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Effective February 1, 2015, revised requirements go into effect for psychiatric hospitals that use Joint Commission accreditation for deemed status. TJC added one new requirement and revised nine elements of performance in order to ensure alignment with the CMS Conditions of Participation. The following is a summary of the revised requirements. Also see the Prepublication Requirements issued by TJC on December 16, 2014.

 

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[tblock title=”LD.04.03.01 The hospital provides services that meet patient needs.” tag=”h3″ color=”title-color” position=”text-left”/]
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If medical/surgical diagnostic and treatment services are not available within the hospital, the hospital has an agreement with an outside source for these services to make sure that the services are immediately available or an agreement needs to be established for transferring patients to a general hospital that participates in the Medicare program.

IMPACT: If you don’t have a formal transfer agreement with a local acute care hospital, get one in place.

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If medical/surgical diagnostic and treatment services are not available within the hospital, the hospital has an agreement with an outside source for these services to make sure that the services are immediately available or an agreement needs to be established for transferring patients to a general hospital that participates in the Medicare program.

IMPACT: Review your therapeutic activities program to make sure it’s robust and recovery focused. Expect more scrutiny on this during surveys.

 

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[tblock title=”PC.01.02.13 The hospital assesses the need of patients who receive treatment for emotional and behavioral disorders.” tag=”h3″ color=”title-color” position=”text-left” /]
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The assessment includes the onset of the patient’s illness and circumstances leading to admission.

IMPACT: Minimal; typically met via psychosocial and psychiatric assessments.

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The assessment includes an inventory of the patient’s strengths and disabilities written in a descriptive manner on which to base a treatment plan.

IMPACT: Assessment formats may need to be redesigned to include this information.

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The assessment includes a social history and reports of interviews with patients, family members, and others.

IMPACT: Psychosocial assessment may need to be expanded to include more family input.

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Complete neurological examination at time of the admission physical examination when indicated.

IMPACT: Make sure there is a smooth process in place for obtaining a full neurological exam (in a timely manner) when indicated based on results of neurological screening.

 

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The written plan of care includes:

  • A substantiated diagnosis
  • Documentation to justify the diagnosis and the treatment and rehabilitation activities carried out
  • Documentation that demonstrates all active therapeutic efforts are included.

IMPACT: If diagnosis is not already documented in the tx plan, need to add. Other impact TBD as this gets surveyed.

 

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[tblock title=”RC.02.01.01 The medical record contains information that reflects the patient’s care, treatment, and services.” tag=”h3″ color=”title-color” position=”text-left”/]
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The diagnosis includes intercurrent diseases and the psychiatric diagnosis.

IMPACT: Already frequently cited by TJC; emphasis will continue.

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Progress notes include recommendations for revisions to plan of care as indicated as well as a precise assessment of the patient’s progress in accordance with the original or revised plan of care.

IMPACT: Progress notes need to closely align with the goals and objectives on the tx plan. Lack of revision to tx plans is a common survey finding; emphasis will likely increase.

 

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The record of each patient discharged needs to include a discharge summary. The exceptions noted in the current 2014 standards (for patients treated for minor problems and patients transferred to a different level of care within the hospital) are no longer allowed. All patients discharged need a discharge summary.

IMPACT: Based on the wording, it appears that discharge summaries would need to be done for transfers from inpatient to PHP or Outpatient.  However, TJC Standards Interpretation Group has advised us that is not the intent. More info to come on this one.

 

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We will be closely monitoring upcoming surveys to see how surveyors apply these new requirements and what their expectations are for implementation. Interestingly, we had two hospital clients surveyed in December and the surveyors discussed these new requirements with them as a “heads-up.” We will be sure to keep you posted on how this plays out in the field so stay tuned!