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Joint Commission Behavioral Health Update

February 2012       
In This Issue
New Client Welcome!
Congratulations Corner
Survey Tip: Renewed Interest in Eyewash Stations
Refresher on Waived Testing Requirements
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

This month, we are focusing on two topics that have provided some challenges on recent Joint Commission surveys.


Our first article deals with the renewed interest during recent surveys on hazardous cleaning products and the need for eyewash stations. Our second article recaps the requirements for waived testing, another area of renewed focus during recent surveys.


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 12th - 14th. Barrins & Associates is a gold sponsor for the meeting and we invite you to visit us at our booth! For more information on this exciting conference, click on 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 - LeftNew Client Welcome! 


Barrins & Associates welcomes our new client: Veritas Collaborative LLC located in Raleigh, North Carolina. Veritas Collaborative is a specialty behavioral health hospital for adolescents with eating disorders. Veritas has three levels of care for eating disorder treatment: inpatient, acute residential and partial hospitalization and is preparing for initial accreditation by The Joint Commission. 

CongratulationsCongratulations Corner


Congratulations to our client McCallum Place in St. Louis, Missouri who earned initial Joint Commission accreditation this month! McCallum Place is a comprehensive eating disorder treatment center for adolescents and adults that provides residential, partial hospital, intensive outpatient, transitional living and outpatient services. Congratulations to the McCallum Place team on achieving the gold standard of Joint Commission accreditation!

 Survey Tip: Renewed Interest in Eyewash Stations 


During recent TJC surveys, the trip to the janitor's closet has resulted in some unexpected survey findings. Surveyors have been focusing on hazardous products stored in the janitor's closet and the need for protective eyewear and emergency eyewash stations. They have typically pursued the following issues:

  • What types of hazardous products do you have stored?
  • Is protective eyewear available and used by staff handling these products?
  • Do you have eyewash stations available as needed for these hazardous products?
  • Are the eyewash stations operating properly?
  • Are the eyewash stations being inspected on a regular basis?
  • Has staff been trained in the use of the eyewash stations?

The standards covering eyewash stations are set by the American National Standards Institute (ANSI) based on  Occupational Safety and Health Administration (OSHA) regulations. A quick summary of the ANSI Z358.1-2009 requirements is as follows:

  • Eyewash stations must be within 10 seconds walking distance of the hazard.
  • The path to the eyewash station must be clear.
  • There must be a sign indicating "eyewash station."
  • The flushing fluid must be between 60 and 100 degrees F ("tepid").
  • There must be a continuous flow of flushing fluid for 15 minutes.
  • One single motion must activate the unit in one second or less.
  • Valves on the eyewash station must stay open without requiring the use of hands.

How do you know if you need an eyewash station?

OSHA regulations (29 CFR 1910.151(c)) requires eyewash stations if the worker has been exposed to "injurious  corrosive materials." However, ANSI standards recommend that eyewash stations should be installed where "caustic or hazardous" substances are found. TJC uses the ANSI standards as their reference point. So, your best guide is to check your Material Safety Data Sheets (MSDS) for the products you are presently storing. Check to see if the MSDS sheet indicates that a 15 minute eye flushing is needed if the eyes come into contact with the product. If so, this means that, practically speaking, an eyewash station is needed. The key words indicating the need for an eyewash station are "15 minutes of flushing." Containers of bottled eyewash do not provide the continuous 15 minute flush. Thus, they are considered a supplement to the eyewash station, not a substitute for it. Bottled eyewash is for immediate use following exposure to the hazard, after which the individual should proceed to the eyewash station for the 15 minute flushing.


The most frequently cited issues on recent surveys have been the following:

  • No protective eyewear in the janitor's closet
  • Bottled eyewash instead of eyewash stations where there were cleaning products  that required a 15 minute continuous flush
  • Fluid in eyewash stations not at the proper temperature (60 - 100 degrees F)
  • No documentation of weekly maintenance of eyewash stations
  • Staff not familiar with how to use eyewash stations.

