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.
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.
Evaluating Your Culture of Safety
Are you expecting a TJC survey in 2018? If so, be ready for surveyors to explore how your organization has evaluated its Culture of Safety and what you’ve done with the results of that evaluation. We’ve already seen this occurring in 2018 surveys based on feedback from our clients. There are two requirements for conducting this evaluation embedded in the Leadership section of both manuals.
Proposed Revisions to National Patient Safety Goal on Suicide Risk Assessment
TJC has proposed revisions to the current National Patient Safety Goal on suicide risk assessment (NPSG.15.01.01) for both the Hospital and Behavioral Health Care Accreditation Programs. The proposed revisions are available for comment until May 7, 2018, and are summarized in this article.
How One Organization is Meeting the New Outcomes Measurement Requirements
Many organizations and programs accredited under TJC’s Behavioral Healthcare standards are striving to implement the new outcomes measurement requirements effective January 2018. Several readers have asked what instruments folks are using. So, we thought it would be helpful to share the experience of our long-term client Four Winds Hospital in Saratoga Springs, New York. This freestanding psychiatric hospital utilizes the Behavior and Symptom Identification Scale (BASIS-32) for both its adult inpatient units and its adult PHP/IOP programs. They had been using the BASIS-32 for many years for inpatients and then later expanded the tool to the PHP/IOP programs.
Survey Findings Related to Ligature Risks
Intense scrutiny on ligature risks continues for inpatient psychiatric units, both in freestanding psychiatric hospitals and inpatient psychiatric units of medical/surgical hospitals. As the field continues to work toward making these settings ligature resistant, it’s important to know just what is being cited by TJC surveyors these days. Thus, we are providing feedback from recent surveys of our clients so you can use this information to guide your environmental risk reduction efforts.