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Joint Commission Behavioral Health Update

April 2011       
In This Issue
New Client Welcome!
Update on TJC's Deemed Status for Psychiatric Hospitals
Feedback from Surveys: 1st Quarter 2011
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

We hope that the first quarter of 2011 has been a productive one for you! Several of our clients had their triennial surveys this quarter. In the spirit of keeping you informed on survey trends, we have summarized the "high scrutiny areas" from these surveys in this month's newsletter. Please know that if you are interested in more detail on a particular topic covered in this article, you can contact me and I will be glad to discuss it with you.


We are also providing an update on The Joint Commission's new deemed status for the special conditions of participation for psychiatric hospitals. Essentially, TJC and CMS are still working on the details of how the new survey process will be implemented. 


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 two new clients:

  • McCallum Place in St. Louis, Missouri  is a comprehensive eating disorder treatment center. It provides residential, transitional living, PHP, IOP and outpatient services.
  • Vista Health in Fayetteville, Arkansas is a psychiatric health care system providing inpatient, PHP, IOP and outpatient services to children, adolescents, and adults.

MegaphoneMegaphone Update on TJC's Deemed Status for Psychiatric Hospitals


As reported in our March newsletter, The Joint Commission has been granted deeming authority by CMS for the special conditions of participation (CoPs) that apply to psychiatric hospitals. The latest update is that TJC and CMS will be providing further guidance to the field on how this will be operationalized. It appears that TJC accredited hospitals will not be officially "deemed" until they have been surveyed under the revised standards which incorporate the CMS CoPs. Stay tuned for further information on this topic. 

Assessment - leftFeedback from Surveys: 1st Quarter 2011

Twice a year, we provide our readers with feedback from the recent Joint Commission surveys that our clients have undergone. During the first quarter of 2011, several clients had their triennial surveys. It's clear that there are some high scrutiny areas where surveyors are consistently focusing their attention. The following summary of these areas includes both psychiatric hospitals and behavioral health organizations.


High Scrutiny Areas in 2011


Medical Staff Chapter: Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)


Psychiatric hospitals continue to be cited for lack of compliance with the requirements for FPPE and OPPE. For OPPE, surveyors are looking for evidence of a review at least twice a year of the LIP's performance. They are also looking for use of  practitioner performance data as part of that review. Several hospitals have been cited for their process not being "data driven." For FPPE, surveyors are looking for the criteria that would trigger such a focused evaluation. Some hospitals have not yet defined these triggers and vague definitions for when FPPE will be conducted are no longer acceptable.


Tip: Most psychiatric hospitals have mechanisms for collecting data on physician performance. These typically include peer review, documentation audits, patient satisfaction data, and performance evaluations. These can be packaged to meet many of the requirements for FPPE and OPPE. Be sure that your medical staff rules/regulations or procedures reflect the language of FPPE and OPPE and that medical staff are conversant on this process.

Check out the BoosterPak on this topic available on your Joint Commission Connect extranet site. It has helpful examples, FAQs, and survey process tips.


Leadership Chapter: Contracts


Contracts are getting more scrutiny than ever before under LD.04.03.09.  The focus is on contracts for clinical services. This includes contracts with agencies and contracts with individual practitioners.


Tip: LIPs that provide services on site at the hospital must go through your Medical Staff credentialing and privileging process. (Don't forget that these LIPs will also need to have FPPE and OPPE as discussed above.) For non-hospital based BH organizations, this means putting these practitioners though your process for credentialing and assignment of clinical responsibilities.

For non-LIP contract services (e.g. speech therapy) that are provided either on site or off site, there needs to be a mechanism for monitoring the quality of the contract service. This should include a documented review of the performance expectations included in the contract. Leadership needs to conduct this review at least annually. Contracted staff working on site must receive orientation and an evaluation of their performance. This can be done either by you (the accredited organization) or it can be built into the contract for the contractor to do.


Life Safety and Environment of Care Chapters


In 2011, an extra day has been added to hospital agendas for the Life Safety Code surveyor. With this new agenda, the LSC surveyor now has more time to conduct the building tour. Also, he typically now covers the Environment of Care and Emergency Management interviews instead of the nurse or physician surveyor. As anticipated, this has meant a higher level of scrutiny in these areas and more RFIs. "Our surveyor this year really focused on our emergency management drills much more than in previous surveys," noted one Safety Officer. "He didn't like the fact that we hadn't drilled on an emergency related to a violent intruder since this was one of the top risks identified in our hazard vulnerability analysis. We're now paying more attention to how we conduct and critique our drills." One welcome outcome of the extra day for the LSC surveyor has been that many of them have spent additional time providing consultation to the hospital which was a welcome addition to the survey.


