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Speaker: Sue Dill Calloway

 | 120 minutes | Time: 01:00 PM EST |

 

Description:

Those practices engaged hospitals must attend the session. This is a burning topic today and there is a lot of survey activity centering on the prevention of suicidal patients from harm or strangulation. As per The Joint Commission, this is one of the four areas to give major attention to while their data shows that hospitals are receiving many RFIs in this area. The CMS has disseminated requirements for hospitals to prevent ligature risk and self- harm from patients who are suicidal. Changes were made in the hospital manual on December 29, 2017 while a 13 page long memo was also issued in the same regard to execute these changes. Hospitals having received Medicare must implement these changes for all patients. This webinar will also discuss the CMS proposed 15 page-guidelines changes for 2019.  


CMS changes tag numbers 144 inpatient rights and tag 701 in facility services. This discusses what units require to be ligature resistant. It also explains what patient assessments must be done and what should be in environmental assessments. The session discusses education, 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 are devoid of the same will require amending their policy and process as well as budgeting 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.

Joint Commission has 16 requirements to ensure compliance with its standards. We will be discussing about these in details including psych hospitals, behavior health units, general acute care inpatients units, outpatient units and emergency departments. The session will also discuss about zero suicide campaign. The TJC sentinel event alerts suicide, NPSG 15 and final changes July 1, 2019 and FAQs on ligature risks. 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.

 

 Session Outline:-

CMS Hospital Ligature Risks

  • Introduction
  • 15 pages proposed guidelines for 2019
  • 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 and 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

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

Session Objectives:-

  • Recall that CMS now has two tag numbers that set forth requirements to prevent ligature 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

 

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

 

Live: 249

DVD: 269

Recorded : 249

Transcript: 249

Live & DVD: 399

Live & Recorded: 389

Live & Transcript: 389

Recorded & Transcript: 389

Recorded & DVD: 399

DVD & Transcript: 389

Corporate Live 1-3-Attendees: 699

Corporate Live 1-6-Attendees: 1099

 

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March 4, 2020 11:00 AM