Accreditation

CMS memo defines ligature risk and clarifies expectations

Accreditation Insider, December 19, 2017

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A new CMS memo creates a definition of a ligature risk, a time frame for correcting them, and interim guidance for surveyors, plus requirements for requesting a time extension for a plan of correction taking longer than 60 days. CMS says that while not all ligature risks can be eliminated, hospitals are expected to show how they identify patients at risk and the steps they are taking to minimize those risks.

According to the 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.

CMS is still collaborating with healthcare organizations and patient safety groups on more comprehensive guidance on ligature risks. The agency says it expects to have the update done in six months. Until then, accrediting organizations (AO) are allowed to use their own judgment on ligature risks. That includes the definition of a ligature risk, plans for correction, how deficiencies are ranked, and how long a facility has to correct the problem. Facilities should double-check with their AO’s ligature risk and self-harm requirements.



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