I
106TH CONGRESS
1ST SESSION
H. R. 1313
To amend title XI of the Social Security Act to restrict the use of physical
and chemical restraints and seclusion in certain facilities receiving Medi-
care or Medicaid funds, to require recording and reporting of information
on that use and on sentinel events occurring in those facilities, and
for other purposes.
IN THE HOUSE OF REPRESENTATIVES
MARCH 25, 1999
Ms. DEGETTE (for herself, Mr. STARK, Ms. DELAURO, Mrs. MORELLA, Mr.
WAXMAN, Ms. KILPATRICK, Mr. GEORGE MILLER of California, Mr.
BROWN of Ohio, Mr. SANDERS, Mr. LANTOS, Mr. MARTINEZ, Ms. EDDIE
BERNICE JOHNSON of Texas, Mr. RANGEL, Mr. CROWLEY, Mrs. CAPPS,
Ms. PELOSI, Mr. FORD, Mr. MCGOVERN, Mr. WYNN, Ms. SCHAKOWSKY,
Mr. CUMMINGS, and Ms. BERKLEY) introduced the following bill; which
was referred to the Committee on Ways and Means, and in addition to
the Committee on Commerce, for a period to be subsequently determined
by the Speaker, in each case for consideration of such provisions as fall
within the jurisdiction of the committee concerned
A BILL
To amend title XI of the Social Security Act to restrict
the use of physical and chemical restraints and seclusion
in certain facilities receiving Medicare or Medicaid funds,
to require recording and reporting of information on
that use and on sentinel events occurring in those facili-
ties, and for other purposes.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘Patient Freedom from
Restraint Act of 1999’’.
SEC. 2. LIMITATION ON USE OF PHYSICAL AND CHEMICAL
RESTRAINTS AND SECLUSION IN CERTAIN
MEDICARE OR MEDICAID FUNDED TREAT-
MENT FACILITIES.
(a) IN GENERAL.—Part B of title XI of the Social
Security Act is amended by adding at the end the fol-
lowing new section:
‘‘LIMITATION ON USE OF RESTRAINTS AND SECLUSION IN
CERTAIN MEDICARE AND MEDICAID FUNDED TREAT-
MENT FACILITIES
‘‘SEC. 1164. (a) FREEDOM FROM RESTRAINTS AND
SECLUSION.—As a condition of participation or receipt of
funds under the medicare program under title XVIII or
under a State medicaid program under title XIX, a cov-
ered facility (as defined in subsection (b)) shall—
‘‘(1) protect and promote the right of each resi-
dent or patient to be free from physical or mental
abuse, corporal punishment, involuntary seclusion,
and any physical or chemical restraints (as defined
in subsection (g)) imposed for purposes of discipline
or convenience;
‘‘(2) meet the requirements of subsection (d)
(relating to recording and reporting on the use of re-
straints and seclusion and sentinel events);
‘‘(3) provide for annual training of all staff with
direct resident or patient care responsibility on the
proper use of restraints and seclusion, their alter-
natives, and techniques and methods to identify and
defuse potential emergency situations; and
‘‘(4)(A) make available to each resident or pa-
tient, and to the guardian of each such resident or
patient, a statement of their rights to freedom from
restraints and seclusion as required by this section
and information on the purpose of the appropriate
protection and advocacy agencies (as defined in sub-
section (g)(4)) and their addresses and telephone
numbers; and
‘‘(B) clearly and conspicuously post such infor-
mation in the facility.
‘‘(b) COVERED FACILITY DEFINED.—For purposes
of this section, the term ‘covered facility‘ means any of
the following:
‘‘(1) A facility that provides inpatient or resi-
dential psychiatric treatment or treatment of mental
illness (including a psychiatric hospital, as defined in
section 1861(f), and an institution for mental dis-
eases, as defined in section 1905(i)).
‘‘(2) An intermediate care facility for the men-
tally retarded (as defined in section 1905(d)).
‘‘(3) A facility that provides residential treat-
ment for children.
‘‘(c) REQUIREMENTS RELATING TO RESTRAINTS AND
SECLUSION.—
‘‘(1) GENERAL LIMITATIONS.—
‘‘(A) IN GENERAL.—A covered facility may
only impose restraints and seclusion—
‘‘(i) to ensure the immediate physical
safety of the resident or patient or others;
and
‘‘(ii) only upon the written order of a
physician that specifies the duration (not
to exceed 2 consecutive hours) and cir-
cumstances under which the restraints and
seclusion are to be used.
