TJC & CMS News Blog
Information for

You may know that the TJC National Patient Safety Goal 15.01.01, Reduce the Risk of Suicide, EPs 1-5 are the five most cited standard and elements of performance in the Behavioral Health Care Standards Manual (CAMBHC). However, you may not know the next 5 most cited high-risk standards and EPs. This blog will focus on these standards including tips for compliance for Behavioral Health Care organizations accredited under the Behavioral Health Care Standards Manual. Hospital behavioral health providers not accredited under the Behavioral Health Care Standards Manual can learn from this blog as well. 

Joint Commission High-Risk Leadership Standards and Elements of Performance

The Joint Commission says that 60% of their survey findings come from staff not following the organization’s rules. So, it’s not surprising that LD.04.01.07 EP1 is one of the top 10 high-risk standards. To meet this standard, leaders need to review and approve all policies. Review high-risk policies yearly, and moderate/low risk policies less often, but at least every three years. Most importantly, leaders must provide adequate oversight to ensure that policies and procedures are fully implemented. Staff members should learn about new policies and have the necessary resources to adhere to them. It’s important to include legal requirements in the policies. 

Compliance with Law & Regulation

Moreover, you must comply with the law and regulations to be authorized to offer care LD.04.01.01 EP 1. This seems self-evident, but the CLIA certificate is where organizations commonly fall out of compliance. Do not perform waived tests unless you have a valid CLIA certificate. Further, make sure that the person named on the CLIA certificate is currently working with your organization. If that person leaves, you must apply to change the named individual on the certificate. Finally, make sure you follow the manufacturer’s instructions for use (IFU) of all CLIA testing equipment and supplies.  

More on Law & Regulation

It is critical that your organization provides care, treatment, and services under licensure requirements, laws, rules, and regulations, LD.04.01.01 EP 2.  Some common pitfalls include not following state required staffing ratios, not having a RN on site as required by law and regulation, and not having a Medical Director as required by law and regulation. Additionally, staff must always adhere to the scope of their license such as who can diagnose, who can perform and sign-off on Bio-psychosocial assessments and administer medication. Make sure that individuals working under contract, interns, and students are all supervised in accordance with organization policy and law & regulation. Finally there are additional requirements for providers performing Telehealth services. They must adhere to their state board licensing requirements and the state licensure requirements.

Medication Management is a High-Risk Endeavor

The Joint Commission has key standards to assist organizations in safely storing, labelling, controlling the temperature, and separating controlled from non-controlled medication MM.03.01.01 EPs 3 & 4. For organizations that store controlled medications, they must be stored in a manner that prevents diversion in accordance with law and regulation. Diversion control practices should include a count of the controlled medication between storage and administration. Controlled substances should always remain secure.  Organizations must have a written policy that addresses the control of medication between receipt by staff and administration of the medication. This policy should include how the medication will be safely stored, handled, wasted, secured, dispositioned, and returned to storage. Remember this policy must be fully implemented by staff including sample medications. 

Joint Commission Resources for High-Risk Leadership and Medication Management Standards

Additional Leadership and Medication Management Standard Resources

Implications for your Joint Commission Survey

First, during a Joint Commission survey, know that these Leadership and Medication Management Standards and EPs are on your surveyors’ radar. For example, during the Leadership and Medication Management sessions you can expect questions related to policy development, implementation and oversight. Further, throughout individual tracers, surveyors will interview staff to confirm their knowledge of the organization’s policy and procedures across all the behavioral health standards. Again, surveyors are confirming that staff both know and follow policies and procedures for care, treatment, and services. Here are specific survey activities you can expect from surveyors:

  • Audit clinical records, personnel, and medical staff files to ensure that individuals are working within the scope of their licenses.  
  • Review the organization’s licenses, certifications and permits often during building tours and individual tracers.  
  • Potentially request to see Manufacturer IFUs, state law & regulation, or other resources during document review or tracer activities. 
  • Review pharmacy logs, crash cart logs, controlled substance logs, PIXYs reports, refrigerator/freezer logs, medication storage, labeling, procurement, handling, wasting, disposition, orders and observe medication administration to confirm medication management practices follow policy.

Barrins & Associates Consultation

Our expert consultants are available to help organizations assess their compliance with the most common high-risk Joint Commission frequently scored standards. We can perform a High-Risk Findings TJC Focused Survey or  incorporate compliance with common high-risk standards into our Mock Survey and Continuous Readiness Consultations. We continue to be your partner in achieving and sustaining Joint Commission Accreditation and regulatory compliance.