Mitigating Ligature & Self Harm Risks: Regulatory Updates and Compliance Best Practices
Tuesday, February 12, 2019 – 1:00-2:30 p.m. (EST)
Suicide is on the rise and is one of the top 10 leading causes of death in the nation. In Massachusetts, the suicide rate increased more than 35% from 1999 – 2016.* The Centers for Medicare & Medicaid Services (CMS) has taken notice, expanding the types of healthcare 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, the agency has made its intentions for compliance clear in a recently released memo. Surveyors and healthcare providers must follow recommendations developed by The Joint Commission’s (TJC) multi-stakeholder Suicide Panel. CMS representatives were participants on that panel and plan to incorporate its recommendations into the next release of the Interpretive Guidelines.
Join us for this important webinar and hear representatives from TJC and JLL healthcare consultants 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 and Prevention, https://www.cdc.gov/vitalsigns/suicide
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 expansion: Inpatient psychiatric hospitals, psychiatric units in acute care hospitals, non-behavioral health units designated for psychiatric patients (ex. ED safe rooms and 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 involuntary psychiatric hold
-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
Kathryn D Petrovic, MSN, RN-BC, Field Director, Surveyor Management and Development, Accreditation and Certification Operations, The Joint Commission
Kathryn Petrovic is currently a field director in the department of surveyor management and development for the behavioral healthcare and psychiatric hospital programs at The Joint Commission. In this role, she is responsible for providing direction and leadership to surveyors. Ms. Petrovic also hires, trains, and evaluates surveyors and ensures surveyed organizations receive excellent customer services and that the on-site accreditation needs of TJC’s customers are met.
Previously, Ms. Petrovic was the senior associate director at the Joint Commission’s Standards Interpretation Group. In this position, she provided oversight for the behavioral healthcare, hospital, critical access, and ambulatory care programs. She also served as a surveyor, and consulted in the development and revision of standards and survey processes. Ms. Petrovic is a Certified Yellow Belt. With this designation, she supports The Joint Commission’s activities associated with establishing and sustaining a Robust Process Improvement® culture. As a Certified Yellow Belt, she is trained in the foundational concepts and tools of problem solving and makes improvements to better meet customer expectations and organization objectives.
Certified in psychiatric-mental health nursing by the ANCC, Ms. Petrovic has more than 17 years of behavioral health nursing experience. Prior to joining The Joint Commission, she served as the Director of Nursing of the Behavioral Health & Obstetric departments at AMITA Health Adventist Medical Center GlenOaks in Illinois where she was responsible for clinical, operational, and financial oversight. Ms. Petrovic received her BS degree in nursing from Saint Mary’s College, Notre Dame, Indiana, and her masters in nursing administration from the University of St. Francis in Joliet, Illinois.
Emily J. Wells, MSW, CSW, Project Director, Surveyor Management and Development, The Joint Commission
Emily Wells is currently a project director for the department of surveyor management and development in the division of accreditation and certification operations at The Joint Commission. In this role, she manages projects, processes, and performance improvement initiatives that help support Joint Commission surveyors, reviewers, and senior leadership. She also serves as a surveyor in the behavioral healthcare program, and has been with The Joint Commission for more than eight years.
Ms. Wells is a certified social worker licensed in the state of Nebraska. She has experience in various clinical healthcare settings including community-based mental health and substance abuse treatment programs (residential and outpatient), child welfare agencies, and intake and assessment for adults and adolescents. She also has experience in grant writing and providing clinical education for licensed professionals in the areas of screening, assessment, and diagnosis.
Ms. Wells received her master’s degree in clinical social work from The University of Chicago, and graduated from Augustana College, Rock Island, Illinois, with a triple major bachelor’s degree in psychology, sociology, and social welfare (concentration). She is also a Certified Yellow Belt and Certified Green Belt under The Joint Commission’s Robust Process Improvement® initiative.
Kathy Tolomeo, CHEM, CHSP, Director, Compliance Strategies, Safety, Security, and Emergency Management, JLL, Healthcare Solutions
Kathy Tolomeo is the director of compliance strategies for the healthcare solutions division of JLL. In this role she provides platform support for safety and emergency management. Prior to joining JLL, Ms. Tolomeo was an engineer for the standards interpretation group of The Joint Commission for four and a half years, where she provided standards interpretation, supported the post‐survey process, managed the Statement of Conditions, managed ligature extensions, was a member of the suicide panel, conducted intracycle monitoring conference calls, and served as faculty for educational programs. She is also a nationally recognized speaker.
Additionally, Ms. Tolomeo has 12 years of experience in healthcare in facilities management as safety manager/officer. In addition to leading the environment of care and life safety committees, she has been responsible for overseeing several construction projects, including a 100,000-plus sq. ft. addition; and multiple process improvements and efficiency initiatives related to regulatory compliance, emergency management, life safety code management, risk assessments, environmental monitoring, hazardous materials and waste, security, and customer service. Ms. Tolomeo is a Certified Healthcare Environmental Manager, Certified Healthcare Safety Professional, and is a Certified Yellow Belt. She also has had leadership training by the Studer Group, GE, and Six Sigma. Ms. Tolomeo received her BS degree from St. Mary’s University in Winona, Minnesota.