Accreditation & Regulatory Journal
November 2023

Healthcare Regulatory Alerts

CIHQ-ARS notifies its client organizations of any new or modified accreditation standard, or CMS COP for acute care hospitals. Alerts are also published when changes are made by CDC, OSHA, NIOSH, NFPA. Each alert summarizes the standard, regulation, recommendations, likely impact to members, and recommendations for compliance strategies. Whenever possible, alerts are limited to one-page in length so that they can be quickly read and disseminated.

New Regulatory Alert

Date: October 6, 2023
Subject: CMS Removes Requirement For Ligature Extension Requests
Source: CMS
In a letter to accrediting organizations (AO’) dated 10/5/23, CMS removed the requirement that hospitals unable to correct a ligature risk identified as a deficiency within 60 days of survey submit a written request to CMS for an extension to implement a plan of correction (POC)
Per CMS; “The updated guidance under 42 CFR § 488.28 has removed the requirement that deficiencies addressed in a POC be corrected within 60 days from receipt of the deficiency report. Based on the actions above, the continuation of ligature risk extensions are no longer necessary.” Effective immediately, Ligature Risk Extension requests will no longer be granted, and facilities should no longer submit these extension requests to CMS.
Hospitals continue to be required to implement interim safety measures until ligature risks can be corrected.
Discussion & Recommendations:
CIHQ Accredited Hospitals, ARS Members and Healthcare Accreditation Certified Professions: To view the discussion & recommendations portion of the alert, log in to your facilities account. All alerts are archived in the library for future access and reference.
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