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Joint Commission Behavioral Health Update

 October 2012      
In This Issue
New Client Welcome!
Congratulations Corner
Feedback from Fall 2012 Joint Commission Conferences
New Focused Standards Assessment Identifies Risk Related Standards
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

This month, our newsletter is devoted to feedback from two important TJC conferences that we recently attended: 2013 Hospital Executive Briefings and the Annual Behavioral Health Conference. Both were chock full of important information on survey trends and challenging issues for 2013.


We are providing highlights from the conferences in this newsletter. We will be providing in depth coverage of these topics via our annual Long Distance Education Sessions that so many clients participated in last year. For more info and to arrange a session, click on the links below:


We look forward to talking directly with you about how the 2013 requirements impact your organization!


Anne Barrins
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 New Client Welcome!         


Barrins & Associates welcomes two new clients who are both working toward initial Joint Commission accreditation:


Sierra Vista Child & Family Services serves children and families in California's Central Valley through a wide array of community based services including counseling, family support, mental health services, and a foster family program.


Penny Lane Centers provides a broad continuum of children's social services in Southern California including residential programs, mental health services, a special education school and a foster family program.


We are pleased to be working with both of these organizations on achieving TJC accreditation!

CongratulationsCongratulations Corner


Congratulations to our client Compass Behavioral Center of Houma in Crowley, Louisiana who achieved initial Joint Commission accreditation in September! Compass Behavioral Center of Houma is a 20 bed psychiatric inpatient hospital that specializes in providing care to adults aged 50 and older. The hospital is part of Compass Health which provides a variety of inpatient and outpatient services throughout the state of Louisiana. 


Congratulations to Compass Behavioral Center of Houma on achieving the gold standard of Joint Commission accreditation! 

MegaphoneFeedback from Fall 2012 Joint Commission Conferences

We attended two important TJC conferences this Fall for the latest information on survey trends and hot topics for 2013. The first was 2013 Hospital Executive Briefings which provided updates on TJC and CMS standards for those surveyed under the Hospital Accreditation Manual. The second was the 2013 Behavioral Healthcare Conference & Accreditation Standards Update.


The following are highlights from the conferences. We will be providing in depth coverage of these topics via our annual Long Distance Education Sessions which were so popular last year. For information on arranging one of these sessions, click on the links below:

Highlights from 2013 Hospital Executive Briefings


CMS Update: Medicare Final Rule:

  • 48 hour timeframe eliminated for authentication of verbal orders; now defers to state law and hospital policy
  • Provision for authentication of verbal orders by another practitioner made permanent
  • Separate nursing care plan not required; can be integrated into the interdisciplinary plan of care


CMS Emphasis in 2013: It was noted at the conference that CMS is "tying everything back to QA/PI." Several hospitals have been cited at the Condition Level in 2012 for lack of compliance with QA/PI Conditions of Participation. CMS is currently testing a comprehensive surveyor worksheet for assessing compliance with the Quality Assessment/Performance Improvement CoP.  To view the draft QA/PI worksheet, click on the May 18 CMS Memo and scroll to the third page.


2013 National Patient Safety Goal on CAUTI: TJC is expecting full implementation of the NPSG on Catheter Associated Urinary Tract Infections (CAUTI). Hospitals were given 2012 as the planning year. In 2013, full implementation of an evidence based practice will be surveyed.  To view a sample evidence based guideline, click on CDC's Guideline for Prevention of Catheter-Associated Urinary Tract Infections. 


Top 2012 Non-Life Safety/EOC Compliance Issues for Hospitals


Eleven of the top 20 compliance issues for hospitals are in the Life Safety and Environment of Care chapters. Since we will be devoting a separate issue of our newsletter to those topics, we are providing info on the other nine standards that made their way into the "Top 20." 







