Accreditation

Young and old: Ex-surveyor worries about where CMS applies ligature risk definition

Briefings on Accreditation and Quality, April 1, 2018

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Hospitals have 60 days to fix ligature risks

In December, CMS unveiled a new definition of a ligature risk, along with a time frame for correcting those risks, interim guidance for surveyors, and requirements for requesting a time extension. These current changes are already expected to make a huge impact on hospitals and nursing homes everywhere. However, should behavioral health adult units and geriatric units be held to the same standards?

According to CMS S&C Letter 18-06, a ligature risk (or point) is “anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation.” That includes handles, coat hooks, pipes, shower rails, radiators, bedsteads, window and door frames, ceiling fittings, hinges, and closures.

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