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Let’s begin again, begin the begin: CMS ligature risks codified!

While I have little doubt that we will yet again revisit the management of ligature risks and behavioral health patients, it would seem that chapter and verse are getting towards stone tablet form—but you have a chance to influence the future state. I suspect we will also be looking back to determine how much influence the field has on the final, final or whether the party line from Chicago holds sway (kind of looks like that at the moment, but there is still time):

  • Back on April 19 (and I do apologize for not picking up on this sooner—I need to get a better strategy for monitoring all these goings-on), CMS issued a draft clarification of the interpretive guidelines relating to ligature risk (you can find the skinny here). All things being equal, I suppose the “newest” thing is the formal introduction of the Ligature Risk Extension Request (LRER—just what we needed, another acronym), which outlines a process for correction of ligature risks that will take longer than the official 60-day turnaround time for the correction of deficiencies. One thing is very clear (well, maybe a couple of things): State agencies and/or accreditation organizations are not allowed to grant LRERs. They can, and in most instances, will act as intermediary between the organization seeking the extension and CMS, and will (basically) advocate for approval based on their analysis of the issues. This is not a Life Safety Code® waiver as ligature risks are not a compliance deficiency relative to life safety requirements. From the process outlined, it does appear that this is to be a reasonable process, (potentially) making allowances for obtaining approval of the governing body, engaging in competitive bidding, applying for funding, obtaining permits for physical changes, and lack of or delays in obtaining products and supplies needed for corrective actions. Needless to say, with the invocation of the LRER, there will be
    • Mitigation strategies to implement
    • Progress reporting to be done
    • A re-survey to verify that the deficiencies have indeed been corrected by the state agency or accreditation organization
  • As has been the case pretty much from the get-go, there are two assessment processes that need to dovetail (or perhaps they are concentric circles): An assessment of the environment and the assessment of patients to determine the level of risk for suicidal behaviors. I do believe that eventually we will be left with the latter upon which to focus, but I suppose there will need to be an ongoing due diligence relative to monitoring the environment. Ultimately, it seems to come down to striking the balance between seeing every aspect of the environment as a big hairy monster as opposed to an element in the environment that can be managed by appropriate means. At the very least, I am hoping that the survey focus returns to general patient care and infection control, with perhaps a side of medication management—I think that’s where the meaningful improvements are hiding (in plain sight).

As a final note, we do have until June 6, 2019 to weigh in on the proposed changes, so I would suggest you gather together a little working group, and if the spirit moves you, weigh right in. The data supports this being a whole bunch of ado about very little (approaching a whole bunch of doodoo), so the sooner we can refocus on the “real” challenges, the better.

 

Like the dust that settles all around me: I got those low-down TJC FAQ blues

I don’t know if there’s anything to be inferred by the fact that the latest updates on the ligature resistance front are “buried” on p. 8 of the May 2019 Perspectives (after an onslaught of what I characterize as Joint Commission advertisements), but it would be nice to think that perhaps folks are going to be allowed to move on at their own “pace” as a function of risk assessments, abatement and mitigation strategies and monitoring for gaps in safety, but I guess we shall see what we shall see.

At any rate, the May Perspectives (on p. 8—imagine that!) provides two topics, one of which, video monitoring we discussed a few weeks back (I guess they like to repurpose content as much as anyone…) and a clarification on the (admittedly somewhat awkwardly worded) requirement that self-closing and self-locking (both, not one or the other) doors are required for the separation of areas required to be ligature resistant and those that are not, with the intent being to eliminate reliance on staff to close and lock those doors to prevent patient harm. The FAQ also prohibits the use of hold-open devices of any kind on these doors, so do keep that in mind. This applies to “staff controlled” areas on a behavioral health unit, like med rooms, utility rooms, consult rooms, etc. This is all based on Recommendation #1 published in the November 2017 Perspectives and the guidance that patient rooms, patient bathrooms, corridors, and common patient areas are to be ligature resistant. If this is news to you (I don’t know that we’ve discussed this particular piece of the puzzle), I can’t say that I am surprised as it really didn’t stand out at the time and really required too much in the way of cogitation to figure out what they were getting at, particularly the descriptor (“Nursing stations with an unobstructed view (so that a patient attempt at self-harm at the nursing station would be easily seen and interrupted) and areas behind self-closing/self-locking doors do not need to be ligature-resistant and will not be cited for ligature risks.”) as it was probably a little too all-inclusive. I think I would have separated them into two bullet points:

