Let’s begin again, begin the begin: CMS ligature risks codified!

While I have little doubt that we will yet again revisit the management of ligature risks and behavioral health patients, it would seem that chapter and verse are getting towards stone tablet form—but you have a chance to influence the future state. I suspect we will also be looking back to determine how much influence the field has on the final, final or whether the party line from Chicago holds sway (kind of looks like that at the moment, but there is still time):

• Back on April 19 (and I do apologize for not picking up on this sooner—I need to get a better strategy for monitoring all these goings-on), CMS issued a draft clarification of the interpretive guidelines relating to ligature risk (you can find the skinny here). All things being equal, I suppose the “newest” thing is the formal introduction of the Ligature Risk Extension Request (LRER—just what we needed, another acronym), which outlines a process for correction of ligature risks that will take longer than the official 60-day turnaround time for the correction of deficiencies. One thing is very clear (well, maybe a couple of things): State agencies and/or accreditation organizations are not allowed to grant LRERs. They can, and in most instances, will act as intermediary between the organization seeking the extension and CMS, and will (basically) advocate for approval based on their analysis of the issues. This is not a Life Safety Code® waiver as ligature risks are not a compliance deficiency relative to life safety requirements. From the process outlined, it does appear that this is to be a reasonable process, (potentially) making allowances for obtaining approval of the governing body, engaging in competitive bidding, applying for funding, obtaining permits for physical changes, and lack of or delays in obtaining products and supplies needed for corrective actions. Needless to say, with the invocation of the LRER, there will be
  • Mitigation strategies to implement
  • Progress reporting to be done
  • A re-survey to verify that the deficiencies have indeed been corrected by the state agency or accreditation organization
• As has been the case pretty much from the get-go, there are two assessment processes that need to dovetail (or perhaps they are concentric circles): An assessment of the environment and the assessment of patients to determine the level of risk for suicidal behaviors. I do believe that eventually we will be left with the latter upon which to focus, but I suppose there will need to be an ongoing due diligence relative to monitoring the environment. Ultimately, it seems to come down to striking the balance between seeing every aspect of the environment as a big hairy monster as opposed to an element in the environment that can be managed by appropriate means. At the very least, I am hoping that the survey focus returns to general patient care and infection control, with perhaps a side of medication management—I think that’s where the meaningful improvements are hiding (in plain sight).

As a final note, we do have until June 6, 2019 to weigh in on the proposed changes, so I would suggest you gather together a little working group, and if the spirit moves you, weigh right in. The data supports this being a whole bunch of ado about very little (approaching a whole bunch of doodoo), so the sooner we can refocus on the “real” challenges, the better.

About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is also a contributing editor for Healthcare Safety Leader. Contact Steve at stevemacsafetyspace@gmail.com.