The Behavioral Health Care Accreditation manual has undergone some revisions over the past several months as part of TJC’s Standards Review Project. The final round of changes is now complete and will be effective January 2018. Highlights of these final revisions are as follows:

Care, Treatment, and Services Chapter

Health Information

New requirements for BH organizations to gather the client’s relevant health information (both behavioral and physical health information) from other providers. This includes both inpatient and outpatient providers. Also, when it’s not possible to obtain this information, the organization must document the reason why it could not be obtained (CTS.02.01.03.)

Nutrition Screening

New requirement for a specific minimum set of triggers that must be included in the nutritional screening. Since problems with nutritional screenings is a Top Ten finding in BH surveys, it’s important to make sure you revise your nutritional screening procedure to comply with the new requirments. (CTS.02.01.11)

Client Supervision in 24 Hour Settings

New requirement for supervision of clients in inpatient/24-hour crisis stabilization settings (CTS.04.03.20)

Physical Holding

Additional requirement for policies/procedures re physical holding of a child or youth. They now must include details about the initiation of physical holding by an authorized staff member.

Restraint & Seclusion

Additional requirement for policies/procedures re restraint and seclusion. They now must include details about how a   debriefing is conducted following restraint or seclusion.

Record of Care Chapter

The standard in the Record of Care chapter re documentation required when restraint or seclusion is used has now been expanded to include documentation of physical holding of a child or youth. The same 15 requirements that apply to restraint and seclusion now apply to physical holding. These are extensive and will likely require changes to policies as well as staff training. The new requirements will also impact the initial clinical assessment process since the organization must now determine if there are any pre-existing medical conditions or clinical history that would put the client at greater risk during a physical hold.

Since the new requirements go into effect January 1, 2018, this last quarter of 2017 is a good time to review them in detail and see if any changes need to be made to your policies or clinical documentation and what the related staff training needs may be. To view the full text of these revisions, see the Pre-Publication standards published in June, 2017.


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