July 2019 FAQ – Acceptable Replacements for Solid Ceilings

TJC FAQ 190722

  • Issued July 22, 2019

National Patient Safety Goals (NPSG) (Behavioral Health / Behavioral Health Care)


Ligature and Suicide Risk Reduction – Ceiling Systems

What ceiling systems are allowable as a replacement for a solid ceiling?


A monolithic ceiling must either be a solid structure or use a concealed grid system that meets the following requirements:

  • No exposed components of the ceiling system can be used as a ligature attachment point (i.e. rails, tees, mains)
  • Panels can in no way be removed by the patient.
  • No impact will dislodge the panel(s)




FREE Suicide Prevention Portal on TJC Website


  • Issued May 2019

The Joint Commission is providing FREE ACCESS to Suicide Prevention publications such as relevant issues of their Perspectives newsletter and other publications that contain the recommendations of the Expert Panel on Suicide Prevention, National Patient Safety Goals regarding suicide prevention and tools for evaluating patient level of intent for self-harm.





May 2019 Perspectives: FAQs for Self-Closing and Self-Locking Doors & Video Monitoring

May 2019 Perspectives FAQThe Joint Commission

  • Issued May 2019

The Joint Commission has clarified Expert Panel on Suicide’s Recommendation #1 (November 2017 Perspectives) relating to Self-Closing and Self-Locking Doors as well as Video Monitoring or “Electronic Sitters” for patients at high risk for suicide.

Full content available HERE





The Joint Commisssion

  • Issued November 26, 2018; updated February 20, 2019

Prepublication Requirements

The Joint Commission has approved the following revisions for prepublication. While revised requirements are published in the semiannual updates to the print manuals (as well as in the online Edition®), accredited organizations and paid subscribers can also view them in the monthly periodical The Joint Commission Perspectives®. To begin your subscription, call 800-746-6578 or visit http://www.jcrinc.com.


Please note: Where applicable, this report shows current standards and EPs first, with deleted language struck­ through. Then, the revised requirement follows in bold text, with new language underlined.



Effective July 1, 2019


Identify individuals at risk for suicide.

Reduce the risk for suicide.


                       Elements of Performance for NPSG.15.01.01



  1. Conduct a risk assessment that identifies specific characteristics of the individual served and environmental features that may increase or decrease the risk for suicide.


  1. The organization conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide; the organization takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging).

Note: Noninpatient 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 harm and continuous monitoring in a safe location while awaiting transfer to higher level of care).

  1. Address the immediate safety needs and most appropriate setting for treatment of the individual served.


  1. Screen all individuals served for suicidal ideation using a validated screening


  1. When an individual at risk fur suicide leaves the care of the organization, provide suicide prevention information (such as a crisis hotline) to the individual and his or her family.


  1. Use evidence-based process to conduct a suicide assessment of individuals served who have screened positive for suicidal ideation. The assessment directly asks about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors.

Note: EPs 2 and 3 can be satisfied through the use of a single process or instrument that simultaneously screens individuals served for suicidal ideation and  assesses the severity of suicidal ideation.


  1. Document individuals’ overall level of risk for suicide and the plan to mitigate the risk for suicide.


  1. Follow written policies and procedures addressing the care of individuals served identified as at risk for suicide. At a minimum, these should include the following:
    • Training and competence assessment of staff who care for individuals served at risk for suicide
    • Guidelines for reassessment
    • Monitoring individuals served who are at high risk for suicide


  1. Follow written policies and procedures for counseling and follow-up care at discharge for individuals served identified as at risk for


  1. Monitor implementation and effectiveness of policies and procedures for screening, assessment, and management of individuals served at risk for suicide and take action as needed to improve compliance.




Additional FAQs: Suicide Risk Reduction Recommendations

The November 2017, January 2018, and July 2018 issues of Perspectives published suicide risk reduction recommendations from an expert panel convened by The Joint Commission. On October 9, 2018, The Joint Commission convened the sixth expert panel to further address questions related to these recommendations. The following set of Frequently Asked Questions (FAQs) is intended to clarify the panel’s recommendations to reduce the risk of suicide in health care settings.

For questions related to the FAQs or the suicide risk recommendations please contact the Standards and Interpretation Group (SIG) via the Standards Online Submission Form.

QUESTION: Are dropped ceilings allowed in corridors and common areas on an inpatient psychiatric unit?

ANSWER: Yes, dropped ceilings are allowed in corridors and common areas where staff are regularly present as allowable by the facility’s safety risk assessment.  These areas do not need to be in constant view of staff but should be a part of the standard safety rounds conducted by staff (for example, 15-minute patient safety checks, shift-to-shift environmental rounds, and so on).

Dropped ceilings in areas that are not fully visible to staff (for example, a right-angle curve of a corridor) should be noted on the risk assessment and have some additional steps taken to make it more difficult for a patient to attempt to access the space above the dropped ceiling (such as gluing or clipping tiles), which would allow staff to hear or see the patient’s suicide attempt and prevent the attempt from occurring.

QUESTION: Has The Joint Commission identified any specific items that should not be allowed to be brought on an inpatient psychiatric unit?

ANSWER: No, The Joint Commission does not determine the items to be prohibited from an inpatient psychiatric unit. Items that ore prohibited to be brought into organizations, due to the risk of harm to self or others, should be determined by the organization. Compliance with such safety measures is based upon organizational policies/procedures, individual core plans, and applicable state rules or regulations.

QUESTION : Does The Joint Commission recommend specific ligature-resistant products?

ANSWER: No, The Joint Commission does not recommend products.  Organizations are required to do the following:

  • Comply with the Recommendations for Suicide Prevention in Healthcare Settings (see the previously fisted Perspectives articles)
  • Conduct a risk assessment of the environment
  • Determine which products to appropriately install (based on manufacturersinstructions)
  • Ensure that the products are functioning properly to maintain ligature resistance P

 Perspective’s, January 2019, Volume 39, Issue1


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.

November 2017 Perspectives: SUICIDE PREVENTION in HEALTH CARE SETTINGS: Recommendations Regarding Environmental Hazards for Providers and Surveyors

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.





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.