CMS SOM App. A, Tag A-0196

the application of restraints, implementation of seclusion, monitoring, assessment, and providing

care for a patient in restraint or seclusion –

(i) Before performing any of the actions specified in this paragraph;

(ii) As part of orientation; and

(iii) Subsequently on a periodic basis consistent with hospital policy.

Interpretive Guidelines §482.13(f)(1)(i) - (iii)

All staff designated by the hospital as having direct patient care responsibilities, including contract or

agency personnel, must demonstrate the competencies specified in standard (f) prior to participating in

the application of restraints, implementation of seclusion, monitoring, assessment, or care of a patient in

restraint or seclusion. These competencies must be demonstrated initially as part of orientation and

subsequently on a periodic basis consistent with hospital policy. Hospitals have the flexibility to

identify a time frame for ongoing training based on the level of staff competency, and the needs of the

patient population(s) served.

Training for an RN or PA to conduct the 1-hour face-to-face evaluation would include all of the training

requirements at §482.13(f) as well as content to evaluate the patient's immediate situation, the patient's

reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or

terminate the restraint or seclusion. An evaluation of the patient’s medical condition would include a

complete review of systems assessment, behavioral assessment, as well as review and assessment of the

patient’s history, medications, most recent lab results, etc. The purpose of the 1-hour face-to-face

evaluation is to complete a comprehensive review of the patient’s condition and determine if other

factors, such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis, etc., are

contributing to the patient’s violent or self-destructive behavior.

Once initial training takes place, training must be provided frequently enough to ensure that staff

possesses the requisite knowledge and skills to safely care for restrained or secluded patients in

accordance with the regulations. The results of skills and knowledge assessments, new equipment, or

QAPI data may indicate a need for targeted training or more frequent or revised training.

Hospitals are required to have appropriately trained staff for the proper and safe use of seclusion and

restraint interventions. It would not be appropriate for a hospital to routinely call upon a law

enforcement agency or agencies as a means of applying restraint or initiating seclusion. If hospital

security guards, or other non-healthcare staff, as part of hospital policy, may assist direct care staff,

when requested, in the application of restraint or seclusion, the security guards, or other non-healthcare

staff, are also expected to be trained and able to demonstrate competency in the safe application of

restraint and seclusion (in accordance with §482.13(f))

Survey Procedures §482.13(f)(1)(i) - (iii)

• Does the hospital have a documented training program for the use of restraint and seclusion

interventions employed by the hospital?

• Does the hospital have documented evidence that all levels of staff, including agency or contract

staff, that have direct patient care responsibilities and any other individuals who may be involved

in the application of restraints (e.g., security guards) have been trained and are able to

demonstrate competency in the safe use of seclusion and the safe application and use of

restraints?

• Review and verify restraint and seclusion education staff training documentation for all new

employees and contract staff.

• Does the training include demonstration of required competencies?

• What areas were included in this training program?