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RESTRAINT & SECLUSION: Implementing the CMS Hospital Patients’ Rights Conditions of Participation Final Rule. National Association of Psychiatric Health Systems Training: February 15, 2007. Faculty. Patricia A. Chmielewski, RN, MS

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RESTRAINT & SECLUSION: Implementing the CMS Hospital Patients’ RightsConditions of Participation Final Rule

National Association of Psychiatric Health Systems Training:

February 15, 2007


Faculty
Faculty

  • Patricia A. Chmielewski, RN, MS

    Deputy Director, Division of Acute Care Services, Survey and Certification Group, Centers for Medicare and Medicaid Services

  • Janice A. Graham, RN, MS

    Division of Institutional Quality Standards, Clinical Standards Group/OCSQ, Centers for Medicare and Medicaid Services

    -continued-

National Association of Psychiatric Health Systems -- February 2007


Faculty continued
Faculty (continued)

  • Dorothy Hill, R.N., C.

    Chief Executive Officer, Acadia Hospital, Bangor, ME

  • Harold Schwartz, M.D.

    Psychiatrist-in-Chief & Vice President of Behavioral Health

    The Institute of Living/Hartford Hospital, Hartford, CT

  • Kathleen McCann, R.N., Ph.D. (moderator)

    Director of Clinical and Regulatory Affairs, National Association of Psychiatric Health Systems

National Association of Psychiatric Health Systems -- February 2007


Overview of the final rule

Overview of the Final Rule

Hospital Conditions of Participation on Patients’ Rights


Final rule
Final Rule

  • In December 8, 2006, Federal Register

  • Effective January 8, 2007

  • Applies to all hospitals participating in Medicare and Medicaid (including both general hospitals and freestanding psychiatric hospitals)

  • Sets minimum standards for patient care

    The 50-page final rule is available at http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/pdf/06-9559.pdf.

National Association of Psychiatric Health Systems -- February 2007


Final rule continued
Final Rule (continued)

  • Reflects responsiveness to the more than 4,000 comments received by CMS

  • Provides strong patient protections

  • Provides significant insight into the thinking and decision-making process CMS used in its development of the final rule

  • CMS interpretive guidelines (used in the survey process) will be updated at a future date

National Association of Psychiatric Health Systems -- February 2007


Five standards in final rule
Five Standards in Final Rule

  • Four standards were finalized without change from the interim final rule.

    • Notice of Rights

    • Exercise of Rights

    • Privacy and Safety

    • Confidentiality

  • The fifth standard on “Restraint or Seclusion” was revised in the final rule in both content and application

    (summary on pages 71418-28 and throughout the final rule)

National Association of Psychiatric Health Systems -- February 2007


Final rule applies to all patients
Final Rule Applies to All Patients

  • Combines requirements for all patients in restraint or seclusion under standard (e) with the goal of reducing restraint and seclusion use in all settings of the hospital.

National Association of Psychiatric Health Systems -- February 2007


Final rule applies to all patients continued
Final Rule Applies to All Patients (continued)

  • Eliminates distinctions made in the interim final rule between requirements for restraint and seclusion for “acute medical and surgical care (e)” and “behavior management (f).”

National Association of Psychiatric Health Systems -- February 2007


Final rule applies to all patients continued1
Final Rule Applies to All Patients (continued)

  • However, the final rule defines special requirements when restraint or seclusion is used to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.

National Association of Psychiatric Health Systems -- February 2007


Key messages
Key Messages

  • “All patients have the right to be free from physical or mental abuse, and corporal punishment;”

  • “Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time;”

    -continued-

National Association of Psychiatric Health Systems -- February 2007


Key messages continued
Key Messages (continued)

  • “All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff;”

  • “The patient has the right to safe implementation of restraint or seclusion by trained staff.”

National Association of Psychiatric Health Systems -- February 2007


What s different

What’s Different

Definitions


Restraint definition modified
Restraint Definition Modified

  • Final rule definition is:

    A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; ……

    -continued-

National Association of Psychiatric Health Systems -- February 2007


Restraint definition modified continued
Restraint Definition Modified (continued)

  • …..or a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.

National Association of Psychiatric Health Systems -- February 2007


Restraint definition continued
Restraint Definition (continued)

  • Clarifies restraint does notinclude:

    • devices such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests,

    • or to protect the patient from falling out of bed,

    • or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort).

