When it comes to providing security, behavioral health is a world unto its own. A behavioral health facility has to protect patients from themselves as well as people inside and outside such a facility.
Locksmith Ledger recently discussed the issues of security and safety in behavioral health facilities with several industry experts. The participants include Christine Cicchetti, product manager for hinges and behavioral health access solutions, and Grant Heppes, distribution development manager for electronic access and data, at dormakaba; Mark Berger, president of Securitech Group; William Sporre, vice president of national and international sales and marketing at Marks USA; Tom Morgan, director of business development-healthcare at ASSA ABLOY Opening Solutions; and John Truempy, an institutional locksmith and the first president of ALOA’s division for institutional locksmiths.
Because of the magnitude of the subject matter and quality of the discussion, we broke up this roundtable. The first part ran in our February 2022 issue.
Q. How has the fallout from dealing with COVID affected security at behavioral health facilities?
Christine Cicchetti/Grant Heppes: Security remains a high priority. Behavioral healthcare facilities have taken additional steps to maintain security and reduce potential contamination points concurrently. Two trends have emerged.
Behavioral health sites, as with most of healthcare, have intense protocols for staff and new patients, because they have a high population of people who can’t be relocated easily. When new patients come in, they typically have to quarantine for up to two weeks in designated areas. COVID has increased the necessity for these spaces, which means that facilities are installing ligature-resistant hardware and hinges throughout a building. In essence, any location has the potential to be transformed into a quarantine space. That’s led to a lot of retrofitting of atypical patient areas.
In addition, touchless technology and automatic operators and closers have emerged as an important frontline defense to reduce the number of touchpoints for staff and patients. The demand for touchless access will continue to grow.
Mark Berger: COVID hasn’t changed the life-safety or security requirements within these environments. Rather, it has gone a step further in restricting who can enter as a visitor to provide services. Certain projects haven’t been undertaken during the COVID period to minimize the introduction of outsiders into these closed environments.
William Sporre: Most facilities were, and some still are, closed to any work being done at their facilities while the COVID risks remain high. They only are providing work on emergency projects, having restricted any outside evaluations or presentations of new ligature-resistant product. They also have limited access to any evaluations on the hospital. It seems that The Joint Commission, which oversees the hospitals and the standards they must adhere to, isn’t as active with the hospitals at present.
Tom Morgan: COVID has caused a myriad of new challenges and requirements for all buildings, and behavioral and mental health facilities are no exception. However, COVID also has presented an opportunity for key stakeholders to look at their buildings and security strategies and make any necessary upgrades, including adding intelligent access control. Intelligent access control not only can be used to help to enhance the safety and security of the building and building occupants, but it also can be used to help manage the flow of people and limit the number of people allowed in a particular area.
Because security requirements for these environments are driven by their unique and diverse occupancy requirements, you have to consider different solutions for different environments. For example, if the area is designed for children or adolescents, there might be a necessity for a delayed-egress maglock to prevent patients from escaping, while an area designed for substance-abuse patients might require less restrictive measures.
Behavioral and mental healthcare facilities also can benefit from real-time location systems (RTLS). By using data-driven analytics, these systems can increase visibility into the specific location of facility assets, such as a bed or pharmaceutical cart, as well as clinicians and staff. This allows for a quick and easy way to perform contact tracing in the event of a COVID exposure.
John Truempy: I’m not sure COVID affected security much in these facilities any more than it did in all healthcare facilities, other than the fact that visitors, such as family members, might be part of a residence’s treatment, or group therapy might require more room that provides social distancing that might not have been behind a secure area before. Adding a COVID screening or isolation area within a facility might expand the footprint. Expanding into an area through hospital latches might not meet other codes and are designed not to be secure.
Q. With respect to solutions and site surveys, what area or facet tends to be overlooked that the security pro should know about?
Cicchetti/Heppes: Solutions and site surveys that overlook the fact that a behavioral healthcare facility is a healing environment and not simply an institution are out of sync with modern philosophy for this special patient population. When it comes to access, the first thing professionals think about is door functionality and requirements. This often comes at the expense of how the door and its functionality will be viewed by the patient. The door must fulfill its primary duties of security and durability, but it also must meet at-risk patient demands as the environment trends toward a more homelike and less institutional setting.
