This message is sent to you by FDA Newswatch

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

Thursday June 28 2018  10:00 AM PDT | 01:00 PM EDT

Training Duration = 120 Min                    Sponsored by Compliance Online

Click Here to register $449.00

Click Here to register and receive recording $299.00

This webinar will discuss the CMS requirements(tag numbers 144 in patient rights and tag 701 in facility services) for hospitals to prevent ligature risk and self-harm from patients that are suicidal.

Why Should You Attend:

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

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

Instructor

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.