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.
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.
Survey of Sober Living Houses in Behavioral Health Organizations
Many substance abuse programs across the country operate sober living houses as part of their continuum of care. Over the years, TJC has grappled with questions from the field on this topic and now they have come out with specific guidelines regarding sober living houses. We recently discussed these with Megan Marx Associate Director for Behavior Health Care Accreditation and she encouraged us to share these guidelines with our readers.
Update: Medication Ordering and Therapeutic Duplication
TJC added three additional policies to the list of documents required for hospitals on the first day of survey. These have been added to the Hospital Accreditation Program Document List in the updated Survey Activity Guide and include medication management policy, abuse and neglect policy for inpatient and ambulatory sites and fall risk assessment and policy.
Influenza Vaccination: An Important Compliance Issue for BH Organizations
The TJC requirements for behavioral health organizations to implement influenza vaccination programs went into effect in 2012 and were expanded in 2013. Most BH organizations now have a process for offering influenza vaccination and educating staff about the importance of the vaccine. However, some BH organizations still struggle with meeting all of the TJC requirements in this area and this standard (IC.02.04.01) has now made its way into the Top Five findings for BH organizations for the first half of 2016.
Highlights from Recent TJC Surveys with CMS Focus
If you are a psychiatric hospital using TJC accreditation for deemed status, you know that TJC recently implemented some significant changes to its survey process and scoring methodology. These include closer scrutiny of the two Special Conditions of Participation for psychiatric hospitals (B Tags) and use of the SAFER (Survey Analysis for Evaluating Risk) matrix for survey reports. The SAFER matrix summarizes survey findings based on the estimated level of risk to patients, staff, and visitors.
Proposed Standards Revision for Behavioral Health Outcome Measures
TJC has published proposed standards revisions for the Behavioral Health Accreditation Program related to outcomes measurement. Currently, there is one standard in the Behavioral Health manual related to outcomes. That standard is CTS.03.01.09 which requires BH organizations to assess the outcomes of care, treatment, or services provided to clients. It requires that organizations monitor the progress of individuals served in achieving their identified goals. It also requires that the organization aggregate outcomes data and evaluate outcomes across the population served.
Surveying Active Treatment in Psychiatric Hospitals
Psychiatric hospitals that use TJC accreditation for deemed status and have been surveyed in the last few months have experienced a shift in focus. Many report that their recent TJC survey felt more like a CMS survey. So, as surveyors conduct tracers on the inpatient units, they are observing the milieu and the implementation of the program schedule to determine if active treatment is being delivered. In light of this, we encourage you to conduct your own tracers and take a look at the programming being delivered on your inpatient units.