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Joint Commission Behavioral Health Update

March 2013       
In This Issue
New Client Welcome!
Visit Us at the National Council for Behavioral Health Conference
Update on CMS Activities
Back to Basics: Survey Management 101
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

We hope that spring is beginning to reach most of you out there across the country! We look forward to seeing many of you at the National Council for Behavioral Health Conference in Las Vegas on April 8th through 10th. We will be exhibiting in the Expo Hall, greeting current clients, and networking with new colleagues. Come visit our booth and be eligible for the special drawing!

This month, we are sharing some information that should be helpful with your survey readiness efforts. Our first article provides an update on CMS survey related activities that could impact your psychiatric hospital. Our second article reviews some basic survey strategies that can benefit all organizations.


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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 New Client Welcome!         


Barrins & Associates is pleased to welcome our new client Adventist Behavioral Health Rockville located in Rockville, Maryland. Adventist Behavioral Health Rockville provides a full continuum of psychiatric services for children, adolescents, and adults and is accredited by The Joint Commission. Their services and programs include acute inpatient treatment, a partial hospitalization program, an intensive outpatient program and a residential treatment center. We are pleased to be working with Adventist Behavioral Health Rockville on their continuous survey readiness program.

Visit Us at the National Council for Behavioral Health Conference


Barrins & Associates is excited to be a part of the National Council for Behavioral Health Conference in Las Vegas on April 8- 10, 2013. We will be exhibiting in the Expo Hall (Booth # 700) and invite you to come visit us there! We would be pleased to talk with you about our services, our approach to Joint Commission consulting and learn about your organization and your programs. If you plan to attend the conference, please email me so that we can arrange a time to meet. We look forward to seeing many of you out there in sunny Las Vegas!


P.S: Make sure to drop your business card in our fishbowl and be eligible for the special prize drawing!

                      Update on CMS Activities 


CMS Complaint Surveys 


It appears CMS Complaint Surveys of psychiatric hospitals may be on the rise. In the past year, several clients have undergone Complaint Surveys for the first time. Frequently, they have been cited on the Complaint Surveys for issues that had not been cited on their last Joint Commission survey.


Now that TJC has deemed status for the Two Special Conditions of Participation for Psychiatric Hospitals, the only reason that CMS would survey a TJC accredited psychiatric hospital would be for a Validation Survey or a Complaint Survey (also known as an Allegation Survey). Complaint Surveys are conducted when CMS receives a complaint and determines that it raises a "credible allegation" of a Condition level deficiency. At the outset of the Complaint Survey, the State Agency (acting on behalf of CMS) typically limits the scope of the survey to the CoP(s) related to the complaint. However, the State Agency has the latitude to expand the survey's scope and review areas beyond those involved in the complaint. If the State Agency identifies a Condition level deficiency, CMS will authorize a full Medicare survey. If the State Agency determines that the hospital is still out of compliance with one or more CoPs, the hospital is placed on a 90 day termination track from the Medicare program.


Why the increase in Complaint Surveys? One contributing factor may be that patients and families are better informed about quality of care issues in general and also better equipped (via Internet access) to pursue their complaints. Sources of complaints are typically the patient, the patient's family, or staff within the organization.


Once a Complaint Survey (and potentially a full survey) have occurred, it's critical for the hospital to respond with a comprehensive Plan of Correction and an effective process for managing that Plan of Correction. We recently came across a helpful resource on the whole CMS survey process: CMS Hospital Surveys: The Legal Perspective. It provides background on the different types of CMS surveys and guidance on how to respond to survey findings.


Be sure to stay on top of the CMS CoPs and any updates and revisions to the State Operations ManualAppendix A contains the A Tags which apply to all hospitals (including psychiatric hospitals). Appendix AA contains the B Tags which apply only to psychiatric hospitals.


CMS Surveyor Worksheets


If you're interested in knowing the areas that CMS will be scrutinizing over the next few years, check out the third draft of the Hospital Surveyor Worksheets . There is one for Quality Assessment/Performance Improvement, one for Infection Control and one for Discharge Planning. The worksheets have been piloted and, once finalized, will be used as part of CMS's survey process. CMS is focusing on these three CoPs as a means to reduce healthcare acquired conditions and hospital readmissions. Although most of the probes in the worksheets relate to care provided in acute hospital settings, many have applicability to the psychiatric hospital setting as well. 


