What CMS actually says now — and where the setting split lives
The operative CMS guidance is the State Operations Manual, Appendix A, under 42 CFR §482.13(c)(2) — the patient’s right to a safe setting, Tag A-0144 — as updated by QSO-25-24 (September 5, 2025). Do not cite QSO-19-12: it was stamped DRAFT, its comment period closed in 2019, and it was never finalized. CMS’s current position is that ligature-risk management should place patients in an environment reflective of their specific needs, with appropriate monitoring; it is not expected that a hospital have the same ligature-risk configuration throughout the facility. And all hospitals should implement an environmental risk-assessment strategy — the obligation is broader than the draft memo implied, not narrower.
The setting split lives in the Joint Commission’s standard, NPG.08.01.01 EP 1, which maps to §482.13(c)(2). For psychiatric hospitals and psychiatric units in general hospitals: conduct an environmental risk assessment and act to minimize risks — removing anchor points, door hinges, and hooks, for example. For nonpsychiatric units: implement procedures — one-to-one monitoring, removing objects that pose a risk, assessing items brought in by visitors. Nonpsychiatric units do not need to be ligature resistant. The word “locked” is not the operative term in either body’s governing text; the locked-versus-unlocked line is FAQ-level interpretation, applied to closed or secure units where staff control entry and exit. State the setting, and flag the locked distinction as interpretation, not standard text.
“The single most-cited ligature document in the field was a draft. Once you tell a survey-experienced coordinator that, and hand him the current citation, you have his attention for the next hour.”
Sources: CMS SOM Appendix A, Tag A-0144, under 42 CFR §482.13(c)(2), as updated by QSO-25-24 (Sept. 5, 2025), superseding QSO-23-19 (2023); NPG.08.01.01 EP 1; verbatim fragments from QSO-23-19.
What would change this: Next SOM Appendix A transmittal (QSO series); JC FAQ updates on locked/unlocked interpretation.
Reviewed July 2026 by the Eagle Systems healthcare practice. The systems referenced are how a facility meets the accountability the regulation creates, not a mandate; the accreditation and compliance determinations belong to the organization and its regulators. Current as of Accreditation 360 (eff. Jan 1 2026).