CMS to Use Joint Commission Recommendations on Ligature Risk as Guide

This member-only article appears in the October issue of Patient Safety Monitor Journal.

In a new memo to its state survey agencies, CMS said it would use Joint Commission ligature recommendations—drawn from a task force that was convened by the commission and included several CMS suicide prevention experts—as the federal agency goes forward with clarifying and updating Interpretive Guidelines for its surveyors.

Regardless of what organization you might use for accreditation, assess your hospital’s suicide prevention compliance against those Joint Commission recommendations with a detailed risk assessment and mitigation plan. If that plan includes renovations or extra staff and training, ensure your C-suite has budgeted money for those items to show surveyors leadership is serious about making changes.

Ensure staff understands policy
At least two hospitals this year each faced a CMS ruling that it was putting its patients in immediate jeopardy after staff failed to keep a continuous watch over at-risk patients even though the hospital’s own policy called for a sitter or other one-to-one observation, according to federal hospital inspection reports on

A finding of immediate jeopardy by CMS or The Joint Commission’s equivalent finding, immediate threat to life and safety, means a hospital could lose its ability to bill Medicare for services.

CMS announced it was embracing The Joint Commission’s recommendations in memo QSO: 18-21-All Hospitals, “CMS clarification of Psychiatric Environmental Risks,” from the Quality, Safety & Oversight Group (QSO), formerly known as the Survey and Certification Group, to CMS state survey agencies. It is dated July 20, although it was not posted online until August 1.

In earlier communications, CMS had indicated it would convene its own group of experts to update its guidance to increase focus on ligatures as well as other physical risks covered under the Condition of Participation (CoP) for patient rights to care in a safe setting.
However, since participating in the Joint Commission panel, CMS officials now think having their own panel would be redundant. “CMS felt that to repeat the work of TJC Suicide Panel (in which CMS participated) would not provide any substantive additional gains and would not be a productive use of the time and expertise of the participants,” according to the newest memo.

CMS is still working to revise the Interpretive Guidelines for its surveyors, but for now, it referred regional offices to expectations set out in its December 8, 2017 memo on clarifying ligature risk, S&C 18-06-Hospitals. That memo carried extensive guidance, including an initial update to parts of the Interpretive Guidelines found in Medicare’s State Operations Manual, Appendix A.

Expect more changes in the future, though. In the most recent memo, CMS said it would continue to work on updates to Appendix A as well as Appendix AA, guidelines for surveyors at psychiatric hospitals, “which will incorporate the standards that were recommended via the collaborative work of The Joint Commission’s Suicide Panel Special Report: Suicide Prevention in Health Care Settings.” The memo provided an online link to the November 2017 recommendations.

Joint Commission wants thorough risk assessment
Since November, The Joint Commission has published 16 recommendations as well as a series of FAQs in its main monthly periodical, Perspectives, and online newsletter BHC News, outlining the findings of four expert panels it convened on suicide prevention.
Those recommendations include specifics on making the care environment for at-risk patients ligature-resistant and the need for continuous supervision of a patient if such an environment cannot be provided.

Hospitals and nonhospital behavioral health organizations should study the 16 recommendations and review the FAQs, advises Jennifer Cowel, president of Patton Healthcare Consulting in Naperville, Illinois. “What we have heard in very recent surveys is that The Joint Commission is not citing a condition-level deficiency for ligature if the hospital has completed a detailed risk assessment, has budgeted dollars or has approved money for fixes, [and] has mitigation plans identified and in place for those non-ligature safe items on the units.”
She emphasizes that the mitigation plans must be implemented to avoid serious findings.

“We strongly recommend that hospitals prepare the risk assessment for both behavioral health spaces and the ED [emergency department] or acute care space where it is likely you will be caring for a patient with a high risk of suicide. The mitigation plans should be well known to staff, and staff should implement them each and every time they care for a high-suicide-risk patient,” warns Cowel.

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