;
c. Slash mark “ / ” for moderate knowledge.
2. Sections for notes and signatures follow the evaluation.

Corrective Action Plan: Trainings Feeding Protocol:

 Cut into 1-inch pieces; See posted charts as needed
CB’s BSP  Direct, constant arm’s-length supervision
 He is to sit upright, not hovering over his food
Challenging Behaviors:  Monitor his pace; Encourage slow eating
 Grabbing and scavenging food  Encourage frequent drinking
 Food stuffing  If choking:
 Inappropriate social boundaries  Clear airway
 Crying  Perform abdominal thrusts/CPR
 Physical aggression  Call 911 and Manager
 Self-injurious behaviors  File incident report

Antecedents: Reactive Methodology (General Behaviors):

 Internal stimuli  Verbal:
 Environmental transitioning  Verbally prompt to stop, in firm tone
 Routine changes  Maintain eye contact
 Items, that he is used to using, being broken  If he responds, praise and redirect him
 Chaotic environments  Physical:
 A demand being placed on him  Touch control to redirect
 If Aggressive: Other staff, safeguard and escort
Proactive Methodology: away other nearby residents
 Encourage to communicate choices (including use of  Assigned staff, try to calm him
pictures, non-verbal communication, etc.)  If he responds, praise and redirect him
 Be mindful of environmental dangers to jumping
 Give as advanced notice as possible of changes to Grabbing/Scavenging & Stuffing Food:
plans to visit his family  Proactive:
 Be mindful or refrain from mentioning potentially  Ensure he’s not hungry; ate meals and snacks
sensitive information within earshot of him  Visually scan for unattended and discarded food in
 Provide positive reinforcement, including praise, sight, e.g., in trash
when he exhibits independence  Antecedent: Pacing
 If he is not engaging in a required task: Offer  Praise for successful redirections
alternatives or revisit the task later  Reactive:
 Engagement that keeps him calm or happy  If he obtained food inappropriately (grabbed from
 Speak to him only in a calm and moderate tone someone or from trash): Direct him to spit it out or
 Communicate reassurance in a gentle tone to put in trash
 That which is seemingly insignificant may be a  If he obtained and ate: Counsel him on unhealthiness
major/important/disturbing to him and inappropriateness
 Give as advanced notice as possible of changes to  Don’t overreact
his routine plans

4-4-19, EF
DSP Protocol Evaluation p. 2 of 4
Terrace ICF, MHANC

 Remind: It’s unsafe to grab, scavenge or stuff/shovel Proactive Methodology:

food  Offer choices of tasks or activities
 Use of his iPad or other electronic devices
Inappropriate Social Boundaries:  Redirect discussions toward appropriateness and
 Attempts to kiss, grope or inappropriately reality
touch:  Praise him for completing household chores
 Verbally redirect  Show support for his musical hobbies
 Advise him that it’s inappropriate  Show support for his family involvement and
 Offer your hand, encourage him to shake it, and religious activities
praise him if he conforms  Facilitate and support his conversing with preferred
staff, his performance of recreational activities and
Crying: his employment
 Console  Keep activities as scheduled
 Resolve issue if able (e.g., fix or recharge item he’s  Offer him choices in activities
crying about) or advise that it will be worked  Immediately provide verbal praise as appropriate
on/tried to be fixed and acknowledgement of his kind gestures
 As needed, use picture cards, etc. to understand  When he indicates dislike of an activity, offer him
issue; See his Work Tools Kit an alternative
 Remind him of appropriate social conduct
Physical Aggression:  Weekly counseling from behavior specialist and
(Slamming doors repeatedly may be self-stimulating supportive counseling every shift and as needed
behavior) (each focused on social boundaries and respect)
 Verbally redirect; Ask him to cease behavior  Provide individual discussion as needed
 Encourage him to take a walk, e.g., in the  If he expresses concerns or complaints, discuss his
playground preferred resolutions
 Intervene if the behavior becomes dangerous  If he expresses an unrealistic notion, be patient and
 Offer him a snack explain how it is unrealistic
 Communicate with him frequently and in a
Challenging Behaviors: moderately gentle tone
 Verbal aggression  Provide encouragement and reassurance daily
 Physical aggression  Support and encourage his desire for autonomy
 Self-injurious behaviors  Support his hobby of autobiographical writing
 Noncompliance
Suicidal Ideation Protocol
Antecedents:
 Other residents displaying agitation  Notify BIS and Supervisor
 Feels he is being picked on or ignored  If immediate danger, call 911 and (another staffer, if
 Being verbally redirected possible) remove and lock away potentially injurious
 Perseveration regarding the health or fate of his objects including all sharps and prepare for hospital
mother transport
 Social anxiety  Assigned staffer does not take attention off of
 Chaotic situations resident and maintains arm’s-length supervision
until BIS does a suicide risk assessment
Proactive Methodology:
 Offer tasks or activities On-Call Nurse Protocol

