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Joint Commission Behavioral Health Update

September 2011  
In This Issue
New Client Welcome!
Psychiatric Hospitals: Additional Survey Days for Deemed Status for CMS Special Conditions of Participation
Coming in 2012: Easing of Physical Exam Requirements for Behavioral Health Residential Programs
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

Now that summer vacations are over, most organizations are returning to their routine flow of business, including Joint Commission readiness efforts. To help with this, we are providing updates on two important topics related to Joint Commission standards and survey process.


Our first article provides updated information on TJC's implementation of the survey process for deemed status for the Special Conditions of Participation for psychiatric hospitals.


Our second article discusses a change coming in 2012 related to physical exams in Behavioral Health residential programs.  


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 - Left        

Barrins & Associates welcomes the following new clients: 

Centra Virginia Baptist Hospital in Lynchburg, Virginia provides a full continuum of mental health and chemical dependency services to children, adolescents and adults. 

Marian Center in Salt Lake City, Utah is part of St. Joseph Villa and specializes in inpatient and outpatient psychiatric care for the geriatric population. 

Pathways Treatment Center is part of Kalispell Regional Medical Center and provides inpatient and outpatient psychiatric and substance abuse services to the residents of Northwest Montana.

The Transition House in St. Cloud, Florida provides residential and outpatient substance abuse treatment services to homeless veterans and clients transitioning back to the community from correctional settings.

To learn more about the wide array of behavioral health services provided by these organizations, click on their web sites via the links above.

   Psychiatric Hospitals: Additional Survey Days for Deemed Status for CMS Special Conditions of Participation

As reported in our March 2011 newsletter, The Joint Commission received deeming authority from CMS in February 2011 for the two Special Conditions of Participation for Psychiatric Hospitals. This means that psychiatric hospitals that elect to use TJC accreditation for deemed status will now have the survey of these two Special Conditions incorporated into their Joint Commission survey.


As part of this new process, TJC has added two surveyor days to the agenda of psychiatric hospitals that elect to use accreditation for deemed status. For example, hospitals that previously had a nurse and a physician for three days will now have a nurse and a physician for four days. Small hospitals that typically had one surveyor for three days will now have one surveyor (either a physician or a nurse) for five days. TJC has indicated that the additional time is for the surveyors to fully survey the Special CoPs according to the CMS survey process.


So, what are the implications for your upcoming survey?


As you prepare for surveys under this new process, keep in mind that the TJC surveyors now must do patient observations according to the CMS protocol. This protocol includes the surveyor observing the patient a minimum of two times (preferably three) and documenting the following information: 

  • Date, location, beginning and ending times of observation
  • Number of patients and number of staff present
  • The modality in progress
  • What the patient is doing (regardless of whether or not a scheduled treatment modality is in progress)
  • What the patient is actually scheduled to be doing during the time of the observation
  • If the modality/ intervention is related to the treatment plan goals and objectives
  • Patient's level of participation in the activity
  • Presence of disruptive behavior and staff''s intervention, if any
  • Surveyor's assessment of the following:
    • Was the treatment plan carried out?
    • Were the patient's needs met?
    • Was the activity individualized to meet the patient's needs?
    • Was active treatment provided?
    • Did the patient achieve the desired outcomes?

Our clients who have recently been through the new survey process report that their surveyors spent increased amounts of time out on the units observing patients. There was also added emphasis on interviewing patients about their treatment. In addition, there were more interviews with staff about their role in the patient's treatment and their knowledge of the treatment plan.


Survey Strategy: It will be more important than ever for staff to be able to articulate how their interventions and interactions with the patient relate to that patient's treatment plan. Staff need to understand the patient's treatment goals and how their work relates to those treatment goals. For example, if a staff person is observed conducting a group, he/she needs to be able to discuss how the focus of the group was individualized to meet the needs of that particular patient. As you conduct your internal tracers, be sure to interview staff and incorporate these issues into your reviews.


We will keep you posted on developments in this new TJC survey process as they unfold. For the official announcement from CMS and helpful FAQs click on CMS Approval of Deeming authority of the Joint Commission for Psychiatric Hospitals (May 6, 2011).

   Coming in 2012: Easing of Physical Exam Requirements for Behavioral Health Residential Programs


Effective January 2012, revised requirements for physical exams go into effect for residential programs and group homes surveyed under The Joint Commission's Behavioral Health Standards.


A new standard in the Care, Treatment and Services chapter (CTS.02.01.06) calls for a screening process to determine whether the client is in need of a physical exam. It will replace the current requirement for a physical exam to be completed either within 30 days of admission or within six months prior to admission (CTS.02.01.07 EP 2.)


Background: For many years, the requirement for residential programs was to complete a physical exam within seven days of admission or within 30 days prior to admission. Over the years, concerns were expressed by the field regarding the rigidity of this requirement and the fact that Medicaid pays for only one physical exam per year. In January 2011, The Joint Commission relaxed this standard and issued an interim requirement which changed the timeframe for a physical exam to 30 days from admission or six months prior to admission. Meanwhile, TJC continued to review the issue and gather input from the field.


The new requirement that goes into effect January 2012 reflects a more individualized approach whereby a screening will be used to determine if there is a need for a physical exam for that particular client. This process is similar to the screening process currently required for non-24 hour behavioral health programs.


Note: The new standard does require that the organization determine if the date of the client's most recent physical exam exceeds one year. If the date exceeds one year, a new physical exam is to be performed (CTS.02.01.06 EP 5.)


To view the official announcement, click on Joint Commission Online July 13 issue  (page 2) or see the article in the August 2011 issue of The Joint Commission Perspectives, page 8.

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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.