Demystify CMS Restraint and Seclusion Interpretive Guidelines

Restraint and seclusion is a hot spot with both CMS and the Joint Commission—and an area where hospitals are frequently cited for being out of compliance. In a recently issued CMS memo summarizing all of the deficiencies against hospitals, the number one? You guessed it: restraints.

Improper restraint usage can and has led to patient injury and death, so it’s no wonder the feds are paying attention. However, as medical legal consultant Sue Dill Calloway affirms, the latest interpretive guidelines for restraint and seclusion in hospitals are lengthy and problematic. She discusses the proposed changes to restraints, published in the Hospital Improvement Rule, in an audio conference for ProfEdOnDemand, “CMS 2018 Hospital Restraint and Seclusion: Navigating the Most Problematic CMS Standards and Proposed Changes.”

And compliance with restraint and seclusion standards affects anyone who directly cares for or transports patients, manages staff, rewrites hospital policies and medical staff bylaws, or who is responsible for compliance with hospital regulations.

Bottom line: Every hospital that accepts Medicare patients must comply with the interpretive guidelines even if the hospital is accredited by the Joint Commission, Healthcare Facilities Accreditation Program (HFAP), Center for Improvement in Healthcare Quality (CIHQ), or DNV Healthcare.

A Closer Look at Restraint and Seclusion

In the Final Patient Rights Rule, CMS defines restraint as “(A) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.”

CMS defines seclusion as “the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving .”

According to CMS Patients’ Rights Condition of Participation (CoP), “All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff.

So when can restraint and seclusion tactics be imposed? CMS specifically states:

• Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time
• Seclusion may only be used for the management of violent or self-destructive behavior
• Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient a staff member or others from harm

A hospital restraint policy is one of the hardest to write and understand in healthcare today. If a CMS surveyor showed up at your hospital tomorrow would you be prepared? Before you say, “yes,” consider that:

• Your staff must understand all 50 pages of the CMS interpretive guidelines and ten pages of training requirements.
• Both CMS and Joint Commission require hospital staff to be educated on restraint and seclusion interpretive guidelines.
• CMS says that restraint training must be ongoing, so you can’t just provide training at orientation and forget about it.
• Any physician or provider who orders restraint must be trained in the hospital’s policy.
• CMS expects specific medical record documentation for the one-hour, face-to-face evaluation required for patients who are violent and/or self-destructive.

Prepare for CMS’s Restraint and Seclusion 2018 Guidelines

Proposed changes in the Hospital Improvement Rule include changing the term “licensed independent practitioner” (LIP) to “licensed practitioner” (LP). This would provide more latitude for hospitals using physician assistants (PAs) who could then order restraint and seclusion.

There are also new training and new death reporting requirements. Calloway asserts that staff must heed the requirements for an internal log and know what information must be documented for patients who die in one or two soft wrist restraints and who die within 24 hours of being in a restraint.

Avoid the restraint compliance nightmare now and take the mystery out of these confusing regulations by attending Calloway’s presentation, in which explains the CMS changes pertaining to the internal log and soft wrist restraints.