Virginia Department of Behavioral Health & Developmental Services

Providing Orientation Training to Direct Support Professionals (DSPs) and Supervisors:

Supporting People in their Homes and Communities

Division of Developmental Services

Department of Behavioral Health and Developmental Services

July 2016

Virginia Department of Behavioral Health & Developmental Services

DSP Orientation Manual Sections

1. The Values that Support Life in the Community
2. Introduction to Developmental Disabilities
3. Waivers for People with Developmental Disabilities
4. Communication
5. Positive Behavior Supports
6. Health and Safety

Virginia Department of Behavioral Health & Developmental Services

SECTION I: VALUES THAT SUPPORT LIFE IN THE COMMUNITY

Section I: Values...

VIRGINIA'S VISION AND PRINCIPLES OF PERSON-CENTERED PRACTICES

Section I: Values...

VISION FOR VIRGINIA

We see a Virginia where people of all ages and abilities have the supports needed to enjoy the rights of life, liberty, and pursuit of happiness and the opportunity to have a good life.

Section I: Values...

Having a good life means different things to different people.

• Dreams
• Happiness
• Work
• FRIENDS
• hope
• Money
• BEING SAFE
• FAMILY

Section I: Values...

We believe a good life is best led by the person following these person-centered principles.

Section I: Values...

VIRGINIA'S PERSON-CENTERED PRINCIPLES

Listening

People are listened to and their choices respected.

Section I: Values...

VIRGINIA'S PERSON-CENTERED PRINCIPLES

Relationships

Community with family, friends, and people in the community are supported.

Section I: Values...

VIRGINIA'S PERSON-CENTERED PRINCIPLES

Self-Direction

Personal informed choice and control are supported.

Section I: Values…

VIRGINIA’S PERSON-CENTERED PRINCIPLES

Talents & Contributions

People have opportunities to use their gifts and talents.

Section I: Values…

VIRGINIA’S PERSON-CENTERED PRINCIPLES

Responsibility

There is a shared responsibility for supports and choices.

Section I: Values…

VIRGINIA’S HCBS (HOME AND COMMUNITY BASED SERVICES) WAIVERS

1. Building Independence Waiver
2. Community Living Waiver
3. Family and Individual Supports Waiver
4. Alzheimer’s Assisted Living Waiver
5. Elderly or Disabled with Consumer Direction (“EDCD”) Waiver
6. Technology Assisted Waiver (“Tech”)

Section I: Values…

People want DSPs who…

• Are respectful and polite
• Are flexible and creative
• Respond quickly
• Keep promises
• Seek win-win solutions
• Are honest and person-centered
• Are good listeners and communicators

Section I: Values…

Section I: Values…

VALUABLE CONCEPTS IN DIRECT SUPPORT

Section I: Values…

PERSON-CENTERED THINKING IMPORTANT TO AND IMPORTANT FOR

Important FOR…

…are those things that keep a person healthy and safe. They include:

• Prevention of illness
• Treatment of illness/medical conditions
• Promotion of wellness (e.g.: diet, exercise)
• Issues of safety: in the environment, physical and emotional well-being, including freedom from fear

They also include what others see as necessary for a person to:

• Be valued and
• Be a contributing member of their community

Important TO…

…are those things in life which help us to be satisfied, content, comforted, fulfilled, and happy. They include:

• People to be with/ relationships
• Status and control
• Things to do
• Places to go
• Rituals or routines
• Rhythm or pace of life
• Things to have

Section I: Values…

PERSON-CENTERED THINKING

• see the person, not the disability
• listen to and respect the person’s choices and preferences
• balance what’s important TO someone with what’s important FOR them
• record what’s learned to improve the support provided

Section I: Values…

RESPECT

DSPs…

• honor people’s rituals and routines
• learn backgrounds and cultures
• encourage talking for oneself
• ask permission when supporting

