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Joint Commission Behavioral Health Update

March 2011      
In This Issue
New Client Welcome!
It's Official: TJC Has Deemed Status for Psychiatric Hospitals
Clarification Regarding Announced Surveys for Behavioral Health Organizations
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

It was great to meet and catch up with so many of you at the annual meeting of the National Association for Psychiatric Health Systems in Washington D.C. earlier this month! Many of our clients are members and, for those that are not, we encourage you to check out their web site There's a wealth of information on pertinent topics for behavioral health providers.


In our newsletter this month, we are providing an update on CMS awarding deeming authority to The Joint Commission for psychiatric hospitals. This is good news for accredited psychiatric hospitals that will no longer need to undergo CMS special condition surveys.


We are also providing clarification for behavioral health organizations regarding The Joint Commission's policy on providing notice of the organization's upcoming survey.


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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New Client Welcome!Welcome - Right


Barrins & Associates welcomes a new client: Parkview Behavioral Health Hospital in Fort Wayne, Indiana. Parkview BH, part of Parkview Health System, provides inpatient psychiatric services to children, adolescents and adults as well as chemical dependency and outpatient services. To learn more about Parkview Behavioral Health Hospital, click on their website: Parkview BH Hospital

 It's Official: TJC Has Deemed Status for Psychiatric Hospitals


Effective February 25, 2011, The Joint Commission has been granted deeming authority by CMS for the special conditions of participation (CoPs) that apply to psychiatric hospitals.


TJC previously had deeming authority from CMS for the Hospital Accreditation Program. This meant that hospitals accredited by TJC were deemed to have met Medicare and Medicaid certification requirements. However, TJC did not have 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.


Based on the deeming authority for psychiatric hospitals that CMS has granted to TJC, these special condition surveys will no longer be required for psychiatric hospitals that are Joint Commission accredited.


For the official notice in the Federal Register regarding CMS granting this new deeming authority to TJC, click on Federal Register Notice.


Is there any action we need to take as a TJC accredited psychiatric hospital to take advantage of TJC's new deeming authority for the special CoPs?


Yes. You must notify both TJC and CMS that you wish to use TJC's deeming authority for the special CoPs for psychiatric hospitals.

  1. Contact your assigned account executive at TJC and advise him/her that you wish to use TJC's deeming authority for the special CoPs for your psychiatric hospital.
  2. Contact both your CMS Regional Office and the State Survey Agency with the same message.


Note: The National Association of Psychiatric Health Systems (NAPHS) has been instrumental in working with TJC and CMS on the deeming authority for psychiatric hospitals. Organizations who are members of NAPHS can obtain additional information on this topic through NAPHS (

Chart LClarification Regarding Announced Surveys for Behavioral Health Organizations

Several readers have asked for clarification regarding TJC's policy for providing notice to behavioral healthcare organizations of their upcoming survey. The official TJC policy is as follows:


The Joint Commission gives the following behavioral healthcare organizations seven business days notice before their full (triennial) survey:

  • All community-based, freestanding programs
  • All freestanding organizations with 10 or fewer staff or a total average daily census of less than 100
  • All in-home behavioral health, case management, or Assertive Community Treatment programs, if not part of a hospital
  • All methadone programs, if not part of a hospital

Note: If a behavioral health program is part of a hospital (for example, a hospital based partial hospital program), there is no 7 day notice. CMS requires that hospital surveys be unannounced.


Also, behavioral healthcare organizations undergoing their initial accreditation survey receive a minimum of 30 days notice of their upcoming survey.


If your survey is announced, be sure to take advantage of this notice and do the following preparation. It can make the difference between a smooth or stressful start to your survey!


  • Carefully review the Survey Activity Guide on your TJC extranet site. It has vital information on the survey process and content.
  • Create an internal copy of the survey schedule posted to your TJC extranet site. Include the names of attendees for all meetings and room locations.
  • Do a dress rehearsal of the following meetings/interviews on your survey schedule. Use the Survey Activity Guide for guidance re content:
    • Orientation to the organization (first morning)
    • Data Use Interview
    • Medication Management Interview
    • Competence Assessment Interview
    • EOC Interview
    • IC Interview
  • Share the surveyor' bio with everyone. It's provided with your survey notice.
  • Prepare the documents required for the first morning (as listed in the Survey Activity Guide.) Have them well organized.
  •  Be ready to produce active census lists for all programs on the first morning of the survey.  The tracers may be picked from these lists.
  • Assign key individuals to accompany each surveyor. These individuals should take notes and record all medical record numbers of records reviewed.
  • Keep a list of all staff who meet with the surveyor.  These are the files most likely to be requested by the surveyor for the HR review.
  • Develop a communication system whereby you report to the next program what has transpired in the program that was just visited.
  • Convene your management team at the end of each day. De-brief on the day's events and what to expect the next morning in the briefing. Identify issues that you may be able to fix immediately. (For environmental issues, some organizations make the fix, take a photo and show it to the surveyor the next day.)
  • Consider sending a daily email to all locations updating them on the survey that day. Their program may not be visited and they will be curious.
  • Keep in mind that there is a post-survey process for "clarifying" findings. There is a 10 day window and a well defined process for appealing a finding to demonstrate that you were in compliance with the standard at the time of the survey. Do not hesitate to use it. It can work.

Final Note: Several of our clients report that they have received more than 7 business days notice of their triennial survey. While this may be the case in that particular instance, the official TJC policy is to provide seven days notice. .

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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.