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.

 

TJC has published proposed revisions to the National Patient Safety Goal (NPSG) on suicide risk assessment for both the Hospital Accreditation Program and the Behavioral Health Care Accreditation Program. The proposed revisions are out for field comment which ends on May 1.
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As we review survey results for our clients surveyed under TJC’s Behavioral Health standards, we see the issue of psychiatric advance directives (PADs) being cited more frequently so thought it was time for a refresher on this topic.
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The Joint Commission recently announced that it is increasing scrutiny during surveys on ligature, suicide and self-harm risks in psychiatric hospitals and inpatient psychiatric units of med/surg hospitals. Specifically, TJC surveyors will document in their report all observations of ligature or self-harm risks that they identify in the hospital’s environment.
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News and updates to keep you informed on what’s going on in the BHC Accreditation Program, including new executive director of Behavioral Health Care and Psychiatric Hospital Accreditation for TJC, information on new Outcomes Measurement Requirement, survey timelines and Phase I revisions to Behavioral Health Care Standards.
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Be aware that there are some revisions coming to the Care, Treatment, and Services chapter of the Behavioral Health Care Manual effective July 1, 2017. One is a fairly substantive addition to treatment planning requirements and the other is a wording clarification regarding health screenings.
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From time to time, we update our readers on standards compliance requirements related to commonly challenging issues we see coming up on surveys. So, take a look at the following updates related to vaccines, CLIA certificates, fire drills, continuing medical education and texting of orders, and make sure these don’t become survey pitfalls for you.
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TJC has approved revisions to the standard in the Behavioral Health manual related to outcomes measurement. The revisions require BH organizations to assess outcomes of care, treatment, or services by using a standardized tool and go into effect January 1, 2018.
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In our October 2016 newsletter, we covered the new TJC requirements on antimicrobial stewardship. Now, it’s clear that TJC is incorporating a significant emphasis on this topic into the 2017 survey process for hospitals. The recently released 2017 Survey Activity Guide provides information on how surveyors will weave the topic of antimicrobial stewardship into the different sessions.
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There are some significant changes to survey reports, scoring of standards, and the post-survey response process that go into effect in January 2017 for behavioral health organizations. These changes have been in effect for psychiatric hospitals since June 2016 and are being implemented in all accreditation programs (including Behavioral Health) effective January 1, 2017.
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For many years, TJC has had a process in place whereby an organization can request to “clarify” a survey finding when the organization believes that it was actually in compliance with the applicable standard at the time of the survey and thus should not have been cited as noncompliant. There will continue to be a clarification process but there are some significant changes to the process that go into effect for all accreditation programs effective January 1, 2017.
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