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

*This program has the prior approval of AAPC for 2 continuing education hours. Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor.

Ligature Risks: Meeting the CMS Hospital and Joint Commission Requirements

CMS amends tag numbers 144 in patient rights and tag 701 in facility services. This discusses what units need to be ligature resistant. Hospitals that do not will need to change their policy and process and budget for this. This 2 hour comprehensive webinar will cover the new proposed changes by CMS to the ligature risk requirements.

Every hospital needs to attend this webinar. It is now a hot area and 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.

Session Objectives:

  • 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

Session Agenda:: 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

li>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 has 16 requirements to ensure compliance with their standards that will be covered in detail. 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.

  • 13 requirements to prevent suicide

  • 3 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

  • 02.06.01 EP 1 requirements

  • Dedicated verses non-dedicated spaces

  • Suicide risk reduction

  • Zero suicide campaign

  • TJC ligature risk FAQs

  • TJC sentinel event alerts on suicide and SEA 56

  • NPSG 15 and changes July 1, 2019

CMS expert Speaker Sue Dill, with 3 decades of experience in hospital compliance will explain key initiatives and equip you with all Resources and Tools to assess patients to determine if they have suicidal ideations, besides simplifying documentation rules. Few important Resources and tools of the trade that will be covered are,

  • 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, SAFE-T Assessment

  • C-SSRS Columbia Suicide Severity Rating Scale

  • 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

  • All hospital risk managers, Hospital legal counsel, Patient safety officer

  • Chief medical officers, CEO, COO, CNO, and Nurse supervisors

  • Director of maintenance and facility services, Security

  • Biomedical engineering, Materials management

  • Director in charge of environment of care requirements and staff, Environmental Services

  • Quality improvement coordinator, Compliance officer

  • Director of Regulatory Affairs, Board members

  • Nurse educator, Clinic and outpatient managers

  • All department directors/nurse managers such as ED, ICU, CCU, Med-surg managers, outpatient, etc.

  • Anyone who is responsible to ensure compliance with the CMS hospital conditions of participation and the Joint Commission standards

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

Webinar Information

Date / Time : 30 May 2019 @ 01:00 PM EST

Duration : 120 Mins

Number Of Attendees

Avail Discount At Checkout

For Group Registration
Contact 1888-437-7218 or
Email us at

Speaker Detail

Sue Dill Calloway RN, Esq. CPRHM CCMSCP AD, BSN, MSN, JD

Alt Text Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is also the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation and a board member. She was a director for risk management and patient safety for readmore...


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Webinar Information

Date / Time : 30 May 2019 @ 01:00 PM EST

Duration : 120 Mins

Number Of Attendees

Avail Discount At Checkout

For Group Registration
Contact 1888-437-7218 or
Email us at