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Joint Commission Behavioral Health Update

February 2011      
In This Issue
Welcome to Our New Clients!
Congratulations Corner!
The Joint Commission Seeks Deemed Status for Psychiatric Hospitals
Check out TJC's Leading Practice Library
New 2011 Survey Activity Guide
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

This month, we are providing information on a new CMS related development for psychiatric hospitals as well as some valuable resources for all behavioral healthcare providers.


Our first article discusses The Joint Commission's application for deemed status for psychiatric hospitals which, if approved, will be a significant change for the industry. Our second article provides information on TJC's new Leading Practice Library; a great resource for all accredited organizations. Our third article is a reminder about the new 2011 Survey Activity Guide, an important tool if you will be surveyed in 2011.


We hope to see many of you at the annual meeting of the National Association for Psychiatric Health Systems in Washington D.C. on March 7th-9th.  Barrins & Associates is a gold sponsor for the meeting and we invite you to visit us at our booth! For more information, see the NAPHS web site


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. 



Anne Barrins
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Welcome to Our New Clients!Welcome - Right


Barrins & Associates welcomes two new clients:

  • Highland Ridge Hospital in Midvale, Utah provides mental health and substance abuse treatment including inpatient, partial hospital and intensive outpatient services. The hospital is a facility of Pioneer Behavioral Health.
  • Sundance Hospital in Arlington, Texas is a new 56 bed psychiatric hospital. It provides inpatient mental health and substance abuse treatment to children, adolescents, and adults and is part of Sundance Healthcare System.

CongratulationsCongratulations Corner!


Congratulations to our client Hopes of Honorable Youth in Atlanta, Georgia who successfully completed their initial Joint Commission survey in January. Hopes of Honorable Youth is a small organization that provides in-home behavioral health services to at-risk children and their families. Despite their size, the leadership decided that Joint Commission accreditation was the one they wanted and they worked diligently over the past year to achieve compliance with the standards. They were especially pleased when the surveyor accompanied them on home visits to their families. Congratulations to Hopes of Honorable Youth on achieving the gold standard of Joint Commission accreditation!

The Joint Commission Seeks Deemed Status for Psychiatric Hospitals


TJC has applied to CMS for deeming authority for the special conditions of participation (CoPs) that apply to psychiatric hospitals. TJC submitted the application to CMS in September 2010 and a decision by CMS is anticipated by March 2011.


TJC currently has deeming authority from CMS for the Hospital Accreditation Program. This means that hospitals accredited by TJC are deemed to have met Medicare and Medicaid certification requirements. However, TJC has not had deeming authority for the CMS special CoPs for psychiatric hospitals. These relate to special requirements for Medical Records (482.61) and Staffing (482.62.) Thus, Joint Commission accredited psychiatric hospitals were still subject to CMS surveys for these special CoPs in addition to their triennial Joint Commission survey.


If the deemed status for psychiatric hospitals is approved by CMS, these special condition surveys will no longer be required for psychiatric hospitals that are Joint Commission accredited.


As part of its application process to CMS, TJC has added specific requirements for psychiatric hospitals to its Hospital Standards in order to align them more closely with the special CoPs for psychiatric hospitals. The first set of new requirements came out in June 2010 and related to staffing, psychiatric evaluations and progress notes. For more information, access our our June 2010 newsletter at our Newsletter Archive.  


Additional new requirements go into effect for psychiatric hospitals on February 1, 2011.  These include the following:


Provision of Care chapter:

PC.01.02.13 EPs 2 and 6 related to assessment and evaluation requirements

PC.01.03.01 EPs 5 and 43 related to treatment plan requirements


Leadership chapter:

LD.04.01.05 EP 10 related to the role of the Director of Social Work Services


Click on Feb 2011 Standards Revisions to view these TJC Standards Revisions effective 2/1/11.


TJC has completed pilot surveys for the special CoPs. The final step in the approval process is for CMS to observe an actual TJC survey of a psychiatric hospital to determine if the survey covers all of the requirements of the special CoPs for psychiatric hospitals.


For the article announcing TJC's application for deemed status for psychiatric hospitals, see the January 2011 issue of TJC Perspectives page 17.

Check out TJC's Leading Practice Library


If you are a Joint Commission accredited organization, there's a valuable new resource available on your Joint Commission Connect extranet site. It's called the Leading Practice Library. It contains articles, tools, and sample policies on a variety of topics related to Joint Commission standards. The resources in the Leading Practice Library have been gathered by Joint Commission surveyors or submitted by accredited organizations. All have been reviewed and accepted by TJC.


There are a variety of topics useful for psychiatric hospitals and behavioral health organizations including suicide risk assessment tools and an environmental safety risk assessment tool for BH settings.


To access the Leading Practice Library, log onto your Joint Commission Connect extranet site.  Scroll down to Quality Improvement Tools and click on Leading Practice Library.


MegaphoneNew 2011 Survey Activity Guide


The new 2011 Survey Activity Guide was released by TJC in January. If your organization will be surveyed in 2011, this SAG is a very valuable resource for you. It's a step by step guide to what will be covered during your survey and contains the following important information:

  • The list of documents that you need to have ready on the first morning of your survey
  • Descriptions of each of the interviews on your survey schedule, typical topics for the interviews and recommended participants

The SAG can be accessed via your organization's Joint Commission Connect extranet site. Also, be aware that TJC has returned to the practice of posting a template agenda for your survey. They had discontinued this practice but have now reinstituted it based on feedback from accredited organizations. The template agenda is also posted on your Joint Commission Connect extranet site and is typically posted once your application for survey has been reviewed and approved by TJC.

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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.