TJC & CMS News Blog Information
for Hospitals and Behavioral Healthcare
To read articles written prior to January 2015, please view our Newsletter Archive.
Proposed Revisions to National Patient Safety Goal on Suicide Risk Assessment
TJC has proposed revisions to the current National Patient Safety Goal on suicide risk assessment (NPSG.15.01.01) for both the Hospital and Behavioral Health Care Accreditation Programs. The proposed revisions are available for comment until May 7, 2018, and are summarized in this article.
Survey Findings Related to Ligature Risks
Intense scrutiny on ligature risks continues for inpatient psychiatric units, both in freestanding psychiatric hospitals and inpatient psychiatric units of medical/surgical hospitals. As the field continues to work toward making these settings ligature resistant, it’s important to know just what is being cited by TJC surveyors these days. Thus, we are providing feedback from recent surveys of our clients so you can use this information to guide your environmental risk reduction efforts.
Feedback from TJC Consultants Forum
We were pleased to once again attend the TJC Consultants Forum last month at their headquarters in Oakbrook Terrace, Illinois. The meeting is an annual invitational event and there were 12 consulting firms represented. We heard several informative updates on TJC initiatives.
Increased Scrutiny of Hand Hygiene During Surveys
Be prepared for increased scrutiny and more stringent scoring of hand hygiene compliance during your next TJC survey. Effective January 1, 2018, if a surveyor observes an individual staff person failing to perform hand hygiene during direct patient care, this single observation will be cited as a deficiency resulting in a Requirement for Improvement under the Infection Prevention and Control chapter. This applies across all accreditation programs.
Update on Surveying of Ligature Risks: CMS Memo, TJC Guidance for Non-Hospital BH Settings
Psychiatric hospitals and inpatient psychiatric units of medical/surgical hospitals continue to grapple with the challenge of eliminating suicide risks in their environment and how this will be evaluated during TJC surveys. In December, CMS released a memo on this topic. Likewise, the January 2018 issue of TJC Perspectives contains recommendations regarding the prevention of suicide in non-hospital behavioral health settings.
New Pain Management Standards Effective January 2018
TJC’s new pain management standards are effective January 1, 2018, for all hospitals including psychiatric hospitals. As the 2018 surveys unfold, we expect to see significant emphasis on these new requirements. The following is a summary of key provisions of the new standards. Â
Guidance from The Joint Commission Regarding Ligature Risks
The topic of ligature risks in inpatient psychiatric settings has been a significant challenge for the industry over the past several months following TJC’s increased scrutiny of this issue since March 1. The latest development is that TJC has now published official recommendations on ligature risks in healthcare settings. These Recommendations Regarding Environmental Hazards for Providers and Surveyors were released in a preview communication on October 25 and subsequently published in the November issue of TJC Perspectives. As part of this communication, TJC has formally defined the term “ligature resistant.”
Update from TJC BH Conference: Surveying of Ligature Risks
A hot topic at the annual Behavioral Healthcare Conference in Chicago this month was TJC’s update on how they are surveying ligature risks in psychiatric hospitals and psychiatric units of med/surg hospitals. As our readers know from our newsletter articles and their own experiences, the findings in this area have been ramping up for the past six months.
Tips for Documenting the Mental Status Exam
As we know, there is an intense focus now during TJC surveys on compliance with the CMS CoP for Special Medical Records Requirements for Psychiatric Hospitals, i.e. the B Tags. During surveys, there is a session devoted to the review of a sample of medical records for compliance with the specific requirements listed in B Tags 113 and 116. One area that is frequently found noncompliant these days is documentation of the mental status exam.
Field Feedback on Surveying of Ligature Risks
The surveying of ligature risks in psychiatric hospitals has almost taken on a life of its own over the past four months. In follow-up to our June article on ligature risks, we’re providing some timely feedback from clients about how this issue has been reviewed during recent surveys. We’ve had six psychiatric hospital clients surveyed since the March 1 announcement from TJC on this topic, and the scrutiny on it has been intense. Here’s a summary of the issues cited for the four hospitals.