  • Nursing stations with an unobstructed view
  • Areas behind self-closing/self-locking doors

But hey, as long as we get there in the end, right? Yeah, sure, fine…

In other news, ASHRAE is in the public comment process relative to proposed changes to ASHRAE 170 Standard for Ventilation of Health Care Facilities (you can see the proposed draft here). Given that NFPA 99 defers to ASHRAE on the ventilation front, I can’t help but think that this is going to continue to be a cornerstone compliance document during survey activities. I don’t know that I noted anything particularly egregious, etc., in the proposed update, but I always try to encourage the folks in the field to review and weigh in when these things are open for comment. Before we got to ligature-resistant considerations, the management of procedural environments as it relates to temperature, humidity, air pressure relationships, etc. was the hot-button topic, so any changes might have a similar impact on the industry. Unfortunately, I just got wind of this last week and the comment period ends May 6, so act fast!

Last Call for 2018: National Patient Safety Goal on suicide prevention

While I will freely admit that this based on nothing but my memory (and the seeming constant stream of reasons to reiterate), I believe that the management of behavioral health patients as a function of ligature risks, suicide prevention, etc., was the most frequently occurring topic in this space. That said, I feel (reasonably, but not totally) certain that this is the last time we’ll have to bring this up in 2018. But we’ve got a whole 52 weeks of 2019 to look forward to, so I suspect we’ll continue to return to this from time to time (to time, to time, to time—cue eerie sound effects and echo).

If you’ve had a chance to check out the December 2018 edition of Perspectives, you may have noticed that The Joint Commission is updating some of the particulars of National Patient Safety Goal (NPSG) #15, which will be effective July 1, 2019, though something tells me that strategies for compliance are likely to be bandied about during surveys before that. From a strategic perspective, I suspect that most folks are already taking things in the required direction(s), so hopefully the recent times of intense scrutiny (and resulting survey pain for organizations) will begin to shift to other subjects.

At any rate, for the purposes of today’s discussion, there is (and always will be) a component relating to the management of physical environment, both in (and on) psychiatric/behavioral health hospitals and psychiatric/behavioral health units in general hospitals (my mother-in-law loves General Hospital, but I never hear her talking about risk assessments…). So, the official “environmental risk assessment” must occur in/on behavioral health facilities/units, with a following program for minimizing the risks to ensure the environment is appropriately ligature-resistant. No big changes to that as an overarching theme.

But where I had hoped for a little more clarity is for those pesky areas in the general patient population in which we do/might manage patients at risk to harm themselves. We still don’t have to make those areas ligature resistant, with the recommendation aimed at mitigating the risk for patients at high risk (the rest of the NPSG covers a lot of ground relative to the clinical management of patients, including identification of the self-harm risks). But there is a note that recommends (the use of “should” in the note is the key here, though I know of more than a handful of surveyors that can turn that “should” into a “must” in the blink of an eye) assessment of clinical areas to identify stuff that could be used for self-harm (and there’s a whole heck of a lot of stuff that could be used for self-harm) and should be routinely removed when possible from the area around a patient who has been identified as high risk. Further, there is an expectation that that information would be used to train staff who monitor these high-risk patients, for example (and this is their example, but it’s a good ‘un), developing a checklist to help staff remember which equipment, etc., should be removed when possible.

