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Joint Commission Behavioral Health Update

July 2010      
In This Issue
New Client Welcome!
New Care, Treatment, and Services Chapter for Behavioral Health
Change to Requirement for History & Physical Exam in BH Residential Programs
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

Although July may bring a more leisurely pace for some organizations, there are changes to The Joint Commission's Behavioral Health Standards that are important to be aware of at this time. So, this month we are providing updates on two changes that are "hot off the presses".


Our first article highlights the new Care, Treatment, and Services chapter just released by TJC. Make sure to review it carefully as it will likely require some changes to your current processes for assessment and service delivery.


Our second article provides information about an "easing up" of the requirement for histories and physicals in behavioral health residential programs.


Be aware that, although these changes are in the Behavioral Health manual, there are many psychiatric hospitals (surveyed under the Hospital manual) that also operate programs surveyed under the Behavioral Health manual. These include, for example, partial hospital programs and residential treatment centers.

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 RNew Client Welcome!
Barrins & Associates would like to welcome our new client Wediko Children's Services which operates programs in Boston, Massachusetts and Windsor, New Hampshire. Wediko operates a residential treatment program, school based services, and a summer program. They recently celebrated their 75th anniversary and will be working toward initial accreditation by The Joint Commission. You can learn more about Wediko Children's Services at
Standards LNew Care, Treatment, and Services Chapter for Behavioral Health
The Joint Commission has revised and renamed the current Provision of Care chapter in the Behavioral Health manual. The new chapter will go into effect January 1, 2011 and will be titled the Care, Treatment, and Services chapter. To view the chapter on the TJC website clik on TJC Care, Treatment, and Services chapter
According to Mary Cesare-Murphy, Ph.D., executive director for Behavioral Health Care Accreditation, "The new Care, Treatment, and Services chapter addresses many of the changes that have occurred in behavioral health care during the past several years." The new chapter aligns the standards with the wide array of programs and services now available in behavioral health care and also emphasizes the concept of recovery throughout the standards.
As you will see from the summary below, some of the changes to the standards will require changes to your assessment, treatment planning, and service delivery processes. In addition, organizations anticipating surveys in 2011 should pay particular attention to the new requirements and revisions to this chapter. Historically, standards in the Provision of Care chapter have been the top most frequently cited standards on Behavioral Health surveys. It is anticipated that this trend will continue with the new Care, Treatment, and Services chapter and that surveyors will be focusing their attention on the new requirements that go into effect in 2011.
Note: The standards in the Behavioral Health manual (including the new Care, Treatment, and Services chapter) apply to the following types of organizations and programs:
  • Freestanding behavioral health organizations
  • Partial Hospital programs with a census of 11 clients or more
  • Intensive Outpatient programs with a census of 11 clients or more
  • Residential treatment programs
  • Opioid addiction treatment programs
  • Foster care organizations/programs
  • Transitional/supportive living programs  
A summary of noteworthy changes in the new Care, Treatment, and Services chapter is as follows:
Physical Holding of Children and Youth
There are eleven new standards (CTS.05.05.01 through CTS.05.05.21) and 53 elements of performance that address the physical holding of a child/youth. By contrast, the current Provision of Care chapter has no standards related to physical holding. The only reference to physical holding is in the introduction to the restraint/seclusion standards which defines physical holding of a child for 30 minutes or less as an exception to the restraint/seclusion standards. 
The new standards for physical holding of children/youth mirror many of the restraint/seclusion standards in that they require the following:
  • Leaders must establish and communicate an organizational philosophy on physical holding.
  • Staffing must be set to minimize circumstances that lead to physical holding.
  • Staff must be trained to minimize the use of physical holding.
  • The initial assessment must include information that would minimize the need for physical holding.
  • Staff must be trained in the safe use of physical holding.
  • A staff member not doing the hold must be assigned to observe the child's physical well-being.
  • The physical hold must be documented in the clinical record.
  • Physical holding must be limited to emergencies with imminent risk of harm to self or others.
  • A debriefing must occur after each episode of physical holding.
