Are you all squared away with the Joint Commission 2021 standards that went into effect January 1st? Now is a good time for a final check to be sure you’re fully compliant with all the new 2021 requirements.
Our experience is when a new year begins, surveyors often focus on the new requirements for that year. So, here’s the highlights of the 2021 changes and some tips for ensuring compliance:
New 2021 Requirements: Same in Behavioral Health Manual and Hospital Manual
There are some changes to the Joint Commission 2021 standards in the Hospital Manual and the Behavioral Health Manual that are the same in both manuals. These are as follows:
90% Flu Vaccination Goal: Infection Control Chapter (IC.02.04.01 EP 5)
TJC eliminated the requirement for having the goal of a 90% compliance rate for flu vaccination. However, this doesn’t mean you don’t need a full-fledged flu vaccination program. You still need to educate staff, offer the vaccine, and collect data on flu vaccination rates.
The difference is you get to set your own targets based on your current compliance rate and your improvement goals. For more details, see our recent post Joint Commission Flu Vaccination Requirements: 90% Goal Eliminated.
What to Do Now: Review your Infection Control Plan and your goals for flu vaccination. If you currently have a 90% goal but want to change it, be sure to update your IC plan so you’re not held to that 90% goal come survey time.
Medication Orders: Medication Management Chapter (MM.04.01.01 EP 2)
This change clarifies the minimum required elements of a complete medication order. For organizations that prescribe medication, this standard has always required a written policy defining the minimum elements of a medication order. The 2021 change is the standard now specifies that these minimum elements must include medication name, medication dose, medication route, and medication frequency.
This requirement seems somewhat obvious and one would expect that medication orders would routinely contain all of this information. But, don’t overlook the policy component of this standard.
What to Do Now: Review your Medication Ordering Policy. Be sure it contains a full list of required elements for medication orders including medication name, medication dose, medication route, and medication frequency.
On a related note, TJC has an FAQ about whether medication orders need to contain a diagnosis, condition, or indication for use. It’s worth reviewing to make sure you’re clear on this topic.
Sentinel Event Definition Includes Falls
TJC is now including a definition for “fall events” in their Sentinel Event Policy. The purpose is to help organizations understand whether a fall qualifies for review as a sentinel event.
“A fall resulting in any of the following: any fracture; surgery, casting, or traction; required consult/management or comfort care for a neurological (for example, skull fracture, subdural or intracranial hemorrhage) or internal (for example, rib fracture, small liver laceration) injury; or a patient with coagulopathy who receives blood products as a result of the fall; death or permanent harm as a result of injuries sustained from the fall (not from physiologic events causing the fall).”
What to Do Now: Update your Sentinel Event Policy to include this definition of a fall. If you receive an incident report for a fall, review it against this definition. Determine if that fall qualifies as a sentinel event. If so, you need to conduct a Root Cause Analysis.
Also, take a look at Sentinel Event Alert 55 Preventing Falls and Fall-Related Injuries in Health Care Facilities. Although originally published in 2015, the information and recommendations in this Alert are still highly relevant.
Spare Sprinkler Heads: Life Safety Chapter (LS.02.01.35 EP 7)
TJC clarified the requirement for the availability of spare sprinkler heads. “At least six spare sprinkler heads of each type and temperature rating installed in the facility are readily available, with the associated wrench or tool to replace the sprinkler head. The spare sprinkler heads and wrench or tool are stored in a cabinet that does not exceed 100°F.”
Note: For organizations accredited under the Behavioral Health Manual, this standard applies to settings that provide sleeping arrangements as a required part of their service and that lock doors to prohibit individuals served from leaving the building or space.
What to Do Now: This requirement for spare sprinkler heads is in the 2012 edition of the Life Safety Code which TJC adopted in 2016. As a result, most organizations have this in place.
However, be aware: The 2021 change is that now you must have six spare sprinkler heads of each type. Thus, if you have more than one type of sprinkler head, you need six spares for each type of sprinkler head.
If you subscribe to the TJC Environment of Care News (a valuable resource) they cover this on page 6 of the January edition.
New 2021 Requirements: Changes to Hospital Manual
The following are changes contained only in the 2021 Hospital Manual:
Discharge Plans: Provision of Care Chapter (PC.04.01.01 EP 32)
TJC added a new requirement for discharge plans of Medicare patients. They now must include a list of resources available to the patient in his/her geographic area. For example: home health agencies, inpatient rehab facilities, and long term care hospitals. Also, the hospital must document in the medical record that this list was given to the patient.
What to Do Now: Review your format for discharge plans. Be sure there’s a place to include this information when relevant. Educate your discharge planning staff about this new requirement. Include it in your medical record audits to be sure the required documentation is present in the record.
