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

Every hospital needs to attend this webinar. It is now a hot area and there is a lot of survey activity around the 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. Any hospital that received Medicare, which is most hospitals in America, must implement these changes for all patients. This webinar will also discuss the CMS proposed 15-page guidelines changes for 2020.

CMS amends tag numbers 144 inpatient 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 its standards. These will be discussed in detail and include psych hospitals, 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 areas 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.

• Recall that CMS now has two tag numbers that set forth requirements to prevent ligature and suicide 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
• Recall that CMS has proposed guidelines

CMS Hospital Ligature Risks

• Introduction
• 15 pages proposed guidelines for 2020
• 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
• 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
• EC.02.06.01 EP 1 requirements
• Dedicated versus non-dedicated spaces
• Suicide risk reduction
• Zero suicide campaign
• TJC ligature risk FAQs
• TJC sentinel event alerts on suicide and SEA 56
• NPSG 15 changes July 1, 2019

Resources and tools of the trade

• Suicide prevention resource center
• VA/DoD Clinical practice guidelines
• Suicide prevention guidelines for training
• Design guide for the 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

• 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
• CEO, COO, CNO, and nurse supervisors
• Chief medical officers
• Director of maintenance and facility services
• Biomedical engineering
• Materials management
• Environmental Services
• Security
• Director in charge of an environment of care requirements and staff
• 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 responsible to ensure compliance with the CMS hospital conditions of participation and the Joint Commission standards