National Association of Psychiatric Health Systems -- February 2007


Seclusion definition
Seclusion Definition

  • Interim final rule has been retained with minor revisions:

    Seclusionis the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving.

National Association of Psychiatric Health Systems -- February 2007


Seclusion definition continued
Seclusion Definition (continued)

  • The revised standards clarify that seclusion may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.

National Association of Psychiatric Health Systems -- February 2007


Revised standard e
Revised Standard (e)

  • Retains all current requirements formerly found under “restraint for acute medical and surgical care”

  • Adds the more stringent requirements formerly found in standard (f) “behavior management.”

    • However, the time limits on the length of each order and the 1-hour face-to-face evaluation only apply when restraint or seclusion are used to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.

National Association of Psychiatric Health Systems -- February 2007


Standard e retains these requirements for all patients
Standard (e) Retains These Requirements for All Patients:

  • Restraint or seclusion may only be used when:

    • less restrictive interventions have been determined to be ineffective to protect the patient or others from harm;

    • the type or techniques used are the least restrictive intervention that will be effective; and

    • it is in accordance with a written modification to the patient’s plan of care and implemented in accordance with safe and appropriate techniques as determined by hospital policy and state law.

National Association of Psychiatric Health Systems -- February 2007


Standard e retains these requirements for all patients1
Standard (e) Retains These Requirements for All Patients:

  • Restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner (LIP) who is responsible for the care of the patient and is authorized to order restraint or seclusion by hospital policy in accordance with state law.

  • The order may never be written as a standing order or on an as-needed basis (PRN).

  • The attending physician must be consulted as soon as possible if restraint or seclusion is not ordered by the patient’s attending physician.

National Association of Psychiatric Health Systems -- February 2007


Standard e retains these requirements for all patients2
Standard (e) Retains These Requirements for All Patients:

  • Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy (see special requirements).

National Association of Psychiatric Health Systems -- February 2007


Standard e retains these requirements for all patients3
Standard (e) Retains These Requirements for All Patients:

  • The use of restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order.

National Association of Psychiatric Health Systems -- February 2007


Standard e retains these requirements for all patients4
Standard (e) Retains These Requirements for All Patients:

  • The condition of the patient who is restrained or secluded must be monitored by a physician or other LIP or by trained staff at an interval determined by hospital policy (see training requirements).

National Association of Psychiatric Health Systems -- February 2007


Standard e retains these requirements for all patients5
Standard (e) Retains These Requirements for All Patients:

  • Physician and other LIP training requirements must be specified in hospital policy.

  • At a minimum, this must include a working knowledge of hospital policy regarding the use of restraint or seclusion. CMS does not require that physicians and LIPs participate in the full training required of other hospital staff.

National Association of Psychiatric Health Systems -- February 2007


Standard e retains these requirements for all patients6
Standard (e) Retains These Requirements for All Patients:

  • When restraint or seclusion is used, there must be documentation in the medical record of:

    • the results of the 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others;

    • alternatives or other less restrictive interventions attempted (as applicable);

      continued

National Association of Psychiatric Health Systems -- February 2007


Standard e retains these requirements for all patients7
Standard (e) Retains These Requirements for All Patients:

  • Documentation requirements (continued):

    • the patient’s condition or symptoms that warranted the use of the restraint or seclusion;

    • the patient’s response to the intervention used, including the rationale for continued use of the intervention.

National Association of Psychiatric Health Systems -- February 2007


Requirements

Requirements

Violent or

Self-Destructive Behavior


Requirements violent or self destructive behavior
Requirements (Violent or Self-Destructive Behavior)

  • Applicable if restraint or seclusion is used to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others

National Association of Psychiatric Health Systems -- February 2007


Requirements violent or self destructive behavior1
Requirements (Violent or Self-Destructive Behavior)

  • Each order may only be renewed in accordance with the following limits for up to a total of 24 hours:

    • 4 hours for adults 18 years of age or older,

    • 2 hours for children and adolescents 9 to 17 years of age, and

    • 1 hour for children under 9 years of age.

National Association of Psychiatric Health Systems -- February 2007


Requirements violent or self destructive behavior2
Requirements (Violent or Self-Destructive Behavior)

  • After 24 hours, before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, a physician or other LIP who is responsible for the care of the patient and authorized to order restraint or seclusion must see and assess the patient.

