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Joint Commission Behavioral Health Update

June 2012        
In This Issue
New Client Welcome!
Congratulations Corner
CMS Eases Verbal Order and Nursing Care Plan Requirements for Hospitals
New Prevention and Wellness Promotion Standards for Behavioral Healthcare
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

Now that summer has come to all parts of the country, we trust that many of you are planning some well deserved vacation time. To support your survey readiness efforts even during this more leisurely season, we are providing information on two topics of interest.


Our first article provides information on some of the key changes in the CMS Final Rule that affect psychiatric hospitals. Our second article previews the new Behavioral Health Prevention and Wellness Promotion standards that go into effect in 2013.


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 Novus Medical Detox Center located in New Port Richey, Florida. Novus Medical Detox Center provides medically monitored drug detoxification services in a residential setting with an emphasis on individually tailored detox programs for each patient. We are pleased to be working with Novus Medical Detox Center on achieving initial Joint Commission accreditation.

CongratulationsCongratulations Corner


Congratulations to our client The Transition House in Saint Cloud, Florida who successfully completed their initial Joint Commission survey in May. The Transition House provides transitional housing and substance abuse services to veterans as well as a transition/work release program for Florida Dept. of Corrections inmates.  Congratulations to The Transition House team on their highly successful survey!

 CMS Eases Verbal Order and Nursing Care Plan Requirements for Hospitals 


Good News! CMS has eased some of its longstanding requirements for hospitals, including psychiatric hospitals. The agency has released a Final Rule which revises some of the Medicare Conditions of Participation (CoPs) for Medical Record Services (42 CFR Section 482.24) and Nursing Services (42 CFR Section 482.23). The Final Rule implements President Obama's executive order to reduce regulatory burdens on hospitals. It was published in the May 16, 2012 Federal Register and will be effective on or about July 16, 2012. Here's a summary of the key changes related to authentication of verbal orders and nursing care plans:


Verbal Orders


48 Hour Timeframe


Current Requirement: Under the current CoP, verbal orders must be dated, timed and authenticated by the ordering practitioner within the timeframe specified by state law or, if state law is silent, within 48 hours. (The related Joint Commission standard in the Hospital Manual is RC.02.03.07 Element of Performance # 4.)


Revised Requirement: Under the Final Rule, CMS has eliminated the 48 hour requirement and, instead, defers to state law or hospital policy to define the timeframe for authentication of verbal orders.


Authentication by Another Practitioner


Current Requirement: Under the current CoP, a verbal order can be authenticated by "another practitioner responsible for the patient's care and authorized by hospital policy to write orders." However, this provision was temporary and expired on January 26, 2012.


Revised Requirement: Under the Final Rule, CMS has made permanent the provision for another practitioner to authenticate orders. Similar to the current CoP, the authenticating practitioner must be "another practitioner responsible for the patient's care and authorized by hospital policy to write orders."


Recommendation:In light of this change to the requirements for verbal orders, we recommend the following actions:

  • Review your state regulations and current policies regarding authentication of verbal orders.
  • Determine if (based on your state's regulations) you can take advantage of CMS's elimination of the 48 hour requirement and if you wish to do so.
  • If so, revise your policies accordingly as well as any related medical record review processes.

Remember: TJC will survey you according to your own policy if it is stricter than the TJC standard.


Nursing Care Plans


Under the Final Rule, CMS has legitimized the use of an interdisciplinary plan of care that incorporates the nursing plan of care. Many psychiatric hospitals have been using this approach for several years and have not encountered any issues on CMS surveys. However, some hospitals had held onto the separate nursing care plan to meet the strict interpretation of the CMS CoP. With the Final Rule, CMS has made it clear that hospitals are free to incorporate the nursing care plan into the interdisciplinary treatment plan.

  New Prevention and Wellness Promotion Standards for Behavioral Healthcare
A growing number of behavioral health organizations provide prevention and wellness services in their communities. These types of services may include, for example, education, screening, and community outreach. In response to this trend, The Joint Commission has developed standards for community based prevention and wellness promotion services. The standards will be in the Care, Treatment and Services chapter of the Behavioral Health manual and will be effective January 1, 2013. A summary of the key requirements is as follows:


CTS.07.01.01 Planning for prevention and wellness promotion services


  • Written plan for these services
  • Community input regarding need for these services
  • Identification of community resources to support the services
  • Consideration of evidence based practices or expert consensus guidelines  

CTS.07.01.02 Management of prevention and wellness promotion services

  • Services meet the demographic needs of the community
  • Staff receives training to provide these services  

CTS.07.01.03 Evaluation of prevention and wellness promotion services

  • Plan for collecting data
  • Evaluation of services
  • Improvements to services based on evaluation of data
  • Regular reporting to leadership on the services.

To view the full pre-publication standards, click on TJC New Requirements for Prevention and Wellness Promotion.

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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.