Inspection and Maintenance 

If you have eyewash stations, they need to be maintained and inspected as per ANSI standards:

  • All plumbed eyewash stations should be activated weekly and maintained to ensure proper operation.
  • In addition to this weekly maintenance, plumbed eyewash stations should also be inspected according to the manufacturer's instructions for the specific eyewash unit being used. 
  • Self contained eyewash stations should also be maintained and inspected according to the manufacturer's instructions.

So, check out your janitors' closets for hazardous products. If you need eyewash stations, make sure they are properly maintained. Also make sure staff has been trained on use of the MSDS sheets and using the eyewash stations. 


As a resource, we are including a sample Eyewash Station Weekly Maintenance Checklist and Log.

Glucometer 108                Refresher on Waived Testing Requirements

During 2011, some organizations had challenges in the area of waived testing during their surveys. So, this month, we are recapping the TJC requirements for waived testing and answering some frequently asked questions from our clients.


What exactly does "waived testing" mean?


Waived testing is defined by the Clinical Laboratory Improvement Amendments (CLIA) of 1988 as tests which have the following characteristics:

  • Employ methodologies that are so simple and accurate as to render the likelihood of erroneous results negligible
  • Pose no reasonable risk of harm to the patient if the test is performed incorrectly
  • Have been cleared by the FDA for home use.

Thus, these tests are "waived" from certain federal requirements. The most commonly used waived tests in behavioral health settings are glucose testing, urine pregnancy screens, rapid strep screens, and urine drug screens. Any organization that performs waived testing needs a CLIA certificate to do so.


What are the TJC requirements for waived testing?


The TJC standards for waived testing are in the Waived Testing chapter of both the Hospital and Behavioral Health Manuals (WT.01.01.01 -WT.05.01.01.) The standards require the following:


Policies and procedures (WT.01.01.01)

  • Which tests will be used
  • Procedures for each test
  • Need for confirmatory testing (if such testing is required)
  • Instrument maintenance
  • Quality control checks

Note: For each test, the policy should define whether the test is screening or definitive. A test is considered definitive when a clinical treatment decision or diagnosis is made based on the result. For example, glucose checks done to adjust sliding scale insulin would be considered definitive. A test is considered screening when additional information from testing is required to make a treatment decision or diagnosis. For example, a rapid strep test done but followed up with cultures prior to determining whether to administer antibiotics would be considered screening. If a test is considered screening, the specific criteria for confirmatory testing should be included in the policy/procedure.


Staff Competency (WT.03.01.01)

  • Staff must be trained in each waived test they perform; documentation required.
  • Competency for each test must be assessed at orientation and annually; documentation required.
  • Competency must be assessed using two of the following methods:
    • Performance of a test on a blind specimen
    • Periodic observation of work by supervisor
    •  Monitoring of each user's quality control performance
    •  Written test

 Quality Control Checks (WT.04.01.01)

  • For instrument-based waived testing, quality control checks must be performed on the instrument each day it us used for patient testing. (Quality control checks are not required on days when the instrument is not used for patient testing.)
  • For instrument-based waived testing, quality control checks must include two levels of control, if commercially available.


  • Tests approved by the FDA for home use only should not be used for professional purposes. For example, glucose meters cleared for home use should not be used in a hospital setting by nursing staff unless they are being used for patient education only.
  • For glucometers, both the container of glucose test strips and the control solution should be labeled with the date of opening. Once opened, the test strips within that container and the control solution should not be used beyond the timeframe that the manufacturer recommends (typically 90 days.)

What types of RFIs do organizations get for waived testing?


The most commonly cited issues on survey are the following:

  • Quality control checks using only one level of control.
  • Containers of glucose test strips not dated when opened.
  • Test strips used beyond 90 days after container was opened.
  • No confirmatory testing in the policy for glucose testing.
  • Only one method (instead of two) used to evaluate staff competency
  • No written policies/procedures for waived testing 

Do the Waived Testing standards apply when patients/clients are using their own glucometers?


No, the Waived Testing standards only apply when organization staff is administering the waived test. However, if patients/clients are conducting their own waived testing, it is critical to assess that they are competent to do so and that the instrument they are using is operating properly.


For a current list of CLIA approved waived tests click on CLIA Waived Tests List.

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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.