Everything you need to know about Compliance with CMS Interpretive Guidelines for Restraints and Seclusions!

The number one area of deficiencies in the CMS CoPs is regarding restraints and CMS compliance is a huge challenge, as any hospital will attest. If a CMS surveyor showed up at your hospital, would you be prepared? The goal of a hospital survey is to determine if the hospital or facility is in compliance with CoPs. Certification of hospital compliance is accomplished through observations, interviews, and document/ record reviews. We’ll look at the CMS regulations and guidelines and what surveyors look at.

An Introduction to Regulations

The Centers for Medicare and Medicaid Services (CMS) has issued regulations regarding seclusion and restraint, called Conditions of Participation (CoP). These CoPs apply to hospitals, psychiatric residential treatment facilities for individuals under age 21, intermediate care facilities for individuals with mental retardation (ICF/MR) and long-term care facilities.

For facilities funded by Medicaid or Medicare, the federal statutes regarding seclusion and restraint can be found under the Children’s Health Act, 2000. Facilities that don’t comply with CHA requirements are not eligible for Medicaid or Medicare. CMS incorporated CHA requirements into amended hospital CoPs regarding restraint and seclusion. Therefore, hospitals in compliance with CoPs are also in compliance with the Children’s Health Act requirements related to restraint and seclusion. Which means knowing Restraint and Seclusion CMS Interpretive Guidelines is essential!

All hospitals (acute care, long-term care, psychiatric, children’s and cancer) must comply with CMS CoP regulations to participate in Medicare and Medicaid programs. That’s not all, these requirements apply to ALL patients of these hospitals, not just patients that are beneficiaries. They apply to inpatients or outpatients in all locations. However, critical access hospitals must only comply if they have distinct-part psychiatric or rehabilitative unit.

What do the CMS CoPs and Interpretive Gudelines contain?

According to federal law, all patients have the right to be free from physical or mental abuse, and corporal punishment. To prevent exploitation of potentially vulnerable patients, the federal law specifies that restraint and seclusion cannot be imposed to coerce, discipline or retaliate against a patient by staff. The only way restraint and seclusion can be imposed is to ensure the immediate physical safety of the patient, staff or others. The operative word here is immediate, i.e. it has to be temporary, and “must be discontinued at the earliest possible time”. It also must only be implemented by trained staff. These are the non-negotiable, non-arguable aspects of the regulations. On the other hand, the CMS interpretive guidelines put the onus on hospitals to create a culture that supports the patient’s right to be free from restraint or seclusion.

What do Hospital Surveyors look at for CMS Compliance?

Surveyors review medical records of patients on whom restraints and seclusion was imposed. Two aspects of the use of restraints and seclusion are looked at: their use to manage non-violent, non-self-destructive behavior and to manage violent, self-destructive behavior. Both, patients currently in restraints and seclusions, as well as those previously in restraints and seclusions are looked at.

Surveyors look for evidence that justifies the use of restraint and seclusion, and whether it was determined that other, less restrictive measures would be ineffective. Simply, you can’t just put the patient in restraints or seclude them without good cause. This relates to the earlier mentioned point, where the only reason for restraints and seclusion to be imposed is if the physical safety of a patient, staff or others is threatened.

That’s not all, interviewers sometimes determine whether patients understand the rationale behind restraint and seclusion policies, whether hospital staff explained the reasons behind restraint for non-violent, non-self-destructive behavior to the patient in understandable terms or not.

The surveyor will review incident and accident reports to check if they happen more frequently to these patients and whether they happen during a restraint and seclusion intervention. If these patients sustain injuries, then the hospital’s actions to prevent further injury are examined, including potential changes to its restraint and seclusion policies.

Patterns of restraint and seclusion are looked for and examined. The idea behind this is to see if restraint and seclusion happens due to convenience, staff availability, staff training etc., instead of as per the needs of the patient.

Most importantly, surveyors will check if the actual use of restraint and seclusion is compliant with the hospital’s policies and CMS requirements.

Both CMS and Joint Commission have made it mandatory for hospital staff to be trained on an on-going basis about the restraint and seclusion CMS interpretive guidelines. It is mandatory for all hospitals to comply with the interpretive guidelines even if accredited by Joint Commission, AOA, CIHQ, or DNV Healthcare. To learn more about the CMS compliance requirements , and to get advice on training staff and preparing proper policies, check out this webinar by expert Sue Dill Calloway, RN, MSN, JD. Sue is a nurse attorney, medical legal consultant and past chief learning officer for the Emergency Medicine Patient Safety Foundation. She is a frequent speaker and is well known across the country in the area of healthcare law, risk management, and patient safety. She has taught many educational programs and written many articles on compliance with the CMS and Joint Commission restraint standards.

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