TJC & CMS News Blog
Information for BH Organizations
To read articles written prior to January 2015, please view our Newsletter Archive.
Changes to TJC Clarification Process Effective January 2017
For many years, TJC has had a process in place whereby an organization can request to “clarify” a survey finding when the organization believes that it was actually in compliance with the applicable standard at the time of the survey and thus should not have been cited as noncompliant. There will continue to be a clarification process but there are some significant changes to the process that go into effect for all accreditation programs effective January 1, 2017.
Survey of Sober Living Houses in Behavioral Health Organizations
Many substance abuse programs across the country operate sober living houses as part of their continuum of care. Over the years, TJC has grappled with questions from the field on this topic and now they have come out with specific guidelines regarding sober living houses. We recently discussed these with Megan Marx Associate Director for Behavior Health Care Accreditation and she encouraged us to share these guidelines with our readers.
Update: Medication Ordering and Therapeutic Duplication
TJC added three additional policies to the list of documents required for hospitals on the first day of survey. These have been added to the Hospital Accreditation Program Document List in the updated Survey Activity Guide and include medication management policy, abuse and neglect policy for inpatient and ambulatory sites and fall risk assessment and policy.
Influenza Vaccination: An Important Compliance Issue for BH Organizations
The TJC requirements for behavioral health organizations to implement influenza vaccination programs went into effect in 2012 and were expanded in 2013. Most BH organizations now have a process for offering influenza vaccination and educating staff about the importance of the vaccine. However, some BH organizations still struggle with meeting all of the TJC requirements in this area and this standard (IC.02.04.01) has now made its way into the Top Five findings for BH organizations for the first half of 2016.
Proposed Standards Revision for Behavioral Health Outcome Measures
TJC has published proposed standards revisions for the Behavioral Health Accreditation Program related to outcomes measurement. Currently, there is one standard in the Behavioral Health manual related to outcomes. That standard is CTS.03.01.09 which requires BH organizations to assess the outcomes of care, treatment, or services provided to clients. It requires that organizations monitor the progress of individuals served in achieving their identified goals. It also requires that the organization aggregate outcomes data and evaluate outcomes across the population served.
Trauma Assessment: Survey Findings and Resources
As we track survey results for our clients, we see that some behavioral health organizations continue to be challenged by the TJC requirements for trauma assessment. There have been several survey findings on this topic in 2015 and 2016. So, let’s recap the requirements and take a look at some resources.
TJC Introduces New SAFER Matrix Scoring Methodology
We’ve been keeping you updated on changes to the scoring methodology and survey process for psychiatric hospitals that use TJC accreditation for deemed status. As previously discussed, the changes to the scoring methodology are effective for psychiatric hospitals as of June 6, 2016. TJC has now formally announced that these changes will go into effect for all other accreditation programs (including Behavioral Health) effective January 1, 2017.
TJC Update on Texting of Orders
Up until now, it has been TJC’s position that the texting of orders did not meet TJC standards. Effective May, 2016, TJC has updated this position and will now allow the texting of orders provided that certain features are in place. First and foremost, the text messages must be sent via a secure text messaging platform include the specific features.
Is Your Sentinel Event Policy Up to Date?
During some recent consultations, we’ve noticed that some organizations haven’t updated their sentinel event policy to include all the current TJC requirements. So, the following is a recap of TJC requirements related to sentinel events.
Updates on TJC Topics of Interest
The scheduling of surveys and composition of survey teams are always topics of interest to our clients, so here are some updates in those areas. Also, be aware of the new Sentinel Event Alert on suicide risk assessment and treatment.