One of the most overlooked facets of a site survey or solution is a well-designed and managed key system. Many behavioral-health scenarios require staff to gain access to areas quickly. If they don’t have the tools or proper equipment, they risk patient safety and overall security, which makes it more difficult for staff and the facility to operate. A well-managed key system has a hierarchy that authorizes use easily and reduces the necessity to fumble through various keys to gain access. For best results, behavioral healthcare facilities should work with a key-system expert and manage control through key-management software.
It’s critical that a security expert visit any behavioral healthcare facility that requests new access control solutions. One-size-fits-all solutions don’t work in this category. Each site must be evaluated to determine the age of the buildings and the type of healthcare delivered. In addition, adding a registered nurse (RN) to the conversation from the start of any evaluation is highly recommended. RNs have a frontline perspective regarding patient care. In a typical healthcare access-control-solutions planning meeting, an RN wouldn’t be involved. In behavioral healthcare, however, they ask important questions and provide details that can make the difference in the success rate of any new solution.
Berger: Every detail of an opening must be reviewed when a security pro performs a site survey, not only those that they might have been brought in to correct. Speaking to the staff and understanding the makeup of the patients are critical in selecting the correct solutions. And if you’re in a youth facility, recommend products that are more durable and abuseproof than you would for an elder-care ward.
And remember: Behavioral healthcare wards should look more like a hotel than a hospital or detention center. All visible elements on a ward are part of the healing environment. Don’t suggest products that conflict with that mission.
Sporre: Ligature-resistant hardware isn’t restricted to just psychiatric hospitals. Although healthcare facilities might be a main user, anywhere people who have a possibility of doing harm to themselves are held would be a candidate for ligature-resistant hardware, including detention areas in schools and courtrooms.
Patient care has changed. No longer are all patents treated the same, and it no longer is just patients’ rooms but complete floors that should use this hardware. This calls for a vast array of lockset designs that have to be furnished.
Morgan: All healthcare facilities, including behavioral-health environments, are required to perform and provide a written record of annual fire-door inspections to stay compliant with the Centers for Medicare & Medicaid Services. The adoption of the National Fire Protection Association (NFPA) 80 National Life-Safety Code requires a minimum of the following items to be verified:
- Labels are clearly visible and legible.
- No open holes or breaks exist in the surfaces of the door or frame.
- Glazing vision light frames and glazing beads are intact and securely fastened in place, if so equipped.
- The door, frame, hinges, hardware and noncombustible thresholds are secured, aligned and in working order and have no visible signs of damage.
- No parts are missing or broken.
- Door clearances don’t exceed clearances listed in 4.8.4 and 6.3.1.7.
- The self-closing device completely closes when operated from the full-open position.
- If a coordinator is installed, the inactive leaf closes before the active leaf.
- Latching hardware operates and secures the door when it’s in the closed position.
- Auxiliary hardware items that interfere or prohibit operation aren’t installed on the door or frame.
- No field modifications to the door assembly have been performed that void the label.
- Meeting edge protection, gasketing and edge seas, where required, are inspected to verify their presence and integrity.
- Signage affixed to a door meets requirements listed in 4.1.4.
For more information, visit www.nfpa.org.
Another great resource is The Joint Commission. The Joint Commission publishes an objective evaluation process of standards that are designed to help to create a strategy to address complex issues and identify vulnerabilities within healthcare environments. You can learn more at www.jointcommission.org.
Truempy: These facilities, just like other specialty conditions, such as MRI, X-ray facilities or pharmacy doors, are never the place for cut-and-paste specs. Just as it might be your first time working, installing or reviewing under these unique conditions, also assume everyone else on a design team might not have done one before. I reviewed a standard many years ago that the hinges and trim were great. The carryover of the coat hook from the bathroom door standard for the rest of the facility wasn’t a good idea. This would be a minor oversight in just about every other door in the world, but not in this type of facility. Codes and hardware demands can change from one door to the next and even from one side of a door to the other.
Ligature resistance often is the talking point when doing this type of facility, but keep in mind that barricade resistance also is required, along with Americans with Disabilities Act (ADA) and tamper resistance, among other things.
