Education event

Ligature and Self-Harm Risks Webinar
Regulatory Updates and Compliance Expectations for all Hospitals

Registration is now closed.
Please call CHA Education at (916) 552-7637.

October 2, 2018
10:00 – 11:30 a.m., Pacific Time


Suicide is on the rise and a leading cause of death in the nation. In California, the rate increased nearly 15 percent from 1999 – 2016.* The Centers for Medicare & Medicaid Services (CMS) has taken notice too, expanding the types of health care facilities and hospital areas that must comply with the Medicare Conditions of Participation (CoPs) regarding ligature and other self-harm risks. 

While CMS’ Interpretive Guidelines regarding ligature compliance are still in development, they have made their intentions for compliance clear in a recently released memo. Surveyors and health care providers are to follow recommendations developed by The Joint Commission’s (TJC) multi-stakeholder Suicide Panel. CMS representatives were panel participants and plan to incorporate the panel’s recommendations into the next release of the Interpretive Guidelines.  

Join us for this important webinar and hear representatives from TJC explain the steps that all hospitals should take to maintain compliance with Medicare CoPs. Hospital representatives will share practical ways to maintain CoP compliance and provide safer environments for at-risk patients.

*Source: Centers for Disease Control,

Recommended for:

Chief nursing officers and managers, chief risk officers and risk managers, facility engineers, compliance officers, behavioral health care directors and managers, and ED directors and managers. 


Background — CMS Conditions of Participation for Ligature/Self Harm

  • How the issue of suicide risk is evolving
  • Shifting CoP categories — from Physical Environment to Patients’ Rights
  • Survey expands — inpatient psychiatric hospitals, psychiatric units in general acute care hospitals, non-behavioral health units designated for psychiatric patients (ED safe rooms, medical units)
  • Interim guidance — CMS Memo supporting The Joint Commission (TJC) panel recommendations

TJC Suicide Panel Recommendations

  • Which patients must be assessed for suicide risk, how to rate, ongoing assessment
  • Training staff to ID risk levels, implement interventions
  • Requirements for designated and non-designated rooms, equipment risks
  • Keeping an eye on patients — video requirements, sitters, patients on 5150
  • Citations and Plans of Corrective Action
  • Upcoming revisions to Interpretive Guidelines — what to expect from CMS

Protecting Patients — Hospital Representatives Share Practices and Insights

  • Policies and procedures that promote patient safety
  • Practical application of CoP requirements


From The Joint Commission (TJC):

Kathryn Petrovic is a field director in the department of Surveyor Management and Development for the Behavioral Health Care and Psychiatric Hospital programs at TJC. She is responsible for hiring, training and providing direction to surveyors. Ms. Petrovic previously served as senior associate director at TJC’s Standards Interpretation Group, where she provided oversight for the behavioral health care, hospital, critical access and ambulatory care programs. Certified in psychiatric-mental health nursing by the ANCC, Ms. Petrovic has more than 17 years of behavioral health nursing experience.

Herman McKenzie is an engineer in the Standards Interpretation Group of TJC. He provides standards interpretation, reviews survey reports, conducts Intracycle Monitoring conference calls, and serves as faculty for educational programs. Mr. McKenzie is trained under the Comprehensive Accreditation Manual for Hospitals and the Comprehensive Accreditation Manual for Critical Access Hospitals as well as Ambulatory Care. He has more than 25 years of health care experience having held managerial and director level roles in clinical engineering, plant operations and facilities services throughout the Chicago area.

From College Hospital Costa Mesa:

Nicolette Pacheco is manager of quality improvement, risk management & infection prevention for College Hospital Costa Mesa (CHCM), a 122-bed acute care hospital offering medical/surgical services and a full spectrum of psychiatric services to treat adults and adolescent patients. Ms. Pacheco is primarily responsible for regulatory compliance, ensuring CHCM meets the standards of performance set by The Joint Commission, CMS and other regulatory agencies. She serves as the hospital’s Patient Safety Officer and also oversees all risk management activities in coordination with the corporate risk manager.

Anthony Gonzalez is director of engineering at CHCM and is responsible for the maintenance of nearly 67,000 sq. ft. of acute care hospital space with 122 beds in secure units. Mr. Gonzalez maintains CHCM’s fire life safety compliance to TJC and CMS standards, which includes documentation, inspections and testing, and also manages their preventative maintenance program. During his tenure he has managed and completed seven OSHPD construction projects.


Full participation in the webinar is required to receive professional continuing education (CE) credit. The registrant must complete an online evaluation, attest to participation and, when required, provide a professional license number.

Behavioral/Social Work — This course meets the qualifications for 1.5 hours continuing education credit for LMFTs and LCSWs as required by the California Board of Behavioral Sciences. California Hospital Association is a California Association of Marriage and Family Therapist-approved provider, #CEP 128427.

Learning Objectives: At the conclusion of this webinar participants will be able to:
1. List environments in the health care setting in which CMS expects compliance with ligature and other self-harm risks.
2. Identify which patients must be assessed for suicide risk, how to rate, and the requirements to fulfill ongoing assessment.
3. Direct change in their own facilities to promote safety from ligature and self-harm in designated and non-designated spaces and other equipment risks.
4. Identify patient supervision requirements for video, sitters and patients on 5150s.

Compliance — The Compliance Certification Board (CCB)® has approved this event for up to 1.8 CCB CEUs. Continuing Education Units are awarded based on individual attendance records. Granting of prior approval in no way constitutes endorsement by CCB of this event content or of the event sponsor.

Health Care Executives — CHA is authorized to award 1.5 hours of pre-approved ACHE Qualified Education credit for this program toward advancement, or recertification, in the American College of Healthcare Executives. Participants in this program who wish to have the continuing education hours applied toward ACHE Qualified Education credit must self-report their participation. To self-report, participants must log into their MyACHE account and select ACHE Qualified Education Credit.

Nursing — Provider approved by the California Board of Registered Nursing, Provider CEP #11924, for 1.8 contact hours.


Members $135
Nonmembers $185
Multiple staff can participate from one location for one tuition fee.

Members are CHA member hospitals, CHA associate members and government agencies. Nonmembers are limited to non-hospital health care providers, clinics, post-acute facilities, and consultants, insurance companies, law firms and other entities that serve hospitals. Education programs and publications are a membership benefit and are not available to eligible nonmember California hospitals.

Cancellation Policy/Late Payment: A $50 non-refundable processing fee will be retained for each cancellation. Cancellations must be made in writing seven or more business days prior to the scheduled session and emailed to No refunds will be made after these dates. Substitutions are encouraged. Please note that payment is due on or before the program. Payments not received by the program date may be subject to a 10% late fee. In the unlikely event the program is cancelled, CHA will fully refund paid participants within 30 days.

Special Accommodations or Questions: If you require special accommodations pursuant to the Americans with Disabilities Act, or have other questions, please call (916) 552-7637.