CMS Hospital Restraint and Seclusion: Navigating the Most Problematic CMS Standards 2025

Description

Restraint and Seclusion is a hot spot with both CMS and an area where hospitals are frequently cited for non-compliance. This program will discuss this most problematic standard.

CMS has fifty pages of interpretive guidelines on restraint and seclusions for hospitals. Every hospital that accepts Medicare patients will have to comply with the regulations even if accredited by an accreditation organization, such as the Joint Commission, HFAP, CIHQ, or DNV Healthcare. 

Any physician or provider who orders a restraint must be trained in the hospital’s policy. CMS requires hospital staff to be educated on restraint and seclusion interpretive guidelines on an annual basis. CMS also requires that training must occur before a staff member/provider can apply or remove restraints and must be ongoing, so it cannot occur at orientation only. There are ten pages of training requirements.

Learning Objectives:-

• Recall that CMS requires that all physicians and others who order restraints 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.
• Define the CMS restraint requirement of what a hospital must document in the internal log if a patient dies within 24 hours with two soft wrist restraints on.

Agenda:-

• Restraints in the news
• Introduction to CoP Manual
• Restraint and seclusion deficiencies
• Complaint manual and process
• Conditions of Participation
• Seclusion – what it is and is not
• Medical restraints
• Behavioral health restraints
• Definition of restraint and seclusion
• Reasons to restrain
• Leadership responsibilities
• Falls and use of restraints
• Drugs used as a restraint
• What restraints do not include
• Side rails, forensic restraints, freedom splints, immobilizers
• Patient assessment
• Need order ASAP
• Order from LP and notification to the attending physician
• Documentation requirements
• Plan of care
• Least restrictive requirements
• RNs and One-hour face-to-face assessment
• Training for an RN doing a one-hour face-to-face assessment
• Training requirements
• Ending at the earliest time
• Revisions to the plan of care
• Time-limited orders
• Renewing orders
• Provider training
• Staff education
• First aid training is required
• Monitoring of the patient in both restraint and seclusion
• Death reporting requirements.

Who Will Benefit?

• All nurses with direct patient care
• Compliance officer
• Chief nursing officer
• Chief of Medical Staff
• COO
• Nurse Educator
• ED nurses
• ED physicians
• Medical staff coordinator
• Risk manager
• Patient safety officer
• Chief Risk Officer
• PI director
• Nurse managers
• Quality director
• Chief medical officer
• Security guards
• Accreditation and regulation staff, and others responsible for compliance with hospital regulations
• Anyone involved in the restraint or seclusion of patients.
• Any staff who could remove/apply restraints as part of care.