Medicare Restraints and Seclusion Update

On Friday, December 8th, the Centers for Medicare and Medicaid Services (CMS) published final patient's rights rule on the use of restraints and seclusion, as a Hospital Conditions of Participation requirement. Key features of the rule include new requirements for staff training, a change in the monitoring interval and in the personnel who may conduct the face-to-face evaluation, and more specific requirements regarding patient record notation. The first four standards—Notice of Rights, Exercise of Rights, Privacy and Safety, Confidentiality of Patient Records—remain unchanged. The new requirements apply to all participating hospitals, including short-term psychiatric rehabilitation, long-term, children's and alcohol/drug treatment facilities.

Training
Staff who employ physical restraints and seclusion when treating patients must undergo what is described as "new, more rigorous training." According to the new regulation, staff must be trained and able to demonstrate competency in the 1) application of restraints, 2) implementation of seclusion and 3) monitoring, assessment, and providing care for a patient in restraint or seclusion. Training must occur before the staff may perform restraint or seclusion and must be included as part of staff orientation. After orientation, training must continue on a periodic basis. The trainer must be qualified by "education, training, and experience" to address the behaviors staff may encounter.

The regulation also specifies the content of staff training. Staff must have education, training, and demonstrated knowledge based on specific needs of the patients they will be working with. At a minimum, this includes the following: 1) techniques to identify staff and patient behaviors, events, and environmental factors that may trigger need to use restraint or seclusion, 2) use of nonphysical intervention skills, 3) choosing least restrictive intervention based on individualized assessment, 4) safe application of restraint and seclusion, including recognition of and response to signs of physical and psychological distress, 5) clinical identifications that restraint or seclusion is no longer necessary, 6) monitoring physical and psychological well-being of patient (e.g., respiratory and circulatory status, skin integrity, vital signs), and 7) first aid and current CPR certification.

The facility must document in staff personnel records when training was completed and evidence of how the staff member demonstrated their competency in the above content.

Monitoring and Evaluation
The current requirement of a "face-to-face" evaluation by a physician or licensed independent practitioner has been expanded to include a trained registered nurse or physician assistant. Other changes include the requirement for monitoring and assessing patients who are in restraint or seclusion The prior rules required "continual" monitoring of patients in restraint or seclusion; the new regulation leaves the time frame of monitoring up to the hospital.

Patient Record Notation
The prior rules did not specify the level of documentation necessary when restraint or seclusion were used. The new regulation requires more formal record notations. In all cases of seclusion and restraint, documentation in a patient's medical record must include a description of the patient's behavior and the intervention used; alternatives or other less restrictive interventions attempted (as applicable); the patient's condition or symptom(s) that warranted the use of the restraint or seclusion; and the patient's response to the intervention(s) used, including the rationale for the continued use of the intervention. If restraint or seclusion is used to manage violent or self-destructive behavior, then the patient's medical record must also include the one-hour face-to-face medical and behavioral evaluation.

For more information, please see the chart of key provisions prepared by the National Council, available online: www.nccbh.org/POLICY/policy.htm

To view the regulations and the agency's response to public comments, visit: http://a257.g.akamaitech.net/7/257/2422/01jan20061800/
edocket.access.gpo.gov/2006/pdf/06-9559.pdf

If you have any questions, please contact Tammy Seltzer, Director of State Policy, at tammys@nccbh.org.