Electronic Report of a Hospital/CAH/LTCH Death Associated with Restraint or Seclusion

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

On December 2, 2019, CMS issued QSO-20-04-Hospital-CAH DPU that impacts all types of hospitals and/or Critical Access Hospitals (CAHs) beginning December 2, 2019.  This 46-page QSO provides a great deal of instructional information so be sure to review it carefully and share it with your staff.

The electronic Form CMS-10455, Report of a Hospital Death Associated with the Use of Restraint or Seclusion is replacing the paper version of the Form starting December 2, 2019. Beginning January 1, 2020, the CMS RO resource mailboxes will no longer accept paper versions of Form CMS-10455. 

Hospitals and/or Critical Access Hospital (CAH) Distinct Part Units (DPUs) will be able to insert the URL below into any browser and click to access the electronic Form CMS-10455.

https://restraintdeathreport.gov1.qualtrics.com/jfe/form/SV_5pXmjIw2WAzto8J

A brief Instructional Video on how to complete and submit the electronic Form CMS-10455 is available on the Surveyor Training Website at: https://surveyortraining.cms.hhs.gov/pubs/ClassInformation.aspx?cid=0CMSRHDRS_ONL.”

The Instructional Slides (41) are also found as part of the QSO as well as on the Surveyor Training Website.