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.

 

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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For several years, there was a requirement in the TJC standards for organizations to conduct an annual proactive risk assessment referred to as a Failure Mode and Effects Analysis (FMEA). The requirements for proactive risk assessment have evolved over the past few years and we frequently get questions about whether a FMEA is still required. […]
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TJC has proposed revisions to the Human Resources chapter in the Behavioral Health Care Accreditation Manual. The proposed revised standards are available on the TJC website on the Standards Field Review page. The Field Review page contains both the proposed new standards/elements of performance and a crosswalk of the current standards to the proposed revisions. […]
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