2026 CMS CoPs: Ligature Risks & Preventing Inpatient Suicide




Compliance with CMS CoPs and TJC Resources 
Suicide prevention and protecting patients from harm or strangulation continues to be a major focus of accreditation surveys. Suicide is the third most frequently reported sentinel event. The Centers for Medicare & Medicaid Services (CMS) has promulgated requirements for hospitals to prevent ligature risk and self-harm from patients who are suicidal. Any hospital that receives Medicare and/or Medicaid payments must implement these regulations for all patients.

For acute hospitals, the CMS Conditions of Participation (CoPs) manual includes guidance on ligature-resistant environments under Tag A-0144 (Patient Rights) and Tag A-0701 (Physical Environment/Facility Services). These sections outline expectations for identifying areas that must be ligature resistant and describe required patient risk assessments, environmental risk assessments, staff education, and related policies and procedures.

For Critical Access Hospitals (CAHs), similar guidance appears in Appendix W of the CMS CoPs manual. In addition, 2025 regulatory updates affecting CAHs reinforce requirements related to patient rights, including the expectation that patients receive care in a safe setting. 

This program includes a discussion on The Joint Commission National Patient Safety Goals and Recommendations for Preventing Suicide in Health Care Settings. Resources will be provided along with tools to assess patients to determine if they have suicidal ideation.
 
Objectives
  • Recall that CMS now has two tag numbers that set forth requirements to prevent ligature and suicide risks for patients with suicidal ideations.
  • Describe that CMS recommends education in orientation when policies change and every two years.
  • Explain recently updated guidelines from CMS.
  • Describe TJC recommendations for psychiatric and non-psychiatric units.

Who Should Attend
Chief Medical Officer, Chief Nursing Officer, Compliance Officer, Emergency Department Personnel, Joint Commission Coordinator, Medical Records, Quality Improvement personnel, Risk Manager, Legal Counsel.

Faculty
Laura A. Dixon, BS, JD, RN, CPHRM has served as the director of risk management and patient safety for the Colorado Region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, she provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. 

Laura has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the western region Director of Patient Safety and Risk Management for The Doctors Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. 

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.
This speaker has no real or perceived conflicts of interest that relate to this presentation.

Registration Fee
$175 $150 for AHA Member Hospital Employees
AHA educational events are developed and provided for member hospitals and their employees. 
Not sure if your hospital is a member? CLICK HERE for a list of member hospitals.


How to Register
Employees of AHA member hospitals are able to log into the AHA website and register online. If you have never logged into the AHA website, please select "forgot password?" under the sign in box to set up a password for your email address that AHA has on file with your record.

Need help logging in? Please contact Laura Whitaker at (501) 224-7878 or lwhitaker@arkhospitals.org.

If you are not an employee of an AHA member hospital and would like to inquire about attendance, please contact Lyndsey Dumas, VP of Education, by email (ldumas@arkhospitals.org). Additional fees may apply if attendance is approved.


When: 05/28/2026, 09:00 AM - 10:30 AM
Where: WEBINAR

2026 CMS CoPs: Ligature Risks & Preventing Inpatient Suicide

2026 CMS CoPs: Ligature Risks & Preventing Inpatient Suicide



Compliance with CMS CoPs and TJC Resources 
Suicide prevention and protecting patients from harm or strangulation continues to be a major focus of accreditation surveys. Suicide is the third most frequently reported sentinel event. The Centers for Medicare & Medicaid Services (CMS) has promulgated requirements for hospitals to prevent ligature risk and self-harm from patients who are suicidal. Any hospital that receives Medicare and/or Medicaid payments must implement these regulations for all patients.

For acute hospitals, the CMS Conditions of Participation (CoPs) manual includes guidance on ligature-resistant environments under Tag A-0144 (Patient Rights) and Tag A-0701 (Physical Environment/Facility Services). These sections outline expectations for identifying areas that must be ligature resistant and describe required patient risk assessments, environmental risk assessments, staff education, and related policies and procedures.

For Critical Access Hospitals (CAHs), similar guidance appears in Appendix W of the CMS CoPs manual. In addition, 2025 regulatory updates affecting CAHs reinforce requirements related to patient rights, including the expectation that patients receive care in a safe setting. 

This program includes a discussion on The Joint Commission National Patient Safety Goals and Recommendations for Preventing Suicide in Health Care Settings. Resources will be provided along with tools to assess patients to determine if they have suicidal ideation.
 
Objectives
  • Recall that CMS now has two tag numbers that set forth requirements to prevent ligature and suicide risks for patients with suicidal ideations.
  • Describe that CMS recommends education in orientation when policies change and every two years.
  • Explain recently updated guidelines from CMS.
  • Describe TJC recommendations for psychiatric and non-psychiatric units.

Who Should Attend
Chief Medical Officer, Chief Nursing Officer, Compliance Officer, Emergency Department Personnel, Joint Commission Coordinator, Medical Records, Quality Improvement personnel, Risk Manager, Legal Counsel.

Faculty
Laura A. Dixon, BS, JD, RN, CPHRM has served as the director of risk management and patient safety for the Colorado Region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, she provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. 

Laura has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the western region Director of Patient Safety and Risk Management for The Doctors Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. 

As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.
This speaker has no real or perceived conflicts of interest that relate to this presentation.

Registration Fee
$175 $150 for AHA Member Hospital Employees
AHA educational events are developed and provided for member hospitals and their employees. 
Not sure if your hospital is a member? CLICK HERE for a list of member hospitals.


How to Register
Employees of AHA member hospitals are able to log into the AHA website and register online. If you have never logged into the AHA website, please select "forgot password?" under the sign in box to set up a password for your email address that AHA has on file with your record.

Need help logging in? Please contact Laura Whitaker at (501) 224-7878 or lwhitaker@arkhospitals.org.

If you are not an employee of an AHA member hospital and would like to inquire about attendance, please contact Lyndsey Dumas, VP of Education, by email (ldumas@arkhospitals.org). Additional fees may apply if attendance is approved.
When
5/28/2026 9:00 AM - 10:30 AM
Where
WEBINAR