CMS Clarification of Anti-Ligature Risk Policy

by Dave Baker, Corporate Energy Director, Prime Healthcare; CSHE State Secretary


Hello everyone!   My name is David Baker the CSHE Education Chair and State Secretary.  In this quarter’s eBulletin, wanted to assure you are aware of the clarification document on ligature risk policy S&C Memo 18-06-Hospitals.  CMS Clarification of Anti-Ligature Risk Policy.

CMS issued a memo in December clarifying several issues related:

  • ligature risk in a psychiatric setting
  • definition of ligature risk
  • focus ligature risks
  • Interim guidance 
  • timeframe for correction of ligature deficiencies
  • monitoring of progress.

Hospitals are expected to demonstrate how they identify patients at risk of self-harm or harm to others and steps they are taking to minimize those risks in accordance with nationally recognized standards and guidelines.

The potential risks include, but are not limited to those from ligatures, sharps, harmful substances, access to medications, breakable windows, accessible light fixtures, plastic bags, oxygen tubing, nurse call bell cords, hand rails, shower rails, bathroom doors, shower curtains, plumbing, soap & paper towels dispensers, ceiling fittings, hinges, handles,  and door closers to name a few.

The hospital must implement some type of risk assessment strategy; CMS states there is no one size fits all tool available, but leaves it up to the hospital to implement the appropriate strategies; for example the risk strategy will be quite different in the emergency department setting Vs post-partum unit.  The assessment tool should be looking at all of the above listed items, as well as, unattended items such as EVS (housekeeping) carts that have any cleaning agents or hand sanitizers etc. inadequate staffing levels for patient observation, furniture that can be easily moved or thrown.  If you are looking for a  comprehensive risk assessment tool, American Society of Healthcare Engineering (ASHE) created one that is free to members to use and modify based on your needs.

Hospital staff must be trained to identify environmental safety risks regardless of whether or not the hospital has chosen to implement the use of an environmental risk assessment tool to identify potential or actual risks in the patient care environment. CMS recommends initial training and then ongoing training at least every two years thereafter.

Any deficiencies found by a regulatory agency will have to be addressed in a Plan of Correction within 60 days from the receipt of a deficiency report; keep in mind since ligature risks are not Life Safety Code deficiencies they are not eligible for life safety code waivers. CMS recognizes that the short amount of days to correct can be troublesome especially when certain equipment might not be available from the manufacture and have a 6 to 8 week lead-time; in those cases your state agency or accrediting organization may recommend additional time to be granted by CMS.

Keep in mind if you request additional time to fix the ligature risk deficiencies you must provide them with the hospital accepted plan of correction, mitigation plan/evaluation of the effectiveness, and an update of the plan of correction; you will need to explain why it is not a reasonable timeframe to correct the deficiencies.  If you have deemed status and can submit the electronic request through your accrediting organization and they will submit on your behalf.  You will need to also submit monthly progress reports to your accrediting organization detailing any communications between equipment vendors or manufactures, purchase order numbers showing proof of purchase, attach any invoices in regards to correcting the ligature risk etc.  Not to mention you will also be required to provide them with ongoing routine status updates on the effectiveness of the mitigation strategies using outcome and process measures to demonstrate the effectiveness of the plan.

All I can say is good luck, my friends, in this forever-changing environment in which we live!