ASHE issues update on CMS ligature-risk policy

The American Society for Healthcare Engineering (ASHE) previously alerted members to a Centers for Medicare & Medicaid Services (CMS) memo that clarified ligature-risk issues. It is now providing additional information specific to emergency departments (EDs) and other areas where at-risk patients may be treated.

The update states that to provide care in a safe setting, hospitals must identify patients at risk for intentional harm to self or others, identify environmental safety risks for such patients, and provide education and training for staff and volunteers. Patients at risk of suicide (or other forms of self-harm) or who exhibit violent behaviors toward others receive health care services in both inpatient and outpatient locations of hospitals.

While regulations focus on a ligature-resistant or ligature-free environment in psychiatric units of acute care hospitals and psychiatric hospitals, all health care facilities are expected to demonstrate how they identify at-risk patients. Special consideration is to be given to EDs and locations where at-risk patients are to be treated. For these areas, health care facilities are expected to demonstrate the steps they would take to minimize risks in accordance with nationally recognized standards and guidelines when an at-risk patient is present. For additional information, ASHE members can read the full CMS memo, Survey & Certification Letter 18-06.

Establishing a policy to perform an environmental-risk assessment when an at-risk patient is present provides the staff with a tool to meet these standards and guidelines. ASHE members have free access to a members-only tool on ligature risks in the physical environment. The tool has been updated to include an assessment worksheet for EDs.

Jonathan Flannery, MHSA, CHFM, FASHE, FACHE is senior associate director of advocacy for the American Society for Healthcare Engineering.