Clarification of Ligature Risk Policy

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Clarification of Ligature Risk Policy
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• Ligature Risks Compromise Psychiatric Patients’ Right to Receive Care in a Safe Setting: The care and safety of psychiatric patients and the staff that provide that care are our primary concerns. The Centers for Medicare & Medicaid Services (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).
• Definition of a Ligature Risk: 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.
• Focus of Ligature Risks: The focus for a ligature “resistant” or ligature “free” environment is primarily aimed at Psychiatric units/hospitals.
• Interim Guidance: 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.
• Timeframe for Correction of Ligature Risk Deficiencies: All 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 Risk Deficiencies Do Not Qualify for Life Safety Code (LSC) Waivers: Ligature risks are not LSC deficiencies. Therefore, a LSC waiver may not be granted.
• Monitoring of Progress: 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.