CMS drafting guidance on ligature and other self-harm risks

From The Joint Commission 9/6/17

The Centers for Medicare and Medicaid Services (CMS) recently identified the need for increased direction, clarity and guidance regarding the definition of what constitutes a ligature risk, as well as other safety risks involved in the care of patients requiring psychiatric care and treatment. Included in this guidance will be direction on:
How these risks should be surveyed
At what level the deficiency should be cited
The elements required for an appropriate Plan of Correction
What constitutes a suitable mitigation plan to minimize the risks to patients who are cared for in environments with identified deficiencies
CMS stated that the focus of its concern is on psychiatric patients in psychiatric units of hospitals and in psychiatric hospitals. CMS is drafting guidance utilizing the skill and expertise of CMS’ regional offices, state survey agencies, accrediting bodies, providers, mental health clinicians, and other stakeholders. CMS expects this guidance to take approximately six months to complete.
In the meantime, CMS has stated The Joint Commission may use its judgment as to the identification of ligature and safety risk deficiencies, the level of severity for those deficiencies, as well as the approval of the facility’s corrective action and mitigation plans to remedy the identified deficiencies.
While the guidance is being developed, CMS will review its enforcement actions related to serious ligature risk deficiencies on a case-by-case basis, and will provide updates via Survey & Certification (S&C) policy memos, as necessary.

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