Accreditation

CMS surveyors agree to use Joint Commission recommendations on ligature risk as guide

Briefings on Accreditation and Quality, October 1, 2018

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.

 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 HospitalInspections.org.

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.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.

Most Popular