Take 4 Major Steps to Comply with CMS/TJC Ligature Risk Standards

Psychiatric hospitals and psychiatric units within general hospitals aren’t the only places that must comply with ligature risk-related safety regulations. Now, The Joint Commission (TJC) and the Centers for Medicare & Medicaid Services (CMS) are cracking down on all hospitals and other healthcare settings to reduce the alarming number of suicides that occur in hospitals and emergency departments.

Pay attention: Your hospital must comply with the CMS and TJC standards, which include assessing patients’ suicide risk, reducing ligature risks, correcting environmental hazards, and creating safe rooms, according to hospital compliance expert Sue Dill Calloway in her webinar, “Ligature Risks: Master Compliance with CMS Hospital CoPs & TJC Requirements.”

Spotlight Is on Ligature Risks

Suicide is a prevalent problem in various healthcare settings, including: psychiatric hospitals, psychiatric units within general hospitals, general medical/surgical wards, and emergency departments. That’s why TJC formed an expert panel to address environmental hazards, specifically potential ligature risks. The panel included representatives from provider organizations, suicide prevention experts, experts on designing behavioral healthcare facilities, JTC surveyors and staff, and other key stakeholders.

Potential changes: Based on the panel’s work, TJC is considering revising the National Patient Safety Goal (NPSG) on identifying patients at risk for suicide in hospital and behavioral healthcare settings, according to a recent announcement. TJC has been conducting field reviews and public comments on the following proposed revisions:

  • Screening for suicide ideation using a validated screening tool;
  • Using an evidence-based process to conduct a suicide assessment for patients who are at risk for suicide ideation;
  • Documenting an individual’s risk level and caring for at-risk patients; and
  • Following written policies and procedures for the patient’s counseling and follow-up care.

CMS has also jumped on board with TJC’s focus on ligature risks. In a Dec. 8, 2017 memo (S&C Memo: 18-06-Hospitals), CMS defined “ligature risk” 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.”

Aim for ‘Ligature Resistant’—or, Better Yet, ‘Ligature Free’

Requirements: The guidance in the CMS memo stresses that hospitals should provide a “ligature resistant” or “ligature free” environment for all patients identified as at-risk for intentional self-harm. Both CMS and TJC outlined the following steps to reduce suicide and ligature risks in healthcare settings:

  1. Identify At-Risk Patients. Select one or more of the numerous models and versions of patient risk-assessment tools available, based on your patient population, care setting, and staff competency.
  2. Implement a Risk-Assessment Strategy. All hospitals must implement a patient risk-assessment strategy and an environmental risk-assessment strategy. Like your patient risk assessment, your environmental strategies must be appropriate for your specific care environment and patient population.

For example: Your environmental risk assessment may involve staff assessing specific items like:

  • Ligature risks such as exposed plumbing/pipes, hand rails, power cords, etc.;
  • Unattended items such as utility or housekeeping carts containing hazardous items;
  • Unsafe items that visitors bring to patients in psychiatric hospitals or units;
  • Windows that patients can open or break;
  • Unprotected light fixtures; and/or
  • Inadequate staffing levels to provide appropriate patient observation and monitoring.
  1. Provide Ongoing Training. Train all staff (including volunteers, contractors, and per-diem staff) on identifying patients who are at risk for self-harm or harm to others. CMS requires hospitals to provide such education and training to all new staff initially upon orientation, whenever your policies and procedures change, and at least every two years.
  2. Correct Environmental Risks. If a surveyor finds a ligature risk-associated deficiency, CMS will allow you 60 days to correct it. Keep in mind that ligature risks are not eligible for Life Safety Code (LSC) waivers because they’re not LSC deficiencies.

Get Started with Suicide Risk-Assessment Tools

In addition to understanding the CMS memo on ligature risk management, you’ll also need to comply with TJC’s 13 requirements and take steps immediately to reduce ligature risks in your hospital, Calloway urges. A good first step is to make sure you’re using the right suicide risk-assessment tools for your facility – and there are plenty to choose from, such as the:

To join the conference or see a replay, order a DVD or transcript, or read more

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