[Federal Register Volume 75, Number 104 (Tuesday, June 1, 2010)]
[Proposed Rules]
[Pages 30306-30309]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2010-13048]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 17

RIN 2900-AN45


Responding To Disruptive Patients

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: 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.

DATES: Comment Date: Comments on the proposed rule must be received by 
VA on or before August 2, 2010.

ADDRESSES: 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).

FOR FURTHER INFORMATION CONTACT: Roscoe Butler, Deputy Director, 
Business Policy, Chief Business Office (163), Veterans Health 
Administration, Department of Veterans Affairs, 810 Vermont Avenue, 
NW., Washington, DC 20420, (202) 461-1586. (This is not a toll free 
number.)

SUPPLEMENTARY INFORMATION: 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 
Sec.  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, Sec.  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 Sec. Sec.  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.''

[[Page 30307]]

However, current Sec.  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 
Sec.  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 Sec.  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 Sec.  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.

[[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.

Unfunded Mandates

    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.

Paperwork Reduction Act of 1995

    This document contains no provisions constituting a collection of 
information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-
3521).

Executive Order 12866

    Executive Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, when regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety, 
and other advantages; distributive impacts; and equity). The Executive 
Order classifies a ``significant regulatory action,'' requiring review 
by OMB unless OMB waives such review, as any regulatory action that is 
likely to result in a rule that may: (1) Have an annual effect on the 
economy of $100 million or more or adversely affect in a material way 
the economy, a sector of the economy, productivity, competition, jobs, 
the environment, public health or safety, or State, local, or tribal 
governments or communities; (2) create a serious inconsistency or 
otherwise interfere with an action taken or planned by another agency; 
(3) materially alter the budgetary impact of entitlements, grants, user 
fees, or loan programs or the rights and obligations of recipients 
thereof; or (4) raise novel legal or policy issues arising out of legal 
mandates, the President's priorities, or the principles set forth in 
the Executive Order.
    The economic, interagency, budgetary, legal, and policy 
implications of this proposed rule have been examined and it has been 
determined to be a significant regulatory action under the Executive 
Order because it is likely to result in a rule that may raise novel 
legal or policy issues arising out of legal mandates, the President's 
priorities, or the principles set forth in the Executive Order.

Regulatory Flexibility Act

    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.

Catalog of Federal Domestic Assistance

    The Catalog of Federal Domestic Assistance numbers and titles for 
the programs affected by this document are 64.007, Blind Rehabilitation 
Centers; 64.008, Veterans Domiciliary Care; 64.009, Veterans Medical 
Care Benefits; 64.010, Veterans Nursing Home Care; 64.011, Veterans 
Dental Care; 64.012, Veterans Prescription Service; 64.013, Veterans 
Prosthetic Appliances; 64.014, 64.015, Sharing Specialized Medical 
Resources; 64.019, Veterans Rehabilitation Alcohol and Drug Dependence; 
and 64.022, Veterans Home Based Primary Care.

Signing Authority

    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.

List of Subjects in 38 CFR Part 17

    Administrative practice and procedure, Alcohol abuse, Alcoholism, 
Day care, Dental health, Drug abuse, Health care, Health facilities, 
Health professions, Health records, Homeless, Medical and dental 
schools, Medical devices, Medical research, Mental health programs, 
Nursing homes.

    Dated: May 26, 2010.
Robert C. McFetridge,
Director of Regulation Policy and Management, Office of the General 
Counsel.
    For the reasons set forth in the preamble, the Department of 
Veterans Affairs proposes to amend 38 CFR part 17 as follows:

PART 17--MEDICAL

    1. The authority citation for part 17 is revised to read as 
follows:

    Authority:  38 U.S.C. 501, and as noted in specific sections.

    2. Section 17.106 is revised to read as follows:


Sec.  17.106  VA response to disruptive behavior of patients.

    (a) Definition. For the purposes of this section:
    VA medical facility means VA medical centers, outpatient clinics, 
and domiciliaries.
    (b) Response to disruptive patients. The time, place, and/or manner 
of the provision of a patient's medical care may be restricted by 
written order of the Chief of Staff of the VA Medical Center of 
jurisdiction or his or her designee if:
    (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;
    (2) The order is narrowly tailored to address the patient's 
disruptive behavior and avoid undue interference with the patient's 
care;
    (3) The order is signed by the Chief of Staff or designee, and a 
copy is entered into the patient's permanent medical record;
    (4) The patient receives a copy of the order and written notice of 
the procedure for appealing the order to the network director of 
jurisdiction as soon as possible after issuance; and
    (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

[[Page 30309]]

determination regarding the need for restrictions.
    (c) Evaluation of disruptive behavior. In making determinations 
under paragraph (b) of this section, the Chief of Staff or designee 
must consider all pertinent facts, including any prior counseling of 
the patient regarding his or her disruptive behavior or any pattern of 
such behavior, and whether the disruptive behavior is a result of the 
patient's individual fears, preferences, or perceived needs. A 
patient's disruptive behavior must be assessed in connection with VA's 
duty to provide good quality care, including care designed to reduce or 
otherwise clinically address the patient's behavior.
    (d) Restrictions. The restrictions on care imposed under this 
section may include but are not limited to:
    (1) Specifying the hours in which nonemergent outpatient care will 
be provided;
    (2) Arranging for medical and any other services to be provided in 
a particular patient care area (e.g., private exam room near an exit);
    (3) Arranging for medical and any other services to be provided at 
a specific site of care;
    (4) Specifying the health care provider, and related personnel, who 
will be involved with the patient's care;
    (5) Requiring police escort; or
    (6) Authorizing VA providers to terminate an encounter immediately 
if certain behaviors occur.
    (e) Review of restrictions. The patient may request the Network 
Director's review of any order issued under this section within 30 days 
of the effective date of the order by submitting a written request to 
the Chief of Staff. The Chief of Staff shall forward the order and the 
patient's request to the Network Director for a final decision. The 
Network Director shall issue a final decision on this matter within 30 
days. VA will enforce the order while it is under review by the network 
director. The Chief of Staff will provide the patient who made the 
request written notice of the Network Director's final decision.

    Note:  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. Patients 
have the right to accept or refuse treatments or procedures, and 
such refusal by a patient is not a basis for restricting the 
provision of care under this section.



    (Authority: 38 U.S.C. 501, 901, 1721)

[FR Doc. 2010-13048 Filed 5-28-10; 8:45 am]
BILLING CODE 8320-01-P