Registration fees for webinars are $175/member and $300/non-member unless otherwise noted in an event description.

NDHA is an approved provider of continuing education by the North Dakota Board of Examiners for Nursing Home Administrators.

Update on Ligature Risks, Suicide Prevention, Restraints & Seclu

Date: 03/24/2021

12:00 PM - 2:00 PM

Target Audience

This program is intended for all hospitals including general acute hospitals, critical access hospitals (CAH), psychiatric hospitals, hospitals or CAH with psychiatric units and anyone involved with compliance regulations and standards, including but not limited to CEO, CMO, CNO, physicians, nurses, quality improvement staff, risk managers, compliance officers and legal counsel, Joint Commission liaisons, safety officers, behavioral health and psychiatric staff, Emergency department staff, and other interested staff.


Hospitals must comply with the Centers for Medicare & Medicaid Services Conditions of Participation. According to CMS and accrediting organizations such as DNV and Joint Commission, one of the most cited deficiencies at the immediate jeopardy level is under Patient Rights regarding the rights of patient to receive care in a safe setting. According to CMS, ligature risks compromise patient’s right to receive care in a safe setting. In addition, the hospital’s responsibility to provide care and safety to psychiatric patients who are at risk of harm to themselves or others is one of their primary concerns. Another one of the most cited Condition Level deficiencies is the Patient Rights and Responsibilities Condition. Regulations governing appropriate restraint and seclusions account for more than 50% of the Patient Rights and Responsibilities Condition. This webinar will address each of these important issues.


Learning Objectives


  • Describe the CMS requirements for providing care in a safe environment for all patients, specifically those patients who are suicidal or in need of behavioral health services.
  • Explain what an immediate jeopardy citation means to the hospital
  • Explain the implications of a Condition Level deficiency
  • Discuss the CMS adoption of the TJC (The Joint Commission) Suicide Panel recommendations of the comprehensive ligature risk interpretative guidelines
  • Explain the specific guidance that surveyors utilize in determining compliance with providing care in safe environment
  • Discuss physical environment issues
  • Discuss potential issues with personal belongings
  • Provide examples of IJ and COP level deficiencies relating to patient safety
  • Explain CMS definitions of restraints and seclusion
  • Describe which restraint regulations which are at greatest risk for citation and how to prevent
  • Explain requirements to utilize restraints
  • Explain which deaths while in restraints must be reported to CMS
  • Describe the internal log requirements for restraint deaths



Nancy Ruzicka, RPh, MBA, MJ, CHC

Nancy Ruzicka has experience teaching and assisting hospitals and other healthcare facilities in understanding applicable Federal and State laws, rules, regulations and interpretative guidelines. Her experience also encompasses teaching all levels of healthcare staff in understanding compliance and HIPAA requirements.

Ruzicka’s previous experiences include Director of Integrity & Compliance and Privacy Official at Mercy Medical Center, Des Moines; Director of Regulatory Compliance at UnityPoint Health and over twenty years of experience with Iowa Department of Inspections and Appeals.

She received her MJ in Health Law, MBA and BS in Pharmacy from Drake University, Des Moines. She is certified in Healthcare Compliance (CHC) and maintains her Iowa pharmacy license.

Ruzicka Healthcare Consulting, LLC has an outstanding reputation for providing solutions through consulting, education, and mock surveys. They focus on current needs and challenges related to regulatory compliance and accreditation. Ruzicka Healthcare Consulting, LLC brings expertise in regulatory, compliance, and accreditation in a customized client focus for proven results.