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Ligature Point and Other Self-Harm Risk Assessment Experience Survey

The APA has heard from members regarding citations due to ligature point and other self-harm risks during the Joint Commission (TJC) hospital accreditation onsite survey process.  We are looking to gather information regarding about where this is happening and the impact of these changes.  The individual responses, including your identity, will be kept strictly confidential.      
1. Are you currently working for, or seeing patients in, a facility that participates in Medicare and is subject to the Centers for Medicare and Medicaid Services (CMS) Hospital Conditions of Participation (CoP)?
2. Please list the name of the facility and the state in which it is located.  (If you are not comfortable with providing the facility’s name, please share the state in which it is located.)
3. Please select the option that best describes the facility subject to the onsite survey.
4. As part of your work caring for patients within this facility, have you had any involvement in the performance of, or preparations for, the Joint Commission (TJC) onsite surveys?
Date of survey (Month/Year) If not yet occured since February 2017, month and year scheduled to reoccur.
6. Prior to the onsite survey did you receive any communication from TJC regarding any changes to the survey process?
8. Has your facility received citations associated with perceived ligature point or other self-harm risks? If yes, please select all options that apply.
9. If you responded yes to the previous question (Q7), please describe if the citations were: 
10. Did that citation result in your facility having to be resurveyed after modifications were made?
11. Please provide the following details regarding your citation(s): 
12. Have patients treated in your facility experienced negative consequences resulting from the environmental modifications undertaken in a response to the ligature risk related citations generated by the recent survey (e.g., reduction in personal dignity, loss of privacy)?
13. Of the areas cited and included in the facility’s plan of correction, did you disagree that the findings cited as ligature risks pose a risk to patient safety?
14. Are you aware of any completed hangings or attempted hangings in your facility?
15. Due to the citation(s), please list any actions your facility has, or is planning to take, that could impact the delivery and/or availability of psychiatric services at your facility, due to the financial burden associated with implementing the modifications in the remediation plan.
16. As a result of the citation, is the facility or healthcare system in jeopardy of losing Joint Commission accreditation?
17. Contact information: Your identity will be kept completely confidential in our tabulating and/or description of these responses.  However, depending on your survey responses, we may follow up with you for further information.