To: P&A Executive Directors
From: Curtis L. Decker, Executive Director
Gary Gross, Senior Public Policy Counsel
Re: HCFA Reporting of Restraint-related Deaths and P&A Follow Up
Date: March 30, 2000
 

This is to inform you about the reports of restraint-related hospital deaths released by the Health Care Financing Administration (HCFA) to a number of P&As around the country, and to request that you supply us with information regarding your follow up activities in connection with these and future reports.
 

We need your assistance in tracking these reports to ensure that they are meaningful and timely. We also need to learn about your actions taken in response to these reports - so that we can share this information with the network generally and with policy makers, who are seeking accountability in this area. As you know, appropriations increases for this year for PAIMI ($2 million) and PADD ($1.5 million) were provided specifically to support P&A investigations related to restraint-related deaths. Also, we want to know if your agency needs any additional resources or other support to effectively address these death reports. We have developed a form to collect this information (attached).
 

Release of Reports
 

On March 23 HCFA's regional offices, in compliance with the agency's recent regulations on patient protections in hospitals, released to P&As reports received from hospitals of patient deaths related to restraint and seclusion. There was a total of 20 deaths reported to HCFA and P&As nationwide - for the period August 2, 1999 (when the regulations became effective) through March 23, 2000. In Florida alone, 7 deaths were reported. Deaths in other states were reported as follows: CT - 1, NY - 1, NC - 1, OH - 1, LA - 1, OK - 1, TX - 3, IA - 1, KS - 1, MO - 1 and CA - 1.
 

Reporting Requirements and HCFA Investigations
 

HCFA's regulations specify that hospitals must report to HCFA's regional offices any death that occurs while a patient is in restraint or seclusion, or where it is reasonable to conclude that the death was related to restraint or seclusion. (The regulations also set out detailed standards on the use of restraint and seclusion in hospitals, among other patient protection requirements.) The reporting requirement applies only to the use of restraints and seclusion for behavior management, as distinguished from the practice as applied in connection with acute medical or surgical care. In the guidance issued with the regulations, HCFA stated that it will share these reports with P&As.
 

There is no guidance, however, on the contents of the reports or when they need be provided. The reports released to date (which have been provided via phone or fax) contain only the name and address of the hospital, the name of the patient and the date of the patient's death.
 

HCFA indicated in the regulations and in a recent meeting that, as result of these reports, it will conduct on-site investigations of hospitals ("complaint surveys") in accordance with its current complaint investigation process. In the future, we will provide more details on this process and how P&As can coordinate with HCFA on investigations.
 

Future Reports
 

With our input, HCFA is developing a reporting protocol to help ensure that sufficient information is reported to facilitate P&A investigations of these deaths. In a recent meeting, HCFA indicated that, in the future, hospital reports of deaths will be shared with P&As as they are received by HCFA, and hopefully within a short period after the deaths occur. 
 

P&A Follow Up Activities
 

There are a number of possible courses of action that can be taken in response to these death reports:
 

1. Your agency could conduct preliminary inquiries and inspect records and facilities based on these HCFA reports. Given that the death occurred during the course of the hospital's attempt to manage patient behaviors, it may be concluded that the report amounts to a "complaint" of potential abuse or neglect - which triggers P&A access authority under both the DD and PAIMI Acts, and the PAIR Program, and their implementing regulations. Moreover, the report should establish a "probable cause" belief that abuse and neglect may have occurred, which is an independent basis to gain access to records and facilities. See definitions of these terms at 42 C.F.R. § 51.2 (PAIMI regulations) and 45 C.F.R. § 1386.19 (DD Act regulations), and Alabama Disabilities Advocacy Program v. J.S. Tarwater Development Center, 97 F.3d 492 (11th Cir. 1996) (Alabama P&A's receipt of an anonymous phone message regarding an institutional death held to amount to a "complaint," and to establish "probable cause," both authorizing access to records).
 

2. Your agency could conduct a full blown investigation, including a thorough on-site inspection of the hospital and interviews of staff and patients, independent of any HCFA investigation.
 

3. Your agency could conduct an investigation in collaboration with HCFA. Contact should be made with the HCFA regional office to coordinate. 
 

Recommendation
 

We strongly recommend that option 1 be implemented regarding all reports of restraint-related deaths received to date and in the future. We also recommend that option 2 or 3 be pursued as well. A collaborative investigation with HCFA may be appropriate if it would not interfere with your agency's independence and ability to obtain full access to records and facilities and seek appropriate corrective action in a timely manner.
 

Network Feedback Needed
 

We have developed the attached form to collect information on reports and follow up activities. We ask that you do the following: (1) If you have already received one or more HCFA death reports, please fill out the form and fax it back to NAPAS ASAP; (2) submit a completed form for any reports received in the future; and (3) provide updated reports on your activities, as warranted. Any questions regarding this issue may be directed to Gary Gross. 
 

Information that may be helpful in responding to these reports - concerning restraint and seclusion policies (including the HCFA regulations) and P&A access authority - may be obtained from our website, at: http://www.protectionandadvocacy.com/private/resscfol.htm and at http://www.protectionandadvocacy.com/private/access.htm.
 

Thanks for your assistance with this critical initiative.

Fax to Gary Gross, 202-408-9520
 

RESTRAINT-RELATED HOSPITAL DEATHS REPORTED 

BY HCFA: SUMMARY OF P&A ACTIVITIES
 

Agency Name: _________________________________________________________________ 

Contact Person: ________________________________________________________________ 

Phone and E-mail: ______________________________________________________________
 

Please provide the information requested below, and attach additional sheets if necessary. PLEASE SUBMIT UPDATED FORMS AS ACTIVITIES WARRANT.
 

