The CMS Restraint and Seclusion: Navigating the Most Problematic of all of the CMS Standards

Event Information
Product Format
Prerecorded Event
Sue Dill Calloway, RN, MSN, JD
90 minutes
Product Description

Understand the Various Compliance Requirements Laid Down By CMS on Hospitals Regarding Patient Restraint and Seclusions

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 by expert speaker Sue Dill Calloway 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?

It has been made mandatory according to both CMS and Joint Commission that hospital staff need to be educated on restraint and seclusion interpretive guidelines. Meet these requirements with the help of this webinar. CMS has also made restraint training mandatory and it 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 webinar will also discuss the internal log requirements and what must be in the log for patients who die in one or two soft wrist restraints. You will know what needs to be documented in medical records, and learn the reporting requirements for patients who die in restraints and within 24 hours of being in a restraint. CMS has also issued interpretive guidelines for seclusions and restraint for hospitals and this program is going to help you simplify the 50 pages with interpretive guidelines. You will crosswalk to joint commission standards and will be able to avoid the restraint nightmares, taking the mystery out of confusing regulations.

It is mandatory for all hospitals to comply with the interpretive guidelines even if accredited by Joint Commission, AOA, CIHQ, or DNV Healthcare. Hospitals have to comply with the policies and procedures and physicians who write an order for restraints will have to be educated on the hospital’s policy.

Session Highlights:

  • CMS restraint requirements about what hospitals need to document in internal log if patients die within 24 hours with having two soft wrist restraints on
  • CMS requirements on all physicians and others ordering restraint with relation to education on the hospital policy
  • CMS restraint education requirements for staff
  • Specific CMS 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.

Session Agenda:

  • Right to be free from restraint
  • Number of deficiencies
  • Providing copy of right to patients
  • Restraint protocols
  • 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

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 who remove and apply them as part of their care such as radiology techs, ultra sound technologists, transport staff, and others.

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About Our Speaker

Sue Dill Calloway - Hospital Coding Expert

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the...   More Info
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