Ligature Risks: Ensuring Compliance with the CMS Hospital CoPs and TJC Requirements

Duration: 120 Minutes
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The Centers for Medicare and Medicaid Services (CMS) has promulgated requirements for hospitals to prevent ligature risk and self harm from patients that are suicidal. A 13 page memo was issued and the hospital manual was amended on December 29, 2017 to implement these changes. Any hospital that received Medicare, which is most hospitals in America, must implement these changes for all patients.
Ligature Risks
Instructor: Sue Dill Calloway
Product ID: 504204
Objectives of the Presentation
  • Recall that CMS now has two tag numbers that set forth requirements to prevent ligature risks for patients with suicidal ideations
  • Discuss that the Joint Commission has requirements for hospitals to follow to prevent patients from self harm including hanging or strangulation
  • Describe that CMS recommends education in orientation, when policies change every two years
Why Should you Attend
CMS amends tag numbers 144 in patient rights and tag 701 in facility services. This discusses what units need to be ligature resistant. It covers what patient assessments must be done and what should be in the environmental assessments. It discusses education and policy and procedure requirements.

Joint Commission has 13 requirements to ensure compliance with their standards. These will be discussed in detail and include psych hospital, behavior health units, general acute care inpatient units, outpatient units and emergency departments. The zero suicide campaign will be discussed. The TJC sentinel event alerts on suicide, NPSH 15, and Frequently Asked Question (FAQ) on ligature risk will be covered.

Resources will be provided. Tools to assess patients to determine if they have suicidal ideations will be included.

Areas Covered
CMS Hospital Ligature Risks
  • Introduction
  • 13 page memo and manual updated
  • Amends tag 144 and 701
  • Deficiency reports
  • Suicide 10th leading cause of death
  • What is a ligature risk? CMS definition
  • Anchor points and examples
  • Policy and procedure requirements
  • Education recommendations
  • Competency requirements
  • Patient assessment
  • 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
  • When are sitters or 1:1 observers required?
  • Ligature resistant requirements
Joint Commission
  • 13 requirements to prevent suicide
  • 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, and toilets
  • Shower curtains
  • SAFER matrix and when at risk for getting RFI
  • EC.02.06.01 EP 1 requirements
  • Dedicated verses non-dedicated spaces
  • Suicide risk reduction
  • Zero suicide campaign
  • TJC ligature risk FAQ
  • TJC sentinel event alerts on suicide and SEA 56
  • NPSG 15
Resources and tools of the trade
  • 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 on the hospital behavioral health unit
  • All staff, nurses, physicians and providers at Psychiatric hospitals
  • All staff, nurses, physicians, and providers in hospital emergency departments
  • All staff, nurses, physicians and providers on hospital units where suicidal patients are taken care of such as ICU, medical-surgical units, OB and post-partum, and outpatient areas
  • All hospital risk managers
  • Hospital legal counsel
  • Patient safety officer
  • CEO, COO, CNO, and nurse supervisors
  • Chief medical officers
  • Director of maintenance and facility services
  • Biomedical engineering
  • Materials management
  • Environmental Services
  • Security
  • Director in charge of environment of care requirements and staff
  • Quality improvement coordinator
  • Compliance officer
  • Director of Regulatory Affairs
  • Board members
  • Nurse educator
  • Clinic and outpatient managers
  • All department directors/nurse managers such as ED, ICU, CCU, Med-surg managers, outpatient, etc
  • Anyone who is responsible to ensure compliance with the CMS hospital conditions of participation and the Joint Commission standards
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Instructor Profile:
Sue is president of Patient Safety and Healthcare Consulting and Education company with 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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