The Latest for CMS Ligature Risks: New Changes & Compliance with CMS, CoPs and TJC
Summary
CMS just released 15 pages of proposed changes to the CMS Conditions of Participation (CoP) requirements to prevent ligature risk and self-harm for patients that are suicidal. This workshop will include these brand-new guideline changes CMS just released for 2019. Changes include revisions to the patient rights and facility services sections of the CoPs. These impact not only behavioral health hospitals and behavioral health units but also any unit with patients with suicidal ideations such as the emergency department or medical surgical units.
The Joint Commission (TJC) also has requirements to ensure compliance with their standards on reducing ligature risk in psych hospitals, behavior health units, and general hospital inpatient units, outpatient units and emergency departments.
CMS expert, Sue Dill Calloway, will provide complete details on how to comply with CMS standards and TJC requirements to reduce ligature risk as well as gain an understanding of TJC's zero-suicide campaign.
- Joint Commission requirements to reduce ligature and environmental risk
- The brand-new, 15-page proposed guidelines for 2019
- Amendments made to tag 144 and 701
- Frequently Asked Question (FAQ) on ligature risks
- Tools to assess patients to determine if they have suicidal ideations
Program Highlights
CMS CoPs: Just released: Changes to Patient Rights, Ligature Risks and TJC Compliance
- What patient assessments must be completed
- The 16 Requirements to ensure TJC compliance across facilities/li>
- 13-page memo and manual updated
- CMS amends tag numbers 144 in patient rights and tag 701 in facility services
Policy and Procedure Requirements: Reduce Risk of Self-Harm and Suicide
- Education, training & competency requirements for staff
- Criteria for designing safe patient rooms and correcting risk
- TJC Focus: What to prepare for, look for and know
- Ligature-resistant requirements to reduce suicide by strangulation
Real-life examples of actions to take to prevent patient suicide
- Joint Commission: Guidance for Psych Units, Hospitals and Emergency Departments
- TJC's standards to identify, mitigate and prevent patient suicide
- Sentinel event alerts on suicide, SEA 56 and NPSG 15
- Zero suicide campaign - guidance to prevent self-harm
Question and Answer Session - Hear expert answers to real-world questions!
About the Speaker
Sue Dill Calloway, RN, MSN, JD CPHRM, CCMSCP, has been a nurse attorney and medical-legal consultant for more than 30 years. She has presented numerous educational programs for nurses, physicians, and other health care professionals on topics such as patient safety, Joint Commission, CMS, and HIPAA issues.
Sue is the past Director of Hospital Patient Safety with The Doctors Company and OHIC Insurance Company. She is on the board for the Emergency Medicine Patient Safety Foundation and previously was their chief learning officer.
- Sue has prior experience as a nursing professor, medical malpractice defense attorney, and director of health policy and risk management for eight years for the Ohio Hospital Association.
- Sue is also past VP of legal services, compliance officer and privacy officer for a community hospital. Sue was part of the patient safety committee and involved in risk management activities.
- She has written 102 books and thousands of articles.
Program Benefits
The Joint Commission announced that this is one of the four top areas of focus. 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. Every hospital needs to attend this workshop and be familiar with the brand-new updates that were just released.
