Navigate the Maze of Ligature Risk; Avoiding Immediate Jeopardy

Hospitals continue to struggle with the challenge of eliminating suicide risks in their environment and how this will be evaluated during TJC and CMS surveys.

Do you need assistance navigating the ligature mitigation maze?

Ligature Risk is a major source of Immediate Jeopardy citations for healthcare organizations.


What We Know

  • The Joint Commission (TJC) published guidance on extensive ligature risk mitigation expectations.

  • CMS published Survey & Certification Memo outlining:

  • Hospitals were not doing enough to protect behavioral health (BH) patients.

  • The guidelines presented were interim

  • In the interim, interpretation is left to the discretion of the surveyor

  • More comprehensive guidance is expected in the next six months

What Is Required


The memo requires assessment of all patient care areas in behavioral health units, Emergency Departments where BH patients are treated, and psychiatric hospitals for possible ligature points and to do what is necessary to correct risks. If a risk has not been satisfactorily mitigated a facility can be placed in immediate jeopardy (IJ) by CMS.


Until final CMS guidance is released, surveyors may use their judgment as to:

  • the identification of ligature and other safety risk deficiencies,

  • the level of citation for those deficiencies,

  • the approval of the hospital’s corrective action and mitigation plans to minimize risk to patient safety and remedy the identified deficiencies.


This area is generating a large number of immediate jeopardy situations for facilities and a lot of variability in surveyor interpretations.


CMS Makes The Call


The State Survey Agencies and Accrediting Organizations do not have independent authority to grant hospitals additional time for the correction of deficiencies. Requests for the extension of timeframes go to TJC and If TJC supports the request, it is sent to the CMS Regional Office and Central Office with a recommendation for approval.


What Should Your Organization Be Doing?

  • Complete a comprehensive ligature risk assessment

  • Establish a comprehensive plan including physical mitigation of risks and nonphysical operational changes to mitigate safety risks

  • While risks are in the process of being physically addressed, policies and procedures must be developed and implemented to mitigate the harm posed by such risks.


DCCS assists health systems in successfully complying with ligature mitigation requirements. Do you need assistance navigating the ligature mitigation maze?