Jul 21, 2015 by Barrins & Associates
Human Resources, Standards Compliance, Survey ReadinessBH Organizations, Hospitals
“How do you know this clinician is competent to run these groups?” That was the question asked by the nurse surveyor during the Human Resources interview on a psychiatric hospital survey. She was reviewing the file of an inpatient therapist who was a licensed clinical...
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Jun 16, 2015 by Barrins & Associates
Standards Compliance, Survey ReadinessBH Organizations, Hospitals
We still sometimes see organizations (both psychiatric hospitals and behavioral health organizations) receiving TJC survey findings related to waived testing. So, this month, we are recapping the requirements for waived testing and answering some frequently asked...
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May 19, 2015 by Barrins & Associates
CMS Regulations, Standards Compliance, Survey ReadinessHospitals
In October 2014, CMS distributed the final version of the three worksheets to be used by the State Survey Agencies (SAs) when conducting their surveys. The worksheets are for Infection Control, Discharge Planning, and Quality Assessment/Performance Improvement (QAPI)....
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May 17, 2015 by Barrins & Associates
Standards Compliance, Survey ReadinessBH Organizations, Hospitals
As discussed in previous articles, the TJC Behavioral Health standards have a specific standard in the Care, Treatment, and Services chapter on trauma assessment. It is standard CTS.02.02.05 (added in 2011): “The organization identifies individuals served who...
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Apr 24, 2015 by Barrins & Associates
Accreditation, Standards Compliance, Survey ReadinessBH Organizations, Hospitals
The April issue of TJC Perspectives has the Top 10 compliance issues for all programs including hospitals and behavioral health organizations. There are no surprises here. For hospitals, once again, the majority of findings are in the Life Safety and Environment of...
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