Section I: Values…

RESPECT AND LANGUAGE

DSPs…

• use person first language
• use everyday language
• consider their tone of voice
• don’t use jargon and labels
• remember that their attitudes and interactions influence others

Section I: Values…

PERSON-CENTERED PLANNING

DSPs need to be able to:

• plan WITH the person using a team approach
• listen and contribute
• continue listening and learning to improve the supports and the person’s plan

Section I: Values…

DIGNITY OF RISK

DSPs need to be able to:

• assure typical experiences in life
• support informed decisions
• understand your role
• safely support risk

Section I: Values…

COMMUNITY CONNECTIONS

DSPs…

• support people to be involved in their community
• encourage independence and participation
• find community opportunities and resources for the person to connect with friends, neighbors and other community members

Section I: Values…

COMMUNITY CONNECTIONS

Community presence may include doing things in the community on a regular basis and being recognized by others who attend, but not really interacting with others. If a person is not there, they are not missed.

Community participation may include doing things in the community on a regular basis, knowing several people by name and having conversations with them about personal lives. The person does things at the event that others depend on and they would be missed if they were not there on a particular day.

Community connection may include a person being included in social gatherings outside of the primary connection, others recognizing and appreciating their contributions, and forming friendships that extend beyond the reason they are gathered. When a person is not there they are missed and people ask about them.

Section I: Values…

NATURAL SUPPORTS

DSPs should be able to:

• learn who people want to be around
• connect people by interest not disabilities
• help locate and nurture unpaid relationships

Section I: Values…

WORK

DSPs …

• talk to people about work
• understand the benefits of work
• focus on Employment First!

Section I: Values…

ALTERNATIVES TO ISOLATING PROGRAMS

DSPs should be able to:

• focus on community, avoiding separation or special groups
• support the person’s ability to contribute
• encourage finding meaningful work

Section I: Values…

PERSONAL CHOICE & DECISION MAKING

DSPs …

• listen to preferences as choices
• encourage and honor choices big and small
• help the person consult with others

Section I: Values…

INDIVIDUAL RIGHTS

DSPs…

• understand human rights policies and consult with a supervisor when there are concerns
• report concerns of abuse or neglect
• include others in decisions involving risk

Section I: Values…

CONFIDENTIALITY

DSPs…

• are aware of privacy rights
• do not discuss individuals’ personal information without permission
• are sensitive to how individuals are introduced in the community

SECTION II: INTRODUCTION TO DEVELOPMENTAL DISABILITIES

Section II: Introduction to DD

Section II: Introduction to DD

DEFINING INTELLECTUAL DISABILITY

Section II: Introduction to DD

MORE ABOUT DD

• Includes people with autism, cerebral palsy, and other mental or neurological conditions
• May be only physical
• May or may not have an intellectual disability

Section II: Introduction to DD

Some causes of intellectual disability

• Genetics
• Other physical causes
• Social and environmental factors
• Unknown

Section II: Introduction to DD

MYTHS AND MISCONCEPTIONS

People with developmental disabilities are all alike and all require the same supports.

Section II: Introduction to DD

MYTHS AND MISCONCEPTIONS

People with developmental disabilities are ill or sick.

Section II: Introduction to DD

MYTHS AND MISCONCEPTIONS

People with developmental disabilities need specialized services to meet all of their needs.

Section II: Introduction to DD

DSPs…

• see the person not the disability
• are creative, taking each person’s wishes seriously
• are positive and don’t let history get in the way
• are a model for others

SECTION III: WAIVERS FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES

Section III: Waivers for People with Developmental Disabilities

VIRGINIA’S WAIVERS

Built upon

• Individual supports
• Person-centered approach
• Individual choices, outcomes, and needs

Section III: Waivers for People with Developmental Disabilities

WAIVER SERVICES

Can be

• Consumer-directed
• Agency-directed OR
• A combination of both

Section III: Waivers for People with Developmental Disabilities

RE-DESIGNED WAIVERS

• More targeted and flexible services
• More choices and opportunities
• Greater consistency, equity, and quality
• Increase flexibility