Infection Prevention & Control Chapter


Medical Equipment


For psychiatric hospitals, nurse surveyors have been closely scrutinizing the cleaning of minor medical equipment such as glucometers, blood pressure cuffs and stethoscopes (as per IC.02.02.01.) They expect to see a defined procedure for cleaning these items and they have been observing during tracers to see if staff is following the procedure. Hospitals have been cited for:

  • No cleaning of blood pressure cuff between patients; hospital policy required wiping down cuff between each patient)
  • Stethoscopes used on multiple patients and not cleaned
  • Nursing staff unaware of any procedure for cleaning glucometer

Tip: Be prepared for the nurse surveyor to observe staff taking vital signs during tracers.


Hand Hygiene


In psychiatric hospitals, surveyors are checking to see that staff is following hand hygiene procedures. RFIs have been given for the following:

  • No hand hygiene after contact with the cup that the patient had touched
  • Hand hygiene not done prior to medication administration
  • Hand washing not done for the appropriate amount of time
  • Lack of monitoring data on hand hygiene compliance
  • No goals set for improving hand hygiene compliance; no data available to measure progress

Although not as closely scrutinized as in hospital settings, those BH organizations that administer medications have also had their surveyors asking for data on hand hygiene observations and checking compliance during tracers. "Our surveyor made sure that she did a tracer during the med pass time at our RTC" reported one survey coordinator. "Unfortunately, the direct care staff who is allowed to administer did not follow our hand hygiene protocol. We got an RFI in infection control and are now doing major re-education of the direct care staff."


Provision of Care Chapter (Hospital Standards)

Care, Treatment and Services Chapter (Behavioral Health Standards)


Treatment Planning


The focus on treatment planning continues as strong as ever in both psychiatric hospitals and BH organizations. Issues currently being cited include:

  • Treatment plan updates not reflecting an assessment of the client's progress
  • No updating of the treatment plan following restraint or seclusion
  • "Cookie cutter" treatment plans that are not individualized
  • Identified medical problems not included in the treatment plan
  • Lack of measurable, behavioral objectives

Also, remember that in the 2011 Behavioral Health Standards, there is a new requirement for the treatment plan to include "goals that are expressed in a manner that captures the individual's words or ideas" (CTS.03.01.03 EP2.)


Nutrition Screenings


For programs surveyed under the BH standards, nutrition screening, assessment and follow-up continue to be problem areas. As in previous years, several organizations were cited for not having clear criteria for when a nutritional screening should lead to a nutritional assessment. For others, the problem was that the nutritional screening identified a nutritional problem but there was no evidence of further follow-up, referral, or disposition of this issue.


Tip: Many outpatient BH programs imbed their nutrition screening in their health screening form. However, having a few nutrition related questions in your health screening is not adequate for compliance. Both your health screening form and your policy should clearly outline the criteria for when the nutritional screening should lead to a referral for a full nutritional assessment. If a nutritional issue is identified, include it in the treatment plan until it has been addressed.


Medication Management Chapter


Multi-Dose Vials


Remember, all opened multi-dose vials must be labeled with a 28 day expiration date from the date that the vial is opened. Most hospitals are aware of this requirement and are in compliance. There were a few where some units were not yet on board and were still labeling the vial with only the date on which it had been opened.


Medication Refrigerators in Outpatient Settings


Surveyors are consistently checking to see that the temperature of medication refrigerators is monitored daily, including weekends when your outpatient clinic may be closed. The old "penny in the cup" method is considered inadequate.


Tip: Get one of those electronic monitoring devices for all outpatient medication refrigerators. To see some of these products, click on Tip Temperature Products.

Make sure that staff knows how to program and read the device. As reported by one PI Director: " We had installed those electronic thermometers but the staff weren't adequately trained to use them. No one was setting it on Friday afternoon to give us the read-out on Monday morning."


Review of Closed Records


For almost all surveys this quarter, surveyors reviewed closed records, a practice that had been dropped in previous surveys. In most cases, surveyors were checking to see that the discharge summary had been completed as required and that the patient had been given written discharge instructions including a list of all of their medications (both psychiatric and non-psychiatric) at discharge.


Stay tuned throughout the year and we'll continue to keep you posted on survey issues and trends! 

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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.