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Joint Commission Behavioral Health Update

 July 2012         
In This Issue
New Client Welcome!
Congratulations Corner
Easing Up of Waived Testing Requirements
Disaster Privileging: Make Sure Your Process is in Order
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

Now that summer has reached its peak, we trust that many of you are off on some well deserved vacation. To keep you informed even in this more leisurely season, we are providing information on two topics of interest.


Our first article covers disaster privileging, a topic of interest for several of our clients' recent surveys.

Our second article provides an update on a revision to the waived testing requirements which can simplify your quality control procedures for those test instruments.


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. 


Enjoy the rest of your summer and we will be in touch in September!



Anne Barrins
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Welcome - LeftNew Client Welcome! 


Barrins & Associates welcomes our new client Apollo Behavioral Health Hospital located in Baton Rouge, Louisiana.  Apollo Behavioral Health Hospital is a new hospital and will be seeking initial Joint Commission accreditation. They provide inpatient, partial hospitalization and intensive outpatient services. We are pleased to be working with Apollo Behavioral Health Hospitalon on achieving Joint Commission accreditation.

CongratulationsCongratulations Corner


Congratulations to our client Veritas Collaborative LLC in Durham, North Carolina who achieved initial Joint Commission accreditation this month! Veritas Collaborative is a Center of Excellence for the Treatment of Eating Disorders and provides inpatient, acute residential and partial hospitalization services. They opened their new, state of the art facility onJune 4th, 2012 and were surveyed three weeks later. Congratulations to Veritas Collaborative on achieving the gold standard of Joint Commission accreditation!

Easing Up of Waived Testing Requirements Glucometer 108


TJC has revised one of the requirements for quality control checks for instrument based waived testing. Up until now, the standard had required that quality control checks be performed on the instrument each day that it was being used. (See WT.01.01.01 EP 4 in both the Hospital and Behavioral Health manuals.)


The revision eliminates the requirement to perform quality control checks on each day that the instrument is used. It allows for quality control checks per manufacturer's instructions. The new requirement reads as follows:


"For instrument-based waived testing, quality control checks are performed on each instrument used for (patient) testing per manufacturer's instructions."


This change is effective immediately and was announced in the July edition of TJC Perspectives on page 13.


Tip: if you want to take advantage of this change to the waived testing requirements, be sure to revise your current policy requiring testing on each day the instrument is used. If you don't revise your procedure to reflect the new, less stringent requirement, TJC will hold you to your own policy and you will be cited for non-compliance if you are not following it.


Note:For more information on the TJC waived testing requirements, see our February 2012 Newsletter article: 'Refresher on Waived Testing Requirements".

    Disaster Privileging: Make Sure Your Process is in Order

It looks like disaster privileging is back on the TJC radar screen. During recent  surveys, we have noticed an increased focus by surveyors on the hospital's disaster privileging process. Some hospitals have been cited for their medical staff bylaws not adequately addressing how they handle disaster privileges. Others have been found lacking for not having a process in place for the non-LIP volunteers.


The requirements for disaster privileging are contained in the Emergency Management chapter of the Hospital Manual. Standard EM.02.02.13 outlines the requirements for volunteer licensed independent practitioners (LIPs). There are a few key points to keep in mind when designing your disaster privileging process:

  • Disaster privileges are only to be assigned when the hospital has activated its Emergency Operations Plan in response to a disaster.
  • The medical staff bylaws must identify who can grant disaster privileges.
  • There must be a written description of how the medical staff will oversee the performance of volunteer LIPs who are granted disaster privileges. (This could be contained in the medical staff bylaws, medical staff rules/regulations or in a policy.)
  • The volunteer LIP must present a government issued ID plus one or more of the following:
    • A current picture hospital/health organization ID card
    • A current license to practice
    • Identification showing that he/she has been granted authority to render patient care in disasters (granted by a federal, state, or municipal entity.)
    • Confirmation by an LIP or staff member at your hospital of the volunteer's ability to act as a volunteer during a disaster
  • Primary source verification of licensure should occur within 72 hours if possible
  • Remember: Disaster privileges and emergency privileges are not the same thing. Disaster privileges are used when practitioners outside of your own medical staff require privileges to treat your patients due to a disaster in your community. Emergency privileges are granted to existing practitioners on your medical staff. The emergency privileges allow LIPs to perform functions outside of their existing privileges in order to save a patient's life.

TJC Hospital standards also outline a similar process for assigning disaster responsibilities to volunteer practitioners who are not LIPs but who are required by law to have a license, certification or registration. This is detailed in standard EM.02.02.15.  Some non-hospital behavioral health organizations have adopted this process to assign disaster responsibilities to volunteers even though the Behavioral Health standards do not contain requirements to do so. 


To assist with designing your disaster privileging process, we are sharing the following resources that we have found helpful:

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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.