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.
CMS Complaint Survey Results on New Website
Be aware! CMS complaint survey results are now posted on their new website. CMS communicated this in their memo QSO-19-01 on October 4th. This means if CMS conducts a complaint survey at an accredited hospital, they will post their official report of findings (the “2567” report) on this website …
National Patient Safety Goal NPSG.15.01.01: Changes Coming in 2019
Suicide risk assessment continues to be a high focus area for The Joint Commission. Accordingly, TJC will further strengthen its approach to suicide risk reduction in 2019 and revise National Patient Safety Goal NPSG.15.01.01. As a result, the expanded NPSG.15.01.01 will require organizations to do the following …
CMS Validation Survey: New Process Being Piloted
At the Consultants Forum meeting in Chicago, Joint Commission COO Mark Pelletier announced an interesting new approach TJC and CMS are piloting. It’s a concurrent validation survey process. This means CMS surveyors conduct their CMS validation survey at the same time...
Joint Commission Complaint Reporting: Time to Change Your Public Notice
The Joint Commission has changed its process for complaint reporting. Effective September 1, a Joint Commission employee will no longer answer the complaint line at TJC's Office of Quality and Patient Safety. Instead, there will be an automated message. Over the...
TJC Survey Outcomes: 2018 Trends
You just received the TJC survey report for your hospital. You have two Condition-Level Deficiencies, and you’re getting a follow-up survey in 45 days. Of course, you’ll develop your Joing Commission corrective action plans and implement the needed fixes. But your...
Joint Commission Surveys: High-Risk Areas
Did you know Dr. Mark Chassin, President and CEO of The Joint Commission, recently sent a letter to CEOs of accredited organizations about four areas surveyors will closely scrutinize during Joint Commission surveys? The June 19 letter identifies “four high-risk areas...
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...