‘‘(B) EMERGENCY EXCEPTION.—Subpara-
graph (A)(ii) shall not apply in emergency cir-
cumstances specified by the Secretary during
the period before a written order can reasonably
be obtained.
‘‘(2) PROHIBITION OF USE OF STANDING OR-
DERS.—Written orders for such restraints or seclu-
sion shall never be written as a standing order.
‘‘(3) USE AS LAST RESORT.—A covered facility
may only use restraints and seclusion as an emer-
gency safety measure and as a last resort and only
after other less restrictive approaches have failed.
‘‘(4) LEAST RESTRICTIVE MANNER.—A covered
facility shall use restraints and seclusion only in the
least restrictive manner possible, to protect the resi-
dent or patient or others from harm, and must re-
move or end restraints and seclusion at the earliest
possible time.
‘‘(5) NO SIMULTANEOUS USE.—A covered facil-
ity may not use restraints and seclusion simulta-
neously.
‘‘(d) 
RECORDING
AND
REPORTING
REQUIRE-
MENTS.—In accordance with the protocol established
under subsection (e)(1)—
‘‘(1) RECORDING USES OF RESTRAINT AND SE-
CLUSION IN PATIENT RECORDS.—
‘‘(A) IN GENERAL.—Each covered facility
shall record and maintain, as part of a resi-
dent’s or patient’s medical record, the following
information on each incident in which restraints
or seclusion are used with respect to a resident
or patient of the facility:
‘‘(i) The uses of restraint and seclu-
sion, including the type of restraint or se-
clusion used and the time and duration of
its use.
‘‘(ii) The rationale for restraint or se-
clusion and types of less restrictive alter-
natives that were tried or considered.
‘‘(iii) Evidence of treatment planning
to reduce the probability of future inci-
dents that would lead to use of restraint or
seclusion.
‘‘(B) AVAILABILITY TO P&A AGENCIES.—
Each covered facility shall make available the
information recorded under subparagraph (A)
for inspection by staff of the appropriate pro-
tection and advocacy agencies.
‘‘(2) SUBMISSION
OF
PERIODIC
REPORTS
ON
OVERALL USE OF RESTRAINTS AND SECLUSION.—
Each covered facility shall submit to the Secretary
and to the appropriate protection and advocacy
agencies a report that specifies the number of times
restraints or seclusion were used during the report-
ing period. Such report shall be submitted on a peri-
odic basis specified by the Secretary, but in no case
less often than annually.
‘‘(3) SUBMISSION OF REPORTS ON ALL SEN-
TINEL EVENTS.—
‘‘(A) IN GENERAL.—Each covered facility
shall submit to the appropriate protection and
advocacy agency a report on—
‘‘(i) each sentinel event (as defined in
subsection (g)(6)) that occurs respecting a
resident or patient, including only the
name of the resident or patient and a gen-
eral description of the event; and
‘‘(ii) if information is available to the
facility, information on the death of any
individual who died within 14 days after
the date of discharge from the facility.
‘‘(B) DEADLINE FOR SUBMISSION.—Each
report under subparagraph (A)(i) shall be sub-
mitted within 7 days of the date of the incident
involved and each report under subparagraph
(A)(ii) shall be submitted within 7 days of re-
ceipt of information concerning the death of the
former resident or patient.
‘‘(C) ANNUAL REPORT.—Each covered fa-
cility shall submit on an annual basis to the
Secretary an annual report on sentinel events
for which reports were made during the pre-
vious year under subparagraph (A).
‘‘(e) IMPLEMENTATION.—
‘‘(1) IN GENERAL.—Not later than 1 year after
the date of the enactment of this section, the Sec-
retary shall establish a protocol for the recording
and reporting of information under subsection (d).
To the extent feasible, the Secretary shall establish
the protocol in a manner that is consistent with
medical records recording systems and that is co-
ordinated with other applicable health care informa-
tion reporting systems. The Secretary shall consult
with appropriate protection and advocacy agencies in
establishing and implementing the protocol.
‘‘(2) PUBLICATION
OF
SUMMARY.—The Sec-
retary shall compile and publish on an annual basis
a comprehensive summary of the reports received
under subsection (d)(3).
‘‘(3) ESTABLISHMENT
OF
GUIDELINES
FOR
PEER REVIEW ORGANIZATIONS.—The Secretary shall
establish guidelines for the use of utilization and
quality control peer review organizations (as defined
in section 1152(a)) in reviewing policies and proce-
dures of covered facilities regarding the use of re-
straints and seclusion consistent with this section.