Q. What’s the latest in technology trends for providing security at behavioral health facilities, and what’s next?
Cicchetti/Heppes: Finding the best balance among compliance, design and function is a top priority in behavioral healthcare. Access control solution providers, security pros and behavioral healthcare facilities must work together to fulfill as many requirements as they can with one product. Key questions include but won’t be limited to:
- Does the lock or lock body fit within current standards?
- Have all aspects of the design-function aesthetic been taken into consideration?
- Will this solution fit into the existing building blueprint or require a retrofit?
- Does the solution meet ADA requirements?
- Does it comply with all codes as determined by the local authority having jurisdiction?
Specific product trends will include further development of ligature-resistant card access locks, card readers built into lock trims, new door closers and auto operators, and the expanded use and technological improvement of antimicrobial and antiviral finishes.
Finally, the demand for behavioral healthcare access solution hardware has increased, because incidents of self-harm are increasing. Access control solutions, such as electronic monitoring, maintaining a holistic planning perspective and increasing knowledge of door hardware with healthcare professionals, such as RNs and other staff, play a role in prevention. Rather than view this as a trend, security pros who view this as an opportunity to improve the safety and security of behavioral-health patients and staff can influence more-positive outcomes.
Berger: Many of the solutions our industry has developed over the past 15 years truly have advanced the art. In many ways, we’ve achieved a 99% solution and are tinkering with that last 1%.
When we look at behavioral healthcare wards, we break them down into spaces. For patient rooms, I’d say there definitely has been a movement to nongraspable levers, ones where you can’t wrap your hand fully around the lever. These are sometimes called “five-point” levers. The enhanced ligature resistance here eliminates tying a sheet around the lever in an attempt to cause self-harm.
Many facilities still are comfortable with the first generation of ligature-resistant levers as facilities balance the risk of harm on those levers versus the less friendly operation of the five-point levers. Newer, ergonomically designed levers attempt to deliver the best of both worlds.
Over-the-door alarms continue to grow in popularity, with newer versions suitable for installation on double-acting doors. Ligature-resistant hinges have matured, with newer double-acting hinges having alarmed tops.
Seclusion-room locking also has matured. Internal multipoint locksets provide superior protection against patients hurling themselves against the door. This, and ward entry doors, are examples where the opposite of forced entry comes into play. Here, the goal is for the products to prevent forcing the door open from the interior.
Electrified ward entry locks also are growing in use, as are sallyports to prevent patient elopement. Sallyports must meet local codes. Some require allowing staff to override the sallyport function at any time, to permit them to exit unimpeded if they believe they’re in danger.
Sporre: Up until now, it was almost entirely mechanical locking. A shift to wireless access with cellphone credentials, providing lockdown capability, audit trail and better access security to patient rooms, will occur. With testing and continued input from healthcare facilities, development of mechanical ligature-resistant hardware also will continue.
Morgan: A layered approach to security has become an emerging trend for many facilities. A layered security approach goes beyond simply controlling access to the building at each opening to developing an integrated and intelligent system for monitoring and safeguarding access to rooms, cabinets and other openings throughout. When designing a layered security approach, it’s important to ask questions, such as:
- Who are the users (patients, staff, visitors, etc.), and how will this affect them?
- Is this high traffic or low traffic?
- What level of security is required for each area, general access, high security or even a lockdown area?
- What’s the budget?
- What areas are subject to fire or egress codes?
- Are there energy-efficiency and LEED or sustainability requirements?
After you know the requirements, you can tailor the access control capabilities of each opening to match the security requirement. For example, Power over Ethernet (PoE) locks provide the opportunity to secure a door via intelligent access control but also limit potential catch points by limiting patient access to the door-position switch, reader and other peripherals that might be accessed by traditional electronic locks.
A layered approach to security not only will improve access to key areas of the facility, but it also can help to ensure compliance, boost patient and staff satisfaction, improve efficiency and reduce the costs of administration and operations and loss prevention.
Truempy: My normal go-to answer for most views of the future is always “electronics,” but this is one I have not seen electronics being the big thing. Other than not-so-new access control and alarms, it’s all mechanical. Designs change over time, but sadly it often is, as with fire and building codes, because a tragedy happened.
This also is an area that changes as society changes as we understand mental health better. A padded room or rubber room isn’t really a thing anymore, but a time-out room that has special hardware that unlatches itself if the attendant lets go for even a second is.