Section III: Waivers for People with Developmental Disabilities

THREE WAIVERS SUPPORT PEOPLE WITH DD

• Community Living Waiver
• Family and Individual Supports Waiver
• Building Independence Waiver

Section III: Waivers for People with Developmental Disabilities

THE COMMUNITY LIVING WAIVER

Section III: Waivers for People with Developmental Disabilities

THE FAMILY AND INDIVIDUAL SUPPORTS WAIVER

Section III: Waivers for People with Developmental Disabilities

THE BUILDING INDEPENDENCE WAIVER

Section III: Waivers for People with Developmental Disabilities

WAIVER SERVICE CATEGORIES

• Employment and Alternate Day Options
• Self-directed and Agency-directed Options
• Residential Options
• Crisis Support Options
• Medical and Behavioral Support Options
• Additional Options

Section III: Waivers for People with Developmental Disabilities

ELIGIBILITY FOR WAIVER SERVICES

To be eligible, an individual must:

• Have a diagnosis of developmental disability,
• Meet Medicaid financial eligibility,
• Meet the Level of Care Criteria as determined by the Virginia Individual DD Eligibility Survey (VIDES), and
• Accept services within 30 days.

Section III: Waivers for People with Developmental Disabilities

Section III: Waivers for People with Developmental Disabilities

SERVICES ARE OFFERED BY THE SUPPORT COORDINATOR AND AUTHORIZED BY DDS

Section III: Waivers for People with Developmental Disabilities

ASSESSMENT AND PERSONAL PROFILE

DSPs…

• share information about what the individual wants in his or her “good life”
• consider what’s working and not working in 8 life areas
• contribute in many ways through conversations and written notes

Section III: Waivers for People with Developmental Disabilities

SUPPORTS INTENSITY SCALE (SIS)

DSPs…

• have valuable information for SIS interviews
• offer information based on knowing the person

Section III: Waivers for People with Developmental Disabilities

PLANNING TEAM

DSPs…

• might help the individual plan the meeting
• might attend with the person
• share information with permission

Section III: Waivers for People with Developmental Disabilities

PLAN FOR SUPPORTS

DSPs…

• know the outcomes, activities and instructions in the Plan for Supports
• follow the instructions as described in the Plan
• know how to respond to change

Section III: Waivers for People with Developmental Disabilities

PC REVIEWS AND DOCUMENTATION

DSPs write notes…

• that convey vital information needed for Person-Centered Reviews
• complete checklists to record that support activities were provided and that relate to outcomes and describe supports

SECTION IV: COMMUNICATION

Section IV: Communication

PEOPLE COMMUNICATE IN A VARIETY OF WAYS

Some ways include:

• Speaking
• Writing
• Gestures
• Body language
• Signs
• Behaviors
• Actions

Section IV: Communication

TWO TYPES OF COMMUNICATION

• Expressive
• Receptive

Section IV: Communication

DSPs…

• Don’t assume that not speaking means not understanding
• Listen to what people say with their words and their actions

Section IV: Communication

DSPs…

• Take the time to understand what someone is saying through his actions
• Model age-appropriate and positive communication

Section IV: Communication

DSPs…

• Respect that everyone needs to communicate
• Know that behaviors are ways to communicate
• Help find ways for people to express themselves

SECTION V: POSITIVE BEHAVIOR SUPPORTS

Section V: Positive Behavior Supports

PBS IS…

PBS is the preferred DBHDS approach to supporting individuals with behavioral concerns.

