R414-502-6. Criteria for Behaviorally Complex Program

In order for the Department to authorize Medicaid coverage for the Behaviorally Complex Program, a nursing facility must:

(1) Demonstrate that the resident has a history of persistent disruptive behavior that is not easily altered and requires an increase in resources from nursing facility staff as documented by one or more of the following behaviors:

(a) The resident engages in wandering behavior with no rational purpose, is oblivious to his needs or safety, and places his self and others at significant risk of physical illness or injury;

(b) The resident engages in verbally abusive behavior where he threatens, screams or curses at others;

(c) The resident presents a threat of hitting, shoving, scratching, or sexually abusing other residents.

(d) The resident engages in socially inappropriate and disruptive behavior by doing of one of the following:

(i) Makes disruptive sounds, noises and screams;

(ii) Engages in self-abusive acts;

(iii) Inappropriate sexual behavior;

(iv) Disrobes in public;

(v) Smears or throws food or feces;

(vi) Hoards; and

(vii) rummages through others belongings.

(e) The resident refuses assistance with medication administration or activities of daily living ; or

(f) The resident's behavior interferes significantly with the stability of the living environment and interferes with other residents' ability to participate in activities or engage in social interactions.

(2) Demonstrate that an appropriate behavioral intervention program has been developed for the resident.

(a) All behavior intervention programs shall:

(b) Be a precisely planned systematic application of the methods and experimental findings of behavioral science with the intent to reduce observable negative behaviors;

(c) Incorporate processes and methodologies that are the least restrictive alternatives available for producing the desired outcomes;

(d) Be conducted following only identification and, if feasible, remediation of environmental and social factors that likely precipitate or reinforce the inappropriate behavior;

(e) Incorporate a process for identifying and reinforcing a desirable replacement behavior;

(f) Include a program data sheet; and

(g) Include a behavior baseline profile that consists of all of the following:

(i) Applicant name;

(ii) Date, time, location, and specific description of the undesirable behavior;

(iii) Persons and conditions present before and at the time of the undesirable behavior;

(iv) Interventions for the undesirable behavior and their results; and

(v) Recommendations for future action.

(h) The interdisciplinary team shall include a behavior intervention plan that consists of all of the following:

(i) The applicant's name, the date the plan is prepared, and when the plan will be used;

(ii) The objectives stated in terms of specific behaviors;

(iii) The names, titles and signatures of persons responsible for conducting the plan; and

(iv) The methods and frequency of data collection and review.