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CMS to Update Ligature Risk Guidance

The Centers for Medicare & Medicaid Services (CMS) in a memo to state survey agency directors provided an update on revisions to ligature risk policies in hospitals.

Ligature risk points are places 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.

CMS announced it will not convene a task force proposed last December to reduce environmental risks associated with the care of psychiatric inpatients. Instead, the agency will incorporate findings from The Joint Commission Suicide Panel’s November 2017 special report on suicide prevention into its revised interpretive guidance. CMS representatives participated on the TJC Suicide Panel; as such, CMS said it would be unproductive to repeat this work with an independent panel.

The agency will continue to seek stakeholder input as it develops comprehensive ligature risk guidance. In the interim, CMS directed state survey agencies and accrediting organizations to use their best judgment to identify ligature risk deficiencies, assess the level of severity, and approve facility plans to remedy the deficiency.

Contact Senior Director of Policy Erin O’Malley at or 202.585.0127 with questions.


About the Author

Emily Schweich is a communications manager at America's Essential Hospitals.

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