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Joint Commission Behavioral Health Update

 November 2012    
In This Issue
New Client Welcome!
Primary Source Verification under the Behavioral Health Standards
Heads Up: Survey Scrutiny on Food Storage
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

We trust that you had a Happy Thanksgiving and are now ready for a hectic holiday season!


In this month's newsletter, we are providing some clarification on the topic of Primary Source Verification as required by the Behavioral Health standards. This area is among the "Top Ten" compliance issues for BH organizations in 2012.


Our second article covers a topic that has been cropping up more often on recent TJC surveys for both BH organizations and psychiatric hospitals: proper food storage


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. 

Best Wishes for a Happy Holiday Season and we look forward to working with you in the New Year!



Anne Barrins
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 New Client Welcome!         


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


WestCoast Children's Clinic is based in Oakland, California and provides clinic based, school based and home based therapy services to children and families. Services include individual, group, and family therapy as well as foster youth development, transition age support groups, and trauma work.


Sunny Hills Services is based in San Anselmo, California and provides education, mental health, supportive housing, and youth/family services. The organization has its proud roots in an orphanage founded in 1895. 


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


 Primary Source Verification under the Behavioral Health Standards


Some behavioral health organizations have trouble ensuring a consistent process for primary source verification (PSV) of credentials. At the TJC Behavioral Healthcare Conference in October, details of the Top Ten Compliance Issues for BH organizations were presented. Problems with primary source verification were among the top three compliance issues for the first half of 2012. As we work with organizations on continuous readiness, there are some common questions raised on this topic. Let's review those and provide some guidance on meeting the standards on this sometimes challenging requirement:


What is primary source verification?


Primary source verification is the process of confirming a credential with the original source that issued that credential or with an approved agent of that source.


What do the Behavioral Health standards require for primary source verification?


There are two standards in the Behavioral Health Human Resources chapter that address primary source verification:


Standard HR.01.02.05 element of performance # 1 requires primary source verification of credentials when staff is required by law or regulation to be licensed, certified, or registered to perform their job responsibilities.


Standard HR.02.01.03 element of performance # 3 requires primary source verification of training/education for licensed independent practitioners. This standard applies only to that designated group of staff that your organization has identified as licensed independent practitioners (LIPs) to whom you will grant clinical responsibilities (also known as "privileges"). TJC defines a LIP as "a practitioner permitted by law and the organization to provide care, treatment, or services without direction or supervision within the scope of the practitioner's license and consistent with assigned clinical responsibilities". This standard requires that you do primary source verification of the LIP's training/education specific to the clinical responsibilities he/she has requested.


When does primary source verification need to be done?


Primary source verification of licensure/registration/certification needs to be obtained at the time of hire and when the licensure/registration/certification is renewed. Primary source verification of training/education for LIPs needs to be done at the time of assigning initial clinical responsibilities. It does not need to be repeated at the time of renewal of clinical responsibilities (which must be done every two years). The exception would be if an LIP requested a new clinical responsibility for which additional education/training were required. In that case, the additional education/training would need to be verified with the primary source.


Who can provide primary source verification?


Primary source verification of licensure can be obtained from State licensing boards. Primary source verification of training/education for LIPs can be obtained from the educational institution that issued the credential or from a designated equivalent source.


What is a designated equivalent source?


A designated equivalent source (DEA) is a selected agency that has been determined to maintain a specific item of credentials information that is identical to the information at the primary source. DEAs recognized by TJC include the following:

  • American Medical Association Physician Masterfile
  • American Board of Medical Specialties
  • Educational Commission for Foreign Medical Graduates
  • American Osteopathic Association
  • Federation of State Medical Boards
  • American Academy of Physician Assistants Profile

Is making a copy of an individual's license considered primary source verification?


No. Making a copy of the license is not considered primary source verification because you have not contacted the primary source that issued the license.


Is contacting the State licensing board via telephone considered primary source verification?


TJC has stated that confirming a license via telephone with the State licensing board is acceptable if this communication is documented. However, in our opinion, verifying the license through secure electronic communication with the State licensing board is far more preferable.


If we get primary source verification from the State licensing board should we also get a copy of the individual's license?


Once you get primary source verification form the State licensing board, you have satisfied the requirement and do not also need to make a copy of the license. However, keep in mind that if you establish an organizational policy requiring a copy of the license in addition to the primary source verification, TJC will hold you to that policy during your survey.


How should we document the primary source verification?


The best way to document the primary source verification is to print off the report from the State licensing board, sign and date it, and place it in the individual's human resource file.


For LIPs, if we obtain primary source verification of their license can this also satisfy the requirement to obtain primary source verification of their training/education since a certain level of training/education is required to receive the license?


Obtaining primary source verification of the license can, in some instances, satisfy the requirement to obtain primary source verification of the LIP's training/education. The key is that you must confirm with the particular State licensing board that they verify training/education as part of their process for license verification.


Can we use an outside agency to conduct the primary source verification for us instead of doing it ourselves?


Yes, you can use a credentials verification organization (CVO) provided that you have confidence in the completeness and accuracy of the information that the CVO is providing. TJC lists ten principles for evaluating CVOs to ensure that they are providing accurate and complete credentials information. These principles are listed in the Glossary of the BH standards manual under the definition of Credentials Verification Organization.


Continuous Readiness Strategy: Establishing a sound process for primary source verification is important for your organization-wide safety program. It ensures that individuals working in your organization have the appropriate credentials to deliver safe, high quality care to your clients and families.

  Heads Up: Survey Scrutiny on Food Storage

If you are storing food for your patients/clients in any of your programs, be aware that TJC surveyors have recently been focusing on proper food storage in the areas they visit during surveys. Here's the scenario on several recent surveys: The surveyor is conducting a tour of the program and comes upon a refrigerator where patient/client food is being stored. The surveyor inspects the refrigerator's contents and identifies problems in one of the following areas:


  • Temperature monitoring for the refrigerator/freezer is not being consistently conducted. There are several gaps on the temperature log and/or the temperature has been recorded as out of range and there is no action noted on the log.
  • There is leftover food stored in the refrigerator that is not labeled as to its contents and/or is not dated.
  • There is leftover food that is dated but that date has passed and the food has not been discarded.
  • When questioned by the surveyor, staff is unclear about the procedures for labeling and discarding food. 

Although these issues may seem relatively minor, non-compliance in any of these areas results in a Direct Impact finding on your survey report under the following standards:

Hospital Manual: PC.02.02.03 EP 11

Behavioral Health Manual: CTS.04.03.33 EP 3


So, the "take-away" here is Back to Basics on your food storage process:

  • Review your policies/procedures for safe food storage. Make sure they address temperature monitoring, labeling of food, and discard timelines.
  • Train all staff who will be involved in inspecting, cleaning, and maintaining the refrigerators.
  • Develop a monitoring mechanism to ensure that staff is following your established procedures.

If you're looking for basic guidelines on safe food storage, check out the USDA Fact Sheet on Safe Food Handling.


Lastly, basic survey strategy includes doing a "real time" inspection of your refrigerators once your survey begins. Ditch those expired and unlabeled containers of food and avoid a Direct Impact finding on your survey report!

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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.