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CMS Revises Ligature Risk Guidance

In a memo to state survey agency directors, the Centers for Medicare & Medicaid Services (CMS) releases draft revised policies for ligature risk.

The policies last were issued in December 2017. Revisions to the CMS State Operations Manual (SOM) clarify policy expectations and establish a process for hospitals to request an extension to remedy deficiencies.

Ligature Risk Definition

Ligature risk points are defined as anything that could be used to create a sustainable attachment point, such as a cord, rope, or other material, for hanging or strangulation. Common points include doors, hooks, handles, window frames, belts, sheets, towels, and shoelaces.

Psychiatric units of acute-care hospitals, locked emergency department psychiatric units, and psychiatric hospitals must achieve a “ligature-resistant” environment to promote safety for patients at risk of harm to themselves or others. Ligature risk requirements do not apply to unlocked psychiatric units and nonpsychiatric hospital units.

Revisions to the SOM appendix A, for hospitals, define ligature risks and add guidance for establishing and maintaining a ligature-resistant environment, including updated safety measures and additional expectations for educating and training staff.

Updated Ligature Risk Extension Process

Under 42 CFR 488.28, facilities must correct identified ligature risk deficiencies within 60 days from receipt of the deficiency report. CMS regional offices can grant hospitals additional time to mitigate the risk in the case of delays caused by:

  • the need for governing body approval;
  • competitive bidding;
  • applying for funding;
  • obtaining permits for physical changes; and
  • obtaining needed products and supplies for corrective actions.

The agency has updated chapter 2 section 2728G of the SOM with processes for both deemed and nondeemed hospitals to request ligature risk extension requests.

CMS seeks input on the draft guidance by June 17; submit comments to HospitalSCG@cms.hhs.gov. The agency will review submitted comments before finalizing a policy memo, appendix A, and chapter 2.

Contact Senior 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.

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