TJC & CMS News Blog
Information for BH Organizations
To read articles written prior to January 2015, please view our Newsletter Archive.
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...
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...
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.
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.
Competency Assessment for Group Facilitators
“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 social worker. The HR Director responded by showing that all of the therapist’s credentials had been verified (license, education, etc.,) but the surveyor kept pushing the issue and asked to speak with the Clinical Director who was the therapist’s supervisor.
TJC Proposed Standards for Eating Disorder Programs
The Joint Commission has published proposed standards for accredited behavioral health organizations providing services to individuals with eating disorders. The proposed standards are the result of collaboration between the TJC Behavioral Health Care Accreditation Program and leaders of several prominent eating disorder programs throughout the country. These proposed standards are posted on the TJC website and TJC is eliciting feedback from the field through August 17.
Refresher on Waived Testing Requirements
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...
Life Events Checklist Trauma Assessment
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 may have experienced trauma, abuse, neglect, or exploitation.”
TJC Top Standards Compliance for 2014
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 Care chapters.