July 2018: Joint Commission FAQs Released

The Joint Commission has released a Frequently Asked Questions (FAQ) that contains responses to inquiries that have been submitted regarding their Recommendations Regarding Environmental Hazards for Providers and Surveyors in several editions of their Perspectives newsletter starting in November of last year.  The FAQs are in the July 2018 edition of Perspectives.

Full text of the FAQ section is now available CLICK HERE


The January 2018 issue of The Joint Commission’s Perspectives addresses the recommendations that came from the Expert Panel’s third meeting  (October 2017) regarding ligature attachment and other risks in non-hospital settings such as:

  • Residential Treatment
  • Partial Hospitalization
  • Intensive Outpatient
  • Outpatient Treatment

The three new recommendations, (#14-16) state that these settings:

#14. Are not required to be ligature resistant.

#15. An environmental safety risk assessment must be performed for staff training purposes.

#16. Policies and procedures for managing patients who may be escalating and for whom self-harm may be an issue while waiting for transfer to a higher level of care.

NOTE: Both James M. Hunt and David M. Sine are members of, and active participants in, this Expert Panel.


The Joint Commission has released their recommendations regarding Hospital Environmental

Hazards for Providers and Surveyors.  In an attempt to get this information circulated quickly, and with concern that the exact wording be communicated, please click on the link below and again on the link on the following page read the article in the, “The Joint Commission Perspectives”, November 2017, Number 11.



August 2017: Official Announcement from The Joint Commission & CMS on Ligature Issues


This email is being sent out on behalf of Mark Pelletier, Chief Operating Officer- Accreditation and Certification Operations

 Dear Colleagues:

Recently, CMS and The Joint Commission have been in discussions regarding deficiencies related to ligature risk and self-harm.  When ligature risks rise to the level of a Condition Level Finding (CLD), CMS requires that they be corrected in 60 dayssimilar to other CLDs. However, we have found that while our accredited organizations are committed to correcting ligature and self-harm risks, correcting these issues may require additional time and resources to achieve full compliance.

After much collaboration with CMS, we are pleased that CMS has agreed to develop guidance in the area of ligature risk. Theyexpect that this guidance will take approximately 6 months to develop.  In the interim, CMS has affirmed that The Joint Commission may use its judgment as to the identification of ligature and safety risk deficiencies; the level of severity for those deficiencies; and the approval of the facility’s corrective action and mitigation plans to remedy the identified deficiencies.

 Below is the official statement from CMS that we received this week. They have stated that the focus of their concern is on psychiatric patients in psychiatric units of hospitals and in psychiatric hospitals. As we have further information from CMS we will share.  If you have questions you can contact me directly at mpelletier@jointcommission.org.



 CMS STATEMENT (received week of August 28, 2017)

 CMS has identified the need for increased direction, clarity, and guidance regarding  the definition of what constitutes a ligature risk and other safety risks involved in the care of patients requiring psychiatric care and treatment; how those risks should be surveyed; at what level should the deficiency be cited; the elements required for an appropriate Plan of Correction (PoC); and what constitutes a suitable mitigation plan to minimize the risk to patients who are cared for in environments with identified deficiencies.  The care and safety of this vulnerable patient population and the staff that provide that care are our primary concerns.  To that end, CMS has begun the process of drafting guidance utilizing the skill and expertise of the Regional Offices, state survey agencies, accrediting bodies, providers, mental health clinicians, as well as other stakeholders central to this issue. CMS expects that this guidance will take approximately 6 months to complete.  In the interim, the Accreditation Organization (AO) may use their judgment as to the identification of ligature and safety risk deficiencies, the level of severity for those deficiencies, as well as the approval of the facility’s corrective action and mitigation plans to remedy the identified deficiencies.

 Facilities should continue to work toward compliance as the guidance is being developed. We expect preliminary guidance within the next two weeks, with more comprehensive guidance within the next 6 months.  We will review CMS enforcement actions related to serious ligature risk deficiencies on a case by case basis while the guidance is being developed, and will provide updates via S&C policy memos, as necessary.

March 2017: TJC Announcement of Ligature Attachment Point Emphasis

For many years The Joint Commission (TJC) has had “Deemed Status” from the Center for Medicare and Medicaid Services (CMS) which means that CMS will accept TJC’s accreditation of a health care provider as proof that they are providing quality service and CMS will pay the health care providers claims for reimbursement.  Also for many years, CMS has performed its own ” follow-up” surveys to verify that they agreed with TJC’s assessments.  In early 2017 CMS decided that increased attention to  ligature attachment points for psychiatric patients  was warranted.  This prompted TJC to issue the following notice to health care providers and its surveyors regarding an increased emphasis on ligature attachment points with some serious and short-term penalties.  To assist with the implementation of this new emphasis, TJC established an “Expert Panel” to assist them and CMS with this process.  The November 2017, January and July 2018 Perspectives articles included in this section are the result of that group’s interaction with TJC and CMS in this regard.

The announcement of this process was as follows: CLICK HERE