Behavioral Healthcare Compliance for Accreditation and Regulatory Requirements: Updates and Resources
See behavioral healthcare compliance posts below from our recent newsletters and access our newsletter archive and behavioral healthcare industry links.
Closed Medical Records Reviews: TJC Survey Feedback
Joint Commission surveys of deemed status psychiatric hospitals include a session for B Tag Medical Record Reviews. In this session, surveyors review a sample of closed medical records to evaluate compliance with the CMS Special Medical Record Requirements for...
Joint Commission Nutrition Screening Requirements for Behavioral Healthcare Programs
Has your nutrition screening tool been updated to comply with the new 2018 Joint Commission requirements? Discover easy steps for compliance.
Joint Commission Puts Infection Control Issues High on Radar
Infection control issues are high on The Joint Commission’s radar these days. While psychiatric hospitals and behavioral health organizations admittedly do not have the same types of infection control challenges as med/surg hospitals, there are...
Trauma Assessment: Feedback from Recent Surveys
As we track survey results for our clients, we are seeing a recent trend related to trauma assessment and want to make you aware of it. The Joint Commission standard on trauma assessment is in the Behavioral Health manual. It’s standard CTS.02.02.05: "The organization...
The Joint Commission Suicide Risk Recommendation FAQs
In the July issue of The Joint Commission Perspectives, responses to frequently asked questions from the field were published, relating to the suicide risk recommendations issued over the past several months. Since we’ve received numerous questions from readers...
Ligature Risk Recommendations for Inpatient Detox Units
The Joint Commission recently clarified some of its recommendations regarding ligature risks in the hospital environment. In the July issue of TJC Perspectives, they published responses to a set of FAQs received from the field. Most of the responses are essentially clarifications of their initial recommendations published in November 2017. However, one clarification is particularly noteworthy. It relates to the requirements for inpatient detox units.
Deemed Status for Psychiatric Hospitals: You Must Notify TJC If CMS Removes Your Deemed Status
Are you a psychiatric hospital that uses your Joint Commission accreditation for deemed status to satisfy Medicare certification requirements? If so, there’s an important new TJC Accreditation Participation Requirement for you to be aware of. Effective July 1, 2018,...
Psychiatric Hospitals: Be Prepared for CMS Validation Surveys
As we know, TJC has deeming authority from CMS for both acute care hospitals and psychiatric hospitals. As part of its oversight of TJC’s deemed status survey process, CMS conducts validation surveys to assess TJC’s performance in evaluating a hospital’s compliance with the CMS Conditions of Participation (COPs.) These validation surveys are conducted within 60 days after a hospital’s triennial TJC survey. The annual sample size for these validations surveys ranges from 2% to 5% of deemed hospitals.
Suicide Prevention Recommendations for Non-Hospital Behavioral Health Settings
In our January newsletter, we covered the suicide prevention recommendations issued by TJC earlier this year for non-hospital behavioral health settings. These were published in the January 2018 issue of TJC Perspectives and apply to residential, partial hospitalization, day treatment, and intensive outpatient behavioral health programs.
Be Ready for the Program-Specific Tracer on Suicide Prevention
We all know the topic of suicide risk assessment is an important focus of TJC surveys in behavioral health settings — whether it’s an inpatient psychiatric unit or a community-based behavioral health program. You may not be aware that surveyors are instructed to conduct a specific tracer on suicide prevention in these behavioral health settings. Surveyors have clear instructions on what to include in the scope of this tracer. So, here are some insights into what surveyors are expected to evaluate.