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.

 

The surveying of ligature risks in psychiatric hospitals has almost taken on a life of its own over the past four months. In follow-up to our June article on ligature risks, we’re providing some timely feedback from clients about how this issue has been reviewed during recent surveys. We’ve had six psychiatric hospital clients surveyed since the March 1 announcement from TJC on this topic, and the scrutiny on it has been intense. Here’s a summary of the issues cited for the four hospitals.
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Congratulations to our client Beachside Recovery in Newport Beach, California, who recently achieved initial Joint Commission accreditation. Beachside Recovery provides a full range of detox, inpatient, and outpatient substance abuse treatment.
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Spring Harbor Hospital in Westbrook, Maine, offers inpatient psychiatric services for children, adolescents, and adults as well as outpatient services.
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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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