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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% of behavioral health organizations found non-compliant on their TJC surveys. The most frequent issues that we see cited on surveys are the following:

  • The suicide risk assessment lacks specific characteristics of the client and environmental features that would increase or decrease the risk for suicide. (Essentially, the assessment is too brief and/or too general in its evaluation of suicide risk.)
  • The suicide risk assessment does not include protective factors that could potentially decrease the risk for suicide.
  • Suicide risk is identified in the assessment but there is no carry-through to the treatment plan in terms of interventions, a safety plan, etc.
  • Suicide risk is assessed at the time of admission but there are no clear guidelines for when suicide risk should be reassessed.
  • There is no competency assessment for clinical staff conducting suicide risk assessments.

So, we encourage you to review your process for suicide risk assessment and make sure it’s addressing these particular areas. Also, TJC has published a Standards BoosterPak for Suicide Risk. It’s an excellent resource that includes a thorough explanation of the standards as well as helpful tips, FAQs, a comprehensive bibliography and an extensive listing of other resources. It’s worth checking out. You can access it on your TJC Connect extranet site. Click on Resources & Tools; then click on Standards BoosterPaks and you will see the one titled Suicide Risk.


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Standard Topic Issues
CTS.03.01.03 Treatment Plans Objectives not stated in behavioral terms such that progress can be measured; not individualized, not updated
NPSG.15.01.01 Suicide Risk Assessment Not addressing specific risk factors; no protective factors; lack of interventions; no reassessment; lack of staff training
HR.02.01.03 Clinical Responsibilities for LIPs Lack of peer review data or National Practitioner Data Bank query; not done every two years
HR.01.02.05 Verifying Staff Qualifications Lack of primary source verification of licensure, certification, or education
EC.02.06.01 Safe, Functional Environment Safety and cleanliness issues identified in the environment of care
HR.01.06.01 Competency Assessment Lack of assessment of clinical competencies; competencies not defined for specific populations
CTS.02.01.11 Nutritional Screening No clear criteria for referral for nutritional assessment; nutritional risk identified but no follow-up
RC.01.01.01 Clinical Record Missing, incomplete or late assessments
MM.03.01.01 Medication Storage Lack of security for medications; expired medications; problems with medication refrigerator monitoring
IC.02.04.01 Flu Vaccination Lack of implementation of annual flu vaccination program