Home Events Restraint and Seclusion: Navigating CMS Standards and Proposed Changes

Restraint and Seclusion: Navigating CMS Standards and Proposed Changes


Date: 6/13/23

9:00 – 11:00 A.M.  Central time


Registration fees:     $225 per facility   |   Non-Members Registration Fee:  $350 per facility


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


Restraint and Seclusion is a hot topic with both the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission (TJC), and is a common area where hospitals are cited for being out of compliance. Restraints are the number one area of deficiencies for a specific requirement in the CMS Conditions of Participation (CoPs). This program will discuss the most problematic standards in the restraint section. Any physician or provider who orders restraint must be trained in the hospital’s policy. Both CMS and TJC require hospital staff to be educated on restraint and  seclusion interpretive guidelines on an annual basis. CMS also says that restraint training must be on-going, so the training should not only be provided at orientation. CMS has 50 pages of  interpretive guidelines on restraint and seclusions for hospitals. Every hospital that accepts Medicare patients must comply with the interpretive guidelines even if the hospital is accredited by the Joint Commission, HFAP, CIHQ, or DNV Healthcare. This program provides a crosswalk to the Joint Commission standards.


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

  • 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.


Laura A. Dixon most recently served as the director of risk management and patient safety for the Colorado Region of Kaiser Permanente. Prior to joining Kaiser, she served as the director, facility patient safety and risk management and operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the director, Western region, patient safety and risk management for The Doctors Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.


This speaker has no real or perceived conflicts of interest that relate to this presentation.




Jun 13 2023


9:00 am - 11:00 am

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