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Joint Commission Behavioral Health Update

 September 2012   
In This Issue
New Client Welcome!
Congratulations Corner
CMS Requires HBIPS Reporting for Inpatient Psychiatric Facilities
Behavioral Health Standards for Peer Support Services
Two Important Joint Commission Conferences Coming Up!
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

Now that summer vacations are over, most organizations are returning to their routine flow of business, including Joint Commission and CMS readiness efforts. To help with this, we are providing updates on two important topics.


Our first article covers the recently released CMS rule on quality reporting requirements for inpatient psychiatric facilities. Our second article reviews the standards in the Joint Commission Behavioral Health manual for peer support services, which many more BH organizations are now providing.

Lastly, we hope to see you at two upcoming Joint Commission conferences that we will be attending: Hospital Executive Briefings on September 24th in Chicago and the Behavioral Health Conference in Lombard, Illinois on October 16th and 17th.

Regards and enjoy the fall season in your part of the country!



Anne Barrins
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Welcome - LeftNew Client Welcome! 


Barrins & Associates welcomes our new client Castlewood Treatment Center located in St. Louis, Missouri.   Castlewood Treatment Center offers residential, day treatment, step-down, intensive outpatient, and outpatient services for individuals with eating disorders  as well as co-existing disorders. To learn more about Castlewood Treatment Center and take an on-line tour, visit their web site at

CongratulationsCongratulations Corner


Congratulations to our client Apollo Behavioral Health Hospital in Baton Rouge, Louisiana who achieved initial Joint Commission accreditation in August! Apollo Behavioral Health Hospital is a newly opened facility which provides inpatient, partial hospitalization and intensive outpatient services. Congratulations to Apollo Behavioral Health Hospital on achieving the gold standard of Joint Commission accreditation!

CMS Requires HBIPS Reporting for Inpatient Psychiatric Facilities   


CMS issued a final rule on 8/31/12 that impacts both freestanding psychiatric hospitals and psychiatric units of general hospitals. The rule applies to all psychiatric hospitals and psychiatric units of general hospitals that are reimbursed under the Medicare inpatient psychiatric facility prospective payment system (IPF PPS). It requires these facilities to report data to CMS on the Hospital Based Inpatient Psychiatric Services (HBIPS) core measures.


There will be a financial penalty from CMS for facilities that do not report the data. Starting with rate year 2014, the annual Medicare payment update will be reduced by 2% for any facility that does not comply with the data submission requirements. Data from fourth quarter 2012 and first quarter 2013 must be submitted to CMS between July 1 and August 15, 2013 to meet the requirements.


Since January 2010, freestanding psychiatric hospitals have been required to report HBIPS data to The Joint Commission (TJC) but this was optional for inpatient psychiatric units of general hospitals. Those facilities that are currently submitting HBIPS data to TJC can work with their vendors to coordinate data submission to CMS to meet the new requirement.


The 8/31/12 rule requires data submission to CMS on the following HBIPS measures:

  • Hours of physical restraint use
  • Hours of seclusion use
  • Patients discharged on multiple antipsychotic medications
  • Patients discharged on multiple antipsychotic medications with appropriate justification
  • Post discharge continuing care plan created
  • Post discharge continuing care plan transmitted to next level of care provider 

For detailed information, see the final rule (pages 53644-53680 Medicare Program: Hospital Prospective Payment System) published  in the 8/31/12 Federal Register.   


Also, members of the National Association of Psychiatric Health Systems (NAPHS) can get additional information on the NAPHS web site under the "Members Only" tab. 

Overlapping Hands   Behavioral Health Standards for Peer Support Services

An increasing number of behavioral health organizations are including peer support services within their continuum. If your organization provides peer support, it's important to know the relevant Joint Commission standards on this topic and how they may be reviewed during your survey.


First, TJC defines peer support services as "services wherein trained consumers support other consumers in recovery." In the Care, Treatment, and Services chapter, there is a specific standard related to peer support services:


CTS.04.03.31: "The plan for care, treatment, or services addresses the involvement of peer support when provided.

  1. The individual served determines the amount of information that can be accessed by, and the involvement of, peers providing support.
  2. Peers providing support assist in developing the plan for care, treatment or services, when indicated by the individual served.
  3. The plan for care, treatment. or services reflects the inclusion of peer support, as determined by the individual served." 

What does all this mean? There a few key points embedded in this standard that are important to developing your process for delivering peer support services:

  • The focus of this standard is on respecting the client's right to determine the level of involvement they want the peer to have in their treatment plan. The client also has a right to determine the type of information that the peer can access, either in the clinical record or from other members of the treatment team.
  • If the client gives permission for a peer to be involved in their treatment plan, that peer should be involved in developing the plan (as opposed to just being informed about the plan.)
  • If the client gives permission for a peer to be involved in their treatment plan, the plan itself must include peer support as one of the services being provided, similar to listing on the treatment plan any services being provided to that client. 

Also, standard HR.01.04.01 EP 14-20 in the Human Resources chapter identifies specific orientation components that must be provided to persons providing peer support services. These include:

  • Their roles and responsibilities
  • Communication techniques
  • Methods to provide support for the individual served
  • Consumer advocacy
  • Methods for disengaging from their relationship with the individual with whom they are working
  • Crisis recognition
  • Procedures for responding to a crisis both for the individuals served and themselves 

In addition, EP # 13 requires that the organization "orient staff to working collaboratively with persons providing peer support services." This means that staff who will be working with peer support specialists need to be oriented to the role of the peer support specialists and how to work with them in a collegial way and include them in the treatment planning process.


So, if your organization is providing peer support services, we recommend that you review your treatment planning and orientation processes to make sure that they meet all these requirements and will stand up to scrutiny during a TJC survey. Be aware that the most common survey findings in this area are that the role of the peer support specialist has not been included on the treatment plan and that some peer support specialists have not had all the required components of orientation.

MegaphoneTwo Important Joint Commission Conferences
Coming Up!


There are two important Joint Commission conferences coming up soon for behavioral health organizations and psychiatric hospitals. We will be attending both and hope to see many of you there!


The first is 2013 Hospital Executive Briefings which provides updates on new Hospital standards, survey process changes, and related CMS requirements. Check out the locations and dates in the Executive Briefings announcement.


The second is the 2012 Annual Behavioral Health Care Conference on October 16th and 17th in Lombard, Illinois. This year, there are two tracks: one for organizations surveyed under the Behavioral Health Accreditation Manual and one for those surveyed under the Hospital Accreditation Manual.  For more information, see the BH Conference announcement.


Please let us know if you will be attending and we will be sure to look for you there!

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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.