Record of Care

Dating, timing of entries; assessments lacking info


Cleaning medical equipment

Improper cleaning/disinfection


Medication storage

Lack of security; med refrigerator temperatures; expiration dates on multi-dose vials



Nursing assessments lack info; nutritional assessments not done when indicated


Verbal orders

Verbal orders not authenticated within 48 hours (should improve with elimination of 48 hour rule)


Medication orders

Hospital policy not followed; preprinted order sheets not updated


Treatment plans

Not individualized; objectives not behavioral


Medical staff bylaws

Requirements for completing H&P not in bylaws


Pre-anesthesia assessment

Lack of two step process for pre-anesthesia assessment



Highlights from 2013 Annual Behavioral Healthcare Conference


New 2013 TJC Requirements:


New Prevention and Wellness Standards: These new standards will be effective January 1, 2013. See the article in our June 2012 newsletter for details.


Examples of prevention/wellness services discussed at the conference include:

  • Substance abuse prevention
  • At-risk youth services
  • Suicide prevention
  • Parenting training
  • Depression screening
  • Child abuse/neglect prevention
  • Domestic violence prevention
  • Truancy prevention
  • Sexual abuse prevention


Flu Vaccination Requirements: These standards were actually effective in July 2012 and will continue to be a focus area for 2013 surveys. See the article in our March 2012 newsletter for details.


Three key points about the flu vaccine requirements were made at the BH Conference:

  • The organization is not required to pay for the flu vaccine.
  • Annual compliance goals need to be increased "by more than 1% or 2% per year."
  • TJC encourages offering the vaccine to contract staff but this is not required.


Top 2012 Compliance Issues for BH Organizations


Seven of the top 10 compliance issues are continuations from 2011 but three are newcomers (see below).







Treatment planning

Plan doesn't reflect assessments; goals don't capture client's ideas; objectives not measurable; no re-evaluation when significant changes occur


Licensed independent practitioners: Clinical responsibilities

No primary source verification of license; no peer review; no National Practitioner Data Bank query; no governing body approval



Verifying staff qualifications

No primary source verification of license; lack of compliance with organization's health screening requirements for staff


Safe environment

Physical plant maintenance problems; cleanliness issues


Food preparation/storage

Refrigerator/freezer temps; no labeling of food


Staff competence

Competence not assessed during orientation; performance evaluations not done; competence assessment doesn't match job description



Health screenings

Health screening not done; no triggers; no follow-up


Suicide risk assessment

Assessment doesn't address both specific characteristics of the client and environmental features


Medication storage

Refrigerator temperatures; expired meds



Foster home safety

Lack of smoke detectors; egress from sleeping room insufficient



Continuous Readiness Tip: If you haven't already done so, be sure to incorporate these issues into your internal tracer program. They will continue to be a focus for surveyors during upcoming 2013 surveys. 

Risk  New Focused Standards Assessment Identifies Risk Related Standards


We're sure that by this time you have heard about TJC's new Focused Standards Assessment (FSA) that will replace the current Periodic Performance Review (PPR).  With the FSA, organizations will have the option to complete the self assessment on a minimum subset of Risk Related Standards that TJC has identified rather than on all standards as currently required by the PPR. For each accreditation program, the risk related standards include the following:

  1. All National Patient Safety Goals for that accreditation program
  2. Standards related to TJC identified risk areas for that accreditation program
  3. Selected Direct and Indirect Impact Standards for that accreditation program
  4. Standards listed as RFIs on the organization's survey(s) in the current triennial survey cycle

The risk related standards in categories # 1 through 3 (above) are identified in the 2013 accreditation manuals with the "risk icon" R. These standards and the risk icon appear in the 2012 Update 2 to the accreditation manuals which has been mailed to all accredited organizations as well as in the E-dition of the standards manuals.


For ease of reference, we have attached two tables that list these risk related standards:

We recommend the following steps to prepare your organization for completing the new Focused Standards Assessment:

  • Review the risk related standards for your accreditation program.
  • Identify the ones applicable to your setting(s).
  • Assign process owners for each risk related standard.
  • Review your policies/procedures relevant to these standards to ensure that they address all the requirements listed in the elements of performance for that standard.
  • Incorporate these risk related topic areas into your internal tracers

Get a heads up now on the risk related standards. They are sure to be a focus of attention in 2013 surveys!

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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.