We attended two important TJC conferences this Fall for the latest information on survey trends and hot topics for 2013. The first was 2013 Hospital Executive Briefings which provided updates on TJC and CMS standards for those surveyed under the Hospital Accreditation Manual. The second was the 2013 Behavioral Healthcare Conference & Accreditation Standards Update.
The following are highlights from the conferences. We will be providing in depth coverage of these topics via our annual Long Distance Education Sessions which were so popular last year. For information on arranging one of these sessions, click on the links below:
Highlights from 2013 Hospital Executive Briefings
CMS Update: Medicare Final Rule:
- 48 hour timeframe eliminated for authentication of verbal orders; now defers to state law and hospital policy
- Provision for authentication of verbal orders by another practitioner made permanent
- Separate nursing care plan not required; can be integrated into the interdisciplinary plan of care
CMS Emphasis in 2013: It was noted at the conference that CMS is "tying everything back to QA/PI." Several hospitals have been cited at the Condition Level in 2012 for lack of compliance with QA/PI Conditions of Participation. CMS is currently testing a comprehensive surveyor worksheet for assessing compliance with the Quality Assessment/Performance Improvement CoP. To view the draft QA/PI worksheet, click on the May 18 CMS Memo and scroll to the third page.
2013 National Patient Safety Goal on CAUTI: TJC is expecting full implementation of the NPSG on Catheter Associated Urinary Tract Infections (CAUTI). Hospitals were given 2012 as the planning year. In 2013, full implementation of an evidence based practice will be surveyed. To view a sample evidence based guideline, click on CDC's Guideline for Prevention of Catheter-Associated Urinary Tract Infections.
Top 2012 Non-Life Safety/EOC Compliance Issues for Hospitals
Eleven of the top 20 compliance issues for hospitals are in the Life Safety and Environment of Care chapters. Since we will be devoting a separate issue of our newsletter to those topics, we are providing info on the other nine standards that made their way into the "Top 20."
TOP 2012 NON-LIFE SAFETY/EOC COMPLIANCE ISSUES FOR HOSPITALS |
STANDARD |
TOPIC |
ISSUES |
RC.01.01.01 |
Record of Care |
Dating, timing of entries; assessments lacking info |
IC.02.02.01 |
Cleaning medical equipment |
Improper cleaning/disinfection |
MM.03.01.01 |
Medication storage |
Lack of security; med refrigerator temperatures; expiration dates on multi-dose vials |
PC.01.02.03 |
Assessments |
Nursing assessments lack info; nutritional assessments not done when indicated |
RC.02.03.07 |
Verbal orders |
Verbal orders not authenticated within 48 hours (should improve with elimination of 48 hour rule) |
MM.04.01.01 |
Medication orders |
Hospital policy not followed; preprinted order sheets not updated |
PC.01.03.01 |
Treatment plans |
Not individualized; objectives not behavioral |
MS.01.01.01 |
Medical staff bylaws |
Requirements for completing H&P not in bylaws |
PC.03.01.03 |
Pre-anesthesia assessment |
Lack of two step process for pre-anesthesia assessment |
Highlights from 2013 Annual Behavioral Healthcare Conference
New 2013 TJC Requirements:
New Prevention and Wellness Standards: These new standards will be effective January 1, 2013. See the article in our June 2012 newsletter for details.
Examples of prevention/wellness services discussed at the conference include:
- Substance abuse prevention
- At-risk youth services
- Suicide prevention
- Parenting training
- Depression screening
- Child abuse/neglect prevention
- Domestic violence prevention
- Truancy prevention
- Sexual abuse prevention
Flu Vaccination Requirements: These standards were actually effective in July 2012 and will continue to be a focus area for 2013 surveys. See the article in our March 2012 newsletter for details.
Three key points about the flu vaccine requirements were made at the BH Conference:
- The organization is not required to pay for the flu vaccine.
- Annual compliance goals need to be increased "by more than 1% or 2% per year."
- TJC encourages offering the vaccine to contract staff but this is not required.
Top 2012 Compliance Issues for BH Organizations
Seven of the top 10 compliance issues are continuations from 2011 but three are newcomers (see below).
TOP 2012 BEHAVIORAL HEALTH COMPLIANCE ISSUES |
STANDARD |
TOPIC |
ISSUES |
CTS.03.01.01 |
Treatment planning |
Plan doesn't reflect assessments; goals don't capture client's ideas; objectives not measurable; no re-evaluation when significant changes occur |
HR.02.01.03 |
Licensed independent practitioners: Clinical responsibilities |
No primary source verification of license; no peer review; no National Practitioner Data Bank query; no governing body approval |
HR.01.02.05
(New) |
Verifying staff qualifications |
No primary source verification of license; lack of compliance with organization's health screening requirements for staff |
EC.02.06.01 |
Safe environment |
Physical plant maintenance problems; cleanliness issues |
CTS.04.03.33 |
Food preparation/storage |
Refrigerator/freezer temps; no labeling of food |
HR.01.06.01 |
Staff competence |
Competence not assessed during orientation; performance evaluations not done; competence assessment doesn't match job description |
CTS.02.01.05
(New) |
Health screenings |
Health screening not done; no triggers; no follow-up |
NPSG.15.01.01 |
Suicide risk assessment |
Assessment doesn't address both specific characteristics of the client and environmental features |
MM.03.01.01 |
Medication storage |
Refrigerator temperatures; expired meds |
EC.02.01.05
(New) |
Foster home safety |
Lack of smoke detectors; egress from sleeping room insufficient |
Continuous Readiness Tip: If you haven't already done so, be sure to incorporate these issues into your internal tracer program. They will continue to be a focus for surveyors during upcoming 2013 surveys.