CHA News Article

CMS Issues Draft Guidance on Ligature Risk
For Chief Legal Counsel, CMOs, Licensing and Certification Staff, Quality and Patient Safety Staff

The Centers for Medicare & Medicaid Services (CMS) has issued draft revised guidance to clarify its ligature risk policies for psychiatric hospitals and psychiatric hospital units.

The draft guidance updates 2017 guidance clarifying what constitutes a ligature risk and the agency’s expectation for psychiatric units. Locked psychiatric units within psychiatric hospitals and acute care hospitals, as well as emergency departments with dedicated psychiatric beds or units within a locked unit, are required to achieve a ligature-resistant environment. Unlocked psychiatric units and general acute care beds designated for the treatment of physical diseases and disorders do not have to meet the ligature resistant standard. The guidance also updates the process for psychiatric hospitals and units to request an extension to remedy identified ligature risks.

CHA is reviewing the draft guidance and will work with members to develop comments, which are due June 17.

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