Discharge Planning Staff: Provision of Care Chapter (PC.04.01.03 EP 3)
TJC added a specific requirement that “Discharge planning is performed by, or under the supervision of, a registered nurse, social worker, or other qualified person.”
What to Do Now: This structure should already be in place in most hospitals. But be sure your organizational chart reflects that line of supervision. And that your job descriptions for discharge planning staff show supervision by a social worker or an R.N.
Block Charting: Record of Care Chapter (RC.02.01.01 EP 2)
TJC clarified that block charting is acceptable for rapid titration of medications. “When rapid titration of a medication is necessary, the hospital defines in policy the urgent/emergent situations in which block charting would be an acceptable form of documentation.”
See also the TJC FAQ on titration orders.
What to Do Now: Our hospital clients typically do not use block charting. However, if you do, be sure to review this requirement and the TJC definition of block charting in the glossary of the Hospital Manual. Make sure your policy reflects the requirements. And that medical and nursing staff understand what’s required.
Emergency Management Drills: Emergency Management Chapter (EM.03.01.03 EP 3)
TJC clarified the requirement for emergency management drills in locations classified as business occupancies (as defined by the Life Safety Code.) If these locations don’t offer emergency services and are not community-designated disaster receiving stations, they only need to conduct one emergency management drill annually.
What to Do Now: Most organizations are already following this procedure for one annual drill in business occupancies. However, make sure your emergency management drills in your business occupancies relate to an issue identified on your Hazard Vulnerability Analysis (HVA.) We’ve seen several survey findings for not making this connection.
Lastly, you may be wondering if your COVID-19 emergency response can qualify as one of your required emergency management drills. It can – if your evaluation includes certain elements. Check out the TJC FAQ on emergency management drills during the Public Health Emergency.
New 2021 Requirements: Changes to Behavioral Health Manual
The following are changes contained only in the 2021 Behavioral Health Manual:
First, the manual has a new title: Comprehensive Accreditation Manual for Behavioral Health Care and Human Services. TJC made this change to better reflect the wide array of human service providers accredited under the Behavioral Health standards. As a result, there are several language changes in the 2021 manual that reflect this new title.
Second, there are nearly 90 new and revised requirements for Child Welfare Services. These went into effect in September, 2020. The requirements address various services for children and families at risk including:
- Child protection services
- Family preservation/wraparound services
- Foster care
- Kinship care
- Respite care
What to Do Now: If your organization provides Child Welfare Services, check out TJC’s R3 Report on the New and Revised Standards for Child Welfare Agencies. You’ll get all the details and some very useful resources related to these new requirements.
Assessment Data: Care, Treatment, Services Chapter (CTS.02.02.01 EP 1)
This standard covers the type of assessment data the organization must collect for each individual served. Specifically, the new requirement is that in the domain of Family Circumstances, the assessment data must now include information about divorce and incarceration.
What to Do Now: Update the format for your Biopsychosocial Assessment to include these elements. Educate your staff about this new requirement. Include it in your medical record audits to be sure assessments include this information.
Safety & Security Risks: Environment of Care Chapter (EC.02.01.01 EP 5)
This standard requires the organization to manage safety and security risks. It’s been around for a while. Element of Performance # 5 requires the organization to maintain all grounds and equipment. TJC added the following Note: “Equipment includes vehicles for transporting individuals served.”
What to Do Now: Does your organization transport clients to any of your services? If so, make sure your Safety & Security Plan addresses how you maintain your vehicles in good working order. Likewise, you should also include a description of the safety training you provide to your drivers.
Joint Commission 2021 Standards: E-dition
All these standards changes are included in the E-dition January 2021 Update 2 to the Comprehensive Accreditation Manual for Hospitals and the Comprehensive Accreditation Manual for Behavioral Health Care and Human Services. There’s a section at the front of each manual titled “What’s New?” This gives you a summary of the 2021 changes.
Additionally, you can use the “Filters” tab at the top of the screen to view only the 2021 changes. Just click on that tab and select “New/Changed EPs as of selected effective date.”
Joint Commission 2021 Survey Activity Guides
Remember that TJC has also published the 2021 Survey Activity Guide for all accreditation programs. That’s available on your Joint Commission Connect extranet site. It includes updates to the survey process and any changes to the content of the survey sessions.
Virtual Joint Commission Surveys
As you know, TJC is conducting an increasing number of virtual surveys. For an update on that front, check out our recent post Virtual Joint Commission Surveys: Get Prepared.
Barrins & Associates Consultation
Most importantly, we’re covering all these updates to the 2021 Joint Commission standards and the 2021 survey process. As always, we’re prepared to support your ongoing compliance and survey readiness even in these challenging times.