Revised standards designed to align with CMS

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Changes affect restraint, seclusion, H&Ps, and emergency management

After reading this article, you will be able to:

1. Discuss the revised time frames for visits by a licensed independent practitioner to a patient assessed for behavioral health restraint

The Joint Commission recently announced revisions to four accreditation standards that hospitals are expected to comply with immediately-three of which directly align with recent CMS revisions to the hospital Conditions of Participation. Among the affected standards are restraint and seclusion; procurement and donation of organs and other tissues; time frames for history and physical (H&P) exams; and emergency management standards.

"These changes are having a lot of impact across the country as facilities face the survey process," said Bud Pate, REHS, practice director of clinical operations and improvement and director of West Coast operations for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, the publisher of this newsletter. Pate spoke during the recent HCPro audioconference "Comply with Revised Joint Commission Standards to Align with CMS: Immediate changes to affect restraint, seclusion, H&Ps, and emergency management."


The good news: The Joint Commission is accepting the CMS changes, announced in December 2006 and put into effect January of this year, that state that an appropriately trained RN or physician assistant (PA) can make the first face-to-face evaluation for behavioral health restraint, said John Rosing, MHA, FACHE, practice director for accreditation and regulatory compliance for The Greeley Company, during the audioconference.

"This used to require a physician, which was often difficult to execute," said Rosing.

However, he cautioned that The Joint Commission still has established time frames for a licensed independent practitioner (LIP) to visit the patient.

"Because we used to have this requirement of a face-to-face within the first hour by the LIP, facilities automatically complied with the EP requiring a visit in the first four hours," said Rosing. "But if that face-to-face is being performed by an RN or PA, the patient is going to need an LIP visit by the four-hour mark."

"This has been revised and gone in and out of favor for 30 years," said Pate. "We're getting to the point where we can have some stability. Keep in mind, this is starting to show up on surveyors' reports again-every few years it is on the highest-cited [standards] lists, and it's back up there again."

(See "Policy Title: Restraint and Seclusion" on p. 12 of the PDF of this issue. This sample policy, created by The Greeley Company, demonstrates how to begin a restraint and seclusion policy. BOJExtra! subscribers, find additional components to the policy at


Inpatient H&P standards were revised to address timing of the exams (PC.2.120). H&P records can be created up to 30 days prior, but if it is created prior to (i.e., 24 hours before) admission, the H&P needs to be updated.

"PC.2.120 talks about inpatients," said Pate. "The question is about outpatients. If you have some sort of an update note that is working well, that's fine, but if it's not working, take a look at your nursing and preanesthesia assessments."

Medication storage

The revisions address-and provide a relaxed interpretation of-authorized individuals.

"The federal regulator has relaxed some rules," said Rosing. "They had been outrageous. People were locking up crash carts to keep them secure."

The bottom line, says Rosing, is that The Joint Commission has toned down the language to say that facilities are required to secure medication in a number of ways and limit access to those storage areas. These changes bring Joint Commission requirements in line with those of CMS.

"You want to take into account how medications are handled after being retrieved and/or administrated," said Rosing of MM.2.20, EP 3.

Areas that must be addressed regarding medication are:

  • Safe handling
  • Safe storage
  • Security
  • How the medication is returned to the pharmacy if not used

    "It's not easily done," said Rosing. Rosing said he had encountered facilities in which three separate policies addressed this EP, but there were inconsistencies between the policies that needed to be aligned.

    MM.2.20, EP 4, states that you must follow the policy addressing MM.2.20, EP 3.

    "It can be highly vulnerable," said Rosing. "You may have requirements in the policy that, once you go out on the floor, you see are handled differently."

    Rosing recently observed, in a postanesthesia care unit, three nurses in the same unit handle morphine not given to patients in different manners-one wasted the remaining morphine after each administration, one kept the excess in his pocket, and one taped it to a bedside table.

    "Spell out in the policy what you want the practice to be," said Rosing.

    Tip: When addressing EP 3, remember to take note of nonclinical staff members.

    "It's wise to say something in the policy regarding housekeeping, engineering, and others who may have access to areas where medication are stored in order to fulfill the duties of their job description," said Rosing.

    Whether they need access to the storage area to mop the floor, fix a thermostat, or restock shelves, the policy should provide blanket authorization to access the area specifically tied to the job description.

    "They shouldn't be lingering in the med room, but if something is needed, they should be able to go in there," said Rosing.

    MM.2.20 is also among the most-cited standards, said Pate. "Make sure your policies are appropriate and relaxed accordingly," he said. "This EP was put into place to let the hospital decide how it's okay to transport these medications through the building when appropriate."

    Telephone and verbal orders

    The bad news about the latest revisions to the telephone and verbal orders EP is that it is still an unforgiving EP-The Joint Commission still scores it as an A element.

    However, the good news is that state law can now overrule the 48-hour rule to have telephone and verbal orders countersigned by the prescribing physician.

    "Normally we go on the assumption that you go on the more restrictive rule if there is a conflict," said Rosing. "The CMS says here that if the state says 72 hours, you can do 72 hours."

    Tread carefully when going this route, Pate said.

    "A caveat-this acknowledgement of state law is weak in public regulations, but there have been some letters to clarify this," said Pate. "There are two types of hospitals: those that get cited for this and those for whom the citation is missing, because everybody has problems with this. I think there will be many more shoes to drop on this."

    Editor's note: For additional information about these revisions, including specifics about organ donation and emergency management, visit BOJExtra! at