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Behavioral Healthcare Compliance for Accreditation and Regulatory Requirements: Updates and Resources

In today’s dynamic regulatory environment, up-to-date information and resources are critical for ongoing regulatory compliance. Our team will help you stay on top of TJC and CMS behavioral healthcare compliance updates so your organization can ensure continuous regulatory readiness.

See behavioral healthcare compliance posts below from our recent newsletters and access our newsletter archive and behavioral healthcare industry links.

Competency Assessment for Group Facilitators

“How do you know this clinician is competent to run these groups?” That was the question asked by the nurse surveyor during the Human Resources interview on a psychiatric hospital survey. She was reviewing the file of an inpatient therapist who was a licensed clinical social worker. The HR Director responded by showing that all of the therapist’s credentials had been verified (license, education, etc.,) but the surveyor kept pushing the issue and asked to speak with the Clinical Director who was the therapist’s supervisor.

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TJC Proposed Standards for Eating Disorder Programs

The Joint Commission has published proposed standards for accredited behavioral health organizations providing services to individuals with eating disorders. The proposed standards are the result of collaboration between the TJC Behavioral Health Care Accreditation Program and leaders of several prominent eating disorder programs throughout the country. These proposed standards are posted on the TJC website and TJC is eliciting feedback from the field through August 17.

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Psychiatric Hospital CMS Worksheets

In October 2014, CMS distributed the final version of the three worksheets to be used by the State Survey Agencies (SAs) when conducting their surveys. The worksheets are for Infection Control, Discharge Planning, and Quality Assessment/Performance Improvement (QAPI). They will be used by the state surveyors to assess compliance with the Conditions of Participation (CoPs) associated with those areas.

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New BH Human Resource Standards

The standards in the new Human Resources Management chapter in the 2015 Behavioral Health Care manual went into effect on January 1. Since then, many behavioral health organizations have been reviewing the new standards and their own HR processes to make sure they are compliant and also to see if they can simplify some of those processes. We’ve received some questions from readers and have provided some clarification to these issues.

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