  • There must be written policies for physical holding that address all of the requirements listed above.
Assessments RThere is a revised standard addressing the use of time-out (CTS.05.02.01). Instead of the term "time-out", the new standard uses the term "exclusionary time-out." Exclusionary time-out is not defined but this term typically refers to time-out interventions in which the individual is removed from the immediate environment and restricted to another environment.
The revisions emphasize the education of the individual regarding the conditions under which time-out is used. There is also a new element of performance which requires the organization to have written policies and procedures limiting the use of time-out and to implement these policies.
There is a new requirement that the organization's philosophy on the use of restraint/seclusion must be communicated to the individual served (CTS.05.06.01 EP 3).
Psychiatric Advance Directives 
There is a new standard regarding psychiatric advance directives (CTS.01.04.01). It applies to organizations that serve adults with serious mental illness and includes the following requirements:
  • The organization must document whether the adult has a psychiatric advance directive.
  • Upon request, the organization must share with the individual sources of help in formulating a psychiatric advance directive.
  • Treating staff must be made aware of the psychiatric advance directive and how to access it.
There is more latitude in how an organization defines the need for educational, legal and vocational screenings. These screenings are now required to be done "as relevant to the needs preferences, interests, and goals of the individual served." (CTS.02.01.13 - CTS.02.01.17).
What are currently two separate standards for psychosocial assessment and emotional/behavioral assessment have been combined into one standard regarding assessment (CTS.02.02.01). New elements to be included in the assessment include the following:
  • Cultural preferences
  • Current and past trauma
  • Community resources accessed by the individual served
Trauma Assessment
There is a new requirement to identify individuals who have experienced trauma and to educate staff about trauma issues and assessment of trauma. (CTS.02.02.05).
Young Adults
Group Meeting RFor organizations that provide service to young adults, there is a new requirement to assist young adults with their "life transitions" (CTS.06.03.01). This includes providing assistance with:
  • Handling finances
  • Finding employment
  • Completing education
  • Finding housing
  • Receiving health care
  • Engaging in social support
Eating Disorders
There are new standards for eating disorder programs (CTS.02.03.09, CTS.04.02.17). These relate to assessment and ongoing clinical monitoring of individuals in these programs.
There is a new requirement for the organization to "evaluate the outcomes of care provided to the population it serves" (CTS.03.01.09). Note: this is in addition to evaluating the progress of the individual client.
Waiting Lists
There is a new requirement to have (and implement) a written procedure for waiting lists, if the organization has a waiting list. (CTS.01.02.01).
Outdoor/Wilderness Programs
There are new standards for outdoor/wilderness programs (CTS.02.01.07, CTS.04.03.23, CTS.04.03.25). These relate to histories and physicals at admission, staff competency and minimizing risks while providing care in these types of programs.
Animal Assisted Therapy
There is a new standard for organizations that provide animal assisted therapy (CTS.04.03.21). It relates primarily to staff training and safety while using animals in therapy.
Please contact Anne Barrins if you have any questions about how the the new requirements in the Care, Treatment, and Services chapter may affect your organization.
Med Assessment LChange to Requirement for History & Physical Exam in BH Residential Programs
The Joint Commission has made an interim revision to its requirement for histories and physicals in behavioral health residential programs. The current standard (PC.2.30 in the 2010 BH manual) requires that a physical health assessment (including a medical history and physical exam) be completed within one week of admission to a residential program.  (The standard also allows use of a history and physical that has been completed within 30 days prior to admission).

The new Care, Treatment, and Services chapter (effective January 2011) also included the same requirement for residential programs (CTS.02.01.07 EP 2). However, during review of the new chapter, TJC heard many concerns from providers about this 7 day requirement. In response, they have made an interim revision to this requirement. The revised interim requirement will allow for a medical history and physical exam to be completed within 30 days of admission to a residential program. It will also allow programs to use a history and physical that has been completed no more than six months prior to admission to the program. 

The revision is termed "interim" because TJC plans to further research this issue to determine how to shape the requirement in the future, based on best practices in the field. 

To view the official announcement, click on Joint Commission Online June 23 issue.
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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.