DEPARTMENT OF HEALTH & HUMAN SERVICES 
Health Care Financing Administration 
  
 Center for Medicaid and State Operations 
7500 Security Boulevard 
Baltimore, MD 21244-1850 
 
                    SMDL #01-023 
            July 11, 2001   
 
Dear State Medicaid Director: 
 
The purpose of this letter is to provide guidance to the Medicaid agency regarding the attestation 
of facility compliance with the Centers for Medicare & Medicaid Services' (CMS), formerly the 
Health Care Financing Administration, January 22, 2001, interim final rule (HCFA-2065 IFC) 
Medicaid Program; Use of Restraint and Seclusion in Psychiatric Residential Treatment 
Facilities (PRTFs) Providing Psychiatric Services to Individuals Under Age 21 (66 Fed. Reg, 
7148) and the May 22, 2001, amendment and clarification (HCFA-2065 IFC2) to the interim 
final rule.  Section 483.374 of the interim final rule requires a psychiatric residential treatment 
facility that provides Medicaid inpatient psychiatric services to individuals under age 21("Psych 
Under 21 benefit," or "Psych Under 21 services") to attest, in writing, that the facility is in 
compliance with all of the standards governing the use of restraint and seclusion.  Also included 
in this letter is a summary of the reporting requirements specified by the rule. 
 
Background 
 
An interim final rule establishing standards for the use of restraint and seclusion in PRTFs 
providing Psych Under 21 services (the Psych Under 21 rule) was published on January 22, 
2001.  An amendment and clarification to this rule was published on May 22, 2001, with an 
immediate effective date.  This rule establishes a definition of a PRTF that is not a hospital and 
that may furnish covered inpatient psychiatric services for individuals under age 21.  The rule 
also establishes a Condition of Participation (CoP) for the use of restraint and seclusion that 
PRTFs must meet in order to provide, or to continue to provide the Medicaid Inpatient Psych 
Under 21 benefit.  The CoP specifies requirements designed to protect the residents against the 
improper use of restraint and seclusion that include, but are not limited to: parental/guardian 
notification when restraints or seclusion is used; reporting of serious occurrences involving a 
resident; staff education and training requirements; requirements for monitoring residents in and 
immediately after seclusion; etc.  The interim final rule published on January 22, 2001, and the 
interim final rule amendment published May 22, 2001, can be accessed on www.access.gpo.gov 
under the published date of January 22, 2001, and May 22, 2001.  The questions and answers on 
the interim final rule can be found on CMS's website at www.hcfa.gov/medicaid/psychq&a.htm. 
 
Reporting  
 
Under the Psych Under 21 rule, each PRTF is required to report a residents death, serious injury, and 
a residents suicide attempt to the State Medicaid agency and, unless prohibited by state law, to the 
state-designated Protection and Advocacy system (P&As).  In addition, Section 42 CFR (cid:31)483.374(c) 
states:  In addition to the reporting requirements contained in paragraph (b) of this section, facilities 
must report the death of any resident to the Centers for Medicare and Medicaid Services (CMS) 
regional office.  Staff must report the death of any resident to the CMS regional office by no later than    
 
 
 
 
close of business the next business day after the resident's death.  Staff must document in the resident's 
record that the death was reported to the HCFA regional office.   
 
The State Medicaid agency should establish a system to accept and monitor the reports of serious 
occurrences submitted by the PRTFs, as required by section 483.374(b) of this rule.  The State 
Medicaid Agency should develop a mechanism for sharing this information with the State Survey 
Agency.  When notifying  PRTFs of the reporting and attestation requirements of the rule, please 
inform them of their responsibility under section 483.374(c) of the rule to notify the CMS regional 
office of  the death of any resident.  A list of the regional office contacts is attached (attachment A).  
 
Attestation 
 
Section 483.374(a) of the rule requires a facility with a current provider agreement with the 
Medicaid agency to provide the Medicaid agency its attestation of compliance by July 21, 2001.  
A facility subsequently enrolling as a Medicaid provider must meet the requirements of the 
Psych Under 21 rule at the time it executes a provider agreement with the Medicaid agency and 
submit an attestation at that time.  The attestation must be signed by an individual who has the 
legal authority to obligate the facility. 
 
A number of states have requested guidance regarding the type of information that should be 
included in the attestation.  While states certainly have the flexibility to design individual 
attestation forms, attached is a model letter that you may find useful (attachment B).  At a 
minimum, the attestation should include:  
 
  the name, address, telephone number of the facility, and a provider identification number;  
 
  the signature and title of the individual who has the legal authority to obligate the  facility; 
 
  the date the attestation is signed; 
 
  a statement certifying that the facility currently meets all of the requirements of Part 483, 
Subpart G governing the use of restraint and seclusion; 
 
  a statement acknowledging the right of the State Survey Agency (or its agents) and, if 
necessary, CMS to conduct an on-site survey at any time to validate the facility's compliance 
with the requirements of the rule, to investigate complaints lodged against the facility, or to 
investigate serious occurrences;  
 
  a statement that the facility will notify the State Medicaid Agency if it no longer complies 
with the requirements of the rule; and 
  2   
 
 
 
  a statement that the facility will submit a new attestation of compliance in the event the 
individual who has the legal authority to obligate the facility is no longer in such position. 
 
