Restraint and seclusion is an area in which hospitals are commonly cited for being out of compliance. This program will discuss the most problematic standards in the CMS Conditions of Participation (CoPs) restraint section.

Any physician or provider who orders restraint must be trained on the hospital’s policy. CMS requires hospital staff to be educated annually on restraint and seclusion interpretive guidelines. CMS also requires restraint training to be ongoing, meaning it should be provided at orientation, as well as through a recurring training program.

CMS has 50 pages of interpretive guidelines on restraint and seclusion for hospitals. Every hospital that accepts Medicare patients must comply with the interpretive guidelines even if the hospital is accredited by TJC, HFAP, CIHQ, or DNV Healthcare.

LEARNING OBJECTIVES:
At the conclusion of this session, participants should be able to:

• Recall that CMS requires all physicians and others who order restraints to be educated on the hospital policy.
• Describe that CMS has restraint education requirements for staff.
• Discuss that CMS requires specific items to document 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.

TARGET AUDIENCE:
Chief Medical Officer, Chief Nursing Officer, Compliance Officer, Emergency Department Personnel, Joint Commission Coordinator, Medical Records, Quality Improvement personnel, Risk Manager, Legal Counsel.