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Ligature Risks: Ensuring Compliance with the CMS Hospital CoPs and TJC Requirements - Webinar (Recorded)

  • Webinar

  • 180 Minutes
  • January 2019
  • Compliance Online
  • ID: 4557698
Why Should You Attend:

CMS amends tag numbers 144 in patient rights and tag 701 in facility services. This webinar will discuss 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.

Areas Covered in the Webinar:
CMS Hospital Ligature Risks

Joint Commission

Resources and Tools of the Trade

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 requirements13 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 15Suicide 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


Sue Dill Calloway is a nurse attorney, a medical legal consultant and the past chief learning officer for the Emergency Medicine Patient Safety Foundation. She is the immediate past director of Hospital Patient Safety and Risk Management for The Doctors Company. She is currently president of Patient Safety and Health Care Education and Consulting. She was a medical malpractice defense attorney for many years and a past director of risk management for the Ohio Hospital Association. She was in-house legal counsel for a hospital in addition to being the privacy officer and compliance officer. She has done many educational programs for nurses, physicians, and other health care providers. She has authored over 102 books and numerous articles. She is a frequent speaker and is well known across the country in the area of healthcare law, risk management, and patient safety. She has taught many educational programs and written many articles on compliance with the CMS and Joint Commission restraint standards.