If you were cited for a ligature violation, it may not be something you can correct immediately. If that occurs, you may need to request a ligature risk extension.
How to Request a Ligature Risk Extension
CMS has a process known as the “Ligature Risk Extension Request (LRER).” CMS issued a QSO memo 19-12, published April 19, 2019, that describes this process. Although the process is labeled as a “draft,” it is available for your use at this time as the “extensive request form” dated 1/1/2020.
This SC18-06 Attachment C LRER form is the one that hospitals must use if they are unable to correct the ligature finding TJC or CMS identifies on survey.
Only the CMS Regional Office can grant the extension, not the TJC accrediting body. In fact, CMS does not want the accrediting body to process them. Instead, the accreditor will learn at the same time you learn whether the CMS RO has approved the request. Having said this, your account rep at TJC may be able to put you in touch with someone in the Standard Interpretation Group who may have suggestions for you on what they have seen been successful when submitting the form to the CMS RO.
One important issue we noted relative to these extension requests is that CMS requires submission to occur before your due date for becoming compliant. For example, in a normal 60-day (or 45-day for Condition Level) 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. So, time is of the essence.
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
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