The Joint Commission
Friday 2:36 CST, February 12, 2016

Standards FAQ Details

Provision of Care, Treatment, and Services (PC) (Hospital and Hospital Clinics / Hospitals)

Restraint /Seclusion For Hospitals That Use The Joint Commission For Deemed Status Purposes
Revised | October 06, 2009
Q. When will the new restraint standards be included in the survey process and the accreditation decision?  

A. Hospitals that use Joint Commission accreditation for deemed status purposes will be surveyed on the new restraint requirements in Standards PC.03.05.01 through PC.03.05.19 from April 6 through June 30, 2009.  However, non-compliance will not impact the accreditation decision.  Beginning July 6, 2009, non-compliance will impact the accreditation decision.

Q.What restraint standards should organizations follow in the Comprehensive Accreditation Manual for Hospitals if they are going to use Joint Commission accreditation for deemed status purposes?
A. Effective July 1, 2009, organizations that use Joint Commission accreditation for deemed status purposes must follow Standards PC.03.05.01 through PC.03.05.19.
Q. What standards related to restraint and seclusion will no longer apply as of July 1, 2009, for hospitals that use Joint Commission accreditation for deemed status purposes?
A. Standards PC.03.02.01 through PC.03.03.31 and RC.02.01.05 will no longer apply.
Q. Is the one hour face-to-face assessment still required if a patient is placed in restraints or seclusion for violent or self-destructive behavior?
A. Yes, in the Comprehensive Accreditation Manual for Hospitals, the one hour face-to-face assessment by a physician or licensed independent practitioner responsible for the care of the patient is required. The physician or licensed independent practitioner evaluates the patient in person within one hour of the initiation of the restraints. A registered nurse or a physician assistant may conduct the in-person evaluation within one hour of the initiation of restraint or seclusion if this person is trained in accordance with requirements in Standard PC.03.05.17, EP3. If the one hour face to face evaluation is completed by a trained nurse or trained physician assistant, he or she would consult with the attending physician or other licensed independent practitioner responsible  for the care of the patient after the evaluation, as determined by hospital policy.(PC.03.05.11 EP2)Some states may have statue or regulation requirements that are more restrictive  than the requirements in this standard.

Q. Where can the organization find the definition of what is and is not a restraint?
A. Standard PC.03.05.09  in the Comprehensive Accreditation Manual for Hospitals includes the definition of restraint and seclusion and also what is not a restraint.  The definition is also in the update of the  Glossary in the Comprehensive Accreditation Manual for Hospitals.The Joint Commission follows the CMS definition of restraint, which is as follows:"The 42 CFR (Code of Federal Regulations)482.13(e)(1) Definitions (i) A restraint is— (A) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or 42 CFR 482.13(e)(1)(i)(B) (A restraint is— ) A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.  42 CFR 482.13(e)(1)(i)(C) A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine
physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort). Note 2: The definition of seclusion per 42 CFR 482.13(e)(1)(ii) is as follows:  Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may be used only for the management of violent or self-destructive behavior.

Q. Do the new standards require a debriefing process after an episode during which a patient has been placed in restraints for violent or self-destructive behavior?
A. No, the Hospital Accreditation restraint/seclusion standards for deemed status purposes do not  require a debriefing process to be completed.This does not prohibit the organization from requiring a debriefing process as they see fit. The debriefing process  is often used when the patient has a behavioral health issue and is part of the process.
Q. Do orders for restraints still have definite time limits?
A. A restraint order that is being used for violent or self-destructive behavior still has a definite time limit associated with it (see Standard PC.03.05.05, EP4).Standard  PC.03.05.05 EP4 states: Unless state law is more restrictive,orders for the use of restraint or seclusion used for the management of violent or self- destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others may be renewed within the following limits: 4 hours for adults 18 years of age or older,2 hours for children and adolescents, 9 to 17 years of age, 1 hour for children under 9 years of age. Orders may be renewed according to the time limits  for a maximum of 24 consecutive hours. Organizations must develop their own guidelines for time limits on orders that use restraints for other than violent and self-destructive behavior.Patient safety, patient assessment, and the type of restraint used will detemine the guideline for the time limit for a restraint that is used for non-violent, non- self destructive behavior.
Q. Are the restraint standards still defined as non-behavioral and behavioral?
A. The new restraint standards are not divided into “non-behavioral” and “behavioral” categories. They do reference “violent or self-destructive behavior” and “non-violent, non-self-destructive behavior” in the  standards that are specific to these types of behaviors.The wording was changed in order to address the framework that the Medicare requirements are written from.


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