Harmony Healthcare International (HHI) Blog

HHI Restraint Definition and Acceptable Usage



Harmony Healthcare International, Inc. (HHI) recommends that every long-term care facility conduct a comprehensive, facility wide, Physical Restraint Assessment on every resident with the below goals in mind:

1. To educate the facility staff on the
definition of a restraint.

2. To determine if the restraint is clinically appropriate for the resident and whether the device can be eliminated.

3. To properly identify, assess and care plan the device as a restraint per the definition from the State Operations Manual (SOM).

Physical Restraints include devices, materials, and equipment that restrict the resident from movement, such as crisscross belts, low beds, tabletops, seating devises, bed rails, cushions, wedges, and more.


1. Defining Physical Restraint


Per the State Operations Manual, Appendix PP, a physical restraint is defined as:


"Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that

the individual cannot remove easily

which restricts freedom of movement or normal access to one’s body

(SOM, Section 483.13(a)).


The State Operations Manual (SOM) further states that:


"The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.”


The device itself does not determine the criterion for classification as a restraint. The effect of the device on the resident determines the classification as a restraint. The same device may be a restraint for one patient but not another. This depends on the individual resident’s condition and circumstances.


“It’s the Effect of the Device, Not the Device.”


2. Clinical Appropriateness of the Physical Restraint


Every long-term care facility should continually strive to reduce and eliminate the use of restraints. It is important to identify any device that could restrain a patient/resident.

Once a restraining device is identified, the team should immediately incorporate the restraint usage into the care plan. This inclusion of this information is for patient safety and for the development of a plan to reduce or eliminate the restraint.


Physical Restraints are associated with many negative outcomes, including, but not limited to:


  • Higher Propensity of Injury.
  • Poor Circulation.
  • Constipation.
  • Incontinence.
  • Weak Muscles and Bones.
  • Pressure Ulcers.
  • Poor Appetite and Infections.


Restraints impede a patient's mobility, increase the risk of isolation and exacerbate existing psycho-social issues.

Acceptable Restraint Usage:


  • The restraint is medically necessary to treat a health symptom.
  • The restraint is not a mechanism to discipline a resident or for staff convenience in the absence of a medical symptom.
  • The restraint is the least restrictive device possible.
  • The restraint is in use for the least amount of time as possible per day.
  • The restraint is incorporated in the current care plan
  • The restraint usage is care planned to decrease usage of the restraint or the eventual removal of the restraint.


3. Identify, Assess and Care Plan the Physical Restraint


The facility wide restraint assessment allows provides to identify all residents with potential physical restraints. Once a resident is identified as having a restraint, the care plan must be updated to include all the below areas:


  • The care plan must state if the device is a restraint.
  • The care plan must provide the rationale for using of the device.
  • The care plan must identify the risks that the device poses for the patient.
  • The care plan must offer interventions to minimize or eliminate the medical symptom(s) causing the need for the restraint.
  • The care plan must identify underlying causes of the medical symptoms.
  • The care plan must define the approach to reduce or eliminate the restraint as soon as possible.
  • The care plan must define the strategy to reduce or eliminate the associated risks as soon as possible.
  • The care plan must cite resident specific details
    • The care plan must state schedule for when the restraint is applied and released.
  • The care plan must state the reasons why prior attempts to reduce the restraint were
    • The care plan must state that the patient or patient representative has been informed of the risk/benefit of the use of a restraint as well as possible negative outcomes associated with restraint use.


HHI Survey Tip


Just because you write in the medical record that the device is not a restraint, this does not automatically classify the device as a non-restraint, nor does it protect the facility from a survey citation.

Health Inspection Surveyors are instructed to determine if the restraint is used for a medical symptom, and whether the medical symptom is clearly documented in the medical record.


The surveyor’s role is to verify if the facility properly assessed the patient, including:


  • If there is another alternative such as providing rehabilitative/restorative care, providing meaningful diversional activities.
  • Attempts to prevent an avoidable decline that was caused using the restraint.
  • If the patient or patient representative has been informed of the risk/benefit of the use of a restraint as well as possible negative outcomes associated with restraint use.
  • A surveyor will evaluate if the clinical decision-making included restraint reduction and/or attempts at restraint elimination.
  • If the medical record states that the device or practice is not a restraint, but the surveyor’s investigation determines otherwise, then the device or practice is a restraint.