Please provide CMS a copy of the transmittal issued to your facilities requesting the 
attestation and attach a list, including the names and addresses, of those facilities in your 
program.  This information should be sent to:  
 
Branch Chief, Continuing Care Provider Branch 
Division of Nursing Homes and Continuing Care Services 
Survey and Certification Group 
Center for Medicaid and State Operations 
Mail Stop S2-12-25 
7500 Security Boulevard 
Baltimore, Maryland 21244 
Fax: 410-786-6730   
 
Validating Facility Attestation 
 
We stated in the preamble of the interim final rule published on January 22, 2001, that we would 
provide guidance for developing a process for sampling facilities to validate their attestation of 
compliance with the rule.  The preamble to the rule specifies that we expect states to validate the 
attestations for a sample of 20 percent of the facilities on an annual basis.  Each year the State 
Medicaid Agency should select a random, representative sample to approximate 20 percent of its 
facilities in the state.  The selected sample should be transmitted to the State Survey Agency in 
order to conduct on-site surveys to ensure the facilities have policies and procedures in place 
consistent with the attestation and are complying with the requirements of the Psych Under 21 
rule.  Documentation of the sampling methodology should be maintained by the State Medicaid 
Agency and conveyed to the State Survey Agency at the time the sample is selected. 
 
We expect facilities to have implemented the interim final rule, including the attestation 
requirement by July 21, 2001.  We are currently developing a proposed timeline to implement 
the enforcement requirements of the Psych Under 21 rule which include but are not limited to:  
 
  the development and dissemination of a survey protocol for validation and investigation 
surveys;  
  training of state and Federal surveyors; and  
  the anticipated enforcement procedures and actions for those facilities found out of 
compliance with the Psych Under 21 rule.   
  3   
If you have any questions, or need further clarification about these requirements, please contact 
Mary Kay Mullen at (410) 786-5480. 
 
            Sincerely, 
 
            /s/   
 
            Penny R. Thompson 
Acting Director 
 
Attachments: 
Attachment A CMS Regional Office Contacts 
Attachment B  Model Attestation Letter 
 
cc: 
CMS Regional Administrators 
 
CMS Associate Regional Administrators 
  For Medicaid and State Operations 
 
Lee Partridge 
Director, Health Policy Unit 
American Public Human Services Association 
 
Joy Wilson 
Director, Health Committee 
National Conference of State Legislatures 
 
Matt Salo 
Director of Health Legislation 
National Governors Association 
 
Brent Ewig 
Senior Director, Access Policy 
Association of State and Territorial Officials 
  4  Attachment A 
 
CMS Regional Office Contacts
 
 
Margaret Leoni-Lugo 
Boston Regional Office 
(617) 565-1299 
 
Lois Suntzenich 
New York Regional Office 
(212) 264-3942 
 
Stuart Cogan          Joseph Hopko 
Philadelphia Regional Office     Philadelphia Regional Office 
(215) 861-4734        (215) 861-4192 
 
Brenda Nimmons        Kellie Wright 
Atlanta Regional Office      Atlanta Regional Office 
(404) 562-7405        (404) 562-7470 
 
Dorsey Lecompte 
Chicago Regional Office 
(312) 353-5183 
 
Amy Fiesler 
Dallas Regional Office 
(214) 767-4434 
 
De Friedrich          Nancy Rios 
Kansas City Regional Office     Kansas City Regional Office 
(816) 426-2011        (816) 426-2408 
 
Dorothy Brinkmeyer        Helen Jewell 
Denver Regional Office      Denver Regional Office 
(303) 844-7043        (303) 844-7048 
 
Ruth Patience 
San Francisco Regional Office 
(415) 744-3727 
 
Diana L. Migchelbrink      Judith Ramberg 
Seattle Regional Office      Seattle Regional Office 
(206) 615-2089        (206) 615-2404 
 
 
 
  5  Attachment B 
 
 
Model Attestation Letter 
 
 
This attestation must be signed by an individual who has the legal authority to obligate the 
facility. 
 
 
Name of the Psychiatric Residential Treatment Facility 
Address 
City, State, Zip Code 
Telephone Number 
Fax Number (if applicable) 
 
Provider Number 
 
Dear <State Medicaid Director>, 
 
A reasonable investigation subject to my control having been conducted in the subject facility, I 
make the following certification.  Based upon my personal knowledge and belief, I attest that the 
<NAME of the FACILITY> hereby complies with all of the requirements set forth in the interim 
final rule governing the use of restraint and seclusion in psychiatric residential treatment 
facilities providing inpatient psychiatric services to individuals under age 21 published on 
January 22, 2001, and amended with the publication of May 22, 2001 (Psych Under 21 rule). 
 
I understand that the Centers for Medicare and Medicaid Services (formerly HCFA), the State 
Medicaid Agency or their representatives may rely on this attestation in determining whether the 
facility is entitled to payment for its services and, pursuant to Medicaid regulations at 431.610, 
have the right to validate that <Name of the Facility> is in compliance with the requirements set 
forth in the Psych Under 21 rule, and to investigate serious occurrences as defined under this 
rule.  
 
In addition, I will notify the <Name of the State Medicaid Agency> immediately if I vacate this 
position so that an attestation can be submitted by my successor.  I will also notify the State 
Medicaid Agency if it is my belief that <Name of the Facility> is out of compliance with the 
requirements set forth in the Psych Under 21 rule.   
 
            Signature 
            Printed Name 
            Title 
            Date 
 
 
 
 
 
 
  6   
 
 
Mmullen\g\bcp\mkmullen\psychreg\attest.doc\revised:6/18/01 
Revised: 6/19/01 per comments from Lewis Morris, Office of Counsel to the IG 
Revised: 6/27/01 per comments 
Revised:6/29/01: per OGC comments; saved as g:bcp:mkmullen/psychreg/attest2.doc 
Revised: 7/10/01: per APHSA/NASMHPD comments and Fsokolok comments: saved as 
g:bcp:mkmullen/psychreg/attest3.doc 
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