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CMS Hospital Restraint and Seclusion: Navigating the Most Problematic CMS Standards and Proposed Changes
- Right to be free from restraint
- Number of deficiencies
- Providing copy of right to patients
- Restraint protocols
- Proposed changes in the hospital improvement rule
· PA to order and change from LIP to LP
- CMS deficiency reports
- CMS changes effective 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 does 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 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 patient in R/S
- Joint Commission Hospital Restraint standards and differences from CMS,
Overview of the webinar
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.
Who should attend?
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 remove and apply them as part of their care such as radiology techs, ultra sound technologists, transport staff, and others
Why should you attend?
- 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
Faculty - Ms.Sue Dill Calloway
Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is also the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation and a board member. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal, patient safety, and risk management issues and writes numerous publications.
Sue has been a medico-legal consultant for over 30 years. She has done many educational programs for nurses, physicians, and other healthcare providers on topics such as nursing law, ethics and nursing, malpractice prevention, HIPAA medical record confidentiality, emergency department patient safety and risk, EMTALA anti-dumping law, Joint Commission issues, CMS issues, documentation, medication errors, medical errors, documentation, pain management, federal laws for nursing, sentinel events, MRI Safety, Legal Issues in Surgery, patient safety and other similar topics. She is a leading expert in the country on CMS hospital CoPs issues and does over 250 educational programs per year. She was the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program.