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

Sue Dill Calloway

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This webinar will discuss the CMS requirements(tag numbers 144 in patient rights and tag 701 in facility services) for hospitals to prevent ligature risk and self-harm from patients that are suicidal.

Why Should You Attend:

CMS amends tag numbers 144 in patient rights and tag 701 in facility services. This webinar will 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.

Joint Commission has 13 requirements to ensure compliance with their standards. These will be discussed in detail and include psych hospital, 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, NPSH 15, and Frequently Asked Question (FAQ) on ligature risk will be covered.

Who Will Benefit:

  • 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 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

Areas Covered in the Webinar:

CMS Hospital Ligature Risks
Joint Commission
Resources and tools of the trade
  • Introduction
  • 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
  • 13 requirements to prevent suicide
  • 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 FAQ
  • TJC sentinel event alerts on suicide and SEA 56
  • NPSG 15
  • 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 Events
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Training CD-USB

Physical CD-USB of recorded session will be despatched after 72 hrs on completion of payment

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Recorded video

Recorded video session

Premier pro price: $404 (save 10%)


Speaker: Sue Dill Calloway, Chief learning officer, Emergency Medicine Patient Safe

Sue Dill Calloway, RN, MSN, JD, is a nurse attorney, a medical legal consultant and the past chief learning officer for the Emergency Medicine Patient Safety Foundation. She is the immediate past director of Hospital Patient Safety and Risk Management for The Doctors Company. She is currently president of Patient Safety and Health Care Education and Consulting. Sue was a medical malpractice defense attorney for many years and a past director of risk management for the Ohio Hospital Association. She was in-house legal counsel for a hospital in addition to being the privacy officer and compliance officer.

She has done many educational programs for nurses, physicians, and other health care providers. She has authored over 102 books and numerous articles. Sue is a frequent speaker and is well known across the country in the area of healthcare law, risk management, and patient safety. She has taught many educational programs and written many articles on compliance with the CMS and Joint Commission restraint standards.


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