…a person-centered approach and focuses on:

• Changing the surroundings and supports
• Teaching new skills that increase choice/control

Section V: Positive Behavior Supports

PBS HAS…

…four basic values:

• Respect for the rights of ALL citizens
• Respect for personal choice and control
• Dignified treatment of people
• Assurance that people with disabilities are not abused and neglected

Section V: Positive Behavior Supports

DSPs…

• Follow PBS plans
• See all behavior as communication
• Seek ways to increase choice and control
• Teach new, positive ways of meeting needs

SECTION VI: HEALTH AND SAFETY

Section VI: Health and Safety

HEALTH AND SAFETY CONSIDERATIONS

• Review all agency policies and procedures for health and safety
• Additional training will be available
• Balance of Important TO and Important FOR

Section VI: Health and Safety

MAINTAINING GOOD HEALTH THROUGH GOOD NUTRITION

• All people need good nutrition
• Special diets help with difficulty chewing or medical conditions
• As people age nutrition becomes even more important!

DSPs…

• Resist the temptation to use food as a reward or for reinforcement

Section VI: Health and Safety

THE FOOD PLATE

Recommendations from Choose My Plate:

• Focuses on variety, amount, and nutrition from all five food groups
• Includes foods and beverages with less saturated fat, sodium, and added sugars
• Eating the right amount of calories based on age, sex, height, weight, and physical activity level

Section VI: Health and Safety

PERSONAL HYGIENE

DSPs…

• Recognize the importance of good hygiene
• Know that people need support with personal care in different ways
• Respect peoples’ privacy with personal hygiene
• Support good hygiene for value in the community

Section VI: Health and Safety

REGULAR MEDICAL AND DENTAL CARE

DSPs…

• Know the connection between clean teeth and health
• Watch for any signs of illness and/or changes in routines or abilities

Section VI: Health and Safety

REGULAR MEDICAL AND DENTAL CARE

DSPs…

• Keep scheduled dental and medical appointments and know how to respond in emergencies
• Report and record any dental or medical concerns immediately

Section VI: Health and Safety

MEDICATION AND SIDE EFFECTS

Complete all training and testing in required Medication Administration Procedures (MAR)

• Some people with DD take multiple medications
• Know the possible side effects of medication
• Give the right medication, to the right person, in the right dose, by the right route and at the right time!

Learn about each person’s medication protocols!

Section VI: Health and Safety

EMERGENCY CARE

DSPs

• Receive additional training in First Aid and CPR
• Call for emergency help when needed
• Follow all agency and program procedures

Any condition which would be considered an emergency if it happened to a member of your family is also an emergency if it occurs with a person you support.

Call 911 at the first sign of a medical emergency!

Section VI: Health and Safety

OTHER HEALTH CONCERNS

People with DD might have other medical concerns. For example:

• Seizures
• Diabetes
• Difficulty walking
• Sleep apnea
• Food or drug allergies
• Difficulty with sight or hearing

Learn about each individual’s unique medical needs!

Section VI: Health and Safety

EXERCISE

DSPs…

• Recognize that people they support may not have experienced an exercise routine or formal fitness program.
• Know that 30 minutes of exercise is recommended most days of the week.
• Are creative and think of ways to get people moving in safe, healthy and preferred ways.

Section VI: Health and Safety

ASSISTIVE TECHNOLOGY

Items or devices that maintain or improve abilities. For example:

• custom eating utensils
• shower benches
• communication devices
• picture boards

Section VI: Health and Safety

ASSISTIVE TECHNOLOGY

DSPs…

• Support the safe use of assistive technology
• Receive training on how assistive technology is used by specific individuals
• Teach individuals how to use their assistive devices

Section VI: Health and Safety

IMPORTANT HEALTH CONDITIONS FOR PEOPLE WITH DD

Health issues that are often overlooked and need to be monitored:

1. Skin Care (pressure sores; skin breakdown)
2. Aspiration Pneumonia
3. Falls
4. Urinary Tract Infections
5. Dehydration
6. Constipation & Bowel Obstruction
7. Sepsis
8. Seizures

Section VI: Health and Safety

SKIN CARE

Healthy skin aids in regulating body temperature, protecting internal organs from injury and environmental elements, and protecting against infection.

