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.

 

We were pleased to once again attend the TJC Consultants Forum last month at their headquarters in Oakbrook Terrace, Illinois. The meeting is an annual invitational event and there were 12 consulting firms represented. We heard several informative updates on TJC initiatives.
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Be prepared for increased scrutiny and more stringent scoring of hand hygiene compliance during your next TJC survey. Effective January 1, 2018, if a surveyor observes an individual staff person failing to perform hand hygiene during direct patient care, this single observation will be cited as a deficiency resulting in a Requirement for Improvement under the Infection Prevention and Control chapter. This applies across all accreditation programs.
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Psychiatric hospitals and inpatient psychiatric units of medical/surgical hospitals continue to grapple with the challenge of eliminating suicide risks in their environment and how this will be evaluated during TJC surveys. In December, CMS released a memo on this topic. Likewise, the January 2018 issue of TJC Perspectives contains recommendations regarding the prevention of suicide in non-hospital behavioral health settings.
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TJC’s new pain management standards are effective January 1, 2018, for all hospitals including psychiatric hospitals. As the 2018 surveys unfold, we expect to see significant emphasis on these new requirements. The following is a summary of key provisions of the new standards.  
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The topic of ligature risks in inpatient psychiatric settings has been a significant challenge for the industry over the past several months following TJC’s increased scrutiny of this issue since March 1. The latest development is that TJC has now published official recommendations on ligature risks in healthcare settings. These Recommendations Regarding Environmental Hazards for Providers and Surveyors were released in a preview communication on October 25 and subsequently published in the November issue of TJC Perspectives. As part of this communication, TJC has formally defined the term “ligature resistant.”
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A significant topic of interest at the annual TJC Behavioral Healthcare Conference in Chicago this month was the new requirements going into effect in January 2018 related to outcomes measurement. These requirements apply to organizations and programs surveyed under the Behavioral Healthcare Accreditation Manual. The relevant standard is CTS.03.01.09 in the BH manual.
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A hot topic at the annual Behavioral Healthcare Conference in Chicago this month was TJC’s update on how they are surveying ligature risks in psychiatric hospitals and psychiatric units of med/surg hospitals. As our readers know from our newsletter articles and their own experiences, the findings in this area have been ramping up for the past six months.
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As we know, there is an intense focus now during TJC surveys on compliance with the CMS CoP for Special Medical Records Requirements for Psychiatric Hospitals, i.e. the B Tags. During surveys, there is a session devoted to the review of a sample of medical records for compliance with the specific requirements listed in B Tags 113 and 116. One area that is frequently found noncompliant these days is documentation of the mental status exam.
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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.
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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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