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.
Psychiatric Advance Directives in Behavioral Healthcare
As we review survey results for our clients surveyed under TJC’s Behavioral Health standards, we see the issue of psychiatric advance directives (PADs) being cited more frequently so thought it was time for a refresher on this topic.
Increased Scrutiny of Environmental Safety Risks in Psychiatric Hospitals
The Joint Commission recently announced that it is increasing scrutiny during surveys on ligature, suicide and self-harm risks in psychiatric hospitals and inpatient psychiatric units of med/surg hospitals. Specifically, TJC surveyors will document in their report all observations of ligature or self-harm risks that they identify in the hospital’s environment.
TJC Updates: Behavioral Health Care Accreditation Program
News and updates to keep you informed on what’s going on in the BHC Accreditation Program, including new executive director of Behavioral Health Care and Psychiatric Hospital Accreditation for TJC, information on new Outcomes Measurement Requirement, survey timelines and Phase I revisions to Behavioral Health Care Standards.
Revisions to BH Standards Effective July 1, 2017
Be aware that there are some revisions coming to the Care, Treatment, and Services chapter of the Behavioral Health Care Manual effective July 1, 2017. One is a fairly substantive addition to treatment planning requirements and the other is a wording clarification regarding health screenings.
Compliance Catch-Up
From time to time, we update our readers on standards compliance requirements related to commonly challenging issues we see coming up on surveys. So, take a look at the following updates related to vaccines, CLIA certificates, fire drills, continuing medical education and texting of orders, and make sure these don’t become survey pitfalls for you.
TJC Approves Revision to Behavioral Health Outcome Measures Standard
TJC has approved revisions to the standard in the Behavioral Health manual related to outcomes measurement. The revisions require BH organizations to assess outcomes of care, treatment, or services by using a standardized tool and go into effect January 1, 2018.
Prepare for Focus on Antimicrobial Stewardship during 2017 Hospital Surveys
In our October 2016 newsletter, we covered the new TJC requirements on antimicrobial stewardship. Now, it’s clear that TJC is incorporating a significant emphasis on this topic into the 2017 survey process for hospitals. The recently released 2017 Survey Activity Guide provides information on how surveyors will weave the topic of antimicrobial stewardship into the different sessions.
Behavioral Health Organizations: New SAFER Matrix Effective January 2017
There are some significant changes to survey reports, scoring of standards, and the post-survey response process that go into effect in January 2017 for behavioral health organizations. These changes have been in effect for psychiatric hospitals since June 2016 and are being implemented in all accreditation programs (including Behavioral Health) effective January 1, 2017.
Changes to TJC Clarification Process Effective January 2017
For many years, TJC has had a process in place whereby an organization can request to “clarify” a survey finding when the organization believes that it was actually in compliance with the applicable standard at the time of the survey and thus should not have been cited as noncompliant. There will continue to be a clarification process but there are some significant changes to the process that go into effect for all accreditation programs effective January 1, 2017.
Psychiatric Hospitals: Prepare for New Antimicrobial Stewardship Standard
In July, 2016 TJC introduced its new standard on antimicrobial stewardship. The standard is contained in the Medication Management chapter (MM.09.01.01) of the Hospital manual and goes into effect January 1, 2017. Antibiotic consumption in psychiatric hospitals is low compared to general hospitals. However, antibiotics have several drug–drug interactions with psychotropic drugs that can lead to adverse events or treatment failure and significantly increase the cost of treatment. Thus, this new standard is relevant for any hospital whose patients are being prescribed antibiotics.