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CMS Hospital Restraint and Seclusion: Navigating the Most Problematic CMS Standards and Proposed Changes


Recent changes made in restraints by CMS in November 2019 changed the term from LIP (licensed independent practitioner to LP (licensed practitioner). This allows hospitals to allow PAs to write orders for restraints in states where they were considered to be dependent practitioners.

The number one area of deficiencies in the CMS CoP is regarding restraints. CMS issued a memo summarizing all of the deficiencies against hospitals. This program will discuss the most problematic standards in the restraint section. There are 50 pages of the CMS interpretive guidelines related to restraints.

Some key issues with restraints from CMS and Joint Commission include a requirement that any physician or provider who orders restraint must be trained in the hospital’s policy; CMS and Joint Commission requirements for hospital staff to be educated on restraint and seclusion on an annual basis. CMS also says that restraint training must be ongoing so you cannot only provide training at orientation. CMS has ten pages of training requirements.

Restraint and Seclusion

Restraint and Seclusion are a hot spot with both CMS and the Joint Commission and a common area where hospitals are cited for being out of compliance. CMS has issued interpretive guidelines on restraint and seclusions for hospitals.

Every hospital that accepts Medicare patients will have to comply with the interpretive guidelines even if the hospital is accredited by the Joint Commission, HFAP, CIHQ, or DNV Healthcare. Hospitals will need to make sure their policies and procedures comply with these. Joint Commission and CMS both require restraint training for staff.

There are basically 21 rules covered by the CMS interpretive guidelines. The Joint Commission standards on restraint and seclusion will be the reference and are now closer in the crosswalk. Patient safety is at risk and patients have been injured or died from improper restraint usage.

What You Will Learn

-Define the CMS restraint requirement of what a hospital must document in the internal log if a patient dies within 24 hours with having two soft wrist restraints on.
-Recall that CMS requires that all physicians and others who order restraints must be educated on the hospital policy.
-Describe that CMS has restraint education requirements for staff.
-Discuss that CMS has specific things that need to be documented in the medical record for the one-hour face-to-face evaluation on patients who are violent and or self-destructive.


Topics Discussed

-Right to be free from restraint 
-Number of deficiencies
-Providing copy of rights to patients
-Restraint protocols
-CMS changes effectively to internal log and soft wrist restraints
-Most current manual
-Medical restraints
-Behavioral health restraints 
-Violent and self-destructive behavior
-Definition of restraint and seclusion
-Leadership responsibilities
-Culture of safety
-Drugs used as a restraint 
-Standard treatment
-Learning from each other
-Restraints does not include
-Side rails, forensic restraints, freedom splints, immobilizers
-Order for restraint
-Documentation requirements 
-Least restrictive requirements
-RNs and One-hour face to face assessment
-New training requirements
-New death reporting requirements
-PI requirements
-Time-limited orders and renewing orders 
-Staff education
-Stricter state laws 
-Monitoring of patient in R/S
-Joint Commission Hospital Restraint standards and differences from CMS


Who Should Participate

-All nurses with direct patient care
-Compliance officer
-Chief nursing officer
-Chief of medical staff
-Nurse Educator
-ED nurses
-ED physicians
-Medical staff coordinator
-Risk manager
-Patient safety officer
-Senior leadership
-Hospital legal counsel
-PI director
-Joint Commission coordinator
-Nurse managers
-Quality director
-Security guards
-Accreditation and regulation staff and others responsible for compliance with hospital regulations 
-Anyone involved in the restraint or seclusion of patients
-Persons responsible for rewriting the hospital policies and medical staff bylaws
-Staff that remove and apply restraints as part of care – such as radiology techs, ultrasound technologists, transport staff, and others.


You may ask your Question directly to our expert during the Q&A session.


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