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Joint Commission Behavioral Health Update

November 2011   
In This Issue
New Client Welcome!
Change to BH Health Screening Requirements Effective January 2012
Psychiatric Hospitals: Do You Have All the Documents You Need for Your Survey?
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

It was a pleasure to see so many of you at the 2012 TJC Behavioral Health Care Conference this month in Chicago! The conference was full of the latest information and updates for behavioral health organizations.


If you weren't able to attend the conference and want an in-depth review of the topics covered, we offer a customized Power Point session that we can arrange for your team. Just contact me and I can provide information regarding cost and scheduling.


In this month's issue, we are providing information on important new requirements related to health screenings in non-24 hour behavioral health settings. This topic was covered in depth at the conference.


Our second article shares information on new documents that are being requested by surveyors during surveys of psychiatric hospitals. Be sure to check out the list if you expect to be surveyed soon!


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. 

Best Wishes for a Happy Holiday Season and we look forward to working with you in the New Year!

Anne Barrins                                     


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Welcome - LeftNew Client Welcome!


Barrins & Associates welcomes our new client: Stars Behavioral Health Group with headquarters in Oakland, California. Stars BH Group operates an extensive continuum of residential and community based mental health programs serving children, adolescents, adults and families. Their programs are located in both northern and southern California.

Change to BH Health Screening Requirements Effective January 2012Med Assessment R


Does your organization operate a non-24 hour program surveyed under the Joint Commission's Behavioral Health standards? If so, there are some important new requirements for the health screening process that go into effect January 1, 2012. These new requirements will most likely require changes to your existing process for conducting health screenings in your non-24 hour settings. The following is a summary of the 2012 requirements with notes regarding changes from the 2011 standards:


2012 Care, Treatment, and Services Chapter


CTS.02.01.05: "The organization implements a written process requiring a physical health screening to determine the individual's need for a medical history and physical examination."

Change from 2011? Minor wording change; intent the same.


EP 1 requires a written physical health screening process to determine the need for a history and physical (H&P). The health screening process must include, at a minimum:

  • Data to be collected
  • Time frame for completion
  • Screening triggers

Change from 2011? The requirements are essentially the same as 2011 but the terminology "screening triggers that indicate the need for a medical history and physical examination" is new and a bit more specific. It replaces the previous wording "decision criteria for determining the need for a physical examination."


EP 2 requires that a qualified practitioner be involved in indentifying the data to be collected and developing the health screening process.

Change from 2011? The requirement is similar but the 2012 wording of "practitioner qualified by the scope of his or her license" broadens the type of professional who can be involved in developing the health screening. The 2011 wording was "a qualified licensed independent practitioner" which was a narrower definition.


EP 3 (NEW) requires the organization to determine whether the date of the individual's most recent physical exam exceeds one year. If the date exceeds one year, an H&P is to be performed.

Change from 2011? Yes. This is a new requirement not included in the previous standard. It essentially requires the organization to take the following three steps:

  • Include as one of the screening triggers for your health screening "individual's most recent physical exam exceeds one year."
  • Determine the date of each individual's last physical exam when conducting the health screening.
  • If the date of the last physical exam exceeds one year, "a medical history and physical examination is performed."

There are two important points that are included with this element of performance:

  1. Securing the individual's agreement to obtain a physical exam may be undertaken as a "process" and may be incorporated into the treatment plan.
  2. If performing a physical exam is not within the organization's scope of service, it may refer the individual to another organization.

In addition, the following points were clarified by TJC at the BH Conference this month:

  • This standard does not apply to organizations that provide physical exams to all clients based on their own policy and/or applicable law and regulation. (Essentially, performing a physical exam supersedes the requirement for conducting a health screening.)
  • A medical professional does not need to review the health screening. The determination of whether the individual needs to have an H&P can be made based on the screening triggers that have been established.
  • If the individual refuses to have a physical exam done (despite the recommendation of the organization), this should be documented in the record.

We recommend that, as part of your continuous readiness program, you review these new requirements and determine if you need to make changes to your existing process for conducting health screenings in your non-24 hour settings. Compliance with these new requirements is sure to be high on the radar screen for surveys coming up in 2012!

Psychiatric Hospitals: Do You Have All the Documents You Need for Your Survey?


As our psychiatric hospital clients have undergone their Joint Commission surveys this year, we have noted several items requested by surveyors that are not on the official Documents List provided in the TJC Survey Activity Guide (available on your extranet site.) Our observation is that some of the new documents requested relate to areas being more closely scrutinized as part of TJC's alignment of its standards with the CMS Conditions of Participation. The following is a list of items that have been requested which are not listed as required documents in the official TJC Survey Activity Guide:


  • Critical test results policy
  • Critical test results performance data for past 12 months
  • Pain assessment and reassessment policy
  • Suicide screening and assessment policy
  • Fall precautions policy
  • Autopsy policy
  • Compliant/grievance policy
  • Food Service Director job description and HR file
  • Head Dietician job description and HR file
  • Medical staff bylaws, rules, regs
  • Medical Executive Committee minutes for past 12 months
  • Description of OPPE/FPPE process
  • List of contracts for patient care services

Be sure to have this information organized and ready to hand over to your survey team just in case they request it. In regard to policies, make sure that you are in compliance with the requirements of your own hospital policy. As you know, if the requirements of your hospital policy are more stringent than the TJC standards, you will be surveyed against your own hospital policies! 

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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.