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Everything your healthcare organization needs to confidently maintain accreditation compliance.
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Simplify & automate policy access, review and approval across your organization
Web-based library of more than 18,000 customizable policy documents
Instantly access up-to-date policies, procedures & forms authored by MCN experts
Automated regulatory notification system of daily email or mobile alerts
Keep current with regulatory changes from more than a dozen federal regulatory bodies, including TJC & NIAHO
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Helpful MCN Healthcare Resources
In order to meet the requirements of the Joint Commission's (TJC) Disease Specific Care Advanced Certification in Heart Failure (ACHF), which was introduced in 2013, organizations must collect data for six mandatory inpatient measures as well as the two existing heart failure (HF) core measures.
In addition, TJC has seven outpatient measures that are designed to help organizations provide care for HF patients when they transition from inpatient to outpatient care. The seven outpatient measures are optional but TJC strongly encourages organizations to collect data on them if it is available.
The Joint Commission has posted ACHF performance measure implementation guides and the HF core measures on their website.Follow the link below for more information.
The Joint Commission (TJC) has issued new and revised several elements of performance for psychiatric hospitals in order to align them with Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs). The new Element of Performance (EP) as well as revisions to several EPs are effective February 1, 2015.
The revisions are applicable to psychiatric hospitals that use Joint Commission accreditation for deemed status purposes. A summary of the revisions is as follows:
- A psychiatric hospital must ensure that if medical and surgical diagnostic and treatment services are not available within the hospital that there is an agreement with an outside source for these services and that the services are immediately available or an agreement needs to be established for transferring patients to a general hospital that participates in the Medicare program.
- There is a therapeutic activities program that is appropriate to the needs and interests of patients and is directed toward restoring and maintaining optimal levels of physical and psychosocial functioning.
- The assessment for patients who receive treatment for emotional and behavioral disorders includes, among other criteria, the onset of the patient's illness and circumstances leading to admission and an inventory of the patient's strengths and disabilities (such as psychiatric, biopsychosocial problems requiring treatment/intervention) written in a descriptive manner on which to base a treatment plan.
- Based on the patient's age and needs, the assessment for patients who receive treatment for emotional and behavioral disorders includes, among other criteria, a social history and reports of interviews with patients, family members, and others and, when indicated, a complete neurological examination at the time of the admission physical examination.
- The written care plan includes:
- A substantiated diagnosis (The substantiated diagnosis is the diagnosis identified by the treatment team to be the primary focus upon which treatment planning will be based. It evolves from the synthesis of data from various disciplines. The substantiated diagnosis may be the same as the initial diagnosis or it may differ, based on new information and assessment.)
- Documentation to justify the diagnosis and the treatment and rehabilitation activities carried out.
- Documentation that demonstrates all active therapeutic efforts are included.
- The diagnosis includes inter-current diseases (diseases that occur during the course of another disease; for example, a patient with AIDS may develop an inter-current bout of pneumonia) and the psychiatric diagnoses.
- Progress notes include recommendations for revisions in the plan of care as indicated, as well as a precise assessment of the patient's progress in accordance with the original or revised plan of care.
- All patients discharged need to have a discharge summary.
The Joint Commission recently announced that they have updated some categories and definitions in their 2015 Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC) glossary.
The changes are as follows:
- Under the category "Community-based home(s)" there is a new definition:
- "Three or fewer individuals living in community-based housing arranged as a required component of care, treatment or services provided by the organization. Housing may include apartments, condominiums, townhouses, and group homes owned, rented or leased by the organization with three or fewer residents in each living unit. They may be staffed up to 24 hours a day, seven days a week, or not staffed."
- Under the category "Foster care, adult" there is a revised definition:
- "A living arrangement where an adult resides as a means of providing protection, shelter and care. These living arrangements are in private, single residences. This living arrangement may require licensure by state authority."
- Under the category "In-home services" there is a revised definition:
- "In-home behavioral health care services many include individual and family counseling, mobile crises evaluation, parent training, early intervention, support, or in-home respite services provided to the primary caretaker(s)."
Featured Policy Library Manuals
MCN's NEW Ambulatory Surgical Center/Outpatient Surgery Department Policy and Procedure Manual is cross referenced to TJC standards, AAAHC standards and CMS regulations. Policies and procedures meet AORN and CDC recommendations and guidelines. This comprehensive reference guide has over 290 policies and procedures that are ready to customize to your organization. See also the Administrative Manual for Ambulatory Care Facilities and the Ambulatory Services EOC Manual.Read more »
MCN's Central Service Policy and Procedure Manual provides over 200 proven, up-to-date policies and procedures in a ready-to-customize format. This manual is cross referenced to federal regulations, as well as Joint Commission and NIAHO standards. References used include AAMI Recommended Practices, IAHCSMM Central Service Technical Manual, ASHCSP Training Manual for Health Care Central Service Technicians and AORN Recommended Practices.Read more »
MCN's Post Anesthesia Care Policy and Procedure Manual is a comprehensive resource that covers the latest "hot topic" regulatory and patient safety issues that are relevant to PACU! This manual includes administrative, operational, functional and patient-centered policies and procedures. Policies and procedures are cross-referenced to CMS regulations, Joint Commission standards and NIAHO standards.Read more »