CHA News Article

New Guidance Clarifies Ligature Risk Policy

As previously reported in CHA News, the Centers for Medicare & Medicaid Services has reevaluated its recent changes to surveying hospitals for ligature risks. To assist providers, particularly psychiatric units and hospitals, the agency has released the attached Survey & Certification Memo 18-06 clarifying the definition of a ligature risk, as well as providing guidance for identifying and correcting deficiencies. The agency also notes it is in the process of drafting comprehensive ligature risk interpretive guidelines to provide direction and clarity for regional offices, state survey agencies and accrediting organizations. Until that is released, those entities are directed to use their judgment in the identification, level of citation and approval of corrective action plans for ligature and other safety risk deficiencies.