August 31, 2017
This email is being sent out on behalf of Mark Pelletier, Chief Operating Officer- Accreditation and Certification Operations
Recently, CMS and The Joint Commission have been in discussions regarding deficiencies related to ligature risk and self-harm. When ligature risks rise to the level of a Condition Level Finding (CLD), CMS requires that they be corrected in 60 dayssimilar to other CLDs. However, we have found that while our accredited organizations are committed to correcting ligature and self-harm risks, correcting these issues may require additional time and resources to achieve full compliance.
After much collaboration with CMS, we are pleased that CMS has agreed to develop guidance in the area of ligature risk. Theyexpect that this guidance will take approximately 6 months to develop. In the interim, CMS has affirmed that The Joint Commission may use its judgment as to the identification of ligature and safety risk deficiencies; the level of severity for those deficiencies; and the approval of the facility’s corrective action and mitigation plans to remedy the identified deficiencies.
Below is the official statement from CMS that we received this week. They have stated that the focus of their concern is on psychiatric patients in psychiatric units of hospitals and in psychiatric hospitals. As we have further information from CMS we will share. If you have questions you can contact me directly at firstname.lastname@example.org.
CMS STATEMENT (received week of August 28, 2017)
CMS has identified the need for increased direction, clarity, and guidance regarding the definition of what constitutes a ligature risk and other safety risks involved in the care of patients requiring psychiatric care and treatment; how those risks should be surveyed; at what level should the deficiency be cited; the elements required for an appropriate Plan of Correction (PoC); and what constitutes a suitable mitigation plan to minimize the risk to patients who are cared for in environments with identified deficiencies. The care and safety of this vulnerable patient population and the staff that provide that care are our primary concerns. To that end, CMS has begun the process of drafting guidance utilizing the skill and expertise of the Regional Offices, state survey agencies, accrediting bodies, providers, mental health clinicians, as well as other stakeholders central to this issue. CMS expects that this guidance will take approximately 6 months to complete. In the interim, the Accreditation Organization (AO) may use their 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.
Facilities should continue to work toward compliance as the guidance is being developed. We expect preliminary guidance within the next two weeks, with more comprehensive guidance within the next 6 months. We will review CMS enforcement actions related to serious ligature risk deficiencies on a case by case basis while the guidance is being developed, and will provide updates via S&C policy memos, as necessary.