From our own experiences and those shared by colleagues in the field, we have seen an increased focus from the Joint Commission on ligature risks in psychiatric hospitals and inpatient psychiatric patient areas in general hospitals.

More than 70 hospitals may currently be in or have received an accreditation decision of Preliminary Denial of Accreditation (PDA) so far this year, and it would appear that lack of compliance with the suicide prevention standards is one of the main reasons for this accreditation decision. Other areas that seem to be in the top citations are high-level disinfection and sterilization, and staff competencies.

Addressing Ligature Risks

CMS expects that closed psych units are free of ligature risks. Medical/surgical units must be ligature resistant. One-to-one observation is still one of the best mitigation strategies; however, staff must have competencies to care for patients and must be relieved by competent staff when they go on breaks (meals, restroom, etc.).

For sterilization and high-level disinfection (HLD) the manufacturers’ instructions for use (IFUs) must be followed.

The hospital must declare which evidence-based sources* it uses. Policies and procedures must be written to meet these guidelines, and staff must be educated and able to articulate and practice accordingly. All quality control monitors and logs must be current, with no blanks.

*Note that some of the guidelines differ. AORN’s advice may not be the same as AAMI’s or the multi-society guidelines for endoscopy. So, it’s important to know the source of evidence.

Corrective Actions and Accreditation Decisions

As we know, when survey deficiencies rise to the level of a Condition-level Finding, CMS requires that the deficiencies be corrected in 60 days. We have learned from clients and colleagues across the country that while hospitals were committed to correcting ligature and self-harm risks, some organizations were having difficulty completing their corrective action plans within the 60-day limit imposed by CMS. Examples of these obstacles included the following:

  • The hardware to retrofit the psych units to make them ligature-free were on backorder and would not arrive within the 60 days.
  • Renovating existing building designs to comply with the recommendations for the design build for psychiatric units requires capital dollars that had been allocated to other projects. Renovation projects involving approval processes and significant dollars typically cannot easily be completed within 60 days.  

We reached out to TJC to share some of the barriers that hospitals were facing in trying to attain full compliance with these standards and learned that CMS has agreed to develop guidance in the area of ligature risk and estimated that it will take approximately six months for its development.

In the interim, CMS has affirmed that TJC may use its judgment as to…

  • The identification of ligature and safety risk deficiencies;
  • The level of severity for those deficiencies;
  • And, the approval of the facility’s corrective action and mitigation plans to remedy the identified deficiencies.

Below is the official statement from CMS to TJC, in which CMS stated that the focus of their concern is on psychiatric patients in psychiatric units of hospitals and in psychiatric hospitals.

CMS has identified the need for increased direction, clarity, and guidance regarding  the definition of what constitutes a ligature risk and other safety risks involved in the care of patients requiring psychiatric care and treatment; how those risks should be surveyed; at what level should the deficiency be cited; the elements required for an appropriate Plan of Correction (PoC); and what constitutes a suitable mitigation plan to minimize the risk to patients who are cared for in environments with identified deficiencies.  The care and safety of this vulnerable patient population and the staff that provide that care are our primary concerns.  To that end, CMS has begun the process of drafting guidance utilizing the skill and expertise of the Regional Offices, state survey agencies, accrediting bodies, providers, mental health clinicians, as well as other stakeholders central to this issue. CMS expects that this guidance will take approximately 6 months to complete.  In the interim, the Accreditation Organization (AO) may use their judgment as to the identification of ligature and safety risk deficiencies, the level of severity for those deficiencies, as well as the approval of the facility’s corrective action and mitigation plans to remedy the identified deficiencies. 

Facilities should continue to work toward compliance as the guidance is being developed. We expect preliminary guidance within the next two weeks, with more comprehensive guidance within the next 6 months.  We will review CMS enforcement actions related to serious ligature risk deficiencies on a case by case basis while the guidance is being developed, and will provide updates via S&C policy memos, as necessary.

Compass will be attending the TJC Executive Briefings at the end of this month. If we learn new information there, we will be sure to share it.

Time-Limited Waivers

CMS informed TJC that time-limited waivers could be issued for life safety issues only and that the ligature risks waivers are “off the table.” We have heard from colleagues recently that TJC clarified that the 60 days is from the date that the survey is posted, not the last day of survey. 

From the Joint Commission:

The post-survey process for these observations will follow standard procedure in which the organization has a 60-day timeframe to correct the physical environmental risks or have the option of applying for a survey-related waiver.”

Read more: Now effective: Surveying, scoring of ligature, suicide, self-harm in inpatient psychiatric setting

Compass Can Help

Is your organization struggling with ligature risks or other suicide prevention standards? We can provide a focused assessment of these areas. Contact our office today by phone at (513) 241.0142, by email, or via our contact form for a confidential discussion of your needs.

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