Complying With CMS Hospital CoPs and TJC Requirements on Ligature Risks

Product Id : HE105
Instructor : Sue Dill Calloway
Mar 25, 2019 1:00 PM ET | 12:00 PM CT | 10:00 AM PT | 90 Minutes

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Ligature risk is now a hot compliance area and there is a lot of survey activity around prevention of suicidal patients from harm or strangulation. The Joint Commission too announced that this is one of the four top areas of focus. The CMS has announced requirements for hospitals to prevent ligature risk and self harm from patients that are suicidal. On Dec 29, 2017 the CMS amended the hospital manual after issuing a13-page memo to implement these changes. Every hospital that receives Medicare must implement these changes for all patients.

While TJC has 16 requirements to ensure compliance with their standards, the CMS amended tag numbers 144 in patient rights and tag 701 in facility services.

This webinar by medical legal consultant, Sue Dill Calloway, RN, MSN, JD, will provide you all the information and insights to make sure you comply with the CMS hospital CoPs and TJC requirements on ligature risk.

In this session, Sue will discuss critical questions such as what units need to be ligature resistant, what patient assessments must be done, and what should be in the environmental assessments. She will touch upon education, policy and procedure requirements, as well as the zero suicide campaign and FAQs on ligature risk.

Session Highlights

  • The two CMS tag numbers that set forth requirements to prevent ligature risks for patients with suicidal risks
  • The Joint Commission requirements for hospitals to prevent patients from self-harm including hanging or strangulation
  • CMS’ recommendation for education in orientation when policies change every two years
  • What do you do if you have a highly suicidal patient and the room is not ligature resistant?
  • TJC’s 16 requirements in detail, including:
    • Psych hospital
    • Behavior health units
    • General acute care inpatient units
    • Outpatient units
    • Emergency departments
  • TJC sentinel event alerts on suicide and SEA 56
  • NPSG 15 and proposed changes in 2019
  • Tools to assess patients with suicidal tendencies
  • TJC ligature risk FAQs

CMS Hospital Ligature Risk Requirements

  • Updated 13-page memo and manual
  • Amended tag 144 and 701
  • Deficiency reports
  • CMS definition of ligature risk
  • Anchor points and examples
  • Policy and procedure requirements
  • Education recommendations
  • Competency requirements
  • Patient and environmental assessment
  • Correction of environmental risk
  • Design guide for creating safe rooms
  • Things to do to reduce ligature risk
  • Documentation requirements
  • VA mental health guide and checklist
  • Ligature resistant requirements

Joint Commission Requirements

  • The 13 requirements to prevent suicide
  • The three requirements for outpatient and residential treatment centers
  • Recommendation for psych unit, psych hospital, and general acute care settings including emergency departments
  • Sentinel event reduction doors and soft suicide prevention doors
  • Ceilings, beds, toilets and shower curtains
  • SAFER matrix and when at risk for getting RFI
  • EC.02.06.01 EP 1 requirements
  • Dedicated versus non-dedicated spaces
  • Suicide risk reduction
  • Zero suicide campaign

Resources and tools:

  • Suicide prevention resource center
  • VA/DoD Clinical practice guidelines
  • Suicide prevention guidelines for training
  • Design guide for built environment of behavioral health facilities
  • Patient health questionnaire PHQ-9 and 3
  • ED-SAFE screeners
  • Patient safety secondary screener
  • ED” Suicide Behaviors Questionnaire SBQ-R
  • Environmental Assessment
  • C-SSRS Columbia Suicide Severity Rating Scale
  • SAFE-T Assessment
  • Suicide Prevention Decision Support Tool and more
  • NY patient safety standards guidelines

Who Will Benefit

  • All staff, nurses, physicians and providers at:
    • Hospital behavioral health units
    • Psychiatric hospitals
    • Hospital emergency departments
    • Hospital units where suicidal patients are taken care of such as ICU, medical-surgical units, OB and post-partum, and outpatient areas
  • Hospital risk managers 
  • Hospital legal counsel
  • Patient safety officers
  • CEO, COO, CNO, and nurse supervisors
  • Chief medical officers
  • Maintenance and facility personnel
  • Materials management personnel
  • Environmental services personnel
  • Security staff
  • Quality improvement coordinators
  • Compliance officers
  • Regulatory affairs personnel
  • Nurse educators
  • Clinic and outpatient managers
  • Nurse managers
Speaker Profile:

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of legal services at a community hospital in addition to being the privacy officer and the compliance officer. She was a medical malpractice defense attorney for ten years. She has 3 nursing degrees in addition to a law degree.

She is a well-known lecturer and the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program. She has written 102 books and thousands of articles.

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