    Back to Basics: Survey Management 101       


Recently, we were contacted by an organization that had just been through their initial TJC survey. They had a long list of Requirements for Improvement (RFIs) and were facing a follow-up survey. As they told us about their survey, it became apparent that their survey experience had been very chaotic and that some of their problem clearly had to do with a lack of sound survey management. It reminded us of how important it is to stick to "Survey Management 101" and what a difference it can make in your survey outcome.


We are strong believers in proactively managing your survey so your organization is showcased in its best light and your staff has a positive survey experience. We are not talking here about the job of ensuring compliance with TJC standards. We are talking about the key survey preparation steps that you take in the months leading up to your survey and the strategies you use to manage the survey while it is happening. While most of these are "Survey Management 101," sometimes these steps are overlooked in the hectic days surrounding your survey. So, let's review some basic survey strategies that support a smooth survey experience:



  • Develop a draft survey schedule based on the template agenda published on your TJC extranet site. Include names of attendees for meetings and room locations.
  • Develop a Communication Plan detailing who should be notified about the start of the survey and how you will communicate during the survey. Include an updated telephone list.
  • Study the 2013 TJC Survey Activity Guide on your TJC extranet site. It's a valuable step by step guide to all of the survey activities.
  • Do a dress rehearsal of the following interviews on your survey agenda. Use the Survey Activity Guide for guidance re content:
    • Orientation to the organization (first morning)
    • Data Use Interview
    • Medication Management Interview
    • Competence Assessment Interview
    • EOC Interview
    • Infection Control Interview
  • For the PI, Medication Management, EOC and IC interviews: Have all attendees read the minutes of these committees for the last year.  This is what the surveyors will read and you need to be on the same page.
  • Review your most recent CMS and licensing reports.  These may be requested and will provide the surveyors with issues to pursue.



  • Distribute a copy of the final survey schedule ASAP. Include names of attendees for meetings and room locations.
  • Share the surveyors' biographies with everyone.
  • Designate a room as the surveyors' meeting room (which is separate from where other meetings are held) so that they can use this as a home base.
  • Have the list of required documents ready on the morning of Day One (see Survey Activity Guide.) Make sure the documents are well organized and clearly labeled.
  • Be ready to provide active census lists for all units/programs on Day One of the survey.  The tracers will be selected from these lists.
  • Make sure that the outpatient programs have discharged clients who have dropped out of treatment or not had contact with the program for a long time. You don't want your census list showing clients who should have been discharged.
  • Make sure that all attendees are gathered in the designated meeting room for the scheduled interviews on time with no stragglers.
  • As soon as the tracer cases have been selected, notify the units/programs so that they can review the medical record and be prepared for the tracer.
  • Assign escorts to accompany each surveyor and stay with them all day. Assign an MD for the MD surveyor and a nurse for the nurse surveyor (if you have those types of surveyors).
  • Assign scribes to accompany the surveyors. They should record all questions asked by surveyors and all medical record numbers of records reviewed.
  • Keep a list of all staff who meets with the surveyor.  These are the files most likely to be requested for the HR interview.
  • Report to the upcoming locations what has transpired in the location that was just visited.
  • Have each unit/program ready to present an overview of their program: patient population, services/program offered, what they do that is special.  This should occur at the beginning of the "tracer meeting" with the surveyor.
  • Designate a "command central" room that is continually staffed by a PI manager who gets reports from the locations as they are visited and maintains a bird's eye view of what is going on throughout the survey.
  •  Relay any requests from the surveyors for information back to command central so that they can respond to the request as quickly as possible.
  • Meet at the end of each day to de-brief on the day's events and what to expect the next morning in the briefing. Include managers whose locations were surveyed that day. Identify issues that you can fix immediately.
  • Make use of the Daily Briefings and the Issue Resolution sessions to clarify issues, bring material to the surveyor's attention, correct misunderstandings, etc.
  • If you don't understand the requirement that the surveyor is referencing, ask him/her to show it to you in the standards manual so that you can be clear.
  • Send out an email to all locations daily letting them know what happened that day. They may not be visited and will be curious.
  • Arrange for quick, efficient lunches for surveyors. Time is limited and they always appreciate this.
  • Remove all "Sign Here" or other reminder stickers from the open records.
  • Do not include reports from TJC consultants in your minutes.

A TJC survey is an important event in the life of your organization. Taking the time and effort to orchestrate the event will pay off for the survey and beyond!

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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.