MF’s BSP  Immediate medical emergency: Call 911

Challenging Behaviors:  Change in health: Notify the nurse
 Stealing  No return call by 15 minutes: Call the back-
 Inappropriate Social Boundaries up nurse
 Negative Self-Talk  No return call by 15 minutes: Call
 Suicidal Ideation the program director
 Any staffer becomes aware of a medication change:
Antecedents: Notify nurse immediately
 Presence of unsupervised electronic devices  No return call by 15 minutes: Call the back-
up nurse

4-4-19, EF
DSP Protocol Evaluation p. 3 of 4
Terrace ICF, MHANC

 No return call by 15 minutes: Call Staffer A

the program director  Notify residents who are on the 1st floor

Documenting Nurse’s Instructions Staffer C

 Starts with basement, sweeps all floors
Data Collection
8am-4pm & 4pm-12am
 Behavior
 Goals Staffer B
 Communication  Notifies residents who are on the 2nd floor
 Evacuates 2nd floor
Communication Log  Exit through 2nd floor fire door

BB’s Seizure Protocol Staffer D (if there’s a 4th staffer)

 Lay him on the floor
 Loosen clothing
 Turn head to the side
 Do not restrain
 Do not place any object in his mouth
 Note time and duration of seizure
 Record SpO2 (blood oxygen saturation) [Unknown:
SpO2 Lower Limit to Call 911]
 Administer 15mg Diastat at 20 minutes
 Call 911 [Unknown: When to Call 911 (at what
duration; if dyspneic, cyanotic or unresponsive)]
 Notify nurse
 Notify legal guardian
 Assists in evacuation of 2nd floor
Staffer A
 Notify residents who are on the 1st floor
 1st Floor
Staffer C
Starts with basement, sweeps all floors
Corrective Action Plan: Emergency Quick Reference
Guide (Not Otherwise Specified)
Levels of Supervision

Fire Evacuation Protocol  BB, Line of Sight at All Times

 JC, General
Acronym  CB, Line of Sight while Awake
 R, Remove  LG, general (LoS recently D/C’d)
 A, Alarm  PM, general
 C, Confine  MF, general
 E, Evacuate (to Synagogue Parking Lot)
PM’s Independent Community Guidelines
Staff Floor Assignments (general)
(Top to Bottom)  Curfew of 9:30pm
 Exceptions (Agitated, Expressions of Harm or of
 B, 2nd Floor Dangerous Intent)
 D, Assists 2nd Floor Elopement:
 A, 1st Floor  Note Clothing Description
 C, Basement  Call BIS & Mgmt.
 Call 911
 ABCD Cards Located in Office near Staff Schedule Unknown Whereabouts at 9:30pm
 Call his Cell Phone
12am-8am  Call 911
 Clothing Description
Staffer B  Frequent Destinations
 Notify residents  Call BIS & Mgmt.
 Evacuates 2nd floor
 Exit through 2nd floor fire door BB’s Skin Picking Protocol

Staffer D (if there’s a 4th staffer)  Document as self-injurious behavior on behavior

 Assists in evacuation of 2nd floor tally sheet
 Log on his Notable Behavior Sheet

4-4-19, EF
DSP Protocol Evaluation p. 4 of 4
Terrace ICF, MHANC

Corrective Action Plan: Overnight Findings (Not  One strike-through/cross-out

Otherwise Specified)  Initial

BB’s Bedroom Lights Other Targeted Protocols

Active Treatment Schedule
Bed/Sleep Checks & Charts  Every 15 minutes

Changing Data

Notes:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________
Printed Name of Evaluated DSP

______________________________________ Date Signed: __________________

Signature of Evaluated DSP

______________________________________
Printed Name of Evaluator

______________________________________ Date Signed: __________________

Signature of Evaluator

4-4-19, EF