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HCFA Revises Final Interim Rules on Use of Restraint and Seclusion in Psychiatric Residential Treatment Facilities for Children and Adolescents

For Immediate Release, May 4, 2001
Contact: Chris Marshall

The Health Care Financing Administration today announced the release of a revised interim final rule setting forth protections for children in Medicaid funded psychiatric residential treatment centers (RTCs). The revised rule changes certain provisions contained in a rule previously published on January 18, 2001. After President Bush took office, he imposed a moratorium on all new regulations approved during the final days of the Clinton Administration until these regulations could be thoroughly reviewed. The new interim rule issued today by HCFA retains many of the features of the Clinton Administration's rule, but makes certain changes as well. Specifically, the new rule modifies requirements for reporting deaths of individuals in RTCs, changes requirements governing who may order the initial use or continuation of restraints in RTCs, and changes the definition of the term "personal restraint". Today's new interim final rule is effective immediately, with a 60-day comment period.

The new rule contains significant protections for children and adolescents with mental illnesses in RTCs, including new standards governing physician consultation, monitoring, reporting, parental/guardian notification, debriefing and education/training on the use of restraint and seclusion. However, the broad standard set forth in the rule for who may initiate the use of restraints in RTCs is cause for concern.

The interim final rule can be found in the Federal Register for Tuesday, May 22, 2001 at 

Who May Order Restraints in RTCs?

The rule creates Conditions of participation (CoP) for psychiatric RTCs that provide Medicaid covered services to individuals under the age of 21. The rule prohibits the use of restraint or seclusion of any form, when "used as a means of coercion, discipline, convenience, or retaliation." It specifies that restraint or seclusion is to be used only in emergency safety situations, preferably under an order from the individual's treatment team physician.

The earlier rule specified that any orders for restraint or seclusion must be issued by a psychiatrist, a licensed physician with specialized training and experience in diagnosing and treating mental illness, or a registered nurse who has received a verbal order from a physician. The revised rule broadens the standard for who may order restraints to include "other licensed practitioners." HCFA states that this change is due to the "serious and immediate concerns raised … about the "severe shortage of registered nurses and the unavailability of psychiatrists" in RTCs. It fears that many facilities would be unable to meet the conditions of participation set forth in the earlier rule and that children and adolescents would therefore be left without residential placements.

Under the revised rule, a registered nurse or other licensed staff (e.g. a licensed practical nurse) may initiate the use of restraints in an RTC as long as he/she obtains a verbal order from a physician to do so. Moreover, the physician need not be present at the time the restraints are initiated, as long as the physician verifies through a signature that he or she gave the order to initiate the restraints.

NAMI is concerned that the term "other licensed practitioner" establishes broad leeway for untrained individuals to initiate the use of restraints. Many deaths documented by the Hartford Courant in 1998 can be linked directly to use of restraints by individuals untrained in the safe use of these potentially deadly interventions. Therefore, although NAMI appreciates concerns about the shortage of qualified professionals in certain areas, this overly broad standard may not adequately protect vulnerable children and adolescents with mental illnesses who are in RTCs.

Definition of "personal restraint"

The revised rule amends the definition of "personal restraint" to clarify that brief holding without undue force, for the purpose of comforting or escorting a child, shall not be considered a restraint.

Reporting requirements:

The revised interim final rule broadens the requirements for RTCs to report the death of any child or adolescent resident to HCFA to enable that federal agency to obtain "sufficient timely information to identify threats to beneficiary health and welfare." NAMI is pleased by the addition of this enhanced reporting requirement in the revised rule.

NAMIs comments on the interim final rule issued in January can be viewed at :   NAMI will be submitting comments to HCFA on the revised interim final rule in the coming weeks. We will share our comments with you at that time.