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Joint Commission Behavioral Health Update

November 2009     
In This Issue
Top Compliance Issues for First Half of 2009
Psychiatric Hospitals: Take Note of Changes to Your Survey Report Format
New Requirement for Submitting Evidence of Standards Compliance
New 2010 BH Standards Still Available Online
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 
This month we provide important information for psychiatric hospitals about the new format for their TJC survey report. See how it's now aligned with CMS findings. 
In addition, there is updated information regarding the top compliance issues for the first half of 2009; always important to keep your eye on!
Also, be sure to read about the recent change regarding submitting your Evidence of Standards Compliance in follow-up to your survey.
We value your feedback on the newsletter. Please email us your comments and tell us what topics you would like to see in future issues.  We look forward to hearing from you!  Also, feel free to forward this newsletter to your colleagues. 

As we approach the holiday season, I wish you and yours the best and look forward to working with you in the New Year!

Regards,Forward this issue
Anne Barrins
2010 Challenging Standards
Top Compliance Issues for First Half of 2009
TJC just released data on the top standards compliance issues for surveys conducted from January 1, 2009 through June 30, 2009. This information is very useful for focusing your ongoing readiness efforts and tracers within your organizations.  The following is a summary of the findings for behavioral health organizations and psychiatric hospitals:
Behavioral Health Organizations

  • Treatment planning (38%)
  • Complete/accurate clinical record (16%)
  • Suicide risk assessment (16%)
  • Medication storage (15%)
  • Emergency management (13%)
  • Competency assessment (12%)
  • Clinical responsibilities for Licensed Independent Practitioners (12%)
  • Hospitals (includes psychiatric hospitals)

  • Life Safety: means of egress (45%)
  • Life Safety: building/fire protection features (43%)
  • Verbal orders (40%)
  • Environment of Care: fire safety (38%)
  • Critical test results (38%)
  • Life Safety: fire/smoke protection building features (36%)
  • Complete/accurate clinical record (33%)
  • Medication storage (33%)
  • Medication orders (32%)

    For the complete article "Top Standards Compliance Issues for First Half of 2009" see the November issue of Perspectives, page 4.
  • PPR CalendarPsychiatric Hospitals: Take Note of Changes to Your Survey Report Format

    If you are a psychiatric hospital that uses TJC accreditation for deemed status, you will notice some changes to the format of your TJC survey report.  Effective July 1, 2009, the report now includes both Joint Commission and Medicare requirements scored non-compliant during your survey. There are two separate sections to the report:
  • Summary of CMS Findings
  • Joint Commission Findings 

    The Summary of CMS Findings section includes a crosswalk of the non-compliant Medicare requirements to the corresponding non-compliant TJC standards and elements of performance. This section also identifies the level of deficiency for any non-compliant Medicare requirement. It identifies the deficiency as being either a "Standard" level deficiency or a "Condition" level deficiency.
    It is important to note that if you receive a "Condition" level deficiency, TJC will conduct a follow-up survey to review the corrective action on the issue cited. 
    The Joint Commission Findings section includes the Medicare condition, standard numbers, tags, and text for the CMS requirements that crosswalk to the Joint Commission EPs that are identified as being less than fully compliant. This section also divides the survey findings into the following levels of criticality:

  • Situational Decision Rules (2)
  • Direct Impact Findings (3)
  • Indirect Impact Findings (4)
    It is important to note that only the Direct Impact Findings count toward the threshold for determining Conditional Accreditation or Preliminary Denial of Accreditation. The Indirect Impact findings do not count toward this threshold.
    To view a sample of the new report format, see the October issue of Perspectives, page 13.
  • PPR Group

    New Requirement for Submitting Evidence of Standards Compliance 

    TJC recently announced that a new level of specificity is required when you are submitting Evidence of Standards Compliance (ESC) in follow-up to your survey. It is no longer acceptable for the ESC to identify a committee or a group of individuals as responsible for implementing a particular corrective action. Rather, you must identify (in the "Who" section of your response) the title of the person who is responsible for implementing the corrective action. If you wish to identify a committee as being responsible, you must list the title of the accountable individual on the committee. So, when you are developing your corrective action plans in follow-up to your survey, make sure that you are clear about who within your organization is responsible for taking action to address the deficiencies found on survey. The titles of those individuals need to be listed in your ESC.

    For the complete article "Revision to the ESC Tool on Secure Extranet" see the October issue of Perspectives,  page 14.
    BH Standards OnlineNew 2010 BH Standards Still Available Online

    Remember that the pre-publication version of the 2010 BH standards is still available online until December 1, 2009. The important feature of the online version is that it includes a "History Tracking Report." This is essentially a crosswalk from the 2009 standards to the 2010 standards. This is very helpful when you are trying to track the specific changes from 2009 to 2010. For example, there is a new Record of Care chapter in 2010. The crosswalk helps you identify where the requirements of this chapter were previously located in the 2009 standards. 
    For the complete text of all the 2010 standards chapters and a tracking of the changes from 2009 to 2010, click on 2010 BH Standards 
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    Barrins & Associates provides Joint Commission consulting services for the Behavioral Healthcare industry. Our clients include both psychiatric hospitals and freestanding Behavioral Healthcare organizations. We specialize in providing Survey Preparation and Continuous Survey Readiness services exclusively for the Behavioral Healthcare industry.  Barrins & Associates was founded by Anne Barrins who was a Joint Commission surveyor for 13 years.