CMS Hospital Restraint and Seclusion: Navigating the Most Problematic CMS Standards 2025

• Type: Live Webinar 
• Speaker: Laura A. Dixon
• Date: Jun 25, 2025
• Time: 01:00 PM EST
• Duration: 90 Minutes 

Course Description:

Navigating CMS Compliance for Restraint & Seclusion: What Every Hospital Must Know

Restraint and seclusion remain one of the most scrutinized compliance issues in hospital settings, drawing frequent citations during audits by CMS and accrediting bodies. This essential training will focus on the most critical aspects of restraint and seclusion regulations under the Medicare Conditions of Participation (CoPs).

CMS has released over 50 pages of interpretive guidance dedicated to this topic, and compliance is mandatory for all hospitals receiving Medicare reimbursement—even if they are accredited by organizations such as The Joint Commission, HFAP, DNV, or CIHQ.

This session provides a deep dive into these federal requirements, with special attention to documentation standards, staff training obligations, and the regulatory expectations for patient safety. Notably, any provider who orders or removes a restraint must be properly trained under the hospital’s policy—and this training must happen prior to any involvement and be refreshed annually. CMS requires ten full pages of training content to be addressed.

Key Learning Objectives:

• Understand the CMS mandate that all healthcare professionals who order restraints must receive formal education on the facility’s policies.

• Review staff training requirements around the use of restraint and seclusion and how frequently it must occur.

• Identify the documentation elements required for the one-hour face-to-face evaluation of violent or self-harming patients.

• Clarify the required reporting if a patient dies within 24 hours of being in soft restraints.

Topics Covered:

• Recent headlines and enforcement related to restraint use

• Overview of the CMS Conditions of Participation Manual

• Most common restraint-related deficiencies found during surveys

• CMS complaint investigation process

• Defining seclusion and differentiating it from other care practices

• Use of restraints in medical and behavioral health settings

• Understanding restraint types and permissible usage

• When and why restraints may be used, and responsibilities of leadership

• Restraints and fall prevention: myths vs. facts

• Recognizing drugs that act as chemical restraints

• Clarifying non-restraint items (e.g., side rails, immobilizers, forensic devices)

• Comprehensive patient assessment requirements

• Orders and documentation: timing, renewal, and medical oversight

• Face-to-face evaluations by RNs: when and how they must be performed

• Developing and updating individualized plans of care

• Minimum necessary force and time-limited restraint use

• Training mandates for staff, including first aid and emergency response

• Monitoring and observation while a patient is restrained or secluded

• Federal death reporting rules tied to restraint use

Who Should Attend:

This training is highly recommended for any hospital staff involved in the application, oversight, or documentation of restraint and seclusion practices, including:

• Direct Care Nurses (ED, ICU, Med/Surg, Behavioral Health)

• Compliance Officers and Risk Managers

• Chief Nursing and Medical Officers

• Emergency Department Physicians and Nurses

• Nurse Managers and Unit Supervisors

• Medical Staff Coordinators and Educators

• Patient Safety and Quality Improvement Directors

• Accreditation and Regulatory Affairs Professionals

• Security Staff interacting with patient care

• Any personnel responsible for applying or removing restraints