CMS Hospital Restraint and Seclusion: Navigating the Most Problematic CMS Standards and Proposed Changes (W4020)
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1 HLT Credit
This is a recording of a live webinar delivered on June 11, 2024.


Restraint and seclusion, a hot topic with the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission (TJC), is an area in which hospitals are commonly cited for being out of compliance. This program will discuss the most problematic standards in the CMS Conditions of Participation (CoPs) 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 requires restraint training to be ongoing, meaning it should be provided at orientation, as well as through a recurring training program.  

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 TJC, HFAP, CIHQ, or DNV Healthcare.  

Finally, this program will briefly cover The Joint Commission standards on restraint and seclusion, many which fall closely with the CMS Conditions of Participation.  

Laura A. Dixon, BS, JD, RN, CPHRM 

Laura A. Dixon 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, she provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. 

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, Dixon 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.

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

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


  • Recall that CMS requires that all physicians and others who order restraints 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. 

  • 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. 

The Georgia Hospital Association Research & Education Foundation is an approved provider of nursing home administrator credits as a professional trade association in long term care under Ga. Comp. R. & Regs. 393-13-.02, (1) (a).  Approved for 2 contact hours.   

By attending CMS Hospital Restraint and Seclusion: Navigating the Most Problematic CMS Standards and Proposed Changes offered by Georgia Hospital Association, participants may earn up to 2 ACHE Qualifying Education Hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation. Attendees who wish to have the hours applied toward ACHE Qualifying Education credit must self-report their participation by logging into their MyACHE account and selecting ACHE Qualifying Education Credit. 

Please complete the course evaluation to earn your certificate of participation.
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