Ligature Risks: Master Compliance with CMS Hospital CoPs & TJC Requirements

Event Information
Product Format
Prerecorded Event
Sue Dill Calloway, RN, MSN, JD
120 minutes
Product Description

Protecting At-Risk Patients Begins with Good Risk Assessment

According to the Centers for Disease Control and Prevention (CDC), suicide was the leading cause of death in 2016. Unfortunately, hospitals are not exempt from this statistic, a reality that led the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission (TJC) to buckle down on enforcement of patient safety rules. Are you aware of – and compliant with – CMS & TJC standards?

Join hospital compliance consultant Sue Dill Calloway for this live webinar to learn, in detail, how to comply with CMS and TJC requirements. She’ll explain key initiatives, such as the zero-suicide campaign and the TJC sentinel alerts on suicide. She’ll equip you with specific actions to correctly gauge patients’ suicide risk, reduce ligature risks, correct environmental risk, and create safe rooms. Best of all, you’ll no longer be left scratching your head when it comes to following documentation rules.

After attending this webinar, you will have the tools you need to asses patients’ mental health—and address high-risk patients’ needs, such as by assigning a 1:1 observer. You’ll have a solid grasp on the various recommendations for psych units, psych hospitals, and general acute care settings. And you’ll be prepared to make needed improvements to your hospital policies and practices to ensure the safety of even your most at-risk patients—all while complying with CMS and TJC rules.

Session Highlights

Here is a taste of what you will uncover:

  • How CMS defines ”ligature risk”
  • What to make of CMS’s 13-page memo on ligature risk management
  • How the changes to tags 144 (patient rights) & 701 (facility services) impact your hospital
  • What the zero-suicide campaign is—and why you need to know
  • How to comply TJC’ 13 requirements on ligature risk management
  • Which assessment tools to use to determine suicide risk
  • What design guides you can use to create safe rooms
  • How to reduce ligature risk
  • How the following relate to ligature risk management:
    • TJC Sentinel Event Alerts on Suicide
    • National Patient Safety Goal (NPSG) 15
    • FAQs on ligature risk
    • The SAFER matrix
    • EC.02.06.01 EP 1 requirements

Session Agenda

  • Introduction into the CMS hospital CoPs
  • Introduction to ligature risk
  • What to make of CMS’s 13-page memo on ligature risk management
  • How to keep up with changes
  • How the changes to tags 144 (patient rights) & 701 (facility services) impact your hospital
  • CMS hospital CoP deficiency reports
  • CMS Ligature Risk Tag 144
  • Identifying patients at risk
  • Environmental safety risks
  • VA mental health guide
  • Environmental safety risks
  • Requests for extension
  • Tag 701 buildings
  • The joint commission standards on ligature risks
  • TJC suicide prevention
  • Recommendations for inpatient psych unit
  • suicide risk reduction
  • Recommendations for the general acute inpatient setting
  • Zero suicide campaign
  • Joint commission FAQs on ligature risks
  • TJC issues SEA 56 on detecting and treating suicidal ideation
  • TJC sentinel event alert on suicide
  • Joint Commission National Patient Safety Goal (NPSG) on patient suicide risk
  • Tools of the trade
  • Resources

Who Should Attend:

This compliance session will benefit anyone responsible for compliance with CMS CoP and TJC standards, as well as professionals working in hospital behavioral units, psychiatric departments, emergency departments, and any unit where suicidal patients receive care (e.g., ICU, surgical, OB, post-partum, and outpatient). This list includes:

  • Hospital risk managers
  • Hospital legal counsel
  • Patient safety officers
  • CEOs, COOs, CNOs, and chief medical officers
  • Nurse supervisors
  • Staff, nurses, and physicians
  • Directors of maintenance and facility services
  • Staff in  materials management, environmental services, security, and biomedical engineering
  • Directors overseeing environment of care requirements and staff
  • Quality improvement coordinators
  • Compliance officers
  • Directors of Regulatory Affairs
  • Hospital board members
  • Nurse educators
  • Clinic and outpatient managers
  • Department directors/nurse managers

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About Our Speaker

Sue Dill Calloway - Hospital Coding Expert

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...   More Info
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