TJC & CMS News Blog
Information for BH Organizations
To read articles written prior to January 2015, please view our Newsletter Archive.
TJC HR Requirement: Competence Assessment by a Qualified Individual
Twenty-two percent of behavioral health organizations surveyed in 2016 received a survey finding related to competence assessment. Frequently, the finding relates to a staff person or contractor not having their clinical competence assessed by an individual qualified to do so. The relevant standard is HRM.01.06.01 EP 2 in the BH Manual and HR.01.06.01 EP 3 in the Hospital manual. Learn how this standard is typically reviewed by surveyors.
Environment of Care Updates: Exit Signs and Fire Drills
TJC began surveying to the 2012 edition of the National Fire Protection Life Safety Code in November 2016. Resulting changes to the Environment of Care and Life Safety standards went into effect January 2017. One of the changes that went into effect for both the Hospital and Behavioral Health programs is a new requirement for inspection of Exit signs. We are now seeing this issue arising on surveys so let’s clarify the requirement.
Proposed Revisions to National Patient Safety Goal on Suicide Risk Assessment
TJC has published proposed revisions to the National Patient Safety Goal (NPSG) on suicide risk assessment for both the Hospital Accreditation Program and the Behavioral Health Care Accreditation Program. The proposed revisions are out for field comment which ends on May 1.
Psychiatric Advance Directives in Behavioral Healthcare
As we review survey results for our clients surveyed under TJC’s Behavioral Health standards, we see the issue of psychiatric advance directives (PADs) being cited more frequently so thought it was time for a refresher on this topic.
TJC Updates: Behavioral Health Care Accreditation Program
News and updates to keep you informed on what’s going on in the BHC Accreditation Program, including new executive director of Behavioral Health Care and Psychiatric Hospital Accreditation for TJC, information on new Outcomes Measurement Requirement, survey timelines and Phase I revisions to Behavioral Health Care Standards.
Revisions to BH Standards Effective July 1, 2017
Be aware that there are some revisions coming to the Care, Treatment, and Services chapter of the Behavioral Health Care Manual effective July 1, 2017. One is a fairly substantive addition to treatment planning requirements and the other is a wording clarification regarding health screenings.
Compliance Catch-Up
From time to time, we update our readers on standards compliance requirements related to commonly challenging issues we see coming up on surveys. So, take a look at the following updates related to vaccines, CLIA certificates, fire drills, continuing medical education and texting of orders, and make sure these don’t become survey pitfalls for you.
TJC Approves Revision to Behavioral Health Outcome Measures Standard
TJC has approved revisions to the standard in the Behavioral Health manual related to outcomes measurement. The revisions require BH organizations to assess outcomes of care, treatment, or services by using a standardized tool and go into effect January 1, 2018.
Behavioral Health Organizations: New SAFER Matrix Effective January 2017
There are some significant changes to survey reports, scoring of standards, and the post-survey response process that go into effect in January 2017 for behavioral health organizations. These changes have been in effect for psychiatric hospitals since June 2016 and are being implemented in all accreditation programs (including Behavioral Health) effective January 1, 2017.
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.