Increasingly, care delivery occurs in outpatient environments—Intensive Outpatient Programs (IOPs), Partial Hospitalization Programs (PHPs), and office-based therapy settings—where clients may be acutely ill, at elevated risk of harm to self or others, and navigating less controlled environments. While these outpatient settings don’t require the same ligature-resistant standards as inpatient psychiatric units, they must still meet high expectations for creating environments that are safe, therapeutic, and responsive to risk. Conducting an environmental risk assessment for outpatient behavioral health settings isn’t just a best practice—it’s a requirement of accrediting bodies like The Joint Commission (TJC), CARF, and Social Current (COA).

So what does it take to do one well?

Why an Environmental Risk Assessment for Outpatient Behavioral Health Settings Matter

Outpatient behavioral health settings must strike a balance: maintaining an inviting, recovery-oriented atmosphere without overlooking risks to clients, visitors, and staff. The goal is to identify and mitigate environmental hazards that could contribute to:

• Self-harm or suicide attempts
• Aggression or violence
• Medication errors or access to restricted items
• Inadequate privacy or confidentiality
• Unsafe responses during behavioral crises

A strong environmental risk assessment helps organizations proactively address these risks—before they lead to a safety event or survey finding.

What Accreditors Require

Here’s a snapshot of what’s expected from major accrediting bodies:

The Joint Commission (TJC)

• Requires outpatient behavioral health settings to identify environmental safety risks and mitigate them appropriately, based on the population served.
• TJC does not require full ligature resistance in settings where clients are continuously supervised or where stays are short, but TJC does expect organizations to document how risk is assessed and mitigated.

CARF (Commission on Accreditation of Rehabilitation Facilities)

• Emphasizes risk management and safety planning in all service environments.
• Requires providers to document an annual and ongoing review of facility safety, including how environments are adapted for populations served.

COA (Social Current Council on Accreditation)

• Looks for evidence of a systematic process to identify and manage physical environment risks, especially those that could endanger clients, visitors, or staff.
• Risk assessments must be ongoing and tied to quality improvement efforts.

What to Document in Your Environmental Risk Assessment

Your risk assessment should be structured, repeatable, and documented. It should include:

• Date of the assessment and the specific locations reviewed
• Who conducted the assessment (titles, credentials)
• Populations served (age groups, acuity, risk factors)
• Identified risks with specific locations and descriptions
• Likelihood and potential severity of each risk
• Current mitigation strategies in place
• Recommended actions with assigned responsibility and target dates
• Follow-up or re-evaluation plan

A common format is a risk matrix or checklist that includes each room or area (e.g., lobby, bathrooms, group rooms, activity rooms) and the risks associated with those spaces.

Common Environmental Risks in Outpatient Behavioral Health Settings

Although these settings do not require ligature resistance, they must still be safe for individuals experiencing behavioral health symptoms. Here are some risks commonly identified:

• Unsupervised access to bathrooms with:
  • Anchor points (door hinges, towel bars)
  • Locking doors without override
  • Sharp items (toilet paper holders, razors in shared spaces)
• Furniture or fixtures that can be used as weapons (metal legs, loose parts)
• Glass picture frames or mirrors in client-accessible areas
• Unrestricted access to utility closets or staff areas containing cleaning agents, sharps, cords
• Medication storage that isn’t secure
• Blinds or cords on windows
• Exit doors without alarms or supervision, creating elopement risks
• Overcrowded or poorly supervised group spaces
• Inadequate visibility into rooms from staff areas

Risk Mitigation Strategies

Outpatient settings require thoughtful design and staff practices to maintain a safe environment. Here are practical ways to reduce environmental risk:

Design Modifications

• Use tamper-resistant hardware on doors and fixtures
• Replace framed art with canvas prints or wall decals
• Install mirrors made of polished metal instead of glass
• Use furniture with rounded edges and bolted-down fixtures
• Equip bathrooms with staff override locks
• Limit access to high-risk spaces via keypads or staff access only

Environmental Controls

• Provide continuous or frequent observation in high-risk areas
• Implement environmental checklists during shift changes or before programming begins
• Keep sharps and medications locked up
• Conduct room sweeps after group sessions or client use
• Use visitor and client screening protocols for belongings

Staff Training

• Train all staff to recognize environmental risks and respond to escalating behaviors
• Review emergency procedures for behavioral code response
• Encourage staff to report concerns about the environment or safety culture

Aligning Safety and Strategy

While regulations may not require outpatient behavioral health environments to be ligature-resistant, they must be actively managed to keep clients, visitors, and staff safe. Conducting a thorough, documented environmental risk assessment is not just a check-the-box task—it’s a core part of your client safety program and accreditation readiness strategy.

With the right structure, staff engagement, and leadership commitment, outpatient programs can create environments that are both welcoming and safe—where healing can truly occur.

Barrins & Associates

Barrins can assist you in developing and implementing an effective and compliant Environmental Risk Assessment for your outpatient behavioral health settings.  Contact us today.

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