TJC & CMS News Blog
Information for

As reported in our March newsletter, significant changes are occurring to the TJC accreditation process for psychiatric hospitals. TJC recently sent an email to all psychiatric hospitals that use accreditation for deemed status. It outlined the changes to survey reports, scoring, and the post-survey response process effective June 6, 2016. In addition, there have been some changes to the TJC survey process for psychiatric hospitals. Specifically, surveyors are now focusing much more closely on the two Special Conditions of Participation (B Tags) that apply to psychiatric hospitals using TJC accreditation for deemed status. These CoPs are Medical Records and Staffing and two key areas are receiving increased attention:

Treatment Planning

TJC surveys have always focused on treatment planning and it has been in the Top Ten findings for many years. However, the new approach is to closely scrutinize medical records to evaluate if they meet all the detailed requirements of the Medical Records CoP (B Tags 103 – 135.) Some findings from recent surveys include the following:

  • Short term goals written in language that the patient would not understand (psychiatric jargon)
  • Short term goals not measurable, behavioral, observable
  • Lacking specific long term goals
  • Specific treatment modalities not identified (e.g. types of groups)
  • Progress notes not addressing treatment plan goals
  • Medical problems not on treatment plans
  • Treatment plans not revised based on progress or lack of progress toward goals/objectives
  • Responsibilities of each member of the treatment team not specified

To reinforce the emphasis on treatment planning, TJC has added a new requirement to standard PC.01.03.01 element of performance # 6. This EP now requires that the plan of care include “the specific treatment modalities used to treat the patient.”

Active Treatment

The other CMS requirement receiving closer scrutiny is the standard related to active treatment (B125) which states that “the treatment received by the patient must be documented in such a way to assure that all active therapeutic efforts are included.”  Active treatment has always been a major focus of CMS surveys and now TJC surveyors will be looking for the same thing. Although CMS does not mandate a specific number of hours for active treatment, the Interpretive Guidelines provide guidance on what is required. They instruct surveyors to look for evidence that the patient is receiving all the aspects of treatment to which the hospital has committed itself based on the patient’s assessments and treatment plan. The guidelines also require treatment notes that document provision of a specific modality (medication, group therapy, art therapy, recreational therapy) and the patient’s response to that modality. In addition, progress notes must provide a chronological picture of how the patient is progressing toward the goals on the treatment plan.  A very important related issue is that when patients are unable or unwilling to attend groups, alternative treatments and interventions must be provided and documented. Several hospitals have recently been cited on that issue.

TJC surveyors have undergone training on reviewing the two Special CoPs and, during surveys, have been completing CMS Form 725 Surveyor Worksheet for Psychiatric Hospital Review. During recent surveys of our clients, the nurse surveyor has spent an increased amount of time reviewing open and closed records to evaluate treatment planning and active treatment.

A bit of background on TJC’s current emphasis on the CMS CoPs for psychiatric hospitals: In 2011, TJC received deeming authority from CMS for the two Special CoPs for psychiatric hospitals (effective until July 2019 when TJC must reapply). TJC is the only accrediting body with deemed status for psychiatric hospitals. CMS monitors the validity of the TJC survey process (i.e. its adherence to CMS requirements) by conducting validation surveys to determine if there were condition level findings that TJC missed. CMS calculates a disparity rate which is the number of TJC surveys with missed condition level deficiencies divided by the number of 60 day validation surveys conducted. The goal is to have a low disparity rate; preferably, below the 20% threshold established in regulation. Earlier this year, the disparity rate for psychiatric hospitals was 55%. As a result, TJC is working with CMS to more closely align the TJC survey process with the intent of the two Special CoPs for psychiatric hospitals.

So, if your next TJC survey feels more like the CMS surveys you had in the past, that’s because the pressure point right now is on fully incorporating the requirements of the two Special CoPs into the TJC survey process and results.

Recommended strategies:

  • Review the CMS Interpretive Guidelines for the two CoPs for psychiatric hospitals.
  • Design your documentation to meet all the requirements in Tags B103 – 135.
  • Train staff on how to document treatment planning that meets these requirements.
  • Implement an auditing process that provides real-time feedback and retraining for those responsible for treatment planning.

Right now, it might also be a good idea to prepare your leadership team for the potential of more condition level findings – another recent trend that we are seeing. Stay tuned for updates from the field and we’ll keep you posted!