TJC has applied to CMS for deeming authority for the special conditions of participation (CoPs) that apply to psychiatric hospitals. TJC submitted the application to CMS in September 2010 and a decision by CMS is anticipated by March 2011.

TJC currently has deeming authority from CMS for the Hospital Accreditation Program. This means that hospitals accredited by TJC are deemed to have met Medicare and Medicaid certification requirements. However, TJC has not had deeming authority for the CMS special CoPs for psychiatric hospitals. These relate to special requirements for Medical Records (482.61) and Staffing (482.62.) Thus, Joint Commission accredited psychiatric hospitals were still subject to CMS surveys for these special CoPs in addition to their triennial Joint Commission survey.

If the deemed status for psychiatric hospitals is approved by CMS, these special condition surveys will no longer be required for psychiatric hospitals that are Joint Commission accredited.

As part of its application process to CMS, TJC has added specific requirements for psychiatric hospitals to its Hospital Standards in order to align them more closely with the special CoPs for psychiatric hospitals. The first set of new requirements came out in June 2010 and related to staffing, psychiatric evaluations and progress notes. For more information, access our our June 2010 newsletter at our Newsletter Archive.  

Additional new requirements go into effect for psychiatric hospitals on February 1, 2011.  These include the following:

Provision of Care chapter:

PC.01.02.13 EPs 2 and 6 related to assessment and evaluation requirements

PC.01.03.01 EPs 5 and 43 related to treatment plan requirements

Leadership chapter:

LD.04.01.05 EP 10 related to the role of the Director of Social Work Services

Click on Feb 2011 Standards Revisions to view these TJC Standards Revisions effective 2/1/11.

TJC has completed pilot surveys for the special CoPs. The final step in the approval process is for CMS to observe an actual TJC survey of a psychiatric hospital to determine if the survey covers all of the requirements of the special CoPs for psychiatric hospitals.

For the article announcing TJC's application for deemed status for psychiatric hospitals, see the January 2011 issue of TJC Perspectives page 17.

Check out TJC's Leading Practice Library

   

If you are a Joint Commission accredited organization, there's a valuable new resource available on your Joint Commission Connect extranet site. It's called the Leading Practice Library. It contains articles, tools, and sample policies on a variety of topics related to Joint Commission standards. The resources in the Leading Practice Library have been gathered by Joint Commission surveyors or submitted by accredited organizations. All have been reviewed and accepted by TJC.

There are a variety of topics useful for psychiatric hospitals and behavioral health organizations including suicide risk assessment tools and an environmental safety risk assessment tool for BH settings.

To access the Leading Practice Library, log onto your Joint Commission Connect extranet site.  Scroll down to Quality Improvement Tools and click on Leading Practice Library.

New 2011 Survey Activity Guide

  

The new 2011 Survey Activity Guide was released by TJC in January. If your organization will be surveyed in 2011, this SAG is a very valuable resource for you. It's a step by step guide to what will be covered during your survey and contains the following important information:

• The list of documents that you need to have ready on the first morning of your survey
• Descriptions of each of the interviews on your survey schedule, typical topics for the interviews and recommended participants

The SAG can be accessed via your organization's Joint Commission Connect extranet site. Also, be aware that TJC has returned to the practice of posting a template agenda for your survey. They had discontinued this practice but have now reinstituted it based on feedback from accredited organizations. The template agenda is also posted on your Joint Commission Connect extranet site and is typically posted once your application for survey has been reviewed and approved by TJC.