HHS' inspector general's office has launched a multipronged investigation of the behavioral health industry.
The investigation and several parallel probes by public and private agencies are believed to be partly in response to media reports of poor quality care-particularly related to the use of restraints-in psychiatric hospitals.
Last fall, the Hartford Courant published a series of articles documenting 142 patient deaths in the past 10 years because of the use of restraints.
"It was shocking to a lot of people, including us," said Dennis O'Leary, M.D., president of the Joint Commission on Accreditation of Healthcare Organizations.
And in April, "60 Minutes II" on CBS broadcast a piece about the use of patient restraints by allegedly untrained personnel at Charter Pines Behavioral Health System in Charlotte, N.C. (April 26, p. 16).
Before the broadcast, Charter announced it would eliminate the use of restraints in its 86 hospitals within three years.
Charter Pines was closed shortly after the CBS broadcast.
The CBS segment also included what many observers considered an unflattering interview with O'Leary. In the interview, O'Leary acknowledged that the JCAHO doesn't disclose information about patient deaths that have been caused by restraints unless it is asked.
In an interview with MODERN HEALTHCARE, O'Leary said the use of restraints is one of the most difficult issues in healthcare. "Properly applied, restraints have a purpose and can be helpful to caregivers and patients," he said. "If you don't do them right, it can create grave danger, even death."
The Joint Commission has made the proper use of restraints one of its top priorities during the past two years. It held public hearings last spring on this issue and got "a lot of good input," O'Leary said. The Joint Commission's board has appointed a special task force to look into the issue.
O'Leary said HHS' inspector general's office has interviewed the Joint Commission at length about the restraints. He said federal auditors are looking into staff competency, training and patient rights.
"Are restraints to be used only for emergency use-as we advocate but the psychiatric industry has resisted- or are they to be used for coercion or convenience?" O'Leary asked. The psychiatric industry refers to its use of restraints "as part of the 'therapeutic plan,' but that is really coercion and convenience," O'Leary said.
Judy Holtz, spokeswoman for the inspector general's office, said the agency is working on three concurrent studies. One is reviewing information from existing patient-abuse reporting systems in psychiatric hospitals. Another is focusing on external quality reviews of freestanding psychiatric hospitals that participate in Medicare, and emphasizing oversight of the use of restraints and seclusion. The inspector general's office of evaluation and inspection is conducting the two studies.
A third study, which the inspector general's office of audit is conducting, is evaluating state procedures for investigating, identifying and resolving reports of abuse of patients with disabilities, including mental illness.
"It's still very early in the process," and draft reports probably won't be circulated for many months, Holtz said.
Holtz said the three surveys were not included in the inspector general's 1999 work plan but they were in the works before the CBS broadcast April 21.
Meanwhile, the General Accounting Office is working on a similar investigation, which is due shortly.
That study was requested by Connecticut Sens. Joseph Lieberman and Christopher Dodd, both Democrats. The senators also have introduced companion bills that would require mandatory reporting of restraint-related deaths to the Joint Commission in the context of its sentinel-event policy, which obligates accredited organizations to report serious accidents or deaths and to conduct a root-cause analysis.
Hospitals are not required by law to report injuries or deaths because of restraints or seclusion. In addition, there is no database listing such injuries or deaths. As a result, the frequency of these deaths, especially among children, has not been recognized until recently.
Ned McCulloch, a staff aide to Lieberman, said the GAO is expected to issue a report about the use of restraints to Congress in September.
In addition, Medicare's revised conditions of participation, which went into effect Aug. 2, require all Medicare- and Medicaid-certified hospitals, physicians and licensed practitioners to evaluate in person a patient placed in restraints or isolation within one hour of the action.
The American Hospital Association and the National Association of Psychiatric Health Systems failed to obtain a federal court order blocking the requirement (Aug. 2, p. 4).