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.
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.
Trauma Assessment: Survey Findings and Resources
As we track survey results for our clients, we see that some behavioral health organizations continue to be challenged by the TJC requirements for trauma assessment. There have been several survey findings on this topic in 2015 and 2016. So, let’s recap the requirements and take a look at some resources.
TJC Introduces New SAFER Matrix Scoring Methodology
We’ve been keeping you updated on changes to the scoring methodology and survey process for psychiatric hospitals that use TJC accreditation for deemed status. As previously discussed, the changes to the scoring methodology are effective for psychiatric hospitals as of June 6, 2016. TJC has now formally announced that these changes will go into effect for all other accreditation programs (including Behavioral Health) effective January 1, 2017.
TJC Update on Texting of Orders
Up until now, it has been TJC’s position that the texting of orders did not meet TJC standards. Effective May, 2016, TJC has updated this position and will now allow the texting of orders provided that certain features are in place. First and foremost, the text messages must be sent via a secure text messaging platform include the specific features.
Update on TJC Survey Process for Psychiatric Hospitals
As reported in our March newsletter, significant changes are occurring to the TJC accreditation process for psychiatric hospitals. TJC recently sent an email to all psychiatric hospitals that use accreditation for deemed status. It outlined the changes to survey reports, scoring, and the post-survey response process effective June 6, 2016. In addition, there have been some changes to the TJC survey process for psychiatric hospitals.
Is Your Sentinel Event Policy Up to Date?
During some recent consultations, we’ve noticed that some organizations haven’t updated their sentinel event policy to include all the current TJC requirements. So, the following is a recap of TJC requirements related to sentinel events.