For those of you who have organizations and programs surveyed under TJC’s Behavioral Health Care manual, remember there are new requirements effective January 1, 2018, now being surveyed by the BH surveyors. We’ve discussed these in past issues and are summarizing them below so you can be sure you’ve modified your processes and policies to comply with all the new requirements. They are definitely on the radar for 2018 surveys!

Care, Treatment, and Services Chapter

Outcomes Measurement (CTS.03.01.09)

This new requirement is getting the most attention from surveyors, so be prepared to address how you’ve implemented the following:

• Use of a standardized tool or instrument to monitor the individual’s progress in achieving the identified goals. The tool can be focused on a population or diagnostic category (e.g. depression) or have a more global focus (such as functional status or quality of life).
• Analyzing this outcome data (for that individual) and using the results to revise the goals and objectives of the individual’s treatment plan based on progress or lack of progress.
• Aggregating and analyzing the data (across the population) and evaluating the outcomes of treatment provided to that population.

Also, see the article on outcomes measurement in our October 2017 newsletter for more info on how this was presented at the annual BH Conference in Chicago last fall.

Nutrition Screening (CTS.02.01.11 EP 1)

New requirement for a specific minimum set of triggers that must be included in the nutritional screening:

• Food allergies
• Weight loss or gain of 10 pounds or more in the last three months
• Decrease in food intake and/or appetite
• Dental problems
• Eating habits or behaviors that may be indicators of an eating disorder, such as bingeing or induced vomiting

If you haven’t yet revised your nutrition screening tool, do so now to avoid a Requirement for Improvement on your next survey. Also, be sure to monitor whether clients identified as being at nutritional risk are referred for a nutritional assessment. This continues to be an area of weakness for many BH organizations.

Health Information (CTS.02.01.03 EP 5)

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. This requirement is applicable “when relevant to the clients’ current care, treatment, or services, as determined by the organization.”

Client Supervision in 24 Hour Settings (CTS.04.03.20)

Two new requirements for inpatient crisis stabilization programs:

• The organization supervises the daily activities of individuals served as needed to prevent them from engaging in behavior that could be detrimental to their health.
• Supervision is conducted by staff; the organization prohibits one individual served from supervising another.

TJC has clarified that this new standard does not preclude organizations from using peer support specialist services, which TJC defines as: “A service wherein a trained consumer supports other consumers in recovery.” These services are allowed in any setting — such as inpatient, crisis, residential, group home or outpatient settings.

Physical Holding of a Child or Youth (CTS.05.05.09, CTS.05.05.11, CTS.05.05.21)

Additional requirements for policies/procedures regarding 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 (CTS.05.06.09, CTS.05.06.35)

Additional requirements for policies/procedures regarding restraint and seclusion, including details about how a debriefing is conducted following restraint or seclusion.

Record of Care Chapter (RC.02.01.05)

The standard regarding 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 applicable to restraint and seclusion now apply to physical holding. These are extensive and will likely require changes to policies and 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.

To view the full text of these revisions, see the Pre-Publication standards published in June 2017.