CMS Memo

As you are well aware, psychiatric hospitals and inpatient psychiatric units of med/surg hospitals continue to grapple with the challenge of eliminating suicide risks in their environment and how this will be evaluated during TJC surveys. TJC has been working closely with CMS on this issue and in December CMS released a Survey & Certification Memo on this topic.  The memo is consistent with all previous communications from TJC. One of the memo’s key points is that CMS is in the process of drafting comprehensive ligature risk interpretive guidance to provide direction and clarity for Regional Offices, State Survey Agencies, and Accrediting Organizations (such as TJC.)  Until this guidance is released by CMS, the Regional Offices, State Survey Agencies, and Accrediting Organizations may use their judgment as to the identification of ligature and other safety risk deficiencies, the level of citation for those deficiencies, as well as the approval of the hospital’s corrective action and mitigation plans to minimize risk to patient safety and remedy the identified deficiencies. Important note: In the memo, CMS acknowledges that the full elimination of ligature risks cited during surveys is sometimes “burdensome” based on variables such as the scope of the deficiencies, the need for governing body approval, capital budget funding requirements, competitive bidding, availability of materials, time for completion of repairs, etc. Thus, they do allow for a process whereby the State Survey Agency or Accrediting Organization may recommend that additional time be granted by CMS in order for the hospital to correct the deficiencies. The State Survey Agencies and Accrediting Organizations do not have independent authority to grant hospitals additional time for the correction of deficiencies. Requests for the extension of timeframes go to TJC and must include the hospital’s accepted plan of correction, mitigation plan, and rationale for why it is not reasonable to meet the correction timeframe. If TJC supports the request, it is sent to the CMS Regional Office and Central Office with a recommendation for approval. The Central Office will respond within 10 business days. If the request is approved, the hospital must provide monthly electronic progress reports to TJC detailing ongoing progress in correcting the ligature risks. TJC, in turn, must provide monthly progress reports to CMS on the hospital’s progress in correcting the deficiencies and the effectiveness of their mitigation strategies. So, while the challenge of eliminating ligature risks continues, it’s reassuring to know there is a process whereby TJC and CMS can work with hospitals to implement the most effective solutions and achieve the shared goal of reducing environmental safety risks.

TJC Guidance re Non-BH Settings

The January 2018 issue of TJC Perspectives contains recommendations re the prevention of suicide in non-hospital behavioral health settings including residential, partial hospitalization, day treatment, and intensive outpatient. There are three “recommendations” which read as follows:

  • “These settings are not required to be ligature resistant.
  • These organizations should conduct a risk assessment to identify elements in the environment that residents could use to harm themselves, visitors, and/or staff…… Staff should be trained to be aware of elements that pose a serious risk to residents with suicidal ideation. Staff should be aware of how to keep a resident safe from these hazards until the resident is stabilized or transferred to a higher level of care.
  • These organizations should have policies/procedures implemented re how to manage a patient who may experience an increase in symptoms that could result in self-harm or suicidality.”

While these recommendations are very broad, there is one thing that is clear both from this communication and recent BH surveys of our clients. There must be a documented environmental risk assessment to identify potential hazards in the environment and address how these will be eliminated or mitigated. It’s also now clear that BH programs are expected to conduct staff training on environmental risks for self-harm and have policies/procedures re how to manage clients with increased symptoms of self-harm or suicidality. We will keep you posted as we see further developments during BH surveys.


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