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 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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The standards in the new Human Resources Management chapter in the 2015 Behavioral Health Care manual went into effect on January 1. Since then, many behavioral health organizations have been reviewing the new standards and their own HR processes to make sure they are compliant and also to see if they can simplify some of those processes. We’ve received some questions from readers and have provided some clarification to these issues.
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The standard is LD.03.01.01 Element requires leaders to “regularly evaluate the culture of safety and quality.” With this standard, TJC is emphasizing that the culture within an organization directly impacts the safety and quality of care provided.
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Findings in the Provision of Care chapter typically account for a significant number of Requirements for Improvement (RFIs) on surveys for both psychiatric hospitals and behavioral health organizations/programs. These findings relate primarily to assessment, treatment planning and clinical documentation. Some of the frequently cited topics have been around for awhile and make the Top Ten […]
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