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Restraint and Seclusion: Requirements to Comply with CMS CoPs and TJC

Tuesday, May 10, 2022
9:00 am10:00 am
Virtual

Course Curriculum

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 internal log 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 be educated 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.