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Webinar – Ligature Risk: Ensuring Compliance with CMS Hospital CoPs

September 11 @ 9:00 am - 11:00 am

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Every hospital needs to attend this webinar. It is now a hot area and there is a lot of survey activity around prevention of suicidal patients from harm or strangulation. The Joint Commission announced that this is one of the four top areas of focus and their data shows that hospitals are receiving many RFIs in this area. The Centers for Medicare and Medicaid Services (CMS) has promulgated requirements for hospitals to prevent ligature risk and self harm from patients that are suicidal. A 13 page memo was issued and the hospital manual was amended on December 29, 2017 to implement these changes. Any hospital that received Medicare, which is most hospitals in America, must implement these changes for all patients.

CMS amends tag numbers 144 in patient rights and tag 701 in facility services. This 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. If you have a highly suicidal patient and the room is not ligature resistant do you have a 1:1 sitter? Hospitals that do not will need to change their policy and process and budget for this.

Joint Commission has 16 requirements to ensure compliance with their standards. These will 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, NPSG 15 and final changes July 1, 2019, and Frequently Asked Question (FAQ) on ligature risk will be covered. This includes one related to whether video monitoring is ever allowed. Again, the Joint Commission announced that this is one of four area of focus so hospitals need to have this issue on their radar screen and be prepared.

Resources will be provided. Tools to assess patients to determine if they have suicidal ideations will be included.

Objectives:

  • Recall that CMS now has two tag numbers that set forth requirements to prevent ligature risks for patients with suicidal ideations
  • Discuss that the Joint Commission has requirements for hospitals to follow to prevent patients from self harm including hanging or strangulation
  • Describe that CMS recommends education in orientation, when policies change and every two years

 

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