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Joint Commission Behavioral Health Update

July 2013         
In This Issue
New Client Welcome!
Determining Client Competency to Self Administer Medication
Proposed New TJC Requirements for Sample Medications
TJC Survey Activity Guide Updated July 1, 2013
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 three topics of interest.  


Our first article covers the topic of how to determine competency for clients to self administer their medications, a sometimes challenging issue for organizations. Our second article alerts you to proposed standards changes related to the use of sample medications. Our third article provides information on updates to the TJC Survey Activity Guide effective July 1, 2013.


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 welcomes three new clients this month:


Crisis Response Network of Southern Arizona is located in Tucson, Arizona and provides a full range of crisis support services. These include a 24 hour Crisis Line, a Crisis Response Center, a 23 hour Observation/Triage Service, a Warm Line and Mobile Crisis Teams. The organization is accredited by The Joint Commission.


Walter B. Jones Alcohol and Drug Abuse Treatment Center (ADATC) in Greenville, NC and Julian F. Keith ADATC in Black Mountain, North Carolina are inpatient treatment facilities of the North Carolina Division of State Operated Healthcare Facilities. These two facilities treat alcohol and drug dependent adults with co-occurring psychiatric disorders. Both are currently accredited by The Joint Commission under the Behavioral Health standards and are planning to become accredited under TJC's Hospital standards.


We are pleased to be working with these organizations on Joint Commission readiness!

Determining Client Competency to Self Administer Medication


Recently, some organizations have been challenged on their TJC surveys by the issue of how they demonstrate that their clients are competent to self administer their own medications. The following is a finding from one such survey and is typical of surveyor findings in this area: "The clients in this program self administer medications. The record does not document that the client has been determined competent to self administer medications."


TJC standards allow for self administration of medications but require that the organization determine that the client is competent to do so. The relevant standard is MM.06.01.03 in the Medication Management chapter of the 2013 Behavioral Health Manual. Element of performance (EP) # 7 states: "When the individual's medications are prescribed or dispensed by the organization, the organization determines that the individual or the family member who administers the medication is competent at medication administration before allowing him or her to administer medications."


So, how does a program determine that a client is competent to self administer their own medications? The following is a checklist of key skills that the client should be able to demonstrate in order to be deemed competent to self administer their own medications:


  • The client is able to state the name(s) of the medication.
  • The client is able to state the purpose of the medication.
  • The client is able to state when and how much medication should be taken and any other instructions about taking the medication (e.g. with food.)
  • The client is able to state the common side effects of the medication and what to do if those side effects are experienced.
  • The client is able to state whether or not he/she should drink alcohol while taking the medication.
  • The client is able to state the potential consequences of not taking the medication or of not taking the medication properly.
  • The client is able to state what to do if he/she misses a dose, takes a wrong dose, or experiences an adverse reaction to the medication. 

The client's competency to self administer medications should be reassessed on an ongoing basis and addressed during the treatment planning review process. 


In addition to determining the client's competency to self administer, TJC also requires a written policy on self-administration of medications. Standard MM.06.01.03 EP 1 states: "If self administration of medications is allowed, the organization has a written policy that addresses the training and supervision of the individual served to guide the safe and accurate self-administration of medications."


The policy on medication self administration should address the following key elements:


  1. The specific type(s) of self administration that the program will utilize: 
  • Supervised self administration: In this procedure, the client is self administering their own medication under the supervision of a staff member. The staff member may be prompting or coaching the client. Typically, the staff member records the act of self administration on some type of medication record.  
  • Independent self administration: In this procedure, the client is self administering their medication on their own without the supervision of a staff member. In this scenario, clients often are in charge of storing their own medications. Typically, there is no recording of the act of self administration.  
  1. Where the medication will be stored: 

Whether stored in a staff office or in a client's own room, the policy needs to dearly describe the procedure for where the medications will be stored; who has access to them; and how they will be kept secure. If the medications will be held by the program (e.g. in a staff office), this area needs to be inspected on a regular basis to ensure that meds are being stored appropriately. Standard MM.03.01.01 states: "The organization inspects all medication storage areas periodically, as defined by the organization, to verify that mediations are stored properly." Ideally, this inspection should be done by someone other than the staff who are routinely handling the medications; i.e. it should be a "fresh set of eyes.") This inspection should also be documented on a checklist and findings shared with the program manager and staff.


