We hope you find the following resources helpful for your ongoing compliance with TJC and CMS requirements. We have included articles from the current issue of our newsletter as well as access to our newsletter archives and useful Industry Links for Behavioral Healthcare.

To read articles written prior to January 2015, please view our Newsletter Archive.

 

If you are a psychiatric hospital anticipating a TJC survey, it’s important to know the details of how TJC is currently surveying ligature risks. They recently provided an update for the field on this topic in follow-up to their March 2017 communication on the scoring of ligature, suicide and self-harm risks. Here are some highlights from this most recent update.
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Twenty-two percent of behavioral health organizations surveyed in 2016 received a survey finding related to competence assessment. Frequently, the finding relates to a staff person or contractor not having their clinical competence assessed by an individual qualified to do so. The relevant standard is HRM.01.06.01 EP 2 in the BH Manual and HR.01.06.01 EP 3 in the Hospital manual. Learn how this standard is typically reviewed by surveyors.
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Congratulations to our client Casa de Amparo in San Diego, California, who recently achieved initial Joint Commission accreditation. The organization provides child abuse prevention services through its residential, counseling, family visitation, and other support services.
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Barrins & Associates is pleased to be working in partnership with DCCS Consulting to support the regulatory readiness needs of their client Anoka-Metro Regional Treatment Center in Anoka, Minnesota. AMRTC is a state operated psychiatric hospital providing inpatient and transitional services to adults with mental health and substance abuse disorders.
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Quail Run Behavioral Health in Phoenix, Arizona, offers inpatient psychiatric treatment for adolescents, adults, and older adults.
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Valley Hospital in Phoenix, Arizona, offers inpatient and PHP/IOP mental health and chemical dependency services for adults, including a military program and a specialized women’s unit.
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Psychiatric hospitals that use TJC accreditation for CMS deemed status were the first organizations to experience the SAFER (Survey Analysis for Evaluating Risk) methodology starting in June 2016. TJC recently published six months of compliance data for these hospitals. Many of the Top Ten issues remain the same but it’s interesting to see how they play out on the SAFER matrix. Here’s some highlights from the TJC data and our own database.
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TJC began surveying to the 2012 edition of the National Fire Protection Life Safety Code in November 2016. Resulting changes to the Environment of Care and Life Safety standards went into effect January 2017. One of the changes that went into effect for both the Hospital and Behavioral Health programs is a new requirement for inspection of Exit signs. We are now seeing this issue arising on surveys so let’s clarify the requirement.
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Congratulations to our client The Foundry Treatment Center in Steamboat Springs, Colorado, who recently achieved initial Joint Commission accreditation. The program offers a holistic approach to addiction treatment and provides detox, residential, and outpatient services.
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Wellbridge Hospital of Plano in Plano, Texas provides inpatient psychiatric services for adults age 50 and over.
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