CMS Memorandum Clarifies Ligature Risk Guidance

PUBLISHED: Aug 8, 2018
Relevant to: Behavioral Health, Community Mental Health Centers, Critical Access Hospitals, Hospitals

The Centers for Medicare and Medicaid Services (CMS) has issued a Survey and Certification Memorandum to communicate an update about their work on addressing ligature and safety risks. In their memorandum CMS announces that the proposed CMS Psychiatric Care Task Force to address environmental risks related to the inpatient care of patients experiencing a psychiatric illness will not be convened as planned. CMS has determined that a workgroup would not be the most appropriate vehicle to foster the required changes.

According to CMS, the successful efforts by The Joint Commission (TJC) Suicide Panel, on which CMS participated, effectively clarifies and refines the issues involving ligature and safety risks and therefore are being incorporated into revisions of CMS Interpretive Guidance.

CMS is continuing to work on revisions to both the Interpretive Guidance for Psychiatric hospitals (Appendix AA) as well as the Interpretive Guidance for Hospitals (Appendix A), and until CMS’ comprehensive ligature risk interpretive guidance is released, survey agencies and accreditation organizations 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 any identified deficiencies.

StayAlert! is monitoring this topic and will publish additional information once CMS announces finalized revisions to their Interpretive Guidance.

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