Ligature Risks: Ensuring Compliance with the CMS Hospital CoPs and TJC Requirements 2018

Ligature Risks: Ensuring Compliance with the CMS Hospital CoPs and TJC Requirements 2018 is a webinar dedicated to the amended CMS requirements for preventing ligature risk and self-harm from patients that are suicidal.

Topics

• Introduction
• CMS Hospital Ligature Risks
• Amends tag 144 and 701
• 13 page memo and manual updated
• Suicide 10th leading cause of death
• Deficiency reports
• Anchor points and examples
• What is a ligature risk? CMS definition
• Education recommendations
• Policy and procedure requirements
• Patient assessment
• Competency requirements
• Correction of environmental risk
• Environmental assessment
• Things to do to reduce ligature risk
• Design guide for creating safe rooms
• VA mental health guide and checklist
• Documentation requirements
• Ligature resistant requirements
• When are sitters or 1:1 observers required?
• 13 requirements to prevent suicide
• Joint Commission
• Sentinel event reduction doors and soft suicide prevention doors
• Recommendation for psych unit, psych hospital, and general acute care settings including emergency departments
• Shower curtains
• Ceilings, beds, and toilets
• EC.02.06.01 EP 1 requirements
• SAFER matrix and when at risk for getting RFI
• Suicide risk reduction
• Dedicated verses non-dedicated spaces
• TJC ligature risk FAQ
• Zero suicide campaign
• NPSG 15
• TJC sentinel event alerts on suicide and SEA 56
• Suicide prevention resource center
• Resources and tools of the trade
• Suicide prevention guidelines for training
• VA/DoD Clinical practice guidelines
• Patient health questionnaire PHQ-9 and 3
• Design guide for built environment of behavioral health facilities
• Patient safety secondary screener
• ED-SAFE screeners
• Environmental Assessment
• ED" Suicide Behaviors Questionnaire SBQ-R
• SAFE-T Assessment
• C-SSRS Columbia Suicide Severity Rating Scale
• NY patient safety standards guidelines
• Suicide Prevention Decision Support Tool and more

Who should Attend

• All staff, nurses, physicians and providers at Psychiatric hospitals
• All staff, nurses, physicians and providers on the hospital behavioral health unit
• 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 staff, nurses, physicians, and providers in hospital emergency departments
• Hospital legal counsel
• All hospital risk managers
• CEO, COO, CNO, and nurse supervisors
• Patient safety officer
• Director of maintenance and facility services
• Chief medical officers
• Materials management
• Biomedical engineering
• Security
• Environmental Services
• Quality improvement coordinator
• Director in charge of environment of care requirements and staff
• Director of Regulatory Affairs
• Compliance officer
• Nurse educator
• Board members
• All department directors/nurse managers such as ED, ICU, CCU, Med-surg managers, outpatient, etc.
• Clinic and outpatient managers
• Anyone who is responsible to ensure compliance with the CMS hospital conditions of participation and the Joint Commission standards