CMS to Issue Guidance on Ligature Risk

This is a very serious topic. As per Care Quality Commission, “Three-quarters of people who kill themselves while on a psychiatric ward do so by hanging or strangulation. A ligature point is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinge sand closures.” The Centers for Medicare & Medicaid Services (CMS) recently announced that during the next six months, it will develop guidance for Joint Commission-accredited facilities regarding the definition of what constitutes a ligature risk, as well as other safety risks involved in the care of patients requiring psychiatric care and treatment.

The announcement comes after a number of concerns were expressed by hospitals accredited by The Joint Commission (TJC) over the burdensome surveys being conducted and the lack of time provided to hospitals to mitigate the risks. As a result of the concerns, TJC and CMS officials have been meeting, and the CMS forthcoming guidance is expected to include the following:
· How risks should be surveyed,
· At what level the deficiency should be cited,
· Elements required for an appropriate Plan of Correction,
· What constitutes a suitable mitigation plan to minimize patient risk in environments with identified deficiencies.

While the guidance is being developed, TJC will use its judgment as to the identification of ligature and safety risk deficiencies, the level of severity for those deficiencies, as well as the approval of the facility’s corrective action and mitigation plans to remedy the identified deficiencies. Hospitals that have already been surveyed should contact their TJC representative if they have any questions or concerns about their survey response.

For more information on Ligature risk, you may refer to the document provided here CRC Brief guide