Behavioral Healthcare Compliance for Accreditation and Regulatory Requirements: Updates and Resources
In today’s dynamic regulatory environment, up-to-date information and resources are critical for ongoing regulatory compliance. Our team will help you stay on top of JC and CMS behavioral healthcare compliance updates so your organization can ensure continuous regulatory readiness.
See behavioral healthcare compliance posts below from our recent newsletters and access our newsletter archive and behavioral healthcare industry links.
Oro 2.0 High Reliability Organizational Assessment
The Joint Commission Center for Transforming Healthcare recently made available the Oro 2.0 High Reliability Organizational Assessment. The assessment is an online tool designed to assist hospitals in evaluating their progress toward high reliability and support them in attaining the goal of zero patient harm. The web-based tool is available to accredited organizations on their Joint Commission Connect extranet site. The Oro 2.0 Assessment guides the leadership team through a series of questions on key strategic performance issues. It’s based on the High Reliability Maturity Model.
New Behavioral Health Care Standards for Permanent Housing Support Services
Effective July 1, 2016, TJC’s Behavioral Health Care Accreditation Program will include standards for case management services provided to individuals being served in a Housing First program. The new standards are designed to assist individuals with serious mental illness, substance abuse disorders, and other behavioral healthcare issues. They are applicable only to TJC accredited behavioral healthcare organizations that provide case management services to for clients in a Housing First program.
New Requirements for Eating Disorder Programs
The Joint Commission has finalized new requirements for accredited behavioral health organizations that treat individuals with eating disorders. The new requirements go into effect July 1, 2016. They are the result of collaboration between the TJC Behavioral Health...
Responding to Changes in a Patient’s Condition
In working with our psychiatric hospital clients, we have noted a standard in the Hospital manual which sometimes gets overlooked. That standard is PC.02.01.19 in the Provision of Care chapter: “The hospital recognizes and responds to changes in a patient’s...
Not in the Top Ten Yet but Heads Up!
As the year winds down, we thought it would be useful to review the top compliance issues encountered by psychiatric hospitals and behavioral healthcare organizations in 2015. However, truth is that the Top Ten list hasn’t changed much and the topics are quite...
Psychiatric Hospitals: New Requirements for Clinical Alarm Management
Effective January 1, 2016 The National Patient Safety Goal on Alarm Management (NPSG.06.01.01) went into effect in January, 2014 for hospitals. TJC defines a clinical alarm as “A component of some medical devices that is designed to notify caregivers of an important...
Survey Strategy: Preparation of Documents
The Document Review session has always been a component of TJC surveys. Years ago, it meant the surveyors spent hours poring over documents and, consequently, less time out visiting programs and units. Once the tracer methodology came along, that emphasis shifted (thankfully) and now surveyors spend more time doing tracers and less time on Document Review. However, the materials that are assembled for the Document Review remain important for two reasons.
Cleaning of Medical Equipment: Top Ten Compliance Issue for Hospitals
TJC recently published data on the “Top Ten” compliance issues for the first half of 2015. For hospitals, it was notable that the # 2 issue is the improper cleaning and disinfection of medical equipment, devices, and supplies. 54% of hospitals were cited for this issue. Although psychiatric hospitals have much less medical equipment and supplies than acute care hospitals, we have seen the trend for more citations on this issue with our own psychiatric hospital clients over the past few years. So, it’s an important area to stay on top of as part of your continuous readiness program.
Environmental Risk Assessment in Behavioral Health Settings
As we monitor TJC survey reports, we continue to see surveyors cite environmental safety risks in behavioral health settings including psychiatric hospitals, psychiatric units in acute care hospitals and sometimes in BH residential settings. In order to address this issue proactively, we highly recommend that you formally evaluate the environmental safety risks in your environment.
Be Prepared for Closed Record Review during Your Survey
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.