In our January newsletter, we covered the suicide prevention recommendations issued by TJC earlier this year for non-hospital behavioral health settings. These were published in the January 2018 issue of TJC Perspectives and apply to residential, partial hospitalization, day treatment, and intensive outpatient behavioral health programs. (We clarified later with TJC that they also apply to outpatient behavioral health settings.) The recommendations are as follows:

1. These settings are not required to be ligature resistant.
2. These organizations/programs should conduct a risk assessment to identify elements in the environment that clients could use to harm themselves, visitors, and/or staff. Those items that have high potential to be used to harm oneself or others should be removed and placed in a secure location when possible.
3. Staff should be trained to be aware of elements in the environment that pose a serious risk to clients who could develop suicidal ideation. Staff should be aware of how to keep a client safe from these hazards until the client is stabilized or transferred to a higher level of care.
4. These organizations/programs should have policies and procedures implemented regarding how to manage a client in these levels of care who may experience an increase in symptoms that could result in self-harm or suicidality.

While these recommendations are broad, there is one thing that is clear both from this communication and recent 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. Surveyors are asking for this document and reviewing it to make sure the organization/program has indeed identified all the environmental safety risks and made decisions about how to handle them.

However, the aspects we see many behavioral health organizations/ programs overlooking are the requirements for staff training and policies/procedures (# 3 and # 4 above.) So, let’s review those. What should be included in the staff training? First, staff should be educated about the environmental risk assessment that has been completed. It should be shared with them and they should understand the rationale for the decisions that were made regarding how to handle the identified safety risks. Staff should also be trained about their role in maintaining the safety of the environment. Next, what type of policies and procedures are required? Essentially, this would include any policies and/or procedures about how these behavioral health programs manage a client who begins to decompensate clinically and to demonstrate significant suicide risk. The policies and procedures should include a clear description of how the client will be evaluated to determine their level of risk; how they will be transitioned to a higher level of care if needed; what role staff will play in this situation, etc.

We recently had a client whose policy on this played to their advantage during survey. It was a residential setting and the surveyor had originally cited the program for not having a ligature proof environment. The surveyor referenced the fact that a resident had recently become suicidal and needed to be transferred to the organization’s inpatient setting. The organization successfully clarified this finding with TJC by pointing out that this level of care is not required to be ligature resistant; that they had completed their environmental risk assessment; and that they had a written policy on transitioning clients in crisis to a higher level of care (which is exactly what had occurred with the client who was transferred to inpatient.) Based on this information, TJC removed the finding from their report.

So, be sure you have your staff training and policies in place on this topic so you too can be confident when you go through this type of scrutiny on your next survey!