CMS Seeks Comment on Draft Clarification of Ligature Risk Interpretive Guidelines

PUBLISHED: Apr 23, 2019
Relevant to: Behavioral Health, Hospitals

The US Centers for Medicare and Medicaid Services (CMS) has released a draft policy memorandum intended to clarify interpretive guidance on ligature risk. CMS is seeking comment on the draft policies through June 17, 2019.

The CMS hospital Condition of Participation, “Patient’s Rights” (42 C.F.R. §482.13(c)(2)) establishes the rights of all patients to receive care in a safe setting and is intended to provide protection for a patient’s emotional health and safety as well as his or her physical safety. Respect, dignity, and comfort are also components of an emotionally safe environment. In order to provide care in a safe setting, hospitals should:

  • Identify patients who are at risk for intentionally harming themselves or others
  • Identify environmental safety risks for such patients
  • Provide environmental safety education and training for employees (those directly employed and those providing services under contract) and volunteers.

Patients at risk of suicide (or other forms of self-harm) or those who exhibit violent behaviors toward others receive healthcare services in both inpatient and outpatient locations of hospitals. The draft revised guidelines are intended to provide increased direction, clarity, and guidance regarding what constitutes a ligature risk and clarify the expectations that hospitals achieve a ligature “resistant” environment in psychiatric units of acute care hospitals, locked emergency department psychiatric units, and psychiatric hospitals.

Because of the inherent challenges in addressing ligature risk deficiencies, the proposed revisions include a process for hospitals to request additional time to address ligature risks with the goal of achieving compliance.

See the proposed changes for in depth review and for comment submission instructions.

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