TJC & CMS News Blog Information
for Hospitals and Behavioral Healthcare
To read articles written prior to January 2015, please view our Newsletter Archive.
Revised Requirements for Psychiatric Hospitals with Deemed Status
Effective February 1, 2015, revised requirements go into effect for psychiatric hospitals that use Joint Commission accreditation for deemed status. TJC added one new requirement and revised nine elements of performance in order to ensure alignment with the CMS...
New Sentinel Event Chapter
Be aware that TJC has revised its Sentinel Event Policy and the Sentinel Event chapter in both the Hospital and Behavioral Health manuals. The revisions were effective January 1, 2015. While the essential components of the Sentinel Event Policy have not changed, there are some new terms and definitions that are important.
National Patient Safety Goal on Alarm Management: Relevance for Psychiatric Hospitals
In January 2014, TJC introduced the National Patient Safety Goal on Alarm Management (NPSG.06.01.01) for hospitals and critical access hospitals. Since psychiatric hospitals are surveyed under the Hospital standards, this National Patient Safety Goal is applicable in...
Suicide Risk Assessment Now # 2 in Top Ten Compliance Issues for Behavioral Health
TJC recently published the Top Ten Standards Compliance Issues for the First Half of 2014. (See table below.) There is not much new or different from previous years but it's worth noting that suicide risk assessment has now climbed to the # 2 spot on the list with 21%...
Feedback from TJC Hospital Executives Briefings
We attended the annual TJC Hospital Executives Briefings and CMS Update in New York City earlier this month. It was chock full of information on the latest TJC and CMS compliance issues. It was also a glimpse into what some of the key TJC focus areas will be in 2015....
Treatment Plans in Psychiatric Hospitals
As we all know, issues with treatment plans are one of the most frequently cited areas of non-compliance on TJC surveys. This is true for both psychiatric hospitals and behavioral health organizations. Recently, however, a new issue has been identified.
Opportunities for Improvement
Organizations surveyed after July 1, 2014 will see a change in how their findings are written up in their TJC survey reports. There will now be an Opportunities for Improvement section included in the survey report. Included in this OFI section will be single...
TJC Changes to PFIs and Life Safety Equivalencies
[thumbnail alt="Tim O’Rourke, CHFM" type="img-thumbnail" alignment="alignright" image="http://barrins.a3creativeloft.com/wp-content/uploads/TimOrourke-219x300.jpg" ]Tim O’Rourke, CHFM, B&A Engineer[/thumbnail]Barrins & Associates engineer Tim O'Rourke, CHFM...
Competence Assessment in Behavioral Health
During surveys of both psychiatric hospitals and behavioral health organizations, issues continue to arise around how the organization is assessing the competence of its clinical staff. We have seen several survey findings for organizations not clearly defining...
Medication Instructions at Discharge
The TJC focus on the discharge process continues in 2014. During surveys, surveyors will frequently request a sample of closed records. In the past, the focus for closed records was on determining if the discharge summary had been completed on time. More recently,...