The Centers for Medicare & Medicaid Services (CMS) has issued updated regulatory guidance regarding requirements for hospitals to assess patients and hospital environments for patient harm risks. The guidance will influence how surveyors evaluate hospital compliance with the Medicare Conditions of Participation specific to ligature risk and assessment in hospitals.

The updated guidance affects CMS 42 CFR §482.13(c)(2)  Condition of Participation: Patient’s rights.  This CoP states: “The patient has the right to receive care in a safe setting.”  

The guidance seeks to clarify the need for ligature-resistant environments based on an individual patient’s risk assessment, staffing/monitoring and environmental risk.

Also applicable to ligature risk is CMS 42 CFR §482.41(a) Condition of Participation: Physical environment. This CoP states: “The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured.”

To further explain the changes to surveyor guidance, CMS has updated the State Operations Manual Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals.  Relevant sections include A-0144 beginning on page 107, and A-0701 beginning on page 371.