CMS Hospital Restraint and Seclusion: Navigating the Most Problematic CMS Standards (ODW5017)

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1.5 ACHE Qualifying Education Hours Credits

1.5 Certificate of Participation Credits

1.5 Nursing Home Administrator Credits

This is a recording of a live webinar delivered on May 20, 2025.

Restraint and seclusion 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 on the hospital’s policy. CMS requires hospital staff to be educated annually on restraint and seclusion interpretive guidelines. 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.  

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.

This 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 all physicians and others who order restraints to be educated on the hospital policy. 
Describe that CMS has restraint education requirements for staff. 
Discuss that CMS requires specific items to document 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 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 1.5 contact hours.

By attending CMS Hospital Restraint and Seclusion: Navigating the Most Problematic CMS Standards Webinar offered by Georgia Hospital Association, participants may earn up to 1.5 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.