Source: https://www.federalregister.gov/documents/2010/06/01/2010-13048/responding-to-disruptive-patients
Timestamp: 2018-03-24 12:20:59
Document Index: 307183688

Matched Legal Cases: ['art 17', '§\u200917', '§\u20091', '§\u20091', '§\u200917', '§\u200917', '§\u200917', '§\u200917']

Federal Register :: Responding To Disruptive Patients
A Proposed Rule by the Veterans Affairs Department on 06/01/2010
https://www.federalregister.gov/d/2010-13048 https://www.federalregister.gov/d/2010-13048
This document proposes to amend the Department of Veterans Affairs (VA) regulation that authorizes appropriate action when a patient engages in disruptive behavior at a VA medical facility. VA needs to update its current regulation to reflect modern medical care and ethical practices. The proposed rule would authorize VA to modify the time, place, and/or manner in which VA provides treatment to a patient, in order to ensure the safety of others at VA medical facilities, and to prevent any interference with the provision of medical care.
Comment Date: Comments on the proposed rule must be received by VA on or before August 2, 2010.
Written comments may be submitted through http://www.Regulations.gov;​ by mail or hand-delivery to the Director, Regulations Management (02REG), Department of Veterans Affairs, 810 Vermont Avenue, NW., Room 1068, Washington, DC 20420; or by fax to (202) 273-9026. Comments should indicate that they are submitted in response to “RIN 2900-AN45—Responding To Disruptive Patients.” Copies of comments received will be available for public inspection in the Office of Regulation Policy and Management, Room 1063B, between the hours of 8 a.m. and 4:30 p.m., Monday through Friday (except holidays). Please call (202) 461-4902 for an appointment. This is not a toll free number. In addition, during the comment period, comments may be viewed online at http://www.Regulations.gov through the Federal Docket Management System (FDMS).
Under 38 U.S.C. chapters 17 and 18, VA has authority to provide medical care to certain veterans and nonveterans. VA is required, per 38 U.S.C. 1721, to prescribe rules and regulations to promote good conduct on the part of VA patients. VA has implemented this authority in 38 CFR part 17.
Regarding the rights of patients receiving VA care, 38 CFR 17.33(a) prescribes, in part, that patients have “a right to be treated with dignity in a humane environment that affords them both reasonable protection from harm and appropriate privacy with regard to their personal needs.” Patients also have “a right to receive, to the extent of eligibility therefor under the law, prompt and appropriate treatment for any physical or emotional disability.” Section 17.33(b) also prescribes rights with respect to visitations and communications, clothing, personal possessions, money, social interaction, exercise, and worship for VA residents and inpatients. These rights may be restricted by the appropriate health care professional in certain circumstances. See 38 CFR 17.33(c). The restrictions authorized by § 17.33(c), however, do not apply to outpatients and only cover restrictions on the listed rights. In certain cases, VA must restrict the provision of medical care to a patient in order to prevent harm to other patients and VA staff and disruptions in VA's provision of medical care due to the patient's behavior.
VA regulations also prescribe rules of conduct for patients and other individuals who have access to VA facilities. See 38 CFR 1.218. In particular, § 1.218(a)(5) prohibits persons on VA property from causing a wide variety of disturbances, including creating “loud or unusual noise,” obstructing public areas, and impeding or disrupting “the performance of official duties by Government employees.” The sole enforcement mechanism provided by paragraph (a)(5) is “arrest and removal from the premises.” 38 CFR 1.218(a)(5). VA has determined that arrest is generally not an appropriate remedy in a situation where the Department must balance the rights and needs of a disruptive patient against the need to protect other patients, guests, and staff. Some patients establish a pattern of disruptive behavior when interacting with VA personnel or when they are on VA property, and we believe that by understanding these patterns of behavior, planning for such behavior in advance, and setting safe conditions for care delivery, we can intervene in ways that can prevent subsequent episodes requiring removal and arrest.