Signs and symptoms of possible skin problems include, but are not limited to:

• Unusual or abnormal color (pale, pink, red, or bluish);
• Rashes or lesions;
• Changes in skin temperature;
• Parasites; and
• Pressure sores – areas of skin damage resulting from a lack of blood flow due to pressure, friction, or pulling on the skin.

Section VI: Health and Safety

SKIN CARE

People at risk for skin breakdown include, but are not limited to, those who:

• Use a wheelchair or who are in bed a lot of the time, require assistance when moving, have loss of bowel or bladder control, and have poor nutrition and hydration;
• Have problem sensing pain or pressure;
• Have limited ability to communicate;
• Have circulatory problems; and/or
• Are older adults, or are obese or very thin.

Section VI: Health and Safety

ASPIRATION PNEUMONIA

Aspiration pneumonia is an inflammation of the lungs and airways to the lungs from breathing in foreign material.

Aspiration pneumonia develops from inhaling food, vomit, liquids, or saliva into the lungs.

Signs and Symptoms of aspiration pneumonia include, but are not limited to:

• Chest pain,
• Cough,
• Fatigue,
• Fever,
• Shortness of breath, wheezing, and
• Bluish discoloration of the skin caused by lack of oxygen (e.g., mouth, nail beds, finger tips).

Section VI: Health and Safety

ASPIRATION PNEUMONIA

People at risk for aspiration pneumonia include, but are not limited to, those who:

• Are less alert due to medicines or illnesses;
• Have a disorder of the esophagus (the tube that moves food from the mouth to the stomach);
• Have problems with swallowing;
• Have poor gag reflex; and/or
• Are older

Section VI: Health and Safety

FALLS

Falls refer to any situation in which someone descends (or falls) suddenly and involuntarily toward a lower surface or the ground.

Fall complications can include broken bones, head injuries, problems with daily activities, and need for home health care.

Factors that contribute to falls include, but are not limited to:

• Health issues and medications;
• Fatigue or illness;
• Cluttered rooms, area rugs, wet or slick surfaces, improper lighting;
• Wet or slick surfaces without non-skid footwear;
• Lack of appropriate medical adaptive equipment; and
• Being shoved or running into a barrier.

Section VI: Health and Safety

FALLS

People at risk for falls include, but are not limited to, those who:

• Are older and have loss of muscle;
• Have arthritis, diabetes, and skeletal problems;
• Have visual and/or hearing loss;
• Take medications that cause gait concerns; or
• Do not have appropriate adaptive equipment

Section VI: Health and Safety

URINARY TRACT INFECTIONS

A UTI is an infection of the urinary tract, which is the body’s system for removing wastes and extra water.

There are two different types of UTIs – the lower UTI relates to infections that occur in the urethra and bladder – and the upper UTI is more severe and relates to infections that may involve the kidneys.

Lower UTI symptoms:

• Pain or burning during urination;
• Increased frequency, urgency of urination, incontinence;
• Lower abdominal, pelvic or rectal pain or pressure;
• Confusion, behavioral changes, increased falls;
• Mild fever or “just not feeling well;” and
• Changes in urine (such as milky, cloudy, bloody or foul-smelling).

Section VI: Health and Safety

URINARY TRACT INFECTIONS

People at risk for UTIs include, but are not limited to, those who have:

• Incontinence of bowel or bladder,
• Limited mobility,
• Extended periods of catheterization,
• A suppressed immune system, or
• A spinal cord injury or other nerve damage around the bladder that causes the bladder not to completely empty (which allows bacteria to grow).

Section VI: Health and Safety

DEHYDRATION

Dehydration occurs when we lose more fluids than we are taking in. The lack of water in the body may result from either a decrease in fluid intake or an increase in fluid loss.

Diarrhea and vomiting are the most common reasons why someone loses excess fluid.

Dehydration symptoms include, but are not limited to:

• Urine is concentrated and more yellow,
• Dry mouth and nose,
• Dry skin,
• Decreased tear production,
• Headache,
• Dizziness,
• Sleepy or tired, and
• Light headed (especially when standing)

Section VI: Health and Safety

DEHYDRATION

Hydration is important for everyone!

