How to Comply with New ‘Ligature Risk’ Hospital CoP Standards

Is your hospital taking steps to protect suicidal patients from ligature risks? If not, you will now face an immediate jeopardy deficiency citation.

The Conditions of Participation (CoPs) for hospitals includes numerous sections, but the section that’s earning hospitals the most deficiencies is Patient’s Rights (482.13), according to hospital compliance expert Sue Dill Calloway in her ProfEdOnDemand webinar, “CMS Hospital CoPs on Patient Rights Standards: Keys to Ensure Compliance.” And now, CMS has added clarification to ligature risks as part of the patient rights requirements in the hospital CoPs.

How CMS Defines Ligature Risks

The latest: The Centers for Medicare & Medicaid Services (CMS) recently issued a Survey & Certification (S&C) memo, Clarification of Ligature Risk Policy (18-06-Hospitals). In the memo, CMS gave hospitals, Regional Offices (ROs), State Survey Agencies (SAs), and accrediting organizations (AOs) a heads-up that it’s drafting comprehensive ligature risk interpretive guidance. The memo goes on to clarify the current ligature risk policy in the meantime.

Definition: According to CMS: “A ligature risk (point) is defined as 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, hinges and closures.”

The ligature risk standard falls under two CoP categories: “Rights of Patient to be Treated in a Safe Setting” (§482.13(c)(2)) and “Buildings” (§482.10(a)). Until CMS releases comprehensive guidance, ROs, SAs, and AOs may use their own judgment when identifying ligature risks, as well as citing deficiencies, setting the citation level, and approving action plans.

Beware: But if a surveyor finds “unmitigated ligature risks” in a psychiatric hospital or psychiatric unit of a hospital, CMS has said this is an “immediate jeopardy situation.” This also includes any location where there are patients at risk of suicide.

Take 3 Actions Immediately

Best strategy: This level of discretion among surveyors is all the more reason to refine your ligature risk policies and practices – pronto. According to the New Mexico Hospital Association (NMHA), your hospital can take three actions right now to comply with the ligature risk standards:

  1. Identify Patients at Risk
    • There are many versions or “patient risk assessment” tools that your hospital can use to identify those at risk for harm to self or others. CMS expects you to implement a tool most appropriate for your patient population, care setting, and staff competency.


  1. Identify Environmental Safety Risks
    • All hospitals must implement an “environmental risk assessment” strategy, which cannot be the same in all hospitals or all hospital units. Your risk assessment may include, but shouldn’t be limited to:
      • Ligature risks such as hand rails, door knobs, shower curtains, exposed pipes, light fixtures, etc.;
      • Unattended utility or housekeeping items;
      • Unsafe items brought to patients by visitors;
      • Windows that patients can open or break; and
      • Inadequate staff levels to provide patient observation.
  1. Mitigate Environmental Risks
    • Mitigate risks in “dedicated” treatment areas while ensuring patients treated in those areas are risk-assessed for harm to self or others.


Don’t forget: The memo also stresses education and training, mandating that hospitals provide education and training to all new staff upon orientation and whenever your policies and procedures change. Your hospital should also provide ongoing training to staff at least every two years after their initial training.

Look for Similar Standards from Joint Commission, Too

Look ahead: The Joint Commission has also announced that its surveyors will begin citing ligature/self-harm deficiencies beginning on July 1, 2018. The Joint Commission deficiencies will mirror CMS’ ligature risk standard. The Joint Commission has reported that suicide continues to be among the top five reported sentinel events, the NMHA stated.

Given the “Zero Suicide” campaign to eliminate suicides in healthcare facilities and these new survey standards, you can expect increased scrutiny of your hospital’s policies and practices to prevent suicides.

Bottom line: If you want to avoid devastating deficiency citations, you need to understand your hospital’s duties under the patient rights CoP standards, Calloway stresses. And this new section on ligature risks will only add to your compliance demands.

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