In addition to §§ 1.218 and 17.33, the behavior of patients is specifically governed by current 38 CFR 17.106. It requires, in part, that VA maintain the good conduct of patients through “corrective and disciplinary procedure.” Start Printed Page 30307However, current § 17.106, which VA promulgated in 1973 and last amended over 10 years ago, does not adequately reflect modern practice or VA's policy regarding disruptive patients in the health care setting, which opposes the use of punishment in the management of disruptive patients. Instead, it reflects the view that patients exhibiting disruptive behavior must be punished. For example, current § 17.106 emphasizes disciplining patients who do not engage in “good conduct,” and includes measures (such as withholding pass privileges) that do not differentiate between providing care and ensuring the safety of others. Moreover, the current rule could be viewed as interfering with VA's legal obligation to provide medical care to certain veterans and nonveterans. Accordingly, VA has determined that amendments to current regulations are necessary to implement its policy regarding disruptive patients, which emphasizes continuation of treatment.
We propose to amend § 17.106 to prescribe the remedial measures VA will take when a patient is disruptive and the procedures for implementing those measures. VA intends that the proposed rule would minimize the risk of a particular patient jeopardizing the health or safety of others, or disrupting the safe provision of medical care to another patient, in a VA medical facility.
In proposed § 17.106(a), we would define “VA medical facility” to mean any VA medical center, outpatient clinic, or domiciliary. We would not include VA nursing homes (also referred to as community living centers) because the limitations on the time, place, and manner for delivering care are not applicable to patients in this residential setting.
Proposed paragraph (b) would authorize VA to restrict the time, place, and/or manner of the provision of a patient's medical care if the patient's behavior at a VA medical facility has or could jeopardize the health or safety of other patients, VA staff, or guests at the facility, or otherwise interfere with the delivery of safe medical care to another patient at the facility. Decisions regarding these restrictions would be made by the VA medical facility Chief of Staff or his or her designee. An appropriate designee might include, for example, a Disruptive Behavior Committee (DBC). VA has mandated DBCs at all of the Department's medical centers, and these committees regularly assess disruptive behavior. As such, they have developed expertise in this area.
Proposed paragraph (b) would also set forth procedures for implementing these determinations. Thus, any order restricting a patient's care would need to be in writing and signed by the Chief of Staff or designee with a copy entered into the patient's VA medical record. The Chief of Staff or designee would provide the patient a copy of the order and an explanation of the procedure for an administrative review under paragraph (e) as soon as possible after issuance. Unless otherwise stated in the order, these restrictions would take effect upon the signature of the Chief of Staff or designee. We have determined that restrictions under this proposed rule would be necessary in situations where a patient's behavior has or could harm another person or interfere with the delivery of medical care to another patient at the facility. Accordingly, in almost every case VA would need to implement the restrictions immediately to prevent the harm and meet its obligation to provide safe medical care.
The proposed procedure would emphasize addressing the disruptive patient's needs in order to advance VA's focus on patient care. We propose to require that authorized officials making determinations under this section narrowly tailor restrictions to avoid interfering with the disruptive patient's care. Ultimately, we expect that actions under this proposed rule would increase the likelihood that the disruptive patient will engage, or re-engage (if it has been necessary to terminate an episode of care), in health care in a safe and efficacious manner, without being disruptive. Indeed, through our DBCs and similar committees, we are already seeing anecdotal evidence of such results.
The standard for making determinations under the proposed rule is in paragraph (b)(1). Under this standard, the Chief of Staff or designee would evaluate whether the patient's behavior has or could jeopardize the health or safety of patients or other individuals who have access to VA medical facilities. The Chief of Staff or designee would also evaluate whether the patient's behavior has or could interfere with the delivery of medical care to another patient at a VA medical facility. In making such determinations, the Chief of Staff or designee would consider, among other things, the patient's individual fears; VA's obligation to provide the patient with high-quality medical care; and all of the pertinent facts, such as any prior counseling of the patient regarding his or her inappropriate behavior. See proposed paragraph (c).
