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 Outcomes: 2018 Trends
You just received the TJC survey report for your hospital. You have two Condition-Level Deficiencies, and you’re getting a follow-up survey in 45 days. Of course, you’ll develop your Joing Commission corrective action plans and implement the needed fixes. But your...
Joint Commission Surveys: High-Risk Areas
Did you know Dr. Mark Chassin, President and CEO of The Joint Commission, recently sent a letter to CEOs of accredited organizations about four areas surveyors will closely scrutinize during Joint Commission surveys? The June 19 letter identifies “four high-risk areas...
Closed Medical Records Reviews: TJC Survey Feedback
Joint Commission surveys of deemed status psychiatric hospitals include a session for B Tag Medical Record Reviews. In this session, surveyors review a sample of closed medical records to evaluate compliance with the CMS Special Medical Record Requirements for...
Joint Commission Puts Infection Control Issues High on Radar
Infection control issues are high on The Joint Commission’s radar these days. While psychiatric hospitals and behavioral health organizations admittedly do not have the same types of infection control challenges as med/surg hospitals, there are...
The Joint Commission Suicide Risk Recommendation FAQs
In the July issue of The Joint Commission Perspectives, responses to frequently asked questions from the field were published, relating to the suicide risk recommendations issued over the past several months. Since we’ve received numerous questions from readers...
Ligature Risk Recommendations for Inpatient Detox Units
The Joint Commission recently clarified some of its recommendations regarding ligature risks in the hospital environment. In the July issue of TJC Perspectives, they published responses to a set of FAQs received from the field. Most of the responses are essentially clarifications of their initial recommendations published in November 2017. However, one clarification is particularly noteworthy. It relates to the requirements for inpatient detox units.
Deemed Status for Psychiatric Hospitals: You Must Notify TJC If CMS Removes Your Deemed Status
Are you a psychiatric hospital that uses your Joint Commission accreditation for deemed status to satisfy Medicare certification requirements? If so, there’s an important new TJC Accreditation Participation Requirement for you to be aware of. Effective July 1, 2018,...
Psychiatric Hospitals: Be Prepared for CMS Validation Surveys
As we know, TJC has deeming authority from CMS for both acute care hospitals and psychiatric hospitals. As part of its oversight of TJC’s deemed status survey process, CMS conducts validation surveys to assess TJC’s performance in evaluating a hospital’s compliance with the CMS Conditions of Participation (COPs.) These validation surveys are conducted within 60 days after a hospital’s triennial TJC survey. The annual sample size for these validations surveys ranges from 2% to 5% of deemed hospitals.
Be Ready for the Program-Specific Tracer on Suicide Prevention
We all know the topic of suicide risk assessment is an important focus of TJC surveys in behavioral health settings — whether it’s an inpatient psychiatric unit or a community-based behavioral health program. You may not be aware that surveyors are instructed to conduct a specific tracer on suicide prevention in these behavioral health settings. Surveyors have clear instructions on what to include in the scope of this tracer. So, here are some insights into what surveyors are expected to evaluate.
Evaluating Your Culture of Safety
Are you expecting a TJC survey in 2018? If so, be ready for surveyors to explore how your organization has evaluated its Culture of Safety and what you’ve done with the results of that evaluation. We’ve already seen this occurring in 2018 surveys based on feedback from our clients. There are two requirements for conducting this evaluation embedded in the Leadership section of both manuals.