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Joint Commission Behavioral Health Update

May 2012       
In This Issue
New Client Welcome!
Congratulations Corner
TJC BH Manual Identifies Standards Applicable to Adoption Services
Psychiatric Hospitals: Scrutinize your Medical Staff Bylaws!
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

We hope that spring has reached your region of the country and that the sunny days of summer are not far behind!


This month we are providing information on the standards in the Behavioral Health manual that TJC recently identified as being applicable to organizations that provide adoption services. We are also providing an update on how the content of medical staff bylaws is being surveyed in psychiatric hospitals. 


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 Compass Health whose home office is located in Crowley, Louisiana. Compass Health operates psychiatric facilities throughout Louisiana including Distinct-Part Psychiatric Units, Free-standing Psychiatric Hospitals and Outpatient Clinics. We are pleased to be working with Compass Health on Joint Commission accreditation for its newly constructed psychiatric hospital Compass Behavioral Center of Houma.

CongratulationsCongratulations Corner


Congratulations to our client Southwest Connecticut Mental Health System in Bridgeport, CT who successfully completed their extension survey under the Joint Commission Hospital Accreditation Program this month! SWCMHS has been accredited under the Behavioral Health standards for many years but was recently advised by CMS that some of their services required accreditation under the Hospital standards. With a very tight deadline, the SWCMHS team tackled the new standards, make the needed changes, and achieved a highly successful outcome on their hospital survey! Congratulations to SWCMHS on their outstanding success!


TJC BH Manual Identifies Standards Applicable to Adoption Services


In response to behavioral health organizations that provide adoption services, TJC has identified specific standards in the 2012 Behavioral Health Manual that are applicable to adoption services. For many years, the Behavioral Health Manual has had standards for foster care services. Some organizations providing foster care services also provide adoption services that focus on the legal adoption component as well as pre and post adoption services for the child and family. TJC includes these adoption services within the scope of its on-site survey and within the scope of the organization's accreditation award.


Specifically, TJC has identified standards in the following chapters that are applicable to adoption services:

  • Accreditation Participation Requirements
  • Care, Treatment, and Services
  • Environment of Care
  • Infection Prevention and Control
  • Information Management
  • Leadership
  • Record of Care
  • Rights and Responsibilities of the Individual


The official communication from TJC on this topic is included in the March 2012 Update to the 2012 Behavioral Health Accreditation Manual which was recently mailed to all accredited organizations. Page 8 of the Update indicates that the Standards Applicability Grid has been revised to identify which standards apply to adoption services. The E-dition (electronic version of the standards available to accredited organizations) has also been updated to include this information.


If you have questions regarding how these standards may apply to your organization, contact the following individuals at TJC:

  • For accredited organizations: Merlin Wessels, LCSW, Associate Director - Standards Interpretation Group,
  • For organizations not yet accredited: Peggy Lavin, LCSW, Senior Associate Director - Behavioral Health Care Accreditation Program,

Psychiatric Hospitals: Scrutinize your Medical Staff Bylaws!


Background: In March 2011, TJC revised standard MS.01.01.01 regarding the specific content required to be included in the hospital's medical staff bylaws. This content is spelled out in Elements of Performance 12 through 36. Each of the requirements listed in these elements of performance must be included in the medical staff bylaws themselves, not in the medical staff rules/regulations or policies.


During recent surveys of our psychiatric hospital clients, the content of the bylaws has been more closely scrutinized than ever. Physician surveyors have been carefully reviewing the medical staff bylaws to confirm that all of the elements listed in EP 12 - 36 are contained in those bylaws.


The element of performance that has received the most scrutiny and caused the most RFIs is EP # 16 regarding the requirements for competing and documenting the medical history and physical exam (H&P).  Several hospitals have received RFIs for not having the requirements for H&Ps in their medical staff bylaws. Often, the issue is that the hospital has the H&P requirements contained in their medical staff rules/regulations and has not moved this wording into their medical staff bylaws.


To ensure compliance, we recommend that you take the following steps:

  • First, closely review your medical staff bylaws to ensure that all of the requirements listed in EPs 12 - 36 are contained in the bylaws. To assist with this review, we are providing a handy Medical Staff Bylaws Checklist.
  • Second, review the wording in your bylaws that addresses EP # 16 (requirements for H&Ps) and make sure that it contains specific wording regarding when and by whom H&Ps are to be done. The following is some sample wording from a psychiatric hospital:  

"A medical history and physical examination must be completed and documented for each patient within 24 hours after admission. The medical history and physical examination must be completed and documented by a qualified licensed physician in accordance with State and federal law, as well as these Bylaws and the Medical Staff Rules and Regulations.  

Whenever a medical history and physical examination has been completed within 30 days prior to admission, an updated examination of the patient, including any changes in the patient's condition, must be completed and documented within 24 hours after admission. The updated examination, including any changes in the patient's condition, must be completed and documented by a qualified licensed physician as described above. Additional requirements for completing a medical history and physical examination are set forth in the Medical Staff Rules and Regulations, Section A III."


So, save yourself a needless RFI by "crossing the t's and dotting the i's" in your medical staff bylaws to make sure they're compliant!
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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.