Proposed paragraph (d) would also suggest a range of possible restrictions that could be imposed. We believe that these suggestions would assist Chiefs of Staff or their designees to narrowly tailor restrictions imposed under the proposed rule. We do not intend to limit the remedial options available to the officials making determinations under this section. Rather, proposed paragraph (d) would illustrate the types of restrictions that might be appropriate in a given situation and would authorize any other restriction that the Chief of Staff or designee deems appropriate short of arrest and removal. Restrictions could thus be tailored to consider the needs of a particular situation or patient.
Proposed paragraph (e) would prescribe the procedures for obtaining an administrative review of restrictions imposed by order of the Chief of Staff or designee under the proposed rule. VA provides medical care through 21 networks of medical facilities known as Veterans Integrated Service Networks. We propose to allow one appeal of an order restricting medical care under this section to the Network Director of jurisdiction. The patient would initiate the Network Director's review by submitting a request to the Chief of Staff within 30 days of the effective date of the Chief of Staff's or designee's order. However, in light of VA's obligation to provide safe medical care for all patients, the order would be enforced while under review by the Network Director. The Chief of Staff would provide the patient written notice of the Network Director's final decision.
At the end of the proposed rule, we would include a note stating as follows: “Although VA may restrict the time, place, and/or manner of care under this section, VA will continue to offer the full range of needed medical care to which a patient is eligible under title 38 of the United States Code or Code of Federal Regulations.” We do not intend to prevent patients from accessing non-emergent VA medical care and will work with veterans to try to find other VA medical facilities that can provide the care. However, we recognize that in a few instances VA restrictions on the time, place, or manner of care may make it very difficult for a veteran to access VA care if the veteran is unwilling to accept the restrictions placed upon his or her behavior by the local facility. We also note that it has been our experience that through creative case management on the part of VA staff and other involved parties, it is almost always possible to find transportation, even for veterans who must travel great distances for routine appointments.Start Printed Page 30308
We do not consider patients disruptive if they merely do not comply with a doctor's orders, decline recommended medical treatment, or leave a facility against medical advice. Such noncompliance can be, and is, addressed most effectively through clinical means. We propose to add a second sentence to the note explicitly stating that noncompliance with VA medical treatment recommendations is not disruptive under this section.
The Unfunded Mandates Reform Act requires, at 2 U.S.C. 1532, that agencies prepare an assessment of anticipated costs and benefits before developing any rule that may result in the expenditure by State, local, or tribal governments, in the aggregate, or by the private sector, of $100 million or more (adjusted annually for inflation) in any given year. This proposed rule will have no such effect on State, local, or tribal governments, or the private sector.
The Secretary hereby certifies that this proposed rule would not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-612. This proposed rule would not cause a significant economic impact on health care providers, suppliers, or entities since only a small portion of the business of such entities concerns VA beneficiaries. Therefore, pursuant to 5 U.S.C. 605(b), this proposed amendment is exempt from the initial and final regulatory flexibility analysis requirements of sections 603 and 604.
The Secretary of Veterans Affairs, or designee, approved this document and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs. John R. Gingrich, Chief of Staff, approved this document on March 22, 2010, for publication.
2. Section 17.106 is revised to read as follows:
VA response to disruptive behavior of patients.
(1) The Chief of Staff or designee determines pursuant to paragraph (c) of this section that the patient's behavior at a VA medical facility has or could jeopardize the health or safety of other patients, VA staff, or guests at the facility, or otherwise interfere with the delivery of safe medical care to another patient at the facility;
(5) The order contains an effective date and any appropriate limits on the duration of or conditions for continuing the restrictions. The Chief of Staff or designee may order restrictions for a definite period or until the conditions for removing conditions specified in the order are satisfied. Unless otherwise stated, the restrictions imposed by an order will take effect upon issuance by the Chief of Staff or designee. Any order issued by the Chief of Staff or designee shall include a summary of the pertinent facts and the bases for the Chief of Staff's or designee's Start Printed Page 30309determination regarding the need for restrictions.
[FR Doc. 2010-13048 Filed 5-28-10; 8:45 am]