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Ligature Risk and Suicide Prevention Regulation

January 30, 2020 @ 10:00 am - 12:00 pm

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Hospitals must comply with CMS conditions of participation (CoPs) or face penalties. According to CMS and accrediting organizations such as Der Norske Veritas and The Joint Commission (TJC), one of the most commonly cited deficiencies at the immediate jeopardy level is about the rights of patients to receive care in a safe setting. According to CMS, ligature risks compromise a patient’s right to receive care in a safe setting. The hospital’s responsibility to provide care and safety to psychiatric patients at risk of harm to themselves or others is one of CMS’ primary concerns. This webinar will explain the specific guidance surveyors use to determine compliance with providing care in a safe environment.

Learning Objectives:

  • Describe CMS’ requirements for providing care in a safe environment for patients, specifically those who are suicidal or in need of behavioral health services.
  • Discuss CMS’ adoption of TJC suicide panel recommendations for the comprehensive ligature risk interpretative guidelines.
  • Discuss physical environment and personal belongings issues.
  • Provide examples of immediate jeopardy and CoPs-level deficiencies relating to patient safety.

Who Should Attend:

This program is intended for all hospitals including general acute, critical access and psychiatric hospitals, and anyone involved with compliance regulations and standards, including CEOs, CMOs, CNOs, physicians, nurses, quality improvement staff, risk managers, compliance officers and legal counsel, safety officers, behavioral health and psychiatric staff, and emergency department staff


Nancy Ruzicka is a consultant on state and federal rules, regulations and interpretative guidelines. She previously worked as director of integrity and compliance and privacy official at MercyOne Des Moines and director of regulatory compliance at UnityPoint Health-Des Moines. She also has more than 20 years of experience with the Iowa Department of Inspections and Appeals. Ruzicka holds master’s degrees in health law and business administration and a bachelor’s degree in pharmacy, all from Drake University. She is certified in health care compliance and maintains her Iowa pharmacy license.