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Joint Commission Behavioral Health Update

April 2012      
In This Issue
New Client Welcome!
Update on TJC's "Integrated Survey Process" for Psychiatric Hospitals
Behavioral Health Organizations/Programs: Does your Health Screening Process Meet the New 2012 Requirements?
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

We hope that Spring has reached all of our readers by this time and that you have had a productive first quarter! 


Over the past few months, several of our psychiatric hospital clients have undergone their triennial TJC surveys that incorporated CMS deemed status for the two Special CoPs for psychiatric hospitals. Our first article provides an update on key features of that new survey process.  


Our second article reviews the new 2012 requirements for health screenings in non-24 hour programs surveyed under the Behavioral Health standards. If those standards are applicable to you, make sure your health screening process meets the new requirements. 


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 San Diego Center for Children with headquarters in San Diego, California. The San Diego Center for Children provides a wide array of mental health and academic services including day treatment, outpatient counseling, a K-12th grade school program, residential treatment and foster care. The organization has been in operation since 1887 and is celebrating its 125th anniversary this year!

Update on TJC's "Integrated Survey Process" for Psychiatric Hospitals


Background: In February 2011, TJC was awarded deeming authority by CMS for the two Special Conditions of Participation for Psychiatric Hospitals. These two Special CoPs are also known as the B Tags. As a result, psychiatric hospitals that elect to use TJC accreditation for deemed status now have the survey of these two Special Conditions incorporated into their Joint Commission survey and are no longer required to have these two Special CoPs surveyed by CMS.


Over the past year, several of our hospital clients have undergone this new survey process which TJC calls the "integrated survey process" for psychiatric hospitals. So, what's the difference between the new survey process and the previous one? The following are some of the key changes you should be prepared for if you will be undergoing an integrated survey this year:


  • Longer Surveys:The length of these surveys has typically been increased by two "surveyor days."  For example, if your previous survey complement was a physician and a nurse for three days, it is typically now a physician and a nurse for 4 days. We have also seen several surveys that were one physician for five days. Note:  This does not include the Life Safety Code surveyor who is now assigned for a minimum of two days. Some of the smaller psychiatric hospitals have voiced concern about the length of the survey being unnecessarily long for their size and volume. Word is that as TJC perfects the new integrated survey process, the length of surveys may be cut back a bit.



  • Closed Record Review: Closed records (typically 5 - 10) are once again being reviewed to assess compliance with discharge planning requirements. These requirements include providing discharge instructions, educating patients about their medications and completing discharge summaries. See our March 2012 newsletter for an in-depth description of this focus on discharge planning.


  • Updated Surveyor Instructions: TJC has provided its surveyors with specific instructions for conducting tracers for the integrated survey process. These are included in the SURVEYOR Activity Guide available only to surveyors. The instructions focus on the following key areas:
    • How to observe and evaluate treatment planning on the units
    • How to conduct staff and patient interviews
    • How to evaluate the adequacy of nursing staffing and physician coverage
    • How to evaluate discharge planning

Surveyors have also been provided the following guidelines for the number of tracers they are to conduct based on the hospital's census.


Number of Patients

Number of Tracers

Up to 100

8 - 10

100 - 250

10 - 12

250 - 400

13 - 15

401 - 500

16 - 18

> 500

18 - 20



Stay tuned and we will keep you posted as more of our clients go through this new integrated survey process this year.


Behavioral Health Organizations/Programs: Does your Health Screening Process Meet the New 2012 Requirements?


Does your organization operate a non-24 hour program that is surveyed under TJC's Behavioral Health Standards? This includes programs such as PHPs, IOPs, and outpatient methadone maintenance programs. If so, you should have updated your health screening process to comply with the new requirements that went into effect January 1, 2012.


The relevant standard is CTS.02.01.05 in the Care, Treatment and Services chapter of the 2012 Behavioral Health Manual. Element of Performance # 3 is new for 2012. It requires the organization to determine whether the date of the client's most recent physical exam exceeds one year. If the date exceeds one year, an H&P is to be performed.


This is a new requirement that was not included in the 2011 standard. It essentially requires the organization to take the following three steps:

  1. Include as one of the screening triggers for your health screening "client's physical exam exceeds one year."
  2. Determine the date of the client's last physical exam when conducting his/her health screening.
  3. If the date of the last physical exam exceeds one year, "a medical history and physical examination is performed."

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

  • Securing the client's agreement to obtain a physical exam may be undertaken as a "process" and may be incorporated into the treatment plan.
  • 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 their annual Behavioral Health Conference in November 2011:

  • 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 client needs to have an H&P can be made based on the screening triggers that have been established.
  • If the client refuses to have a physical exam done (despite the recommendation of the organization), this should be documented in the record.

So, if this standard is applicable to you, be sure to review your health screening process to ensure it's compliant with the new 2012 requirements.

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Barrins & Associates provides Joint Commission and CMS 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.