A 23 year old male presents to your Emergency Department under the influence of a synthetic substance known on the streets as “K2”. He is paranoid, agitated, and striking out at staff. The patient is emergently placed in restraint and an order for the restraint is obtained immediately after. So far so good. Now the next challenge is to have a face-to-face evaluation (F2F) performed within one hour as required by CMS.

So what is the F2F? The CMS interpretive guidelines in Appendix A of the State Operations Manual at §482.13(e) forms the basis for this discussion.

When is the F2F required?
When restraint or seclusion is used to manage violent or self-destructive behavior, the patient face-to-face evaluation must occur within one hour after the initiation of the intervention. This requirement also applies when a drug or medication is used as a restraint to manage violent or self-destructive behavior. The F2F is required even if the patient is released from restraint or seclusion within an hour following initiation of the intervention. A F2F is not required if restraint is used for non-violent / non-self-destructive behavior.

What is the purpose of the F2F?
The basic purpose of the evaluation is to determine the appropriateness and continued need for the use of restraint or seclusion, as well factors that may have contributed to the patient’s violent or self-destructive behavior.

What is the minimum content of the F2F?
Basically, the F2F is designed to address the following:

• The patient's immediate situation;
• The patient's reaction to the use of restraint or seclusion;
• The patient's medical and behavioral condition; and
• The need to continue or terminate the restraint or seclusion.

This includes a complete review of systems, a behavioral assessment, and an assessment of the patient’s history, drugs and medications, most recent lab results, etc. The purpose is to complete a comprehensive review of the patient’s condition to determine if other factors, such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis, etc., are contributing to the patient’s violent or self-destructive behavior.

Who can perform the F2F?
The F2F can be performed by a physician or other licensed independent practitioner; as well as a trained registered nurse (RN) or physician’s assistant (PA). If an RN or PA conducts the F2F, they must consult with the patient’s attending physician or other licensed independent practitioner who is responsible for the care of the patient as soon as possible after the evaluation has been completed.

Note that basic training in the management of restraint or seclusion is not sufficient to assure that an RN is qualified to perform the F2F. The RN must receive sufficient training to perform the contents of the F2F. For example, in order to determine the patient’s medical condition, CMS requires that a review of systems be conducted. This is a standard part of physician training, but not necessarily nursing. An RN would need to demonstrate that they can perform a review of systems as part of the F2F evaluation.

Does the F2F have to be documented?
Yes, the patient’s medical record must contain documentation that the F2F occurred and that it was performed in a timely manner. Though not prescriptively required, it is strongly recommended that documentation specifically address the content requirements mentioned above.

Traci's past positions include Chief Quality Officer for a multi-hospital community based health system where she was responsible for accreditation and regulatory compliance. Prior to joining CIHQ, Traci served as the Executive Director of Quality for a large regional medical center, providing executive management oversight in the areas of quality, risk, medical staff credentialing, and patient relations.

Traci received her degree in education from Pima in Tucson Arizona. She is nationally certified in healthcare accreditation, and serves on the Board of Examiners for the Healthcare Accreditation Certification Program.