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.

 

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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The Joint Commission has published proposed standards for accredited behavioral health organizations providing services to individuals with eating disorders. The proposed standards are the result of collaboration between the TJC Behavioral Health Care Accreditation Program and leaders of several prominent eating disorder programs throughout the country. These proposed standards are posted on the TJC website and TJC is eliciting feedback from the field through August 17.
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We still sometimes see organizations (both psychiatric hospitals and behavioral health organizations) receiving TJC survey findings related to waived testing. So, this month, we are recapping the requirements for waived testing and answering some frequently asked questions from our clients.   What exactly does “waived testing” mean? Waived testing is defined by the Clinical Laboratory […]
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In October 2014, CMS distributed the final version of the three worksheets to be used by the State Survey Agencies (SAs) when conducting their surveys. The worksheets are for Infection Control, Discharge Planning, and Quality Assessment/Performance Improvement (QAPI). They will be used by the state surveyors to assess compliance with the Conditions of Participation (CoPs) associated with those areas.
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As discussed in previous articles, the TJC Behavioral Health standards have a specific standard in the Care, Treatment, and Services chapter on trauma assessment. It is standard CTS.02.02.05 (added in 2011): "The organization identifies individuals served who may have experienced trauma, abuse, neglect, or exploitation."
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The April issue of TJC Perspectives has the Top 10 compliance issues for all programs including hospitals and behavioral health organizations. There are no surprises here. For hospitals, once again, the majority of findings are in the Life Safety and Environment of Care chapters.
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TJC now publishes Quick Safety. It’s a brief informational posting on patient safety issues. Issue 10 has an article that’s relevant as many organizations transition to an electronic health record. The topic is the practice of “copying and pasting” in EHRs.
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TJC publishes a monthly e-newsletter titled Physician Leader Monthly. The target audience is Chief Medical Officers and the topics are geared toward physician leaders. So, check it out and see if it might be a good resource for your CMO.
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For a few years now, TJC surveyors have been conducting suicide prevention tracers when applicable to the setting they are surveying. This is known as a “program specific tracer.” We recently had a client that had this type of tracer during their survey and thought it would be helpful to share their impressions.
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