DNV announces new Patient Rights standard

In response to updates the Centers for Medicare & Medicaid Services (CMS) made to ligature risk compliance standards last July, the accrediting organization (AO) DNV Healthcare USA Inc. has followed suit and also updated the ligature risk accreditation requirements in its Patient Rights (PR) Chapter.

The changes went into effect March 24 and are published in Revision 24-0 of the National Integrated Accreditation for Healthcare Organizations® (NIAHO®), which includes DNV’s accreditation requirements, interpretive guidelines and surveyor guidance for hospitals.  

The new standard, PR.10, Care in a Safe Setting: Patients at Risk of Harm to Self or Others, states that, “Organizations shall identify patients at risk for intentional harm to self or others, identify environmental safety risks for such patients, implement the appropriate monitoring and observation, and provide education and training for staff and volunteers.” The standard applies to both acute care hospitals and critical access hospitals.

The new standard includes four requirements that focus on patient risk screening and assessment, safety precautions, education and training, and an environmental ligature and safety risk assessment.  Also included in Revision 24-0 are interpretive guidelines that give further direction on how to comply with the new standard.

In conjunction with the new standard, DNV discontinued its Ligature Risk Extension Request (LRER) program, which was also discontinued by CMS. The LRER program was used in instances when organizations were given a nonconformance citation related to ligature risk but were unable to make the corrections in the required 60-day time period. By applying for and being granted an LRER, organizations were given more time to make corrections if they were able to demonstrate a hardship that prevented them from complying within 60 days.

The Quality, Safety & Oversight memo released by CMS in July 2023 provides further guidance on this change. Also, the CMS State Operations Manual has been updated to state that accredited organizations are required to correct ligature risks “as soon as possible, but within the timeframe noted” by the organization’s local CMS office, state survey agency or AO.  

DNV’s interpretive guidelines for PR.10 give more context on how it will address nonconformities.