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Last December, CMS issued a 13-page memo for hospitals to prevent ligature risk and self-harm from patients who are suicidal. Tag 144 and Tag 701 were amended to reflect these changes, specifically on patient assessments, environmental assessments, unit updates, and education requirements. This program will review CMS and The Joint Commission’s requirements on ligature risks, TJC’s Sentinel Event Alert on suicide, Zero Suicide Campaign, and National Patient Safety Goals.
Our expert will address FAQ on ligature risks and provide tools and resources to help hospitals assess patients. Ensure you have required policies and procedures in place to protect your patients.
CMS Hospital Ligature Risks
|- Definition of ligature risks||- Tag 144 & 701||- Deficiency reports|
|- 13-page memo||- Anchor points & examples||- Education recommendations|
|- Patient assessment||- Documentation requirements||- VA mental health guide & checklist|
|- Safe room requirements||- 1 to 1 observers||- Ligature resistant requirements|
|- Environmental assessment||- Environmental risk||And more!|
The Joint Commission
|- TJC's SAFER Matrix & risk for getting RFI||- Recommendation for psych hospitals & acute care settings||- TJC's Sentinel Event Alert on suicide & SEA 56|
|- Sentinel event reduction doors||- Soft suicide prevention doors||- TJC's ligature risk FAQs|
|- Dedicated vs. non-dedicated spaces||- TJC's EC.02.06.01 EP1 requirements||- Zero Suicide Campaign|
|- TJC's 13 requirements||- Suicide risk reduction||And more!|
Resources & Tools of the Trade
|- Columbia-Suicide Severity Rating Scale||- Design guide for behavioral health facilities||- Suicide prevention decision support tool|
|- Suicide Assessment Five-Step Evaluation and Triage Assessment||- Suicide Behaviors Questionnaire-Revised||- Patient Health Questionnaire-9|
|- ED-SAFE materials||- Suicide prevention resource center||- VA/DoD clinical practice guidelines|
|- NY patient safety standards guidelines||- Patient safety secondary materials||And more!|
Anyone involved with or interested in ligature risks, including but not limited to: Hospital Behavioral Health Unit Staff, Psychiatric Hospital Staff, Hospital Emergency Department, ICU Staff, Medical-Surgical Unit Staff, OB & Postpartum Staff, Outpatient Staff, Biomedical Engineers, Materials Management, Environmental Services, CEOs, CFOs, COOs, CMOs, CNOs, CE Directors, Quality Improvement Staff, Physicians, Nurses (all levels), Clinic Managers, Outpatient Directors, Compliance Officers, CMS Liaisons, TJC Liaisons, Safety Officers and Staff, Consumer Advocates, Risk Managers, Legal Counsel, Discharge Planners, Case Managers, Hospice Staff and Regulatory Affairs Staff.