Ligature Risk And Assessment in Hospitals For Patient Safety

on the radar alert

In a memorandum dated July 17, 2023, the Centers for Medicare and Medicaid Services (CMS) focused on the Medicare Hospital Conditions of Participation regulation §482.13(c)(2) that states, “The  patient has the right to receive care in a safe setting.” In this memo, CMS details expectations of safe care in Medicare-certified hospitals and how hospitals can demonstrate compliance in the following ways:

Patient Assessment:

CMS does not endorse or require any particular patient screening and assessment tools. CMS expects that hospitals will use effective tools to determine risks that are specific to their patient population, setting, and staff competency. When screenings and assessment tools point to risks, hospitals should enact targeted actions to mitigate the risks.


Related to risks, hospitals should provide individualized, timely training and education to their staff on the identification and mitigation of safety risks.

Environmental Risk:

Hospitals should also implement an environmental risk assessment strategy that is individualized to the setting and patient population.

You can find current and past CMS memorandums at the website - Policy and Memos to States and CMS Locations.

Please contact Courtemanche and Associates for questions or assistance in maintaining continuous survey readiness at 704-573-4535 or

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