As we know, regular Joint Commission surveys are resuming in June. Thus, as you ramp up your survey readiness, it’s important to focus on areas that will be a high priority for TJC. Clearly, in the face of the COVID-19 pandemic, infection control will be one of those high priority areas. TJC Behavioral Health leadership confirmed this during the recent COVID-19 Webinar Q & A for Behavioral Health Care.
So, what can you do to be survey-ready in this area?
Joint Commission Surveys: Infection Control Risk Assessment
TJC requires organizations to conduct an annual Infection Control Risk Assessment. (Standard IC.01.03.01 in both the Hospital and Behavioral Health Care manuals.) This standard also requires the organization to update that risk assessment “whenever significant changes occur.”
Therefore, one of the first things to do is revise your current IC risk assessment to include COVID-19. You can use data from your local Health Department to help analyze the risk for your location(s) and the counties you serve. Next, you can determine the severity of the risk based on your patient population and the type of services you provide.
Joint Commission Surveys: Infection Control Plan
TJC standards also require a written Infection Control Plan (IC.01.05.01.) Hence, this is another document you’ll need to update.
In your Infection Control Plan, be sure to include a description of the steps you took to minimize the risk of COVID-19 for your patients and staff. That would include any new policies and procedures you developed to address COVID-19.
Also, any equipment or supplies you purchased. Similarly, any training and education you conducted for your staff and patients. Keep in mind the Infection Control Risk Assessment and the Infection Control Plan are both included on the Documents List you need to prepare for your survey.
TJC COVID-19 FAQs for Behavioral Health
As you update your Infection Control Plan and Risk Assessment, be sure to review the recent FAQs that TJC published specific to the behavioral healthcare industry.
- Topic: Personal Protective Equipment – Mask Considerations When Caring for Known or Suspected COVID-19 Patients
- Topic: Personal Protective Equipment – Use of Face Coverings on a Behavioral Health Patient for Source Control
- Topic: Ligatures and/or Suicide Risk Reduction – Monitoring High Risk Patients With Known or Suspected COVID-19
- Topic: Public Health Recommendations to Prevent COVID-19 Spread From Community to Healthcare Facilities
Note: The FAQs listed above apply to both the Hospital and Behavioral Health Care manuals.
CMS Focus on Infection Control
CMS suspended routine surveys in March. However, they continued with complaint surveys related to infection control allegations.
In their announcement Suspension of Survey Activities, CMS included two important documents that describe how surveyors will evaluate IC programs:
- Attachment A- Survey Planning in Facilities with Active or Suspected Cases of COVID-19 Cases. This describes how surveyors will go about conducting these infection control focused surveys.
- Attachment B- Infection Prevention, Control & Immunizations. This is the evaluation tool that surveyors will use to score the facility’s compliance.
These tools will give you insight to how CMS will be reviewing infection control programs as we move forward. Understandably, much of CMS’ emphasis has been on nursing homes.
However, most of the content in these tools is highly applicable to the psychiatric hospital setting. And also to other types of behavioral healthcare organizations.
CMS is urging healthcare organizations to conduct self-assessments of their infection control programs. In short, it’s the best way to identify opportunities for improvement and help prevent the spread of COVID-19.
Continuous Readiness as Surveys Resume
With routine TJC surveys resuming, continuous readiness is once again critical. Our Mock Surveys and Continuous Readiness Consultations will help you recharge your ongoing readiness efforts and be ready for that next survey.