CMS issued a new QSO memo this past month. QSO 19-12, published April 19, 2019, addresses ligature hazards. In fact, they use the term “ligature risk extension request” to address this issue.
Ligature Risk Extension Request
It is important to note that this memorandum is in a draft status. We expect that states, accreditors, and hospitals may choose to provide feedback to CMS on this memorandum. Send public comments to: HospitalsSCG@CMS.hhs.gov
The first thing we noticed is CMS changed the acronym. In the past, they wrote about “ligature facility extension request,” or called an LFER. They retitled as LRER, or “ligature risk extension request.”
But, regardless of the acronym, this is the tool that hospitals must use if they are unable to correct the ligature finding TJC or CMS identifies on survey. This is consistent with guidance issued by TJC earlier. Only the CMS Regional Office can grant the extension, not the accrediting body. In fact, CMS does not want the accrediting body to process them. Instead, the accreditor will have to seek approval from CMS after their review.
Here is one important issue we noted relative to these extension requests. CMS requires submission to occur before your due date for becoming compliant. For example, in a normal 60-day ESC process, you can’t wait until the last minute to submit an extension request. That’s because both the accreditor and CMS won’t have time to review in time for your final submission. Instead, make sure you identify potential delays in correcting the environment early on when developing your ESC.
If approved, your LRER will require monthly progress reports to the accreditor who, in turn, will share them with CMS. In addition, when you do receive new fixtures, install them and do other necessary remodeling. The accreditor will need to conduct a one-day focused survey to verify correction of the hazards.
Patton Healthcare Consulting
Patton Healthcare Consulting provides Joint Commission Compliance Assistance and a full range of pre-survey and post survey services including assessing ligature safety.
Contact our office at 888-742-4621, via email or through our website contact page to schedule a discussion of your needs and learn more about our compliance and readiness expertise.Patton Healthcare Consulting provides Joint Commission Compliance Assistance and a full range of pre-survey and post survey services including patient suicide prevention.