Hydration considerations include:

• The average person requires 64 ounces (8 cups) of water daily;
• Some people cannot tolerate that much fluid and must have restrictions – their medical doctor should be consulted regarding the recommended amount for them based on their health concerns;
• Good hydration is important with or without a g-tube-especially if a person drinks thickened liquids;
• Some people may have difficulty swallowing which can lead to a decrease in fluid intake; and
• If caring for someone who cannot communicate to ask for something to drink, remember to offer fluids frequently (every hour) to keep them hydrated.

Section VI: Health and Safety

CONSTIPATION AND BOWEL OBSTRUCTION

Constipation is the slow movement of feces through the intestine which results in infrequent bowel movements and hard, dry stools.

Constipation signs and symptoms include, but are not limited to:

• Changes in bowel habits;
• Infrequent bowel movements (less than 3 a week or more than 3 days between);
• Difficulty passing stools – straining, painful;
• Hard, dry, lumpy, small stools;
• Belly pain relieved by bowel movement; swollen abdomen;
• Bright red blood in stools; and
• Leaks of wet, diarrhea-like stool between regular bowel movements.

Section VI: Health and Safety

CONSTIPATION AND BOWEL OBSTRUCTION

People at risk for constipation include, but are not limited to, those who:

• Have diet changes, low fiber, high fat, high refined sugar, excessive caffeine;
• Lack regular exercise and are inactive or immobile;
• Do not have adequate fluid intake and hydration;
• Are stressed;
• Have a disruption of regular routine (travel, change in daily schedule);
• Have medical and psychological conditions;
• Take medications;
• Have poor bowel habits (holding back bowel movements);
• Use laxatives and/or enemas excessively; and
• Are older.

Section VI: Health and Safety

SEPSIS

Sepsis is a serious medical condition caused by an overwhelming immune response to infection. Sepsis can arise unpredictably and can progress rapidly. Sepsis springs from two factors: an infection (such as pneumonia or a urinary tract infection) and a powerful and harmful response by the body’s own immune system.

Stages and symptoms of sepsis include, but are not limited to:

• Sepsis – fever, increased heart and respiratory rate, probably infection
• Severe sepsis – decreased urine output, change in mental status, decrease in platelet count, difficulty breathing, abdominal pain, abnormal heart pumping function
• Septic shock – severe sepsis symptoms plus extremely low blood pressure that doesn't adequately respond to simple fluid replacement

Section VI: Health and Safety

SEPSIS

People at risk for sepsis include, but are not limited to, those who have:

• Weakened immune systems (children, infants, elderly);
• Chronic illnesses (diabetes, AIDS, cancer, kidney/liver disease);
• Severe burn or physical trauma resulting in damage to internal tissues; and
• An infection due to damage to internal tissues – invasive medical procedures – kidney infection – UTI and pneumonia.

Section VI: Health and Safety

SEIZURES

Seizures are defined as abnormal movements or behavior due to electrical activity in the brain. Seizures might include shaking and convulsions, and can last a few seconds or over 5 minutes.

Possible signs of a seizure include, but are not limited to:

• Brief blackout followed by a period of confusion;
• Changes in behavior;
• Drooling or frothing at the mouth;
• Eye movements;
• Shaking of the entire body;
• Grunting or snorting;
• Loss of bladder or bowel control;
• Sudden falling;
• Teeth clenching;
• Tasting a bitter or metallic flavor;
• Temporary stop in breathing;
• Uncontrollable muscle spasms with twitching and jerking limbs; and
• Mood changes

Section VI: Health and Safety

SEIZURES

People at risk for seizures include those who have:

• A history of seizures,
• Had a head injury,
• Had brain infections,
• Had a stroke,
• Had a brain tumor,
• Alzheimer’s disease, and
• Genetic factors.