Use of Restraint and Seclusion in Psychiatric Residential Treatment Facilities (RTF)

Written by Peg J. Dierkers, Ph.D., Deputy Secretary for Medical Assistance Programs. Effective Date July 20, 2001.

PURPOSE:

The purpose of this bulletin is to inform JCAHO Accredited RTF's of new Federal requirements regarding the use of restraint and seclusion in RTF's.

SCOPE:

This bulletin applies to JCAHO Accredited RTF's enrolled in the Medical Assistance (MA) Program and participating in either the fee-for-service or an MA managed care delivery system.

BACKGROUND:

Regulations at 55 Pa. Code Chapter 3800 relating to Child Residential and Day Treatment Facilities include limitations on the use of restrictive procedures. RTF's must comply with these regulations relating to restraint and seclusion in order to participate in MA.

On November 17, 1994, HCFA, recently renamed the Center for Medicare and Medicaid Services (CMS), published in the Federal Register proposed regulations establishing standards for psychiatric residential treatment facilities. Included in the proposed standards was information on HCFA's position on the use of restraint and seclusion. In the years since these proposed regulations were published there have been a number of restraint-related deaths such as cardiac arrest, fire and strangulation across the nation. A review of 20 such cases indicated that 40% of the deaths were caused by asphyxiation. Since this is such a serious safety related issue, HCFA published an interim final rule on January 22, 2001, implementing one of the conditions of participation from the November 17, 1994, proposed regulations: the use of restraint and seclusion in Psychiatric RTF's providing services to individuals under age 21. (66 Fed. Reg. 7147.) The January 22, 2001 interim final rule was amended May 22, 2001, 66 Fed. Reg. 28110, and was effective on May 22, 2001.

DISCUSSION:

MA enrolled RTF's are required to adhere to the provisions of the State regulations regarding restraint and seclusion that are more stringent than the Federal interim final rule, 42 USC § 290ii (c). In the event the State rule is silent or less stringent than the Federal rule, the provisions of the Federal rule govern. Thus even though the Federal rule allows seclusion, seclusion is not permitted because it is prohibited by State regulation. Conversely, although the State regulations do not, the Federal rule requires a) reporting of certain incidents, b) orders for restraint must be ordered by a physician or other licensed practitioner permitted by the State and the facility to order seclusion or restraint, c) a verbal order for manual restraint must be received by a registered nurse or other licensed staff such as a practical nurse while the emergency safety intervention is being initiated by staff or immediately after the emergency situation ends, and d) within one hour of the initiation of the emergency safety intervention, a physician or other licensed practitioner trained in the use of emergency safety interventions and permitted by the state and the facility to evaluate the physical and psychological well being of residents, must conduct a face to face assessment of the physical and psychological well being of the resident.

Each party involved in restrictive procedures may only perform as permitted by their training and scope of practice. This bulletin is not intended to increase current scope of practice.

PROCEDURE:

For your convenience we have attached a summary of the restrictive procedures permitted under Chapter 3800 and the Federal interim final rule. JCAHO Accredited RTF's providing services to MA recipients under the age of 21 should review the entire text of the Federal rule and related documentation of the facility and identify where changes to current policy and procedures must be made to bring the facility into compliance.

The facility must notify the Department that it is in compliance with the policy, procedures, and employee training requirements set forth in the Federal rule promulgated on January 22, 2001, as revised on May 22, 2001 rule. The facility director must complete the enclosed attestation form letter or your own letter of compliance (MA 1D #required) and attach a copy of the material distributed to the residents/family/guardian/custodian regarding the facility's use of restrictive procedures. This information must be mailed no later than August 13, 2001, to:
Bureau of Fee for Service Programs
Provider Enrollment
P.O. Box 8045
Harrisburg, PA 17105

The facility must report a resident's death, any serious injury to a resident, and a resident's suicide attempt to the Office of Children Youth and Family Services Regional Office in accord with existing Chapter 3800 requirements, and to the Pennsylvania Protection Agency no later than 24 hours after the serious occurrence.

In addition, the facility must report any restraint related death to the Center for Medicare and Medicaid Services, Regional Office no later than close of business the next business day after the resident's death.

See also summary of Restricted Procedures Permitted Under Chapter 3800 and the Federal Interim Final Rule.

This Medical Assistance Bulletin issused by the Commonwealth of Pennsylvania, Department of Public Welfare and be found on the Internet at: http://www.dpw.state.pa.us/omap/provinf/mabull/530101.asp.

Parents Involved Network (PIN), a project of
Mental Health Association of SE PA
1211 Chestnut Street, 11th Floor
Philadelphia, PA 19107
215-751-1800 or 800-688-4226
Email: law@pinofpa.org