TJC & CMS News Blog
Information for

The April issue of TJC Perspectives has the Top 10 compliance issues for all programs including hospitals and behavioral health organizations. There are no surprises here. For hospitals, once again, the majority of findings are in the Life Safety and Environment of Care chapters. Eight of the Top 10 findings are either Life Safety or EOC issues. This is consistent with the continuing disparity rate between TJC surveys and CMS validations surveys in the areas of Life Safety and Physical Environment so the emphasis here will likely continue.

For behavioral health organizations, the list is also similar to past years. Treatment planning tops the list once again. Suicide risk assessment is #3 and there are three Human Resource requirements that made the list. One notable newcomer is the requirement for BH organizations to facilitate staff receiving influenza vaccination (IC.02.04.01.) That is #4 on the list with 17 percent of BH organizations receiving a Requirement for Improvement (RFI) on that standard. So, heads up! Review this standard and all of its elements of performance to be sure you’re fully compliant with all the requirements. This includes gathering data on flu vaccine declinations, aggregating the data, and setting an annual improvement goal. (See our June 2013 newsletter article for full coverage of the flu vaccination requirements for BH organizations.)