Joint Commission’s, HCFA’s standards now match

The new standards for restraint and seclusion from the Joint Commission on Accreditation of Healthcare Organizations are now much closer to those of
the Health Care Financing Administration (HCFA), notes Kathleen Catalano, RN, JD, senior consultant to the Greeley Co., a health care professional consulting firm in Marblehead, MA, specializing in regulatory compliance.

The new Joint Commission standards will become effective Jan. 1, 2001, and HCFA’s became effective in August 1999. Where the standards differ, your policy should always state the stricter requirement, urges Catalano.

In July 2000, HCFA issued interpretive guidelines for state surveyors to help enforce the new regulations for patient restraint and seclusion, notes Catalano. (See sources box for how to obtain a copy of the guidelines, right.) The HCFA requirements apply to all hospitals participating in Medicare or Medicaid, regardless of whether they are accredited, says Catalano.

Because restraint is such a heated public issue, the Joint Commission would look very out of step if they were to be more lenient than HCFA, says Ann Kobs, president and CEO of Type 1 Solutions, a Fort Myers, FL-based compliance consulting firm specializing in preparation for accreditation surveys. "Last summer, the Office of the Inspector General accused the Joint Commission of being lax and not seriously scoring the standards as deemed status would require," she notes.

Since then, Joint Commission has been working diligently to come into line with HCFA’s more stringent standards, Kobs reports. "They don’t want to lose deemed status, since that basically would put them out of business," she says.

Here are several issues pertaining to restraint use and how to comply with Joint Commission and HCFA’s requirements:

• The "one-hour" rule for a restraint order. The Joint Commission has switched to the "one-hour" rule mandated by HCFA for restraint and seclusion of patients under the behavioral health standards, says Robert Wise, MD, vice president of standards at the Joint Commission.

The HCFA rule says a physician or licensed independent practitioner (LIP) is required to evaluate patients in person within one hour of restraint or seclusion, says Catalano. The Joint Commission is using the one-hour standard in its surveys, as of Sept. 1, 2000, notes Catalano. Previously, the Joint Commission’s standards said the order must be obtained within four hours for adults, two hours for adolescents, and one hour for children under age 9.

Because HCFA requires that the one-hour rule must be enforced for hospitals participating in Medicare, the Joint Commission also has agreed to enforce this requirement for hospitals, reports Wise.

"This clears up long-standing confusion between the two standards," says Catalano.

In-person evaluation for updated orders. The HCFA interpretive guidelines say that a physician assistant or nurse practitioner may evaluate restrained or secluded patients, if they are considered licensed independent practitioners under state law, Catalano explains.

The new Joint Commission standards state that the LIP must be contacted after four hours for an updated order, Catalano says. "The attending LIP must be contacted if he or she was not present when the order for the use of restraint was made by an associate or other LIP."

Under Joint Commission standards, this is the time limit for restraint orders when behavioral restraint is being used, says Catalano:

— four hours for adults;

— two hours for ages 9-17;

— one hour for under age 9.

As of January, the Joint Commission will allow emergency placement of a patient in restraint by a trained individual, notes Catalano. "Then the LIP must see the patient within four hours," she says.

Joint Commission standards require that if a patient is no longer in restraint when the original verbal order expires, the LIP must conduct an in-person evaluation of the patient within 24 hours, says Catalano. "This differs from HCFA," she notes.

The LIP must re-evaluate patients in person at least every eight hours for patients 18 and older, and every four hours for ages 17 and younger, says Catalano. "This differs greatly from HCFA and is the tougher standard," she states.

• Debriefing. The Joint Commission standard also requires debriefing of the patient by staff within 24 hours of the episode of restraint use, says Catalano. "HCFA has nothing comparable to this," she notes. "The debriefing is new and must involve the patient/family, staff, and be documented."

The July 2000 Interpretive Guidelines for Hospital Conditions of Participation for Patient Rights can be accessed at HCFA’s Web site (

The interim final rule for Quality of Care Standards for Hospital Conditions of Participation for Patient Rights, which addresses restraint and seclusion, is available via the Internet at the Government Printing Office Web site. The address is Click on the "Federal Register" icon to search for the July 2, 1999 issue. The Federal Register is available at many libraries. Copies of the Federal Register can be ordered by mail. The cost of each copy is $8. Specify the date of the issue, and include a check or money order payable to Superintendent of Documents. Contact:

New Orders, Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Credit card orders may be placed by calling (202) 512-1800; fax: (202) 512-2250.