The Centers for Medicare & Medicaid Services (CMS) is increasing its focus on ligature and self-harm risks. Currently, there are no specific regulations that clearly explain physical methods to lessen these risks, but CMS is working on creating increased clarity and guidance regarding what constitutes a ligature or safety risk in behavioral health settings.

While CMS works on this additional guidance, the Joint Commission and other accrediting organizations are using their judgment in identifying ligature and safety-risk deficiencies; the level of severity for those deficiencies; and the approval of the facility’s corrective actions and mitigation plans. 

Although there is currently no specific CMS requirement related to these issues, citations are being issued under the general requirements of K-100. Joint Commission Standard EC.02.06.01, EP 1, specifies that interior spaces must meet the needs of the patient population and are safe and suitable to the care, treatment and services provided. 

To help members understand the possible patient and staff safety risks, ASHE has developed a resource listing potential ligature points and other self-harm concerns for behavioral health areas. The list is categorized by room type and contains items that are known to pose specific ligature or self-harm risks. 

This list is not meant to be exhaustive, but it does provide an idea of what surveyors may be looking for in behavioral health areas. For example, toilets can be used as an anchor point and, if damaged, can be used as a weapon. The tops of doors can be used as anchor points by tying a knot in a rope or sheet and lodging it over a closed door; door tops should be monitored or cut to eliminate ligature opportunity. 

Mitigating ligature risks is a necessary component of building and maintaining safe health care facilities, and will help to address a nationwide issue. The number of suicides continues to increase in the United States, and is now the 10th leading cause of death, according to the Centers for Disease Control and Prevention. 

Although inpatient suicides are a relatively small percentage of the overall number of suicides, the reason some patients are in a behavioral health inpatient setting is to help protect them from self-harm. Health care facilities should work to protect patients from self-harm hazards.

This new resource not only explains various lists, but also allows members to record their facility’s mitigation efforts for each potential hazard. Members can download the list by going to and searching for ligature risks within the Resource Library. 

Deanna Martin is the membership and communications director for the American Society for Healthcare Engineering.