It would seem we have a little time to get this completed, but I would encourage folks to start their risk identification process soon if you have not already done so. I personally think the best way to start this is to make a list of everything in the area being assessed and identify the stuff that can be removed (if it is not clinically necessary to care for the patient), the stuff that can’t be removed (that forms the basis of the education of staff—they need to be mindful of the stuff that can’t be removed after we’ve removed all that there is to be removed) and work from there. As I have maintained right along, in general, we do a good (not perfect) job with managing these patients and I don’t think the actual numbers support the degree to which this tail has been wagging the regulatory dog (everything is a risk, don’t you know). Hopefully, this is a sign that the regulatory eyeball will be moving on to other things.

CMS Ligature Risk Update: Not quite finished…

Cast aside the doubt that nothing good came come this way again!

On July 20, 2018, CMS issued further information regarding its expectations for ensuring that behavioral health patients are being provided a safe and appropriate environment. There had been some indication that CMS might be undertaking their own analysis of the current state of things, but it appears that CMS is going to incorporate the outcomes of The Joint Commission’s (TJC) suicide panel (in which CMS representatives participated) into a comprehensive ligature risk interpretive guidance. The memorandum does not indicate when we can expect the finalized interpretive guidance, but things do seem to be moving at a pretty good clip, so I’m thinking (maybe, just maybe), we’ll see that information before the end of the year. As a point of information (and you know I’m all about the points), the Joint Commission guidance cited in the CMS memorandum can be found here: and some clarifying FAQs issued by TJC last month (but not specifically referenced in the CMS memorandum) can be found here: (the information specific to ligature risks is about half way down the page). I know we’ve covered this over the past few months, but I can never be sure at which point in the conversation folks tune in, so I figured it doesn’t hurt to have links for what is current (at the moment…).

For those of you who have not yet tackled all of the particulars relating to the guidance issued from Joint Commission (mostly because you do not use TJC for deemed status accreditation purposes), I do think that the compliance path appears to be fairly reasonable and straightforward from an implementation standpoint. That said, until the interpretive guidance is finalized by CMS, there will likely continue to be some surveyor interpretation in the mix, particularly on the part of those accreditation and regulatory organizations other than Joint Commission (DNV, CIHQ, HFAP, state agencies, etc.). Which means it will be incumbent upon pretty much all hospitals to know where they stand relative to TJC recommendations, particularly as a function of how the strategies and facilities modifications they’ve made meet the intent of the recommendations. Some recent non-TJC survey activities indicate that the “other” accreditation organizations are starting to focus on this topic and, right now, are very much where TJC was in early 2017 when surveyors were inclined to identify anything and everything as a potential, unmanageable risk. And lots of re-surveys following in the wake of those determinations

Beyond a familiarity/assessment relative to the TJC recommendations, the “other” piece of which you need to be mindful is that whatever fixes they identify need to be completed before survey or there will likely be some back and forth relative to Immediate Threat, the need for re-survey, etc.  As we’ve discussed in the past (and this surely goes beyond ligature-resistant hardware), a lot of folks with a significant number of fixes are very much at the mercy of the supplies of needed hardware, etc. At a minimum, hospitals that haven’t completed their “laundry list” of fixes must have a risk assessment in place that outlines not only what is to be done from a facilities standpoint, but what strategies are in place to ensure that the risk to patients is being properly managed in the interim (this is very similar to the survey methodology dealing with Interim Life Safety Measures). As I’ve told folks time and again, you don’t get credit for doing the math in your head—at the end of the day, when you have a survey team “in the house,” the only “good” risk assessment is a risk assessment that is fully documented, approved by the appropriate organizational authorities, etc. If you don’t have an assessment ready to go for survey, it’s likely to be a very tough slog.

At any rate, it does appear that this one is going to be winding down in terms of survey activity, which will bring no small measure of relief to the survey preparation process, but it does beg the question of whether this is the last big environmental dope-slap or if there’s something else waiting in the wings to make us crazy. Any thoughts?