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Is your psychiatric hospital feeling the burden of CMS regulations? If so, you’re not alone.

The National Association for Behavioral Healthcare (NABH) recently released a report on this important topic: The High Cost of Compliance: Assessing the Regulatory Burden on Inpatient Psychiatric Facilities.

CMS Regulations

The report focuses on three regulatory requirements for Medicare certified psychiatric hospitals:

Cost of CMS Regulations

The report estimates these three regulatory requirements cost $1.7 billion annually nationwide. This represents about 4.8% of an average psychiatric hospital’s annual revenue for all inpatient services from all sources.

Additionally, the report points out that some of these regulations are outdated. For example, CMS issued the B Tags in 1966 and hasn’t updated them since that time. Also, many of the regulations are subject to inconsistent application and surveyor variability.

Easing CMS Compliance Burdens

Essentially, the report urges federal regulators to ease these compliance burdens. Some of the requirements are seen as low-value in terms of their contribution to quality patient care. Hopefully, easing some of these low-value requirements would allow clinical and financial resources to shift to the delivery of high quality patient care.

Key Findings and Recommendations

The report contains key findings and recommendations for the three regulatory requirements as follows:

B Tags

The B Tag requirements for medical records (assessments, treatment plans, etc.) are essentially low-value documentation requirements. Frequently, they produce multiple survey citations. Equally important, they impose significant costs in terms of paperwork, monitoring, and survey compliance.

Recommendation is for CMS to convene a commission to determine if the B Tag CoPs are still relevant. And decide if they should be revised or discarded.

Ligature Risk Requirements

Clearly, behavioral health providers strive to keep patients from self-harm while in their facilities. However, some ligature risk requirements imposed by surveyors focus on issues that carry only minimal risk for patients in that setting yet are costly to renovate.

Recommendation is for CMS to issue guidance as follows:

  • Standardize survey practices by adopting an evidence based approach to ligature risk reduction.
  • Eliminate the need for redundant renovations. Once a surveyor accepts a design feature, future surveyors should not be allowed to reverse that finding for a prescribed period of time.
  • Clarify that areas under constant staff supervision do not need to be ligature resistant.


Some regulators interpret EMTALA in a way that imposes new requirements on psychiatric hospitals. As a result, they do not allow hospitals to determine Qualified Medical Persons (QMPs) who can conduct screenings. Instead, they require an Advanced Practice Clinician in the place of an RN or a clinical social worker.

Recommendation is for CMS to ensure surveyors respect EMTALA’s provision that each provider’s medical staff can determine which clinicians are competent to conduct emergency medical screenings as per applicable state licensure regulations.

NABH Statement on CMS Regulatory Burden

When NABH released this report at its 2019 Annual Meeting, NABH President/CEO Mark Covall succinctly summed up the message: “This report emphasizes what our members have been saying for too long: regulatory overload takes time away from patient care. As our nation works to address its deadly opioid and suicide crises, we need our behavioral healthcare providers to focus on what they do best: provide mental health and substance use disorder patients with the right care, in the right setting, at the right time.”

Integrating CMS Regulations and Joint Commission Standards

Often, the challenge for deemed status psychiatric hospitals is integrating CMS regulations and Joint Commission standards. We’ve worked with psychiatric hospitals nationwide for 20 years to accomplish this goal. See how our consultation on integrating CMS and TJC requirements can help you operationalize these requirements and ease the challenge of regulatory compliance.