HFAP ligature standard remain same after newest CMS memo

HFAP, one of the oldest accrediting organizations for U.S. hospitals, recently updated 13 of its standards to align with the expectations on ligature risk and other hazards that CMS outlined in a memo in December. The standards have been approved by CMS, but will not be revised again in light of the July memo, says Alise Howlett, AIA, CFPE, CHFM, HFAP’s emergency management, physical environment, and life safety standards advisor.

The July CMS memo states that surveyors would use Joint Commission ligature recommendations. Howlett says that the additional guidance is simply that, additional guidance. 

The updated HFAP standards range from staff training on identifying patients for risk of self-harm to building safety policies and monitoring, from building security to life safety compliance, from privacy and safety concerns in a safe setting to requirements for environmental risk assessments.

“The HFAP standards have been approved by CMS and simply outline updates for accreditation expectations. They will be enforced per the direction of CMS which stated that AOs will use their judgment as to the identification of ligature and safety risks, what level of citation will be made for deficiencies, and the corrective action to be taken for mitigation and remedy. This is all outlined in QSO 18-21,” says Howlett.

HFAP was not part of The Joint Commission’s panel of experts, but “all accrediting organizations with deeming authority are working from the same playbook: the CMS regulations,” says Howlett.