Recognizing prohibited procedures, including subtle ones

Minnesota Rules part 9544.0060 lists actions and procedures that are prohibited when used as a substitute for adequate staffing, as a behavior program, as punishment or for staff convenience. Some are what most people picture: prone restraint, metal handcuffs or leg hobbles, painful techniques, tripping or pushing, and any action that might restrict a person's airway or breathing. Mechanical and chemical restraint are prohibited, and manual restraint is prohibited except in an emergency under the separate emergency rules.

Many items on the list are subtler and show up in everyday routines. The rule prohibits speaking to a person in a way that ridicules, demeans or threatens; using physical intimidation or a show of force; requiring a person to hold a certain posture; forced exercise; restricting a person's senses; and using intense sounds, lights or noxious sprays. It prohibits isolating or secluding a person without monitoring or when medically contraindicated. It prohibits using one person receiving services to discipline another. It prohibits interfering with a person's legal rights except as the statute allows.

Two items deserve special attention in plan review. First, the rule prohibits denying or restricting access to equipment and devices such as walkers, wheelchairs, hearing aids and communication boards. If temporary removal is needed to prevent injury or serious damage, the device must be returned as soon as the imminent risk has passed. Taking away a communication device is taking away a person's voice. Second, the rule prohibits depriving a person of normal goods and services or requiring them to earn those things, and it prohibits token or level programs that include a response cost or other negative punishment. A plan that says a person earns snacks, phone time or outings by behaving is a warning sign.

Hidden restrictions often come from good intentions, habit or thin staffing. When you see one, ask curious questions first: what is this practice meant to achieve, what happens before the behavior, and what would the person say about it? Formal determinations of whether a violation occurred belong to DHS Licensing and the investigations process. Suspected maltreatment of a vulnerable adult or child must be reported under Minnesota's mandated reporting laws, whatever else is happening.

Emeka, a case manager, reads a draft support plan addendum for Lina, who communicates mainly with a tablet. The plan says that when Lina throws objects, staff will put her tablet away for the rest of the day, and that she can earn it back by completing chores. The provider describes this as teaching responsibility. Lina's mother has mentioned that Lina seems withdrawn and has stopped trying to communicate in the evenings.

In the next support plan or addendum you review, search for words like earn, privilege, lose, removed and until, and ask the team about any practice that makes ordinary goods, activities or equipment conditional on behavior.

Think of a routine in a service setting you know that could quietly limit someone's choices. What might it look like from the person's point of view?