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Integrating CMS and TJC Requirements

Barrins working through CMS and TJC integrationThe vast majority of psychiatric hospitals use their Joint Commission accreditation for deemed status with the Center for Medicare/Medicaid Services (CMS.) By achieving and maintaining TJC accreditation, the hospital is “deemed” to be in compliance with the CMS Conditions of Participation (CoPs.) Thus, the hospital is qualified for Medicare and Medicaid reimbursement.


TJC Deeming Authority for Psychiatric Hospitals

In 2011, TJC obtained deeming authority from CMS for psychiatric hospitals. TJC is currently the only accrediting organization that has deeming authority for psychiatric hospitals. This is why integrating CMS and TJC requirements is extremely important for your psychiatric hospital.

Impact on Psychiatric Hospitals

Since 2011, Joint Commission surveys of psychiatric hospitals have included an evaluation of the hospital’s compliance with the CMS B Tags (Special CoPs for Psychiatric Hospitals.) The B Tags include:

  • Special Medical Record Requirements for Psychiatric Hospitals
  • Special Staff Requirements for Psychiatric Hospitals

So, the challenge for psychiatric hospitals is they must meet both sets of requirements: CMS CoPs and Joint Commission standards. Currently, problems with B Tag compliance are a leading cause for Condition level findings and TJC/CMS follow-up surveys for psychiatric hospitals. Our team of CMS and TJC integration experts are here to help your organization.

Complying with CMS and TJC Requirements

When we provide technical assistance to psychiatric hospitals on integrating CMS and TJC requirements, our clients typically have several questions:

  • How do the CMS and TJC standards fit together?
  • How do we avoid Condition level findings for the B Tags?
  • How do we make sure our treatment plans meet the surveyor’s expectations?
  • How do we get our physicians to complete their documentation the way TJC and CMS expect?
  • How will the surveyors evaluate active treatment? Many of our patients won’t attend groups.

We’ve worked with psychiatric hospitals nationwide to tackle these issues. We zero in on the high risk compliance issues and help you find solutions for integrating CMS and TJC requirements.Information on integrating CMS and TJC requirements

Avoiding Condition Level Findings

We have the pulse on CMS and TJC compliance for psychiatric hospitals. Through our extensive database of survey findings, we’re able to identify the issues that most commonly lead to Condition level findings and follow-up surveys.

You get the benefit of our nationwide perspective and know where to prioritize your efforts to avoid adverse survey findings.

Treatment Planning

We work with your team to design treatment plan formats that meet both TJC and CMS requirements. That includes long term goals (both psychiatric and medical), measurable objectives, discipline-specific interventions, and treatment plan updates based on patient progress or lack of progress.

Your benefit: You have a treatment plan format that meets both sets of requirements and has been proven successful on actual TJC and CMS surveys.

Physician Documentation

Currently, both TJC and CMS surveyors focus heavily on physician documentation; specifically psychiatric evaluations and physician progress notes. We know the type of physician documentation TJC and CMS expect to see. Our team of CMS and TJC requirement experts work with you to build user friendly formats that help your physicians provide the documentation surveyors want.

Your benefit: Your physicians get the tools they need to provide compliant documentation and you avoid adverse findings in these areas.

Active Treatment

Provision of active treatment is a major focus during both TJC and CMS surveys of psychiatric hospitals.  We know what type of active treatment surveyors expect to see. Our CMS and TJC requirement specialists also know what type of documentation they want. Based on this, we help you tackle the common active treatment challenges:

  • How to design program schedules with sufficient active treatment hours
  • How to engage patients in active treatment
  • How to provide alternative treatment when patients don’t attend groups
  • Documenting active treatment and alternative treatment
  • Individualizing treatment plans for patients not attending groups

Your benefit: Your clinical team is prepared to present your active treatment program and answer surveyors’ questions about how they implement it.

Why Choose Barrins & Associates for Technical Assistance on Integrating CMS and TJC Requirements?

To ensure you’re meeting current regulatory challenges, you need a consulting firm that specializes in regulatory compliance for the behavioral healthcare industry. Working with us gives you the peace of mind that you’ve partnered with proven specialists in this field.

Get started with the experts on integrating CMS and TJC requirements for psychiatric hospitals. Call us at 1-888-742-4621 to discuss your needs or fill out our online contact form.

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Prior Posts

Learn how to tackle both CMS and TJC Requirements at your hospital. We'll design an ongoing readiness program that integrates both sets of standards.