TJC & CMS News Blog Information
for Hospitals and Behavioral Healthcare
To read articles written prior to January 2015, please view our Newsletter Archive.
TJC Survey: Changes to the Survey Agenda
Are you ready for the changes TJC has made to the survey agenda? TJC recently announced “minor modifications” to the survey agenda effective March 1st. Although they’re small changes, they do have implications for your onsite survey – and how you manage it. So, best...
TJC Restraint vs. Physical Holding: What’s the Difference?
Are you a behavioral health organization that uses restraint or physical holding as interventions? Does TJC survey your organization under the Behavioral Health Care manual? If so, make sure you understand the TJC restraint definition and the distinction between restraint and physical holding …
TJC Tracer: Patient Transferred to Emergency Room
Heads up on a potential TJC tracer to keep on your radar. It's patients transferred from an inpatient behavioral health setting to the ER. We frequently see TJC (and also CMS) surveyors select this type of case for a tracer. So, what are the key things they’re looking...
NPSG 15 Suicide Risk Reduction: Feedback from the Field
It’s now been seven months since the new requirements for NPSG 15 on Suicide Risk Reduction took effect on July 1st. So, how is this important topic playing out on surveys? First, we know surveyors are closely scrutinizing each of the seven elements of performance...
New CMS Survey Process for Psychiatric Hospitals
On January 13, 2020, CMS announced it will change its survey process for psychiatric hospitals. Certainly, this is a significant change so it’s important to understand all the details.
TJC Standards Update: New Requirements for Substance Use Disorder Treatment
Heads up! Does your behavioral health organization/program provide treatment for substance use disorders? If so, you’ll need to address new TJC standards going into effect on July 1, 2020. TJC Standards: Behavioral Health Care Manual TJC accredits opioid treatment...
TJC Tracer Update: Focus on Dietary Services
Ready for the new focus area that’s now a part of Joint Commission surveys? It’s the Dietary Tracer. TJC now includes a Dietary Tracer on all triennial surveys of hospitals (including psychiatric hospitals) that use Joint Commission accreditation for deemed status....
NPSG.15.01.01 Suicide Risk Reduction: Monitoring High Risk Patients
Have you seen the latest FAQ from TJC on NPSG.15.01.01 – Suicide Risk Reduction? It’s about monitoring patients at high risk of suicide. Important information for everyone grappling with the new requirements effective 7/1/19 …
Unannounced Surveys: Are You Prepared for an “Early Survey?”
Heads Up! Recently, several of our clients had their unannounced TJC surveys earlier than they anticipated. That includes both psychiatric hospitals and behavioral health organizations. So, is this a trend? Hard to tell but best to be prepared in case you encounter...
SAFER Matrix: A Closer Look at Scoring
TJC’s SAFER matrix has been around since January 2017. Feedback from the field has been very positive. At the same time, clients often ask just how surveyors make decisions about scoring on the matrix. So, let’s take a closer look at that. SAFER Matrix Decisions TJC...