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Joint Commission Behavioral Health Update

June 2010     
In This Issue
Welcome to a New Client
Congratulations Corner!
New Requirements for Psychiatric Hospitals
TJC Clarifies 28 Day Expiration Date for Multi-dose Vials
Do We Need Self Closing Doors in our Residential Program?
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

The second quarter of 2010 continued at a busy pace. Several clients underwent their triennial surveys and one achieved initial TJC accreditation. So, it's as important as ever to be on top of survey trends and changes to Joint Commission standards.


 This month we are providing updates on some new requirements and a clarification on a Life Safety issue. Our first article highlights new requirements for psychiatric hospitals. The second article covers TJC's most recent clarification regarding labeling of multi-dose vials.  Lastly, there is information for BH residential programs regarding a frequently asked Life Safety question.

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. 

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Anne Barrins
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Welcome - LeftWelcome to a New Client
Barrins & Associates would like to welcome our new client: Laureate Psychiatric Clinic and Hospital in Tulsa, Oklahoma. Laureate is a Joint Commission accredited freestanding psychiatric hospital and offers a full continuum of mental health and chemical dependency services to children, adolescents, and adults. Services include inpatient, IOP, Outpatient, and a specialized Eating Disorders Program. Laureate Psychiatric Clinic and Hospital is part of the St. Francis Health System. You can learn more about Laureate and its programs at .
BH Standards OnlineCongratulationsCongratulations Corner!
Congratulations to our client Memorial Hermann Prevention and Recovery Center in Houston, Texas who successfully completed their initial Joint Commission survey this month! Memorial Hermann PaRC operates a full continuum of substance abuse services for adults and adolescents including inpatient, residential, IOP, transitional living and outpatient. They are part of the nationally recognized Memorial Hermann Healthcare System which operates 11 hospitals in the greater Houston area. The PaRC has been gearing up for TJC accreditation for the past year and had outstanding success on their initial survey with only two Indirect Impact findings. Congratulations to the PaRC team on achieving the gold standard of Joint Commission accreditation! To learn more about Memorial Hermann PaRC and take a virtual tour of their program, visit their web site at
New Requirements for Psychiatric Hospitals
The Joint Commission has released new requirements (effective immediately) for psychiatric hospitals that use Joint Commission accreditation for deemed status purposes. The reason for the new requirements is to align Joint Commission standards with existing CMS requirements for psychiatric hospitals. Thus, most psychiatric hospitals will already be in compliance with the requirements since they have been part of the CMS Conditions of Participation. However, these specific requirements for psychiatric hospitals have not previously been included in Joint Commission standards and it is anticipated that they will receive increased scrutiny during upcoming surveys. Notable highlights of the new requirements are as follows:
Human Resources Chapter 
  • Director of Psychiatric Nursing: There must be a "Director of Psychiatric Nursing" who is an RN with a master's degree in psychiatric or mental health nursing, or its equivalent.
  • Director of Social Work: There must be a "Director of Social Work" who has a master's degree or equivalent education and experience. 
  Leadership Chapter
  • Staffing: One of the new elements of performance specifically states that the psychiatric hospital must meet the staffing requirements of 42 CFR 482.62.
 Provision of Care Chapter  
  • Psychiatric Evaluation: A psychiatric evaluation must be completed for all patients within 60 hours of admission.
 Record of Care Chapter   

  • Progress Notes: Requirements for progress notes now mirror the CMS requirements. Progress notes by the MD, nurse and social worker are required weekly for the first two months and then at least monthly for the remainder of the patient's stay.
 For the official announcement on these changes, see the article on page 10 of the June 2010 issue of The Joint Commission Perspectives.
Note: These new requirements do not apply to general acute care hospitals with psychiatric units.
Charts - RightTJC Clarifies 28 Day Expiration Date for Multi-dose Vials
The Joint Commission has clarified that (effective immediately) it now requires a 28 day expiration date for multi-dose vials from the date of the opening of the vial. This requirement is based on USP and APIC recommendations. Specifically, in order to be in compliance, the multi-dose vial must be labeled with the expiration date (also known as a "beyond use date") that is 28 days after the date on which the vial was opened.
Since medication storage is one of the most frequently cited areas of non-compliance on surveys, it's important to make sure that your existing medication storage procedures are in compliance with this new requirement. We recommend that you check on the following issues within your organization: 
  • Do you have a written policy/procedure regarding the labeling of multi-dose vials?
  • Does your procedure specify that the vial be labeled with a 28 day expiration date?
  • Have you decided if you will label with both an open date and a 28 day expiration date?  (TJC does not require that the vial be labeled with an open date but if your own policy requires it, they will hold you to that requirement.)
  • Has all nursing staff been trained on the procedure for labeling with a 28 day expiration date?
  • Does your med room inspection process include checking for the 28 day labeling as well as appropriate discarding of any vials after the 28 day expiration date?
To read the clarification, click on multi-dose vials to access the article in the June 9th issue of Joint Commission Online.
                        Do We Need Self Closing Doors in our Residential Program?
EOC - Left 
Several Behavioral Health organizations that run residential programs have asked if TJC requires that doors in these settings be self closing. The Joint Commission has clarified that self closing doors are not required in residential settings if the following life safety features are in place: 
  • The building is two stories or less in height and is equipped with appropriate egress-sized windows 
  • Employees are on duty 24/7.
  • Employees make rounds at least every 30 minutes during sleeping hours.
  • Smoke detectors are placed in every sleeping room and public hallway.
  • If a smoke detector is battery powered, it is tested at least monthly and the batteries are replaced every six months.
  • Fire drills are conducted monthly (one per shift per quarter).
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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.