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Joint Commission surveyors to focus on suicide, self-harm, and ligature

Accreditation Insider, March 7, 2017

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The Joint Commission announced that as of March 1, its surveyors will place special focus on suicide, self-harm, and ligature observations in psychiatric hospitals and units. Now, surveyors will document any and all observations of ligature or self-harm risks in the environment during the survey. Each observation will be documented, classified as a requirement for improvement, scored at EC 02.06.01, element of performance 1, and placed on the facility’s SAFER Matrix.

When documenting these observations, surveyors will also evaluate whether the facility has:

•    Identified these risks before
•    Prepared existing plans for dealing with these risks
•    Conducted an effective environmental risk assessment process

Findings will be cited in Condition of Participation 482.41 on the physical environment. If the finding occurs in a high-risk area, it will be marked as High Risk in the SAFER Matrix and the facility will receive a Condition-level finding. Multipurpose areas such as common rooms and ERs will be surveyed to see if staff are aware of self-harm, ligature, and suicide prevention and mitigation policies. And for all findings the facility will be given 60 days to correct the problem.

The accreditor recommends facilities read up on the “Design Guide for the Built Environment of Behavioral Health Facilities,” for more information on environmental hazards to patients.

 See our previous Accreditation Insider and Briefings on Accreditation and Quality coverage on suicide risks.


 

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