National Association of Psychiatric Health Systems -- February 2007


Requirements violent or self destructive behavior3
Requirements (Violent or Self-Destructive Behavior)

  • Expansion of the type of practitioners permitted to conduct the 1-hour face-to-face evaluation represents a major change in the Condition of Participation.

National Association of Psychiatric Health Systems -- February 2007


Requirements violent or self destructive behavior4
Requirements (Violent or Self-Destructive Behavior)

  • A physician or other LIP or a registered nurse (RN) or physician assistant (PA) trainedin accordance with the requirements specified in the CoP (see training section) must see the patient face-to-face within 1 hour after the initiation of the intervention.

National Association of Psychiatric Health Systems -- February 2007


Requirements violent or self destructive behavior5
Requirements (Violent or Self-Destructive Behavior)

  • This practitioner must evaluate:

    • the patient’s immediate situation,

    • the patient’s reaction to the intervention,

    • the patient’s medical and behavioral condition, and

    • the need to continue or terminate the restraint or seclusion.

National Association of Psychiatric Health Systems -- February 2007


Requirements violent or self destructive behavior6
Requirements (Violent or Self-Destructive Behavior)

  • If the 1-hour face-to-face evaluation is conducted by a trained RN or PA,

    • the attending physician or other LIP who is responsible for the care of the patient must be consultedas soon as possible after completion of the evaluation.

      - continued-

National Association of Psychiatric Health Systems -- February 2007


Requirements violent or self destructive behavior7
Requirements (Violent or Self-Destructive Behavior)

  • Patients in both restraint and seclusion must be continually monitored face-to-face by an assigned, trained, staff member, or continually monitored by trained staff using both video and audio equipment.

    • This monitoring must be in close proximity to the patient.

National Association of Psychiatric Health Systems -- February 2007


Training requirements

Training Requirements

Standard (f)


Standard f
Standard (f)

  • Is a new section that expands staff training requirements

National Association of Psychiatric Health Systems -- February 2007


Training requirements standard f
Training RequirementsStandard (f)

  • Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion before performing any of these actions, as part of orientation, and subsequently on a periodic basis consistent with hospital policy.

National Association of Psychiatric Health Systems -- February 2007


Training requirements standard f1
Training RequirementsStandard (f)

  • In addition, the hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:

    -continued-

National Association of Psychiatric Health Systems -- February 2007


Training requirements standard f2
Training RequirementsStandard (f)

  • techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require restraint or seclusion;

  • the use of non-physical intervention skills;

    -continued-

National Association of Psychiatric Health Systems -- February 2007


Training requirements standard f3
Training RequirementsStandard (f)

  • choosing the least restrictive intervention based on an individualized assessment of the patient’s medical or behavioral status or condition;

  • the safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (e.g., positional asphyxia);

    -continued-

National Association of Psychiatric Health Systems -- February 2007


Training requirements standard f4
Training RequirementsStandard (f)

  • clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary;

    -continued-

National Association of Psychiatric Health Systems -- February 2007


Training requirements standard f5
Training RequirementsStandard (f)

  • monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to,

    • respiratory and circulatory status,

    • skin integrity,

    • vital signs, and

    • any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation;

      -continued-

National Association of Psychiatric Health Systems -- February 2007


Training requirements standard f6
Training RequirementsStandard (f)

  • the use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification.

National Association of Psychiatric Health Systems -- February 2007


Training requirements standard f7
Training RequirementsStandard (f)

  • Individuals providing staff training must be qualified as evidenced by education, training, and experience in techniques used to address patients’ behaviors.

  • The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed.

National Association of Psychiatric Health Systems -- February 2007



Standard g retains these requirements for all patients
Standard (g) Retains These Requirements for All Patients:

  • The hospital must report to CMS each death:

    • that occurs while a patient is in restraint or in seclusion at the hospital;

    • that occurs within 24 hours after the patient has been removed from restraint or seclusion;

      -continued-

National Association of Psychiatric Health Systems -- February 2007


Standard g retains these requirements for all patients1
Standard (g) Retains These Requirements for All Patients:

  • The hospital must report to CMS each death:

    • known to the hospital that occurs within one week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death.

    • For the purpose of the regulation, “reasonable to assume” includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.

