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 www.laureate.com .
 

 

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 www.memorialhermann.org/specialtyfacilities/preventionandrecoverycenter/

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?

 

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: 

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.