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Ligature and/or Suicide Risk Reduction – Environmental Risk Assessment Expectations in Non-Inpatient Behavioral Health Care Settings

Are environmental risk assessments required for non-inpatient behavioral healthcare settings, such as residential, partial hospitalization, day treatment, outpatient, and intensive outpatient programming facilities?

Any examples are for illustrative purposes only.

Yes , as per NPSG.15.01.01 EP1, these organizations are required  to conduct a risk assessment to identify elements in the environment that individuals served could use to harm themselves, visitors, and/or staff. Those items that have high potential to be used to harm oneself or others should be removed and placed in a secure location (for example, putting sharp cooking utensils in a locked drawer) when possible. Staff should be trained to be aware of the elements of the environment that may pose a serious risk to an individual  who could develop serious suicidal ideation. Staff should be aware of how to keep an individual safe from these hazards until they are stabilized and/or able to be transferred to a higher level of care. The technical advisory panel recognized that a patient placed in this level of care may have a change in mental state based on some trigger within the environment or in their treatment, and staff should be prepared for this. 

Furthermore, these organizations must  have policies and procedures implemented to address how to manage an individual in these levels of care who may experience an increase in symptoms that could result in self-harm or suicidality.
These settings are not required to be ligature resistant.   These levels of care are less restrictive than locked units. Creating a ligature-resistant environment may not prevent individuals from attempting suicide because individuals are able to exit the facility. Moreover, individuals have been assessed and determined to be at low risk in the near term for self-harm and therefore appropriate for placement in a less restrictive level of care than that of inpatient psychiatric care. 

Additional Resources
Suicide Prevention Portal
Manual: Behavioral Health
Chapter: National Patient Safety Goals NPSG
New or updated requirements last added: June 30, 2022. New or updated requirements may be based on revisions to current accreditation requirements, regulatory changes, and/or an updated interpretation in response to industry changes. Substantive changes to accreditation requirements are also published in the Perspective Newsletter that is available to all Joint Commission accredited organizations.
Last reviewed by Standards Interpretation: June 30, 2022 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
This page was last updated on June 30, 2022 with update notes of: Reflects new or updated requirements Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.

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