  1. How staff will be trained on the function of supervising clients' self administration of medication: 

It is not uncommon in behavioral health settings that the staff who are supervising the self administration of medications are non-nursing staff. Thus, it is critical that they receive appropriate training on the medications commonly taken by their clients, their purposes and side effects, and how to effectively supervise the self administration of these medications. Their training and competency assessment on these skills should be documented in their Human Resource file. 


  1. How clients will be educated about their medications and determined to be competent to self administer: 

This section of the policy should describe the process for educating clients about their medications: purposes, side effects, instructions, etc. It should also describe the process for determining the client's competency to self administer (in keeping with the skills outlined in the first section of this article.).


As a resource, we are providing a Sample Medication Competency Tool.

Proposed New TJC Requirements for Sample Medications


TJC is in the process of updating the Medication Management standards to more thoroughly address the use of sample medications. Many Behavioral Health organizations use sample medications based on the needs of the population they serve. For several years, this has been an area where surveyors frequently cite organizations for improper storage and/or lack of control over the sample medications. Some BH organizations have eliminated the use of sample medications because of these challenges.


TJC is paying attention to this topic and has issued draft changes to the Medication Management standards to more adequately address requirements related to sample medications. The proposed revisions identify which elements of performance apply to sample medications. There is also a proposed new standard MM.09.01.01 with specific new requirements for sample medications.


If the topic of sample medications is important for your organization, we encourage you to provide feedback to TJC on the proposed changes. The deadline is fast approaching but you can still review the proposed revisions and complete the Sample Medication Field Review on the TJC website until August 6, 2013.

TJC Survey Activity Guide Updated July 1, 2013


TJC has issued an updated Survey Activity Guide effective July 1, 2013. The Survey Activity Guide is an important resource for preparing for survey and is available on your organization's TJC Connect site. It includes specific instructions regarding materials to prepare and provides helpful guidance regarding each of the survey activities.


The update for Behavioral Healthcare organizations seems relatively minor but actually reflects a trend we have seen in recent surveys to focus more heavily on Environment of Care issues. The change to the Survey Activity Guide is in the Documents List that BH organizations are required to have ready for the first morning of survey. TJC has become more specific regarding the types of Environment of Care data they want to see that first morning. Specifically, they have added the following documents to the list:


  • Critiques of fire drills 
  • Reports of the following:
    • Injuries to individuals served
    • Occupational illnesses
    • Staff injuries
    • Property damage
    • Security incident
  • Environmental monitoring for deficiencies, hazards or unsafe practices 

So, how does this translate to the documents and reports that you need to organize for that first morning?


Critiques of fire drills: This one is straightforward. All fire drills need to be critiqued to evaluate what went smoothly and what needs to be improved. If you are looking for a tool for fire drill critiques, see the attached Sample Fire Drill Critique.


Reports of injuries, incidents, occupational illnesses, etc: This is the data produced by your incident reporting program. It should be presented in aggregate form; typically in quarterly reports. The data should be reviewed by whichever committee you have designated as responsible for review of incident data; e.g. Safety Committee, EOC Committee, Special Review Committee. The minutes should show appropriate analysis of the data and discussion of the results and follow-up actions to be taken.


Environmental monitoring for deficiencies, hazards or unsafe practices: This refers to your environmental rounds. These rounds should be documented on a checklist. The results should be shared with program managers and reported to your EOC/Safety Committee. If you're looking for a tool for environmental rounds, see the attached Sample Environmental Tour Form. This best practice tool was generously shared by our client Seneca Family of Agencies, a TJC accredited organization based in Oakland, California. The tool can be adapted to suit your setting, services, and internal requirements.


So, be prepared for the first morning of your survey with your EOC documents well organized. Surveyors will closely scrutinize those and ask more questions in the subsequent EOC interview about your organization-wide safety program and the issues you have identified and addressed.

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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.