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Directors for Accredited Organizations are now requiring your Organization to conduct an Environmental Risk Assessment for inpatient psychiatric hospitals, inpatient psychiatric units in general acute care hospitals, and non-behavioral health units DESIGNATED for the treatment of psychiatric patients (i.e. special rooms/safe rooms in Emergency Departments or Medical Units): The hospital Patient’s Rights Condition of Participation (CoP) at § 482.13(c)(2) provides all patients with the right to care in a safe setting.

The Joint Commission requirements are found in the Environment of Care (EC) chapter of the accreditation manual at EC.02.06.01 EP 1 which requires hospitals to establish and maintain a safe, functional environment. Element of Performance # 1 states “Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided”. Therefore, ligature and self-harm risks must be identified and eliminated. While risks are in the process of being eliminated, policies and procedures must be developed and implemented to mitigate the harm posed by such risks. Mitigation plans must include, at a minimum the following:

In non-behavioral health units (i.e. Emergency Rooms or Medical Inpatient Units) that are NOT DESIGNATED specifically for the treatment of psychiatric patients; however, where psychiatric patients may temporarily reside, ligature/self-harm environmental risks must also be identified.

All physical risks not required for the treatment of the patient that can be removed, must be removed. Furthermore, an appropriate level of effective surveillance must be implemented if self-harm risks remain in the environment. Organizational policies and procedures must adequately guide staff in the assessment of patients’ risk for suicide/self-harm and the implementation of interventions based upon the patients’ individual needs.

For non-inpatient programs surveyed under the Hospital Accreditation manual, an environmental risk assessment should be completed. Based upon the results of that assessment, considering the individuals they serve, the organization determines if any modifications to the environment should be made. Policies and procedures should also be developed and implemented to address the immediate action to be taken by staff when a patient is assessed to be at risk for suicide.

BRAND SERVICES Ligature assessment includes assisting your Clinical and Facility TEAM with an onsite Environmental Risk Assessment of your Organization. Items identified as Ligature risk in the Environment are as follows, but not limited to: Door handles, door frames, Door hardware, Window fasteners, Coat hooks, Pipes, Shower curtain rods, Shower/tub controls, Sink faucets, Grab bars, Hand rails, Tile ceilings, Door hinges and closures, Bed steads, A/C units, Belts, Shoe laces, Diffuser grills, Vents, Gaps behind toilets, Bed cords, Psych safe beds** Clothing items, Bed sheets, Jewelry, Light fixtures, Paper towel holders, Soap dispensers, Fire extinguisher cabinets, Fire alarm pull stations, Courtyards, furniture, chairs, tables, nightstands

For more Information on Brand Services Ligature service please contact
Director Healthcare Services Joseph Glaski, MBA,FASHE,FDAI at

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BRAND SERVICES is the industry leader in passive fire protection and life safety services, including fire door inspections and repairs, fire and smoke damper inspections and repairs, firestopping services, fireproofing services and facility maintenance. BRAND’s service region includes: Connecticut (CT), Massachusetts (MA), Rhode Island (RI), Vermont (VT), New Hampshire (NH), Maine (ME), New York (NY), New Jersey (NJ), Pennsylvania (PA), Maryland (MD), Washington D.C. (DC), Delaware (DE), Virginia (VA), Ohio (OH), North Carolina (NC), South Carolina(SC), Georgia(GA) and nationwide for large scale projects.

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