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.
Heads Up on Battery Operated Smoke Detectors in Behavioral Health Residential Settings
One of our clients that operates a residential treatment program recently underwent their initial TJC survey. They were surveyed under the Life Safety Code Residential Occupancy requirements for Lodging and Rooming Houses that have from 4 to 16 occupants. The...
TJC Changes to PFIs and Life Safety Equivalencies
[thumbnail alt="Tim O’Rourke, CHFM" type="img-thumbnail" alignment="alignright" image="http://barrins.a3creativeloft.com/wp-content/uploads/TimOrourke-219x300.jpg" ]Tim O’Rourke, CHFM, B&A Engineer[/thumbnail]Barrins & Associates engineer Tim O'Rourke, CHFM...
Competence Assessment in Behavioral Health
During surveys of both psychiatric hospitals and behavioral health organizations, issues continue to arise around how the organization is assessing the competence of its clinical staff. We have seen several survey findings for organizations not clearly defining...
Medication Instructions at Discharge
The TJC focus on the discharge process continues in 2014. During surveys, surveyors will frequently request a sample of closed records. In the past, the focus for closed records was on determining if the discharge summary had been completed on time. More recently,...
High Reliability: Important Topic for TJC Leadership Interview
For several years, the common topic for the leadership interview on the last day of the survey was the five "pillars of leadership" as described in standards LD.03.01.01 - LD.03.06.01: Using data Planning Communicating Changing Performance Staffing This topic is still...
No More Complimentary Standards Manuals
Be aware that effective January 2014 TJC will no longer be mailing complimentary hard copies of the standards manuals and standards updates to accredited organizations. Standards manuals and standards updates will be available to accredited organizations via E-dition...
Suicide Risk Assessment: Patient Bathrooms
During surveys of inpatient psychiatric units (and sometimes in residential programs) TJC surveyors continue to cite suicide risks they identify in the environment. Commonly occurring issues are plastic trash can liners, loopable hardware in bedrooms and bathrooms,...
Competence Assessment by a Qualified Individual
There is a standard tucked into the TJC Human Resources chapter that seems innocuous at first reading but frequently causes challenges on surveys. The standard is HR.01.06.01 Element of Performance # 3 in both the Behavioral Health and Hospital manuals: "Staff with...
Clarification: Current TJC Requirements for FMEAs
For several years, there was a requirement in the TJC standards for organizations to conduct an annual proactive risk assessment referred to as a Failure Mode and Effects Analysis (FMEA). The requirements for proactive risk assessment have evolved over the past few...
Proposed Revisions to Behavioral Health Human Resources Chapter
TJC has proposed revisions to the Human Resources chapter in the Behavioral Health Care Accreditation Manual. The proposed revised standards are available on the TJC website on the Standards Field Review page. The Field Review page contains both the proposed new...