Hospital Restraint Compliance Guidelines

Key Takeaways:

• Benchmark at 100% – Since CMS CoPs allow for zero error, your internal goals must align with a 100% compliance target for regulatory measures.
• Bridge the Timestamp Gap – Use “Smart Phrases” in your EMR to document the actual time of the face-to-face evaluation, distinct from the later data-entry timestamp.
• Expand & Train – Utilizing trained RNs and PAs for evaluations can improve timeliness, provided there is clear accountability for every restraint episode.

What Are CMS Hospital Restraint Compliance Guidelines?

How do you establish benchmarks for restrain use that align with hospital restraint compliance guidelines? More specifically, what are the nationally accepted targets for restraint-related measures? The answer depends on whether the measures are required by the CMS or are driven by your hospital’s internal policy expectations.

CMS Driven Measures	Policy Driven Measures
Linked directly to Conditions of Participation (CoPs).	Internal expectations developed by individual hospitals
Target – 100% Compliance	Target – 100% Recommended

CMS Hospital Restraint Compliance Guidelines

The first two measures typically evaluated in restraint programs are related to CMS Conditions of Participation (CoPs) and carry a regulatory target of 100% compliance. Because these measures stem directly from CMS requirements, that should be your benchmark. Anything less represents a potential compliance risk.

Policy Driven Restraint Compliance Guidelines

The other restraint measures, such as those related to time frames for clinical monitoring or documentation, are not CMS-mandated. Instead, they are policy-driven expectations developed by individual hospitals. The intervals outline in your restraint policy were likely set during procedure development.

We recommend setting your internal benchmark at 100% compliance with your own policies and procedures. Even though a national variation exists, this approach demonstrates a commitment to consistently meeting your organization’s defined standards.

Addressing Face-to-Face Evaluation Compliance

One of the most common challenges in restraint documentation involves meeting the face-to-face (FtoF) within one hour requirement. In many organizations, staff report that the FtoF is consistently completed within the required time, yet electronic medical record (EMR) timestamps show otherwise.

This discrepancy often occurs because the FtoF assessment is performed on time, but documentation is entered later, resulting in an auto-timed entry that exceeds the 60-minute window.

A practical solution is to build a “smart text” or “smart phrase” into your EMR. This allows the provider to document when the FtoF was actually performed, even if the entry is finalized later. For example:

“The FtoF evaluation was performed at [time] and documented at [time].”

This simple modification helps demonstrate compliance and prevents false late entries in audit reports.

Training for FtoF Evaluations

CMS requires that all staff authorized to perform the FtoF evaluation receive specific training and competency validation. Eligible disciplines may include physicians, advanced practice nurses (APNs), physician assistants (PAs), and registered nurses (RNs).

If your organization limits the FtoF responsibility solely to physicians or APNs, consider expanding authorization to include PAs and RNs once they are properly trained and validated. Doing so may improve timeliness and overall compliance rates.

However, allowing multiple disciplines to perform the FtoF can introduce ambiguity around accountability. In some hospitals, the task is assigned to “whoever is available,” resulting in confusion and missed documentation. Strong performance requires clear role assignment during each restraint episode. Someone must explicitly take ownership of the FtoF to ensure it is both completed and documented within the required timeframe.

If PAs or RNs are authorized in your organization, remember to update signature lines and documentation templates to reflect these disciplines.

Need Help with CMS Compliance Standards?

Patton Healthcare Consulting helps hospitals nationwide interpret and apply CMS hospital restraint compliance guidelines, ensuring readiness for Joint Commission, CMS, and other accrediting body surveys. Our experts assist in reviewing policies, strengthening documentation workflows, and improving restraint compliance performance. Contact us to learn how we can help your organization remain compliant and survey ready.