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

Restraint and Seclusion is a hot spot with both CMS and the Joint Commission and an area where hospitals are frequently cited for being out of compliance. The number one area of deficiencies for a specific requirement in the CMS CoP is regarding restraints. This program will discuss the most problematic standards in the restraint section.

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 interpretive guidelines even if the hospital is Joint Commission, HFAP, CIHQ, or DNV Healthcare accredited.

CMS made changes regarding restraints in 2019. Specifically, CMS changed the term from LIP (licensed independent practitioner to LP (licensed practitioner). The change allows PAs to write orders for restraints in states where they are considered dependent practitioners.

Any physician or provider who orders restraint must be trained in the hospital’s policy. Both CMS and Joint Commission requires hospital staff to be educated on restraint and seclusion interpretive guidelines on an annual basis. CMS also says that restraint training must be ongoing so you cannot just provide training at orientation and forget about it. CMS has ten pages of training requirements.

Finally, this program will cover The Joint Commission standards on restraint and seclusion, many of which fall closely with the CMS Conditions of Participation.

• 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.
• 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 of patients who are violent and or self-destructive.

• Introduction to CoP Manual
• CMS deficiencies and access
• Complaint process
• CMS changes to restraint and seclusion
• Conditions of Participation for CAH
• Seclusion – what it is and is not
• Medical restraints
• Behavioral health restraints
• Definition of restraint and seclusion
• Manual holds of patients,
• Leadership responsibilities
• Drugs used as a restraint
• Restraints do not include
• Side rails, forensic restraints, freedom splints, immobilizers
• Patient assessment
• Need order ASAP
• Order from LP and notification to attending physician
• Documentation requirements
• Least restrictive requirements
• RNs and One-hour face-to-face assessment
• Training for RN doing a one-hour face-to-face assessment
• Training requirements
• Death reporting requirements
• Ending at the earliest time
• Revisions to the plan of care
• Time-limited orders
• Renewing orders
• Staff education
• First aid training required
• Monitoring of patients in R/S
• Joint Commission Hospital Restraint standards

• 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
• Hospital legal counsel
• Chief Risk Officer
• PI director
• Joint Commission coordinator
• 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.
• Persons are responsible for rewriting the hospital policies and medical staff bylaws.
• Staff that remove and apply them as part of their care such as radiology techs, ultrasound technologists, transport staff, and others