‘‘(f) SANCTIONS.—
‘‘(1) LOSS OF MEDICARE AND MEDICAID FUND-
ING.—A covered facility that fails to comply with the
requirements of subsection (a) (including failure to
provide for annual training of staff in accordance
with subsection (a)(3)) is subject to disqualification
from participation in the medicare program under
title XVIII and the medicaid program under title
XIX for such period at the Secretary may specify.
‘‘(2) CIVIL MONEY PENALTY FOR FAILURE TO
FILE SENTINEL REPORTS.—A covered facility that
fails to file a report required to be made under sub-
section (b)(3) within the period so required is sub-
ject to a civil money penalty not to exceed $5,000
for each such violation. The provisions of section
1128A (other than subsections (a) and (b)) shall
apply to civil money penalties under this subsection
in the same manner as they apply to a penalty or
proceeding under section 1128A(a).
‘‘(g) DEFINITIONS.—For purposes of this section:
‘‘(1) 
RESTRAINTS.—The 
term 
‘restraints’
means any chemical or physical restraint (as defined
in paragraphs (2) and (3)).
‘‘(2) CHEMICAL RESTRAINT.—The term ‘chem-
ical restraint’ means the use of any medication or bi-
ological for the purpose of immobilizing the indi-
vidual, inducing a state of sleep or unconsciousness,
or reducing the ability to move freely. Such term
does not include involuntary administration of medi-
cation when administered pursuant to a court order
or the administration of medication for voluntary or
emergency treatment (such as anesthesia adminis-
tered before a surgical procedure).
‘‘(3) PHYSICAL RESTRAINT.—The term ‘phys-
ical restraint’ means any mechanical or personal re-
striction that immobilizes or reduces an individual’s
ability to move arms, legs, or head freely. Such term
does not include devices, such as orthopedically pre-
scribed appliances, surgical dressings and bandages,
protective helmets and supportive body bands, and
other physical holding when necessary for routine
physical examinations or tests or for orthopedic sur-
gical or other similar medical treatment purposes or
when used to provide support for the achievement of
functional body position or proper balance or to per-
mit an individual to participate in ongoing activities
with the risk of physical harm.
‘‘(4) PROTECTION AND ADVOCACY AGENCY.—
The term ‘protection and advocacy agency’ means an
appropriate board under the protection and advocacy
system established under part C of title I of the De-
velopmental Disabilities Assistance and Bill of
Rights Act (42 U.S.C. 6041 et seq.).
‘‘(5) SECLUSION.—The term ‘seclusion’ means
the involuntary confinement of a resident or patient
in a room from which the resident or patient is
physically prevented from leaving.
‘‘(6) SENTINEL
EVENT.—The term ‘sentinel
event’ means an unexpected occurrence involving a
substantial impairment of the physical or psycho-
logical condition of a resident or patient, including
any burn, laceration, or abrasion of the skin, frac-
ture of any bone, substantial hematoma, injury to
any internal organ, or any injury that occurs as a
result of repeated harm to any bodily function or
organ (including the skin), if the occurrence is unre-
lated to the natural course of the individual’s illness
or underlying condition, and includes the death of
the individual in any case.’’.
(b) EFFECTIVE DATES.—
(1) PROTECTION
AGAINST
USE
OF
PUNITIVE
RESTRAINTS AND SECLUSION.—The requirements of
subsections (a)(1) and (c) of section 1164 of the So-
cial Security Act, as added by subsection (a), apply
to restraints and seclusion used on or after the first
date of the first month that begins more than 6
months after the date of the enactment of this Act.
(2) REPORTING REQUIREMENTS.—
(A) DEADLINE
FOR
ESTABLISHING
PRO-
TOCOL.—The Secretary of Health and Human
Services shall first establish the protocol de-
scribed in section 1164(e)(1) of the Social Secu-
rity Act, as added by subsection (a), within 1
year after the date of the enactment of this Act.
(B) REPORTS.—Covered facilities are first
required to record information and submit re-
ports under section 1164(c) of the Social Secu-
rity Act, as so added, for restraints and seclu-
sion used on and after a date (specified by the
Secretary of Health and Human Services ) that
is not later than 2 months after the date of the
establishment of the protocol under section
1164(e)(1) of such Act.
(3) ANNUAL
TRAINING.—The requirement of
section 1164(a)(3) of the Social Security Act, as so
added, applies for annual periods beginning after the
effective date described in paragraph (1).
(4) POSTING INFORMATION.—The requirement
of section 1164(a)(4) of the Social Security Act, as
so added, takes effect on such date, not later than
the effective date described in paragraph (1), as the
Secretary of Health and Human Services shall speci-
fy.
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