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.

 

Effective July 1, 2016, TJC’s Behavioral Health Care Accreditation Program will include standards for case management services provided to individuals being served in a Housing First program. The new standards are designed to assist individuals with serious mental illness, substance abuse disorders, and other behavioral healthcare issues. They are applicable only to TJC accredited behavioral healthcare organizations that provide case management services to for clients in a Housing First program.
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The Joint Commission has finalized new requirements for accredited behavioral health organizations that treat individuals with eating disorders. The new requirements go into effect July 1, 2016. They are the result of collaboration between the TJC Behavioral Health Care Accreditation Program and leaders of prominent eating disorder programs throughout the country. The goal is to […]
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In working with our psychiatric hospital clients, we have noted a standard in the Hospital manual which sometimes gets overlooked. That standard is PC.02.01.19 in the Provision of Care chapter: “The hospital recognizes and responds to changes in a patient’s condition.” The rationale behind this standard is that a significant number of critical inpatient events […]
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As the year winds down, we thought it would be useful to review the top compliance issues encountered by psychiatric hospitals and behavioral healthcare organizations in 2015. However, truth is that the Top Ten list hasn’t changed much and the topics are quite familiar (treatment planning, competencies, pain screening, etc.) So, we decided to take […]
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Effective January 1, 2016 The National Patient Safety Goal on Alarm Management (NPSG.06.01.01) went into effect in January, 2014 for hospitals. TJC defines a clinical alarm as “A component of some medical devices that is designed to notify caregivers of an important change in a patient’s physiologic status. A clinical alarm typically provides audible and/or […]
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The Document Review session has always been a component of TJC surveys. Years ago, it meant the surveyors spent hours poring over documents and, consequently, less time out visiting programs and units. Once the tracer methodology came along, that emphasis shifted (thankfully) and now surveyors spend more time doing tracers and less time on Document Review. However, the materials that are assembled for the Document Review remain important for two reasons.
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TJC recently published data on the “Top Ten” compliance issues for the first half of 2015. For hospitals, it was notable that the # 2 issue is the improper cleaning and disinfection of medical equipment, devices, and supplies. 54% of hospitals were cited for this issue. Although psychiatric hospitals have much less medical equipment and supplies than acute care hospitals, we have seen the trend for more citations on this issue with our own psychiatric hospital clients over the past few years. So, it’s an important area to stay on top of as part of your continuous readiness program.
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As we monitor TJC survey reports, we continue to see surveyors cite environmental safety risks in behavioral health settings including psychiatric hospitals, psychiatric units in acute care hospitals and sometimes in BH residential settings. In order to address this issue proactively, we highly recommend that you formally evaluate the environmental safety risks in your environment.
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Although it is not a part of the formal agenda, most TJC surveys typically include a review of a sample of closed records in addition to the open record review that takes place during tracer activities. There are specific elements that surveyors are evaluating when they review closed records, including Timeliness of Discharge Summaries, Content of Discharge Summaries, Discharge Instructions and Discharge Information Shared with Other Providers.
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"How do you know this clinician is competent to run these groups?” That was the question asked by the nurse surveyor during the Human Resources interview on a psychiatric hospital survey. She was reviewing the file of an inpatient therapist who was a licensed clinical social worker. The HR Director responded by showing that all of the therapist’s credentials had been verified (license, education, etc.,) but the surveyor kept pushing the issue and asked to speak with the Clinical Director who was the therapist’s supervisor.
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