The Centers for Medicare & Medicaid Services (CMS) has issued a memo clarifying several issues related to ligature risk. Although the memo is not comprehensive final interpretive guidance from CMS, it provides a definition of a ligature risk, interim guidance for surveyors, a timeframe for correction of ligature risk deficiencies, and the requirements for requesting a time extension for a plan of correction taking longer than 60 days.
To provide care in a safe setting, hospitals must identify patients at risk for intentional harm to self or others, identify environmental safety risks for such patients, and provide education and training for staff and volunteers. Patients at risk of suicide (or other forms of self-harm) or who exhibit violent behaviors toward others receive health care services in both inpatient and outpatient locations of hospitals.
The focus for a ligature “resistant” or ligature “free” environment is that of psychiatric units of acute care hospitals and psychiatric hospitals, and does not apply to non-psychiatric units of acute care hospitals that provide care to those at risk of harm to self or others. Although all risks cannot be eliminated, hospitals are expected to demonstrate how they identify patients at risk and the steps they are taking to minimize those risks in accordance with nationally recognized standards and guidelines.
Ligature risk definition
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 frames, door frames, ceiling fittings, handles, hinges, and closures.
Hospitals must implement an environmental risk assessment strategy. Environmental risk assessment strategies may not be the same in all hospitals or hospital units. ASHE members have free access to a members-only tool on ligature risks in the physical environment.
Interim guidance for surveyors
CMS has begun the process of drafting comprehensive guidance in collaboration with regional offices, state survey agencies, accrediting bodies, providers, mental health clinicians, and other key stakeholders. CMS expects that developing comprehensive guidance will take about six months. In the interim, state survey agencies, and accrediting organizations may use their judgment as to the identification of ligature and safety risk deficiencies, the level of severity for those deficiencies, and the facility’s corrective action and mitigation plans. An attachment to the CMS memo provides more advanced guidance for state survey agencies and accrediting organizations.
Timeframe for correcting ligature risk deficiencies
Regulations require that the deficiencies addressed in a plan of correction be corrected within 60 days from the receipt of the deficiency report. Since ligature risks are not Life Safety Code® deficiencies, ligature risks are not eligible for Life Safety Code waivers. CMS realizes that correcting ligature risks within a limited number of days can be burdensome. In cases where the state survey agency or accrediting organization determine that it is not reasonable to expect compliance within the specified number of days, they may recommend additional time be granted by CMS in accordance with the regulations at § 488.28. The state survey agencies and accrediting organizations do not have independent authority to grant additional time for the correction of deficiencies, however.
Requesting a time extension
Hospital requests for additional time to correct ligature risk deficiencies must include the hospital’s accepted plan of correction, mitigation plan, an evaluation of the effectiveness of the mitigation plan, and an update on the status of the plan of correction. The hospital request must also include a rationale for why it is not reasonable to meet the correction timeframe. Hospitals without deemed status can submit the request electronically to the state survey authority; hospitals with deemed status can submit the request electronically to their accrediting organization. The state survey agency or accrediting organization will forward the submission electronically to the appropriate office.
Health care facilities are required to provide electronic progress reports to the state survey agency or accrediting organization on a monthly basis. These progress reports include, but are not limited to, copies of invoices, receipts, communications with vendors, and other documents detailing ongoing progress correcting the ligature risks and other safety deficiencies. The facility is also required to provide ongoing electronic routine status updates on the effectiveness of mitigation strategies using outcome and process measures to demonstrate the effectiveness of the plan.
For additional information, see the full CMS memo, S&C Letter 18-06.