As aways, please feel free to contact Harmony Healthcare International, Inc. (HHI) with any questions or assistance with your compliance, analysis, auditing, regulatory, rehabilitation, reimbursement, education or survey needs.

Contact Kris

Kris Mastrangelo OTR/L, MBA, LNHA, President and CEO

Harmony Healthcare International, Inc. (HHI)

Cell: 617.595.6032

Office: 1.800.530.4413




About the Authorkris-1

Kris Mastrangelo, OTRL/L, LNHA, MBA

President and CEO


Kris is a nationally recognized keynote speaker with more than 32 years of experience in the Health Care industry with a specialty in the Long Term Post-Acute Care Setting. An Occupational Therapist degree from Tufts University followed by a Master's in Business Administration from Salem State University coupled with a Nursing Home Administrator's License, affords Kris an in-depth perspective into the clinical, financial, and operational components critical for business success. Initially providing direct care as an Occupational Therapist, Kris became familiar with the Medicare, Medicaid, and multiple other reimbursement systems.


Kris is the founder, owner, President and CEO of Harmony Healthcare International, Inc (HHI) an internationally recognized, premier Healthcare Consulting firm. Kris started the company in 2001. Harmony Healthcare International, Inc. (HHI) is a recognized consulting firm that uses a systematic approach in addressing the C.A.R.E.S. platform which is trademarked and created by HHI and stands for Compliance, Analysis, Audit, Regulatory, Rehabilitation, Reimbursement, Education, Efficiency and Survey.


Kris speaks on an array of subject matters including Leadership, Compliance, Auditing and Monitoring, QAPI, Analysis, Reimbursement (PDPM, Case Mix, Medicare, Medicaid, HMOs) Regulatory, Survey (Process, IIDR, IIDR, Appeals), Five-Star Quality Rating, Rehabilitation, Program Development, MDS, Facility Assessment, Quality Measures, Value-Based Purchasing, Infection Control, COVID-19, Team Building, Staff Retention, Staff Recruitment and Revenue Cycle Management to name a few. Kris proclaims that:


"HHI’s on-site and off-site medical record review process is the nucleus for C.A.R.E.S.

optimization and ongoing systems improvement."


I. Service and Performance Requirements

II. History of Harmony Healthcare International, Inc. (HHI) and Services


Harmony Healthcare International, Inc. (HHI) founded in 2001, is a Woman Owned Small Business (WOSB) certified by the National Women Business Owners Corporation (NWBOC). With headquarters in Topsfield, MA, Harmony Healthcare International, Inc. (HHI) services clients in the following continuums:


  • Skilled Nursing Facilities (SNF)
  • Inpatient Rehabilitation Facilities (IRF)
  • Long-Term Care Acute Hospitals (LTACH)
  • Assisted Living Facilities (ALF)
  • Home Health Agencies (HHA)
  • Inpatient Hospitals
  • Inpatient Psychiatric Facilities (IPF)
  • Outpatient Therapy
  • Critical Access Hospitals (CAHs)


with Compliance, Analysis, Audits, Regulatory, Rehabilitation, Reimbursement, Education, Efficiency and Survey services. The HHI staff is comprised of accomplished HHI Consultants with expertise in the above care continuums and CARES spectrum. HHI serves the For-Profit, Not-For-Profit, stand alone and multi-facility chains across the country. ‘


Harmony Healthcare International, Inc. (HHI) has been ranked among the top 5,000 fastest growing private companies in the U.S. for three consecutive years by Inc. Magazine.



To learn more about Harmony Healthcare International, Inc. (HHI)

visit us at: www.harmony–healthcare.com




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Management and Financial Consulting, Acquisition and Grants Management Support, and Business Program, and Project Management Services



Professional and Management Development Training


Order Level Materials


Topics: Survey, Regulatory, Restraint, Acceptable Usage

Kris Mastrangelo, OTR/L, LNHA, MBA


Kris Mastrangelo, OTR/L, LNHA, MBA

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