The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has instructed its surveyors to enforce the federal one-hour rule on seclusion and restraint after its proposed alternative was rejected by the Health Care Financing Administration (HCFA).

Hospitals using JCAHO accreditation for Medicare or Medicaid reimbursement must arrange to have a physician or licensed independent practitioner available to evaluate a patient within one hour of the patient’s being restrained or secluded. The goal is to protect patients with behavioral or emotional disorders from harming themselves or others.

Hospitals with JCAHO accreditation are automatically eligible for Medicare or Medicaid reimbursement unless the federal requirements are considered to be at a higher standard.

HCFA recently told the JCAHO that the controversial one-hour rule was indeed a higher standard than the JCAHO’s proposed alternative. That proposal called for a licensed independent practitioner (LIP) to be notified and consulted within one hour of a patient’s restraint or seclusion and to conduct a face-to-face evaluation within four hours for adults and two hours for children.

APA considered the JCAHO standard more tenable than the one-hour rule, as did the American Hospital Association (AHA) and the National Association of Psychiatric Health Systems (NAPHS). These groups had asked HCFA and Congress to reconsider the one-hour rule, noting that implementation will be "costly" and "difficult."

Nonetheless, Robert Streimer, deputy director of HCFA’s Office of Clinical Standards and Quality, wrote JCAHO President Dennis O’Leary, M.D., on May 9 that he was not persuaded by the JCAHO’s arguments that "these requirements, in combination with other restraint and seclusion standards, provide a level of safety and quality of care that is equal [to] or greater than that provided by the federal requirement."

Streimer concluded in the letter that the one-hour requirement must be enforced if hospitals want Medicare/Medicaid reimbursement.

HCFA issued its final interim rule on seclusion and restraint in August 1999 after legislators and patient advocacy groups demanded greater protections for patients with psychiatric problems.

Many of the calls for legislative and regulatory remedies were prompted by reports in the Hartford Courant alleging that several deaths resulted from the abuse of seclusion and restraint. The reports also generated concerns that the JCAHO’s existing standards on seclusion and restraint were inadequate because the JCAHO had accredited some of the facilities where the alleged abuses had occurred.

In January 1999 the JCAHO began holding public hearings and established a task force to look at improving its standards on seclusion and restraint, according to Mary Cesare-Murphy, JCAHO executive director for behavioral health.

After a comprehensive review process, the JCAHO’s Board of Commissioners approved the revised standards on seclusion and restraint in May. The standards become effective January 2001.

The JCAHO commented in a press release last month that in certain areas its standards are more rigorous than the HCFA rules. For example, the JCAHO requires a physician or licensed independent practitioner to reevaluate adult patients in restraints after eight hours and children and adolescents after four hours. This is contingent on a qualified registered nurse or staff member reevaluating adult patients after four hours or child patients after two hours.

In contrast, HCFA requires the licensed independent practitioner to reevaluate the patient in restraints every 24 hours.

HCFA has no corresponding requirements for the JCAHO standards requiring debriefings with staff and patients after an episode of seclusion or restraint, documentation in patients’ clinical records, and data collection by hospitals to monitor the use of seclusion and restraint.

Charles Riordan, M.D., the APA liaison to the JCAHO’s Professional Technical Advisory Committee (PTAC) for Hospital Accreditation, commented that practitioners’ reactions to the new standards are mixed.

"Implementing the burdensome one-hour rule and the new JCAHO standards will require additional staffing and resources. This will be particularly challenging for hospitals that are experiencing financial difficulties," said Riordan.

Cesare-Murphy said that the JCAHO is trying to resolve certain discrepancies between the standards and the rules on seclusion and restraint with HCFA. "For example, the regulations’ definition of restraints includes drugs, while our standards mention only physical restraints."

Meanwhile, a U.S. District Court judge heard oral arguments in August in a lawsuit filed by the AHA and NAPHS against HCFA last year. The two groups allege that HCFA violated federal administrative and regulatory laws when it issued the final interim rule without giving practitioners adequate notice or doing a complete impact analysis. The judge is expected to rule soon, according to Carole Szpak, NAPHS director of communication.