1. Report(s) Received. If a written report of a restraint-related patient death was provided by HCFA, attach it to this form. If the report was oral, or additional information not contained in the initial written report was obtained, describe below the following:
 

HCFA report attached: Yes ___ No ___

a. Date of report: ___________________

b. Date of patient death: ______________

Also, if known, describe (if information is not available, state "NOT REPORTED"):

c. The circumstances of the death: 
_____________________________________________________________________________________________

d. Clinical information provided about the patient:
______________________________________________________________________________________________
 

2. Follow Up Activities. Indicate the activities your agency has taken or plans to undertake in response to the report(s):

a. Inquiries and requests for records and other information (describe information sought and response, if any):
____________________________________________________________________________________________

_______________________________________________________________________________________________

b. Full investigation - independent of State licensing and certification agency (describe method and findings, if any):
____________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

c. Full investigation - in collaboration with State licensing and certification agency or another agency (describe method and findings, if any):
_____________________________________________________________________________________________

d. Other activities (e.g., outreach to media):
_____________________________________________________________________________________________
 

3. Obstacles
 

Are there any obstacles preventing effective follow up of these reports (e.g., insufficient information in report, denial of access to records, witnesses or facility):

_______________________________________________________________________________________________

4. Assistance Needed

Is there any assistance needed to follow up that ATTAC/NAPAS may provide or facilitate:
______________________________________________________________________________________________
 
 
 

M E M O R A N D U M
 

To: P&A Executive Directors
From: Curtis L. Decker, Executive Director
Gary Gross, Senior Public Policy Counsel
Re: Coordination with State Licensing Agencies on Restraint Investigations
Date: March 31, 2000
 

This follows up on our memorandum of yesterday regarding the reports of restraint-related hospital deaths released by the Health Care Financing Administration (HCFA) to P&As. This memorandum provides information on how P&As may coordinate with State health care licensing and certification agencies, which HCFA has authorized to conduct on-site investigations of hospitals in response to the hospitals' reports submitted to HCFA of restraint-related deaths.
 

In our earlier memorandum, we encouraged P&As to pursue a number of courses of action to follow up on these death reports. These recommendations include conducting an investigation in collaboration with HCFA, and making contact with the HCFA regional office to coordinate. 
 

Based upon discussions with HCFA today, this statement should be clarified: we now understand that P&As should coordinate their investigative activities with their State licensing and certification agencies (also know as State survey agencies), rather than with HCFA's regional offices (although the regional offices themselves oversee the State agencies' activities). 
 

The national office of HCFA has directed its regional offices to encourage State certification agencies to coordinate activities with the local P&A. We recommend that P&A Directors make direct contact with the Directors of these agencies - regarding death reports already received or which are provided to you in the future - to enter into a discussion about coordination of investigative activities. A directory of the State certification agencies may be obtained from the HCFA website, at http://www.hcfa.gov/medicaid/saddir.htm. The following discusses how HCFA anticipates these agencies to respond to the death reports, and suggests approaches for P&A collaboration. 
 

State Licensing and Certification Activities
 

State licensing and certification agencies are funded by HCFA to conduct inspections of health care facilities pursuant to HCFA's standards; the agencies also apply state law standards, as appropriate. As noted above, HCFA has authorized these agencies to conduct on-site investigations of the restraint-related reports of hospital deaths, applying the HCFA regulatory standards on restraint and seclusion. These investigations may occur in any one of the nation's 6000 hospitals, including those which are accredited by the Joint Commission on Accreditation of Health Care Organizations. The agencies generally will conduct focused investigations of the issues raised by the reports. However, if they uncover systemic problems, the investigations (at the direction of HCFA) will be expanded to examine a large variety of hospital operations. The scope of the investigation will vary depending on the resources of a particular State agency.
 

If the hospital is found to have violated HCFA's standards - and according to HCFA, this is the presumed outcome in the case of a restraint-related death - the hospital is subject to termination of Medicare and Medicaid funding. Depending on the severity of violations uncovered, the hospital is given up to 90 days to demonstrate it has taken appropriate corrective action to achieve compliance with the standard. 
 

P&A Coordination
 

As mentioned above, P&A Directors are encouraged to discuss directly with the local licensing and certification agency Directors possible avenues to coordinate their investigative activities.

An initial approach may be to request from the State agency the results of any investigation already conducted. (HCFA did not know whether any restraint death investigations had been completed.) Depending on the thoroughness and findings of the investigation, P&As can focus or streamline their own investigative activities.
 

HCFA indicated that the investigation reports of these agencies are public information (e.g., they may be obtained under the Freedom of Information Act.) Indeed, such reports also are available to P&As pursuant to their federal access authority. Under the regulations implementing the PAIMI and DD Acts, access is authorized to reports of an agency charged with investigating abuse, neglect or injury, and to supporting information that was relied upon in creating the reports. Access also is authorized to reports prepared by entities conducting certification or licensure reviews. See 42 C.F.R. § 51.41 (c)(2) and 45 C.F.R. § 1386.22(b)(2) and (c)(1),
 

Alternatively, if the State agency has not initiated or completed an investigation, P&As might inquire about conducting joint investigative activities or otherwise sharing information.
 

Please be sure to complete and return the form provided with yesterday's memo on your activities in this area, and provide information (in sections 2b and c) on coordination with the State agencies.