CMS Conditions of Participation

Update on ligature risks and suicide prevention

Nov. 17, 2022, 12:00 - 1:30 p.m.


According to CMS and accrediting organizations such as Det Norske Veritas, Inc. (DNV) and Joint Commission, one of the most cited deficiencies at the immediate jeopardy level is under patient's 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 and the hospital’s responsibility to provide care and safety to psychiatric patients who are risk of harm to themselves, or others is one of their primary concerns. 


  • 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 Joint Commission Suicide Panel's 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 immediate jeopardy and CoP level deficiencies relating to patient safety 


Nancy Ruzicka, BS, RPh, MBA, MJ, CHC has experience teaching and assisting hospitals and other health care facilities in understanding applicable federal and state laws, rules, regulations, and interpretative guidelines. Her experience also encompasses teaching all levels of health care staff in understanding compliance and HIPAA requirements.

Nancy’s previous experiences include director of integrity and compliance and privacy official, director of regulatory compliance and over twenty years of experience with Iowa Department of Inspections and Appeals. Nancy received her Master of Jurisprudence (MJ) in Health Law, Master of Business Administration, and Bachelor of Science in Pharmacy from Drake University, Des Moines. She is certified in Healthcare Compliance (CHC) and maintains her Iowa pharmacy license.

Recommended to attend

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 chief executive officer, chief medical officers, chief nursing officers, 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.

Continuing Education

This program has been designed to meet the Minnesota Board of Nursing continuing education requirements for a total of 1.5 contact hours.

Nursing Home Administrators: The content of this conference is being reviewed by the Board of Examiners for Nursing Home Administrators for clock hours. The quantitative value assigned will be indicated on the certificate of attendance awarded to participants who attend sessions. 


  • $45 per person for MHA member hospital and health systems
  • $45 per person for MHA associate members
  • $60 per person for nonmembers 

Registration deadline

Please register by noon on the day before the webinar to ensure timely delivery of access instructions.

Approximately four business days before the web conference, you will receive an email containing instructions on connecting. Advance registration is required to ensure the delivery of instructional materials.

If you do not receive an email prior to the program with web conference details, please connect with our events and education through Contact Us.

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When and Where
  • 11/17/2022 12:00 PM CST
  • 11/17/2022 1:30 PM CST
  • Zoom Webinar