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CMS Hospital Restraint and Seclusion – Webinar

July 24, 2019 @ 9:00 am - 11:00 am

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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? This program will also discuss the proposed changes to restraints published in the Hospital Improvement Rule which address changing the term to licensed practitioners so PAs can order restraints.

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? This program can be used to help hospitals meet this requirement. CMS also says that restraint training must be on-going 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 reporting requirements for patients who die in restraints and within 24 hours of being in a restraint.

As discussed, Restraint and Seclusion is 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 those 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 to 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 reference and are now closer in 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.