Accreditation

Answers to your FAQs on the CoP

Briefings on Accreditation and Quality, April 1, 2007

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Editor's note: Sue Dill-Calloway, RN, MSN, JD, director of hospital risk management for OHIC Insurance Company in Columbus, OH, is the CMS Corner lead contributor. Submit a topic idea to her by contacting BOJ editor Matt Phillion at mphillion@hcpro.com. This month, Dill-Calloway answers two questions she received about the CMS Conditions of Participation (CoP) during an all-day inservice.

Q: Regarding the new CMS restraint and seclusion standards, do you have to report deaths to CMS even if the patient's death is not due to the restraint?

A: CMS published changes to the restraint and seclusion standard on December 8, 2006, in the Federal Register. (Federal Register Vol. 71, No. 236, p.71377- 71428.)

The hospital must report each death to CMS that occurs while a patient is in restraints or seclusion and within 24 hours after the patient has been removed from restraint and seclusion, regardless of whether the death was due to a restraint. For example, say a terminal patient is expected to die. If the patient had restraints on or was restrained within 24 hours of death, you would need to report that.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.

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