Ligature and Suicide Risk: Ensuring Compliance with CMS CoPs and Joint Commission Requirements

Darlene Evans

Darlene Evans

Darlene Evans is a healthcare quality leader with more than 25 years of experience, specializing in clinical and regulatory operations management, accreditation readiness and response, staff training, and business development. With her expertise in Centers for Medicare and Medicaid Services, Joint Commission, and Healthcare Facilities...
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90 Mins
Darlene Evans

There is a great deal of survey activity around the prevention of suicidal patients from any harm or strangulation. Any hospital that received Medicare, which are most hospitals in America, must implement these changes for all patients. Moreover, CMS tag numbers 144 inpatient rights and tag 701 in facility services 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 multiple requirements to ensure compliance with their standards. These will be discussed and will include psychiatric hospitals, behavior health units, general acute care inpatient units, and emergency departments. 

Resources will be provided including tools to assess patients to determine if they have suicidal ideations

Webinar Agenda

  • CMS Hospital Ligature Risk
    • CMS CoP manual 
    • Deficiency reports
    • Suicide rates and processed to consider
    • What is a ligature risk? CMS definition
    • Anchor points and examples
    • Tag 144 – patient safety and rights
    • Policy and procedure requirements
    • Education recommendations
    • Competency requirements
    • Patient assessment
    • Tag 701 and Environmental assessment
    • Correction of environmental risk
  • Joint Commission
    • Requirements to prevent suicide
    • 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, and toilets
    • 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
    • ED and safe rooms
    • TJC ligature risk FAQs
    • NPSG 15 January 2022
  • Resources and Tools
    • Behavioral Health Design Guide
    • Suicide prevention resource center
    • VA/DoD Clinical practice guidelines
    • Suicide prevention guidelines for training
    • Patient health questionnaire PHQ-9 and 3
    • ED-SAFE screeners
    • Patient safety secondary screener
    • ED Suicide Béhavioral 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 Should Attend

  • 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
  • Hospital risk managers 
  • Hospital legal counsel
  • Patient safety officer
  • CEO, COO, CNO, and nurse supervisors
  • Chief medical officers
  • Director of maintenance and facility services
  • Environmental Services
  • Security
  • Director in charge of the environment of care requirements and staff
  • Quality improvement coordinator
  • Compliance officer
  • Director of Regulatory Affairs
  • Nurse educator
  • Clinic and outpatient managers
  • All department directors/nurse managers such as ED, ICU, CCU, Med-Surg managers, outpatient, etc.
  • Anyone responsible to ensure compliance with the CMS hospital conditions of participation and the Joint Commission standards
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