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

Do you know the recent change made in restraints by CMS, effective November 29, 2019? CMS changes 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 changes will be discussed in detail.

Did you know that the number one area of deficiencies in the CMS CoP is regarding restraints? CMS issued a memo summarizing all of the deficiencies against hospitals which is updated quarterly. This program will discuss the most problematic standards in the restraint section.  If a CMS surveyor showed up at your hospital tomorrow would you be prepared? Does your staff understand all 50 pages of the CMS interpretive guidelines?.

Did you know any physician or provider who orders restraint must be trained in the hospital’s policy? Did you know that both CMS and Joint Commission require hospital staff to be educated on restraint and seclusion interpretive guidelines on an annual basis? This program can be used to help hospitals meet this requirement. CMS also says that restraint training must be ongoing so you can’t just provide training at orientation and forget about it. Did you know that CMS has ten pages of training requirements?

This program will discuss the requirements for an internal log and what must be in the log for patients who die in one or two soft wrist restraints. It will include what must be documented in the medical record also. It will also discuss the new electronic reporting requirements for patients who die in restraints and within 24 hours of being in a restraint.

As discussed, 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. The restraint policy is one of the hardest to write and understand in healthcare today.

CMS has issued interpretive guidelines on restraint and seclusions for hospitals. This program will simplify and take the mystery out of that 50-page restraint and seclusion interpretive guidelines. It will provide a crosswalk to the Joint Commission standards. Avoid the restraint nightmare now and let us take the mystery out of these confusing regulations by attending this program.

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 is also a requirement that physicians and anyone who writes an order for restraints will have to be educated on the hospital’s policy. The guidelines explain the training requirements for the RN doing the one-hour face-to-face visits for patients who are violent and or self-destructive. 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 to the crosswalk. Patient safety is at risk and patients have been injured or died from improper restraint usage.

• 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.

• Right to be free from restraint
• Number of deficiencies
• Providing a copy of rights to patients
• Restraint protocols
• Final changes in the hospital improvement rule
  • PA to order and change from LIP to LP
• CMS deficiency reports
• 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
• Manual holds of patients
• Leadership responsibilities
• Two soft wrist restraints, internal log, and documentation
• Culture of safety
• Drugs used as a restraint
• Standard treatment
• Learning from each other
• Restraints do not include
• Side rails, forensic restraints, freedom splints, immobilizers
• Assessment
• Need order ASAP
• Order from LIP and notification of attending physician ASAP
• Documentation requirements
• Least restrictive requirements
• Alternatives
• RNs and One hour face to face assessment
• Training for RN doing one hour face to face assessment
• New training requirements
• New death reporting requirements
• Ending at the earliest time
• Revisions to the plan of care
• PI requirements
• Time-limited orders
• Renewing orders
• Staff education
• First aid training required
• Stricter state laws
• Monitoring of patients in R/S
• Joint Commission Hospital Restraint standards and differences from CMS

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, senior leadership, hospital legal counsel, Risk Manager, Chief Risk Officer, PI director, Joint Commission coordinator, nurse managers, quality director, chief medical officer, security guards, compliance officer, chief risk officer, accreditation and regulation staff and others responsible for compliance with hospital regulations and anyone involved in the restraint or seclusion of patients. Persons responsible for rewriting the hospital policies and medical staff bylaws should attend. This also includes staff that removes and applies them as part of their care such as radiology techs, ultrasound technologists, transport staff, and others.