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 recently published the Top Ten Standards Compliance Issues for the First Half of 2014. (See table below.) There is not much new or different from previous years but it’s worth noting that suicide risk assessment has now climbed to the # 2 spot on the list with 21% of behavioral health organizations found non-compliant […]
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We attended the annual TJC Hospital Executives Briefings and CMS Update in New York City earlier this month. It was chock full of information on the latest TJC and CMS compliance issues. It was also a glimpse into what some of the key TJC focus areas will be in 2015. The following are highlights from […]
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As we all know, issues with treatment plans are one of the most frequently cited areas of non-compliance on TJC surveys. This is true for both psychiatric hospitals and behavioral health organizations. Recently, however, a new issue has been identified.
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Organizations surveyed after July 1, 2014 will see a change in how their findings are written up in their TJC survey reports. There will now be an Opportunities for Improvement section included in the survey report. Included in this OFI section will be single observations of non-compliance with Category C elements of performance (EPs.) A […]
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If your organization operates an Opioid Treatment Program (OTP), be sure to review the recent changes to the TJC Behavioral Health standards that apply to these programs. There are some changes to the following chapters: Care, Treatment and Services Medication Management Information Management Rights and Responsibilities of the Individual Although the changes are not extensive, […]
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One of our clients that operates a residential treatment program recently underwent their initial TJC survey. They were surveyed under the Life Safety Code Residential Occupancy requirements for Lodging and Rooming Houses that have from 4 to 16 occupants. The organization had a finding that we had never seen before in the Life Safety chapter […]
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Barrins & Associates engineer Tim O’Rourke, CHFM has an alert for our psychiatric hospital clients surveyed under Joint Commission Hospital standards. Tim has worked with many of you over the years on mock surveys and compliance with the Life Safety and Environment of Care standards. He wants you to be aware of upcoming changes to […]
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During surveys of both psychiatric hospitals and behavioral health organizations, issues continue to arise around how the organization is assessing the competence of its clinical staff. We have seen several survey findings for organizations not clearly defining competencies and not having a process for ongoing evaluation of clinical competencies. So, in this article, we are […]
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The TJC focus on the discharge process continues in 2014. During surveys, surveyors will frequently request a sample of closed records. In the past, the focus for closed records was on determining if the discharge summary had been completed on time. More recently, however, surveyor focus has been on evaluating whether the patient/client was given […]
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For several years, the common topic for the leadership interview on the last day of the survey was the five “pillars of leadership” as described in standards LD.03.01.01 – LD.03.06.01: Using data Planning Communicating Changing Performance Staffing This topic is still often used during leadership interviews on Behavioral Health surveys. Thus, BH leaders should be […]
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