TJC Clarifies Applicability of Requirements for NPSG.15.01.01

PUBLISHED: Mar 12, 2019
Relevant to: Ambulatory Care, Behavioral Health, Community Mental Health Centers, Critical Access Hospitals, Hospitals

The Joint Commission (TJC) has added a Note to their recently revised National Patient Safety Goal (NPSG) NPSG.15.01.01, Element of Performance (EP) 1 to clarify the applicability of EP 1 for behavioral health care settings.

NPSG.15.01.01 EP 1 requires behavioral health organizations to reduce the risk for suicide. EP 1 requires that behavioral health organizations conduct an environmental risk assessment to identify features in the physical environment that might be used to attempt suicide (e.g., anchor points, door hinges, hooks) and then take actions necessary to minimize the risks.

With the addition of Note 1, which is effective July 1, 2019, TJC clarifies that:

  • “Non-inpatient behavioral health care settings and unlocked inpatient units do not need to be ligature resistant. The expectation for these settings is that they conduct a risk assessment to identify potential environmental hazards to individuals served; identify individuals who are at high-risk for suicide; and take action to safeguard these individuals from the environmental risks (for example, removing objects from the room that can be used for self-harm and continuous monitoring in a safe location while awaiting transfer to higher level of care).”

Follow the link below for more information. Included with today’s notice are example policies related to the requirements outlines above.

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