Understanding CMS Ligature Risk Regulatory Requirements

Identification and mitigation of suicide risk in the health care setting is not a new or novel idea. The Centers for Medicare & Medicaid Services and accrediting organizations like The Joint Commission have identified suicide prevention as a top priority for nearly 20 years. While there have been numerous workgroups, guidance documents and National Patient Safety Goals on suicide prevention, the efforts of regulatory bodies have culminated into a focused effort within the last two years. On Aug. 1, CMS posted a memo, “CMS Clarification of Psychiatric Environmental Risks,” from the Quality, Safety & Oversight Group that was sent to state agency survey directors clarifying their intent to use the outcomes of TJC Suicide Panel, as well as subsequent guidelines to establish comprehensive ligature risk interpretive guidance.

While TJC lead efforts to establish new guidelines for survey and scoring of ligature and suicide self-harm in inpatient psychiatric settings and psychiatric hospitals, CMS had intended to establish its own Psychiatric Care Task Force to examine ligature risk and other physical risk to update its previous guidance published in December 2017, including Conditions of Participation for patient rights to care in a safe setting. However, CMS had several agency experts who participated on TJC Suicide Panel and noted, “CMS felt that to repeat the work of the TJC Suicide Panel (in which CMS participated) would not provide any substantive additional gains and would not be a productive use of the time and expertise of the participants.”

Hospitals and psychiatric hospitals should refer to CMS’ memo, “Clarification of Ligature Risk Policy,” as well as TJC Suicide Panel’s “Special Report: Suicide Prevention in Health Care Settings” until CMS releases new interpretive guidelines. Current expectations regarding ligature risk and safety issues for patients receiving care and treatment for psychiatric disorders can be found in the CoP under Patient’s Rights to Care in a Safe Setting – Appendix A.

MHA has several resources available to assist hospitals in meeting regulatory requirements surrounding ligature risk and suicide prevention, including the following.

• Ligature Risk Reduction presentation by Jim Hunt, a participant on TJC Suicide Panel, discussing environmental and structural design surrounding suicide mitigation
• The Design Guide for the Built Environment of Behavioral Healthcare Facilities
• TJC Sentinel Event Alert, Issue 56: Detecting and Treating Suicide Ideation in All Settings

For additional information on CMS requirements for assessing a safe environment, including suicide risk assessment, review the following Transmittal from CMS. Additional interpretive guidance from CMS will be forthcoming.