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.
Field Feedback on Surveying of Ligature Risks
The surveying of ligature risks in psychiatric hospitals has almost taken on a life of its own over the past four months. In follow-up to our June article on ligature risks, we’re providing some timely feedback from clients about how this issue has been reviewed during recent surveys. We’ve had six psychiatric hospital clients surveyed since the March 1 announcement from TJC on this topic, and the scrutiny on it has been intense. Here’s a summary of the issues cited for the four hospitals.
Update on TJC Surveying of Ligature Risks
If you are a psychiatric hospital anticipating a TJC survey, it’s important to know the details of how TJC is currently surveying ligature risks. They recently provided an update for the field on this topic in follow-up to their March 2017 communication on the scoring of ligature, suicide and self-harm risks. Here are some highlights from this most recent update.
TJC HR Requirement: Competence Assessment by a Qualified Individual
Twenty-two percent of behavioral health organizations surveyed in 2016 received a survey finding related to competence assessment. Frequently, the finding relates to a staff person or contractor not having their clinical competence assessed by an individual qualified to do so. The relevant standard is HRM.01.06.01 EP 2 in the BH Manual and HR.01.06.01 EP 3 in the Hospital manual. Learn how this standard is typically reviewed by surveyors.
Psychiatric Hospitals: Top Ten Compliance Issues on the SAFER Matrix
Psychiatric hospitals that use TJC accreditation for CMS deemed status were the first organizations to experience the SAFER (Survey Analysis for Evaluating Risk) methodology starting in June 2016. TJC recently published six months of compliance data for these hospitals. Many of the Top Ten issues remain the same but it’s interesting to see how they play out on the SAFER matrix. Here’s some highlights from the TJC data and our own database.
Environment of Care Updates: Exit Signs and Fire Drills
TJC began surveying to the 2012 edition of the National Fire Protection Life Safety Code in November 2016. Resulting changes to the Environment of Care and Life Safety standards went into effect January 2017. One of the changes that went into effect for both the Hospital and Behavioral Health programs is a new requirement for inspection of Exit signs. We are now seeing this issue arising on surveys so let’s clarify the requirement.
Proposed Revisions to National Patient Safety Goal on Suicide Risk Assessment
TJC has published proposed revisions to the National Patient Safety Goal (NPSG) on suicide risk assessment for both the Hospital Accreditation Program and the Behavioral Health Care Accreditation Program. The proposed revisions are out for field comment which ends on May 1.
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.