CMS SOM App. N, Tag N0100

Seclusion in Psychiatric Residential Treatment Facilities Providing

Inpatient Psychiatric Services for Individuals Under Age 21

Interpretive Guidelines Subpart G

Surveyors must make a determination regarding the compliance or non-compliance of

the overall Condition of Participation under Subpart G at the end of each facility survey.

A determination of non-compliance may be based upon either patterns of performance or

isolated instances with real or potential harm for residents. Deficiencies cited in the

following areas:

Section 483.354 General requirements for psychiatric residential treatment facilities

Section 483.356 Protection of Residents;

Section 483.358 Orders for the use of restraint or seclusion;

Section 483.372 Medicaid treatment for injuries resulting from an emergency safety

intervention,

Section 483.374 Facility Reporting and/or

Section 483.376 Education and Training

Surveyors should consider the seriousness and significance of the aggregate findings in

the survey areas when determining any non-compliance at a Condition level. If the

determination is made that the facility is out of compliance with the Condition of

Participation, the surveyor must make this finding at N-0100. The determination must

include a list of the N tag findings which resulted in the Condition non-compliance to be

made.

§483.350 Basis and Scope

(Rev. 131; Issued: 01-16-15, Effective: 01-16-15, Implementation: 01-16-15)

(a) Statutory basis. Sections 1905(a)(16) and (h) of the Act provide that inpatient

psychiatric services for individuals under age 21 include only inpatient services that

are provided in an institution (or distinct part thereof) that is a psychiatric hospital as

defined in section 1861(f) of the Act or in another inpatient setting that the Secretary

has specified in regulations. Additionally, the Children's Health Act of 2000 (Pub. L.

106-310) imposes procedural reporting and training requirements regarding the use

of restraints and involuntary seclusion in facilities, specifically including facilities

that provide inpatient psychiatric services for children under the age of 21 as defined

by sections 1905(a)(16) and (h) of the Act.

(b) Scope. This subpart imposes requirements regarding the use of restraint or seclusion

in psychiatric residential treatment facilities, that are not hospitals, providing

inpatient psychiatric services to individuals under age 21.

§483.352 Definitions

(Rev. 131; Issued: 01-16-15, Effective: 01-16-15, Implementation: 01-16-15)

For purposes of this subpart, the following definitions apply:

Drug used as a restraint means any drug that—

(1) Is administered to manage a resident's behavior in a way that reduces the safety risk

to the resident or others;

(2) Has the temporary effect of restricting the resident's freedom of movement; and

(3) Is not a standard treatment for the resident's medical or psychiatric condition.

Emergency safety intervention means the use of restraint or seclusion as an immediate

response to an emergency safety situation.

Emergency safety situation means unanticipated resident behavior that places the

resident or others at serious threat of violence or injury if no intervention occurs and that

calls for an emergency safety intervention as defined in this section.

Mechanical restraint means any device attached or adjacent to the resident's body that

he or she cannot easily remove that restricts freedom of movement or normal access to

his or her body.

Minor means a minor as defined under State law and, for the purpose of this subpart,

includes a resident who has been declared legally incompetent by the applicable State

court.

Personal restraint means the application of physical force without the use of any device,

for the purposes of restraining the free movement of a resident's body. The term personal

restraint does not include briefly holding without undue force a resident in order to calm

or comfort him or her, or holding a resident's hand to safely escort a resident from one

area to another.

Psychiatric Residential Treatment Facility means a facility other than a hospital, that

provides psychiatric services, as described in subpart D of part 441 of this chapter, to

individuals under age 21, in an inpatient setting.

Restraint means a “personal restraint,” “mechanical restraint ”, or “drug used as a

restraint” as defined in this section.

Seclusion means the involuntary confinement of a resident alone in a room or an area

from which the resident is physically prevented from leaving.

Serious injury means any significant impairment of the physical condition of the resident

as determined by qualified medical personnel. This includes, but is not limited to, burns,

lacerations, bone fractures, substantial hematoma, and injuries to internal organs,

whether self-inflicted or inflicted by someone else.

Staff means those individuals with responsibility for managing a resident's health or

participating in an emergency safety intervention and who are employed by the facility

on a full-time, part-time, or contract basis.

Time out means the restriction of a resident for a period of time to a designated area

from which the resident is not physically prevented from leaving, for the purpose of

providing the resident an opportunity to regain self-control.

N0101-N0119

(Rev. 131; Issued: 01-16-15, Effective: 01-16-15, Implementation: 01-16-15)

§483.354 General requirements for psychiatric residential treatment

facilities.

(Rev. 131; Issued: 01-16-15, Effective: 01-16-15, Implementation: 01-16-15)

§483.354 A psychiatric residential treatment facility must meet the requirements in

§441.151 through §441.182 of this chapter.

Interpretive Guidlines§483.354

Surveyors should reference guidelines for requirements §441.151 through §441.182 in

the ASPEN system.

§483.356 Protection of Residents.

(Rev. 131; Issued: 01-16-15, Effective: 01-16-15, Implementation: 01-16-15)