November 10, 2020




120 Min


Sue Dill Calloway, RN, Esq.

Comply with CMS & TJC Ligature Risk Management Rules for Hospitals
Trending 11/10/2020

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 discuss 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.

Webinar Objectives

  • 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

Webinar Agenda

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 verses 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 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

Webinar Highlights

  • How CMS defines ”ligature risk”
  • What to make of CMS’s 13-page memo on ligature risk management
  • How the changes to tags 144 (patient rights) & 701 (facility services) impact your hospital
  • What the zero-suicide campaign is—and why you need to know
  • How to comply with TJC’ 13 requirements on ligature risk management
  • Which assessment tools to use to determine suicide risk
  • What design guides you can use to create safe rooms
  • How to reduce ligature risk
  • How the following relate to ligature risk management:
    • TJC Sentinel Event Alerts on Suicide
    • National Patient Safety Goal (NPSG) 15
    • FAQs on ligature risk
    • The SAFER matrix
    • EC.02.06.01 EP 1 requirements

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
  • Director of 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


Webinar Planet Speaker Sue Dill Calloway RN, Esq.

Sue Dill Calloway RN, Esq.

(A.D., B.A., B.S.N., M.S.N., J.D. CPHRM, CCMSCP, CC)

Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is also the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation and a board member. She was a director for risk management and patient safety for five years for the Doctors Company. She was the past VP of Legal Services at a community hospital in addition to being the Privacy Officer and the Compliance Officer. She worked for over 8 years as the Director of Risk Management and Health Policy for the Ohio Hospital Association. She was also the immediate past director of hospital patient safety and risk management for The Doctors Insurance Company in Columbus area for five years. She does frequent lectures on legal, patient safety, and risk management issues and writes numerous publications. Sue has been a medico-legal consultant for over 30 years. She has done many educational programs for nurses, physicians, and other health care providers on topics such as nursing law, ethics and nursing, malpractice prevention, HIPAA medical record confidentiality, emergency department patient safety, and risk, EMTALA anti-dumping law, Joint Commission issues, CMS issues, documentation, implementing a falls program, medication errors, medical errors, documentation, pain management, federal laws for nursing, sentinel events, MRI Safety, Legal Issues in Surgery, patient safety and other similar topics. She is a leading expert in the country on CMS hospital CoPs issues and does over 250 educational programs per year. She was the first one in the country to be a certified professional in CMS. She also teaches the course for the CMS certification program.