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CMS Clarifies Ligature Risk Policy

In a memo to state survey agency directors, the Centers for Medicare & Medicaid Services (CMS) clarified agency policies on ligature risks in psychiatric units and hospitals.

Ligature risk points are defined as anything that could be used to attach a cord, rope, or other material for hanging or strangulation. The most common points are doors, hooks, handles, windows, belts, sheets, and towels.

According to the memo, the primary focus for promoting a ligature “resistant” or ligature “free” environment is psychiatric units of acute-care hospitals and psychiatric hospitals. Such policies do not apply to nonpsychiatric units of acute-care hospitals, such as emergency departments.

CMS is working with regional offices to draft comprehensive ligature risk interpretive guidance for state survey agencies and accrediting organizations; the agency estimates this guidance will be completed in six months.

In the interim, state survey agencies and accrediting organizations should use their best judgment to identify ligature risk deficiencies, assess the level of severity, approve a plan to remedy the deficiency, and set a deadline for compliance.

Contact Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.

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About the Author

Emily Schweich is a communications associate for America's Essential Hospitals.