CMS Clarifies Ligature Policy

PUBLISHED: Dec 11, 2017
Relevant to: Behavioral Health, Critical Access Hospitals, Hospitals

The Centers for Medicare and Medicaid Services (CMS) has identified the need for increased direction, clarity, and guidance regarding the definition of what constitutes a ligature risk and other safety risks involved in the care of patients requiring psychiatric care and treatment. To that end, CMS has published a memorandum that clarifies its ligature policy including the following:

  • A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes, and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges and closures.
  • The focus for a ligature “resistant” or ligature “free” environment is primarily aimed at psychiatric units/hospitals.
  • CMS is in the process of drafting comprehensive ligature risk interpretive guidance to provide direction and clarity for Regional offices (RO), State Survey Agencies (SAs), and accrediting organizations (AOs).
  • Until CMS’ comprehensive ligature risk interpretive guidance is released, the ROs, SAs and AOs may use their judgment as to the identification of ligature and other safety risk deficiencies, the level of citation for those deficiencies, as well as the approval of the facility’s corrective action and mitigation plans to minimize risk to patient safety and remedy the identified deficiencies.
  • All ligature risk deficiencies are expected to be corrected within the timeframe designated by the CMS RO, SA or AO. In cases where it is determined that it is not reasonable to expect compliance within the designated timeframe, only CMS may grant additional time for correction.
  • Ligature risks are not Life Safety Code (LSC) deficiencies. Therefore, a LSC waiver may not be granted. When additional time for correction is granted, the hospital is required to provide monthly electronic progress reports to the SA or AO, including substantiating evidence of progress towards compliance. The SA or AO will update the RO or Central Office (CO) monthly, respectively.

StayAlert! is monitoring this topic and will publish additional information once CMS’s comprehensive ligature risk interpretive guidance is released.

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