CMS SOM App. A, Tag A-0144

Interpretive Guidelines §482.13(c)(2)

The intention of this requirement is to specify that each patient receives care in an environment that a

reasonable person,

similarly situated as the patient would consider to be safe. For example, hospital staff

should follow current standards of practice for patient environmental safety, infection control, and

security. The hospital must protect vulnerable patients, including newborns, children and the elderly.

Additionally, this standard is intended to provide protection for the patient’s emotional health and safety

as well as his/her physical safety. Respect, dignity, and comfort are also components of an emotionally

safe environment. To provide care in a safe setting, hospitals should also identify patients at risk for

intentional harm to self or others, identify environmental safety risks for such patients, and provide

environmental safety education and training for staff and volunteers.

Patients at risk of suicide (or other forms of self-harm), or who exhibit violent behaviors toward others,

receive healthcare services in both inpatient and outpatient locations of hospitals. Although all risks cannot

be eliminated, hospitals should be able to demonstrate how they identify patients at risk of self-harm or harm

to others and the steps they are taking to minimize those risks in accordance with nationally recognized

standards and guidelines. The potential risks include, but are not limited to, those from ligatures, sharps,

harmful substances, access to medications, breakable windows, accessible light fixtures, plastic bags (for

suffocation), oxygen tubing, bell cords, etc.

Hospitals should consider three main elements in ensuring patient safety related to ligature risks:

1. Patient Assessment

There are numerous models and versions of patient screening and assessment tools to identify

the risk of harm to self or others. CMS does not endorse nor require the use of any particular

tool. The type of patient screening or assessment tool used to determine the risk of harm to self

or others should be appropriate to the patient population served, care setting, and staff

competency. Hospitals should implement a patient screening and risk assessment strategy that is

appropriate to the patient population. For example, a patient screening and risk assessment

strategy in a post-partum unit would most likely not be the same screening and risk assessment

strategy utilized in the emergency department.

All patients in psychiatric hospitals and psychiatric units should be screened for suicidal

ideation in order to ensure patient safety. In acute care hospitals, patients being evaluated and

treated for behavioral health conditions as their primary reason for care should be screened for

suicidal ideation. Hospital policy should address any other circumstances where suicidal

screening is required.

Hospitals may find the recommendations and resources in the 2018 report, Recommended

standard care for people with suicide risk: Making health care suicide safe, issued by the

National Action Alliance for Suicide Prevention (Action Alliance), to be highly useful in

developing the best practices for effective patient screening and assessment for those patients at

risk for harm to themselves, as well as for improving the care of patients at risk of suicide.

1

The

Action Alliance is a public-private partnership working to advance

1

National Action Alliance for Suicide Prevention: Transforming Health Systems Initiative

Work Group. (2018). Recommended standard care for people with suicide risk: Making

health care suicide safe. Washington, DC:

the National Strategy for Suicide Prevention and reduce the suicide rate by twenty percent by

2025. Notably, the report advances two of the goals of the National Strategy for Suicide

Prevention (National Strategy): (a) Promote suicide prevention as a core component of health

care services, and (b) Promote and implement effective clinical and professional practices for

assessing and treating those identified as being at risk for suicidal behaviors. (To download a

copy of the National Strategy, please visit: www.actionallianceforsuicideprevention.org).

2.Staffing/Monitoring

Hospitals should also provide the appropriate level of education and training to staff regarding

the identification of patients at risk of harm to themselves or others, the identification of

environmental patient safety risk factors, and mitigation strategies. Staff would include direct

employees, volunteers, contractors, per diem staff, and any other individuals providing clinical

care under arrangement. Hospitals have the flexibility to tailor the training to the services staff

provide and the patient populations they serve. CMS expects hospitals to provide education and

training to all new staff initially upon orientation and whenever policies and procedures

change. Additionally, CMS recommends ongoing training at least every two years after initial

training.

3.Environmental Risk

Just as all hospitals should implement a patient risk assessment strategy to ensure patient safety,

all hospitals should implement an environmental risk assessment strategy to provide patient care

in a safe setting. Environmental risk assessment strategies may not be the same in all hospitals or

hospital units. The hospital should implement environmental risk assessment strategies

appropriate to the specific care environment and patient population. Risk assessments should be

appropriate to each unit and should consider the possibility that the unit may sometimes care for

patients at risk for the threat of harm to self or others.

Survey Procedures §482.13(c)(2)

• Review and analyze patient and staff incident and accident reports to identify any incidents or

patterns of incidents concerning a safe environment. Expand your review if you suspect more

widespread or pervasive problems with safe environment issues in the hospital.

• Observe patient care environments and other areas frequented by patients for unattended items

such as utility or housekeeping carts that contain hazardous items that may pose a safety risk to

patients, visitors and staff. Examples of these items could include cleaning agents, disinfectant

solutions, mops, brooms, tools, etc

.

• Review policy and procedures and interview staff in patient care areas to determine how the

hospital trains staff on assessment of the patient care environment upon hire, before

providing patient care or working independently, and whenever policies and procedures are

revised or updated.

• Review policy and procedures and interview staff to identify processes to keep staff members

current on meeting the needs of the patient population served, to identify risks in the care

environment, and if risk is found, how staff report those findings.

• Review policy and procedures and interview staff to determine how the hospital defines

continuous visual observation or 1:1 monitoring in which a staff member is assigned to

observe only one patient at all times. The policy should include the ability of the assigned

staff member to immediately intervene when patient safety may be at risk.

• Observe and interview staff at units where infants and children are inpatients. Are appropriate

security protections (such as alarms, arm banding systems, etc.) in place? Are they functioning?

• Review policy and procedures on what the hospital does to curtail unwanted visitors,

contaminated materials, or unsafe items that pose a safety risk to patients and staff.

• Access the hospital’s security efforts to protect vulnerable patients including newborns, children,

the elderly, and patients at risk of suicide or intentional harm to self or others. Is the hospital

providing appropriate security to protect patients? Are appropriate security mechanisms in place

and being followed to protect patients? Security mechanisms should be based on nationally

recognized standards of practice.

• Determine if the hospital has a policy for assessing and reassessing patients who have been

identified as being at risk for suicide or harm to self or others, according to nationally accepted

standards of practice. Review policies and interview staff to verify processes are established to

protect these vulnerable patients and ensure care is provided in a safe setting.