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

CMS Hospital Restraint and Seclusion: Navigating CMS Standards and Proposed Changes

NDHA is an approved provider of continuing education by the North Dakota Board of Examiners for Nursing Home Administrators.

Date: 5/10/22

9:00 AM – Noon Central time


Registration fees:       $175 per NDHA member  |  $225 per non-member


The Centers for Medicaid and Medicare Services (CMS) and the Joint Commission (TJC) require hospital staff to be educated on restraint and seclusion, and these topics continue to be major concerns for both CMS and TJC. CMS and TJC have also promulgated requirements for hospitals to prevent ligature risk and self-harm from patients who are suicidal. This session will provide resources to aid hospital staff in achieving compliance with the CMS and TJC requirements regarding restraint and seclusion. Participants will also learn how to assess a facility’s ability to meet safety requirements and assess patients for risks of self-harm and suicide.

Learning Objectives:

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

  • Define the CMS restraint requirement of what a hospital must document in the internallog if a patient dies within 24 hours of having two soft restraints placed on the wrists.
  • Recall that CMS requires that all physicians and others who order restraints must beeducated on the hospital policy.
  • Describe that CMS has restraint education requirements for staff.
  • Discuss that CMS has specific items 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.



Sharon Courage, RN, BSN, MPH, Senior Consultant
Nash Healthcare Consulting

Sharon Courage is a registered nurse with a Master of Public Health. She has 30 years of experience in hospital quality and risk management, quality improvement, development of hospital programs, patient safety, and acute and long-term care. Since 2002, Courage has helped hospitals nationwide develop programs and system improvements in patient safety, quality and risk management, infection control, program assessment, and accreditation preparation. She has assisted with the development and implementation of regulatory plans of correction, and process development and implementation. She has also assisted hospitals with strategy development and implementation to meet Joint Commission and CMS compliance.

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


May 10 2022


9:00 am - 11:00 am

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