There are several areas in which the education of off-duty law enforcement personnel will help to insulate a hospital from being found deficient in regards to Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (C.o.P.s). Topics may include a description and brief history of CMS, C.o.P.s; the survey process; patients’ rights; standards for restraint (acute medical/surgical care and behavior management); and interpretive guidelines as related to weapons and handcuff usage.
Another important issue that should be communicated to personnel is the Emergency Medical Treatment and Active Labor Act (EMTALA) rule. EMTALA deals with the failure of a health-care facility to provide initial medical screening, stabilization of emergency medical conditions and safe transfer for individuals and women in active labor seeking emergency treatment. It has several triggers, which can be set in motion by security personnel (imagine a patient being trespassed and removed from the property before he or she can be medically screened).
The roles and responsibilities of security (full time and PRN staff) and clinical staff need to be clearly communicated regarding restrictive interventions and patient interactions that have the potential to impact CMS regulations. Such training should include applicable policy reviews; least restrictive uses of force as related to health-care interventions; and the security/off duty law enforcement officer’s role in communicating with emergency department care team members.
Should any off-duty law enforcement officer be expected to assist in patient restraints, he or she must be educated and assessed in the proper application and removal of facility-approved medical or behavioral restraint devices. The officer must also understand the justification for employing such interventions.
Using Weapons in Hospitals Can be Tricky
All off-duty law enforcement personnel who will be working in health care should be specifically educated on a campus’ existing use of force policy. They should be trained on how lethal and less-lethal weapons are affected by the CMS Interpretative Guidelines for Patients’ Rights Standards (as updated in 2004). These guidelines state that “CMS does not consider the use of weapons in the application of restraint as safe appropriate health-care interventions.” Additionally, “CMS does not approve the use of weapons by any hospital staff as a means of subduing a patient to place the patient in restraint/seclusion.”
Weapons are then defined to include “pepper spray, nightsticks, Tasers, cattle prods, stun guns, pistols and other such devices.” The standard also considers “handcuffs, manacles, shackles and other chain-type restraint devices” as law enforcement restraints. The use of any such weapons or restraint devices are considered appropriate only in response to a criminal activity. Any perpetrators should be turned over to local law enforcement.
This can prove to be a challenge, especially if off-duty law enforcement employees are employed by an agency in the facility’s jurisdiction. Are they acting as health-care security or as police? Was it a criminal activity or a patient restraint that turned into a criminal activity? Where was the demarcation between the two?
These are the tough questions that will be asked of all involved. Therefore, everyone needs to be well versed in what is and is not acceptable regarding the aforementioned items when dealing with a patient. Bear in mind, a “weapon” does not have to be deployed to create a breech of C.o.P.s. since psychological harm is viewed by CMS as being just as serious as physical harm. The mere threat of a weapon’s use could be sufficient to prompt an investigation.
Consider Developing Your Own Program
Should a hospital develop its off-duty law enforcement training program by itself or hire a consultant? This decision depends on several factors, one of which is what type of security force the organization currently deploys. If it is proprietary, then the campus must examine the pros and cons of using in-house resources. Proprietary security could be less expensive, and the off-duty officers may already be known to many employees. 
An outside consultant can be hired to create such a program. A benefit to this approach is that the program is already completed and little-to-no internal resources are required. On the down side, using a consultant may be expensive, and the hospital may not have as much control over content. If a hospital uses a contract agency as its security force, the company might then offer such programs or be willing to have one of its employees assist with the creation of the program.
Education Programs Come in All Shapes, Sizes
Training can take many different forms. There are formal lecture types of programs (with or without PowerPoint presentations) that can be provided to a large audience. Smaller “lunch and learns” can be provided to an individual department or section of an organization (such as the emergency department). Self-learning modules or informational materials can be easily disseminated to a targeted audience.
Many health-care organizations use Web technologies for the sharing of information internally, and this is a great vehicle for educating staff while they are on the job. It also documents that the instruction took place. For organizations without such a network, the tried and true method of hand-outs and post-tests works well for disseminating information (especially at facilities with a smaller workforce).
It should be noted, however, that there must be a process to demonstrate all off-duty law enforcement personnel working at the facility received such training and have a clear understanding of its content. Written examinations on each topic with minimal acceptable scores is one method (for example, requiring all employees take post-tests and score at least 90 percent on each subject). These should be combined with regular competency assessments to ensure that participants retain the material. Those who fail such post-tests or competency surveys would be suspended from duty until they could demonstrate an acceptable level of aptitude and comprehension of the subject matter.
Off-Duty Law Enforcement Can be a Great Resource
As today’s economy continues to impact the health-care industry, many organizations are looking to off-duty law enforcement officers to supplement their existing security force for a variety of reasons. In doing so, they must be mindful of the challenges and the inherent risks that accompany such a decision. 
Health-care security is distinct from many other security industries, in part by the number of regulations and standards that are applied, particularly regarding patient interactions. If off-duty law enforcement personnel are not properly educated on their role in safe and appropriate health-care interventions, their actions can draw unwanted scrutiny and have a potentially disastrous impact upon a health-care facility.
So should health-care facilities completely abandon the concept of using off-duty law enforcement to augment their security programs? Not at all. These officers can provide a wealth of knowledge and experience to a health-care security department. Creating and maintaining these associations can strengthen relationships between a hospital’s personnel and local police.
However, such programs must include an educational component to ensure compliance with CMS regulatory requirements. Otherwise, these relationships could be undermined by just one adverse event.
CMS Guiding Principles
Centers for Medicare and Medicaid Services surveyors consider the following guidelines to determine if a facility is placing a patient at risk:
- Only one individual needs to b
e at risk - Serious harm, injury, impairment or death does not have to occur before considering there to be immediate jeopardy
- Serious harm can result from both abuse and neglect (psychological harm is viewed equally as seriously as physical harm)
- Any high potential for such to occur in the very near future also constitutes a violation
- Individuals must not be subjected to abuse by anyone including, but not limited to, facility staff, consultants or volunteers, family members or visitors
Accredited Certification
Programs Can Help
Off-duty law enforcement officers and security departments can benefit from certification through an accredited de-escalation or crisis intervention program. The Management of Aggressive Behavior (M.O.A.B) course or Crisis Prevention Institute’s Non-Violent Crisis Intervention program are two examples of this type of training. Such techniques are invaluable when dealing with emotionally charged situations and distressed individuals who end up in emergency departments following an incident.
These programs will also strengthen a security department’s use of force guidelines by providing proven alternatives to hands-on techniques whenever practical – the less hands on, the less the risk to patient safety. Initial certification and annual refreshers are typically required to maintain a program’s effectiveness. Whenever possible, training should be conducted in concert with medical personnel so that everyone on the patient’s care team is knowledgeable, not only about their roles should violent behavior occur, but also the techniques to prevent or mitigate such occurrences.
Signs and symptoms of psychological distress is another topic that should be considered for off-duty law enforcement education. Materials should include pertinent information collected from a facility’s behavioral health professionals or by using an existing course (such as the Backup Training Corp.’s “Emotionally Disturbed Persons: A Challenge for Law Enforcement” program).
Bryan Warren, CHPA, CPO-I, is the interim director of corporate security at Carolinas Healthcare System. He can be reached at [email protected].