National Association of Psychiatric Health Systems -- February 2007


Standard g retains these requirements for all patients2
Standard (g) Retains These Requirements for All Patients:

  • Each death referenced in this section:

    • must be reported to CMS by telephone no later than the close of business the next business day following knowledge of the patient’s death.

    • Staff must document in the patient’s medical record the date and time the death was reported to CMS. This requirement modifies and clarifies the interim final rule.

National Association of Psychiatric Health Systems -- February 2007


Compliance with the joint commission

Compliance with the Joint Commission

Restraint/Seclusion Standards


Restraint seclusion standards
Restraint/Seclusion Standards

  • In addition to complying with the CMS final rule, accredited organizations must also be in compliance with all requirements of the Joint Commission.

National Association of Psychiatric Health Systems -- February 2007


Status of current discussions
Status of Current Discussions

  • The Joint Commission and CMS are in discussion regarding the CMS requirement that organizations using The Joint Commission accreditation for deemed status be in compliance with the 1999 Interim Final Rule (CAMH PC.12.90 Element of Performance 4.)

  • They will notify the field as soon as a decision is made about how this will be handled.

National Association of Psychiatric Health Systems -- February 2007


A checklist for implementing the cms final rule

A Checklist for Implementing the CMS Final Rule

Next Steps within Your Hospital


To do
To Do:

  • Share the complete 50-page Federal Register final rule with your hospital leadership team.

  • Review principles highlighted in the Federal Register final rule to understand the rationale that CMS used in formulating the requirements.

National Association of Psychiatric Health Systems -- February 2007


To do1
To Do:

  • Review with staff your progress in establishing and maintaining a culture that minimizes the use of restrictive interventions.

National Association of Psychiatric Health Systems -- February 2007


To do2
To Do:

  • Work with medical staff, nursing staff, and other disciplines to describe patterns of communication and exchange of clinical information that will facilitate safe, high-quality care of patients in restraint or seclusion.

National Association of Psychiatric Health Systems -- February 2007


To do3
To Do:

  • Participate in the development/revision of:

    • definitions of restraint and seclusion and applicability to patient populations

    • policies and procedures;

    • medical staff rules and regulations;

      -continued-

National Association of Psychiatric Health Systems -- February 2007


To do4
To Do:

  • Participate in the development/revision of (continued):

    • performance improvement strategies;

    • clinical interventions;

    • orientation and training-- relative to the avoidance of the use of (and, when necessary, the safe use of) restraint and seclusion

National Association of Psychiatric Health Systems -- February 2007


To do5
To Do:

  • Develop guidelines for (in the event of the need for R/S):

    • the assessment of the patient’s immediate needs;

    • physical and psychological status;

    • frequency of observation;

      -continued-

National Association of Psychiatric Health Systems -- February 2007


To do6
To Do:

  • Develop guidelines for (in the event of the need for R/S): (continued)

    • changes in treatment plan (potentially including the need for a face-to-face assessment by a physician);

    • content and frequency of orders;

    • least restrictive interventions;

    • plan/criteria for discontinuation of R/S.

National Association of Psychiatric Health Systems -- February 2007


To do7
To Do:

  • Develop training program for staff who may be permitted to do the one hour face-to-face evaluation. Pay close attention to the list of competencies outlined in the 12/8/06 Final Rule.

  • Develop competency assessment and documentation policies and procedures

National Association of Psychiatric Health Systems -- February 2007


To do8
To Do:

  • Review content and frequency of training programs for all staff caring for patients in R/S (including prevention, safe application of physical, assessment, documentation, etc.)

National Association of Psychiatric Health Systems -- February 2007


To do9
To Do:

  • Review training requirements for staff who are providing staff training. Establish procedures for documenting these competencies in the staff personnel record.

  • Train staff on death reporting requirements.

National Association of Psychiatric Health Systems -- February 2007


To do10
To Do:

  • Provide education on the new regulations with special emphasis on definitions of restraint and seclusion and applicability of standards to patient populations

National Association of Psychiatric Health Systems -- February 2007


To do11
To Do:

  • Develop a system for monitoring compliance with all applicable policies and procedures and incorporate all functions into ongoing performance improvement, quality, and assessment activities.

National Association of Psychiatric Health Systems -- February 2007


For more information
For More Information

  • Centers for Medicare & Medicaid Services: www.cms.hhs.gov

  • The Joint Commission: www.jointcommission.org

  • NAPHS: www.naphs.org

National Association of Psychiatric Health Systems -- February 2007


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