TJC Announces Change in Citations for Ligature and Self-harm Deficiencies, Effective July 1, 2018

PUBLISHED: May 31, 2018
Relevant to: Behavioral Health, Critical Access Hospitals, Hospitals

The Joint Commission (TJC) has announced that, after consultation with the Centers for Medicare & Medicaid Services (CMS), TJC will, effective July 1, 2018, cite ligature/self-harm deficiencies under Patient’s Rights Condition of Participation (CoP) 482.13. Previously, these deficiencies were cited under Physical Environment CoP 482.41, as well as under The Joint Commission’s Environment of Care (EC) standard EC.02.06.01, element of performance (EP) 1.

TJC will continue to use (and cite) EC.02.06.01, EP 1, but TJC will now add the relationship between this requirement and CoP 482.13 in thier crosswalk:

  • CoP 482.13 will be cited for ligature/self-harm findings
  • CoP 482.41 will now be cited for non-ligature/self-harm findings

EC.02.06.01 addresses several areas beyond those that could be considered as a self-harm risk. This standard requires the hospital to establish and maintain a safe, functional environment. A note for this standard further requires the environment to be “…constructed, arranged and maintained in a manner that fosters patient safety, provides facilities for diagnosis and treatment and provides for special services appropriate to the needs of the community.” Element of Performance 1 for this standard requires that “interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided.”

Included with today’s notice is an example policy addressing ligature risk assessment.

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