Responsibilities

5170.2 - Responsibilities (Rev. 243; Issued: 06-12-26; Effective: 06-12-26; Implementation: 06-12-26) CMS Locations The CMS location receives Hospital Restraint/Seclusion Death Reports which hospitals are required to submit in accordance with 42 CFR 482.13(g)(1). The CMS location is responsible for communicating with hospitals in its region whether the required reports are to be submitted electronically by facsimile and/or e-mail, providing appropriate addresses or fax numbers, or whether it will also accept mail submissions. The CMS location is also responsible for data entry of reports received into the Automated Survey Processing Environment (ASPEN) Complaint Tracking System (ACTS) Hospital Restraint/Seclusion Death Module and for maintenance in ACTS of information related to disclosures to Protection and Advocacy Agencies. (See Process discussion below.) Each CMS location designates one contact person and a backup person who serves as the hospital point of contact regarding reporting, and who is responsible for coordinating the review of reports received, and authorization of complaint surveys when appropriate. State Agencies (SAs) Hospitals report patient deaths associated with restraint or seclusion to their CMS location, not to the SA. Any hospital patient restraint or seclusion death report received by a SA directly from a hospital (or other source) must be forwarded immediately by the SA to its CMS location. The SA conducts a complaint investigation related to a patient death associated with a hospital’s use of restraints or seclusion only when the CMS location authorizes the investigation. The investigation must be completed no later than five working days after CMS location authorization. SAs assist CMS locations in educating the hospitals in their State about their obligation to report to their CMS location any death that meets the reporting requirements found at 42 CFR 482.13(g)(1). Upon request, SAs are to provide hospitals with the applicable CMS location contact information, as well as the hospital reporting procedures contained in this policy. The SAs respond to requests from Protection and Advocacy (P&A) organizations, or any other parties, for information on survey findings related to specific cases identified by the requestor. The SAs handle these requests in accordance with standard CMS policy on disclosure of Federal survey information.