The Greeley Company
November 12, 2019 6 Min Read

Looking Forward to 2020: Questions and Answers from Greeley’s Insights Webinar Presented by NAHQ

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The Greeley Company was delighted to share its insights about how to best prepare for and deal with CMS and accreditation findings in hospitals in the coming year. The following is our response to questions posed during the November 6 webinar presented by the National Association for Healthcare Quality.

Watch the On-Demand Webinar > 

Q: Can you offer some concrete solutions to meet suicide screening and ligature resistance standards, since it appears that the most ‘compliant’ way to meet the standard is through 1:1 observation? 

A: The identification and protection of potentially suicidal patients is the subject of a very complex set of moving-target CMS and accreditation requirements. Greeley’s written summary of current CMS draft interpretive guidelines, Joint Commission standards and Joint Commission Frequently-asked questions alone is 40 pages. Even though our motto is “Simplify and Comply,” our model policy and procedure addressing this topic is 3 pages long and refers to 8 separate attachments. So, with that inherent complexity in mind, please consider the following as you plan compliance with this challenging set of requirements. (The following guidance assumes a patient presenting to a general emergency department with or without a psychiatric unit.)

We will address three phases of care: presentation and suicide screening, suicide precautions, and suicide assessment.


We recommend that the hospital reserve formal suicide screening (using the Colombia or similar evidence-based tool) for patients with a primary behavioral health diagnosis or compliant (including substance abuse). All others should receive a standard psychosocial assessment, which may, of course, lead to further psychiatric evaluations or additional precautions. Why reserve screening for behavioral health patients? Because applying a Columbia-like scale to all patients is not required and leads, in our experience, to many, many “false positive” screens. It also tends to de-emphasize the importance of rigorous screening and precautions for behavioral health patients.


For this discussion, we will assume three levels of suicide risk that derive from suicide screening: High, Moderate and None. At least for now (and we believe this may change in the future), “High Risk” patients (patients who have the intent to harm themselves, with or without a plan, and patients with a recent suicide attempt whether or not aborted) must be on 1:1 observation. The observer must be in the direct line of sight of the “High Risk” patient and must be close enough to intervene to protect the patient from any attempt at self-harm. Although “Moderate Risk” patients (patients with suicidal thoughts but without the intent or plan to harm themselves) must receive a full suicide assessment, they are not required to be placed on 1:1 observation while waiting for the evaluation. The hospital is free to establish a level of observation less than 1:1 for patients who are not “High Risk.”


A full assessment using an evidence-based tool with specified elements must be completed by a practitioner with appropriate competencies for any patient expressing suicidal thoughts or exhibiting self-harm behaviors (in other words, both high and moderate-risk patients). This assessment may also serve as the “screening” mentioned above. The hospital may allow the Emergency Medicine practitioner and a wide range of behavioral health practitioners to complete this assessment. It is possible for a patient formerly considered “High Risk” to be downgraded, or even discharged, based on this assessment. However, unless the patient is in a controlled environment and under a psychiatric treatment plan, it is usually safest to continue 1:1 observation until the patient is relocated to a psychiatric unit or institution.

View our comprehensive workshop: Identifying and Protecting Patients At-Risk for Suicide. We also offer a companion workshop about creating a compliant ligature-resistant environment, which you may access here.

Q: What is the easiest way to access the new CMS CoP’s that are effective this month? 

A: You can access the Federal Register directly if you want to look at the source documents, but be warned, the combined length is 150 pages in very small print.

The Discharge Planning CoP is posted here. 

The other CoP changes, including the new Infection Prevention and Infection Control and Antibiotic Stewardship CoP, the “assessment vs. H&P” rules, and a zillion other things are found here.

Greeley also offers webinars and additional blogs on CMS requirements, which is the easiest way to understand the new CoPs.

Q: What CMS CoP’s are typically cited with medication management-related findings: Pharmaceutical Services, Nursing Services, both? (For example, medications per order). 

A: Both.

Medication administration is covered in the Nursing Services condition of participation (§482.23(c) Standard: Preparation and Administration of Drugs). Most other medication management requirements (orders, order review, security, post-surgical monitoring, etc.) are located within the Pharmaceutical Service CoP (§482.25).

Q: Have you heard if The Joint Commission has made a determination regarding the requirement for a focused standards assessment?

A: We are not aware of any recent changes to that process, but we believe it is under review. Future changes to the process will likely be first published in The Joint Commission’s *Perspectives*. Also, keep tuned to this blog for any significant changes to the accreditation process.

Q: Could you clarify on the “Airflow in critical areas EC.02.05.01 EP15,”? You mentioned something about the mechanical room serving the Sterile Processing Dept.

A: This requirement refers to “critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust) …” The EP requires that “…the ventilation system [for these areas] provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, temperature, and humidity.”

There is a lack of consistency among surveyors and survey reports as to which spaces are covered by this rule, but it is safe to assume it covers at least decontamination areas in central sterile supply that generate “contaminated” water droplets, operating rooms where there is high sensitivity to dust and other airborne contaminants during open procedures, and equipment rooms that generate significant mists, dusts or fumes, such as the mechanical room behind built-in steam sterilizers that generate water droplets.

Non-critical areas are covered under EP.16 of the same standard. Citations at that element of performance are less frequently associated with the higher SAFER designations. Non-critical areas include “nursing units; clean and soiled utility rooms in acute care areas; laboratories, pharmacies, diagnostic and treatment areas, food preparation areas, and other support departments”.

(Quoted phrases are from The Joint Commission’s Accreditation Manual for Hospitals.)

Q: What is Radar (under Communication)? 

A: Radar is one of the three critical components of an organization’s “communication” capability in The Greeley Company’s Framework for High Reliability. Radar generically is a system for detecting obstacles ahead and, with respect to Greeley’s “Framework,” it refers to a frictionless process for promptly communicating organizational risks to hospital leaders, including executives. The idea is that the CEO should never hear about a significant adverse event or adverse situation (organizational risk) from a reporter or a surveyor. Instead, executive leaders should receive daily briefings about new significant adverse events or situations and also receive follow-up reports about any immediate actions necessary to reduce significant risk. Although events that become apparent through the event reporting process are included, we find a number of these situations become apparent through informal channels: security reports, newspaper articles,  customer service representatives, etc. The more robust and inclusive the event reporting and issue analysis capability, the easier Radar becomes.


Bud Pate 

Bud Pate, VP of Compliance Content

Mr. Pate has been with Greeley for 16 years. Before joining Greeley he spent 15 years as the Southern California Regional Director of Licensing and Accreditation for Kaiser Foundation Hospitals and, prior to that, as a regulator involved with Medicare Certification and state licensing for non-long-term care institutions in Los Angeles County.



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