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.

 

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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Be aware that effective January 2014 TJC will no longer be mailing complimentary hard copies of the standards manuals and standards updates to accredited organizations. Standards manuals and standards updates will be available to accredited organizations via E-dition (the electronic version of the standards) on their Joint Commission Connect extranet site. (See December 2013 TJC […]
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During surveys of inpatient psychiatric units (and sometimes in residential programs) TJC surveyors continue to cite suicide risks they identify in the environment. Commonly occurring issues are plastic trash can liners, loopable hardware in bedrooms and bathrooms, and non-breakaway fixtures in closets and showers. When these risks are identified, the surveyor typically asks if the […]
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There is a standard tucked into the TJC Human Resources chapter that seems innocuous at first reading but frequently causes challenges on surveys. The standard is HR.01.06.01 Element of Performance # 3 in both the Behavioral Health and Hospital manuals: “Staff with the educational background, experience, or knowledge related to the skills being reviewed assess […]
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