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Joint Commission Behavioral Health Update

September 2013        
In This Issue
New Client Welcome!
Congratulations Corner
Psychiatric Advance Directives
News Items
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 continuous readiness efforts. To help with this, we are providing a "Survey Scrutiny" update and some news items of interest to our readers.


Our first article deals with the topic of Psychiatric Advance Directives and how this is being surveyed. Our second article provides information on an important TJC appointment and some upcoming conferences.


We hope to see many of you at the TJC Behavioral Health Care Conference on October 22nd and 23rd! We also look forward to seeing many of our California clients at the California Alliance of Child and Family Services Conference on August 18th - 20th in Del Mar, California!


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 regards and enjoy the fall season in your part of the country!   
Anne Barrins
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 New Client Welcome!         


Barrins & Associates welcomes two new clients this month:


Bayes Achievement Center is located in Huntsville, Texas and provides a continuum of prevention services, residential treatment and a day school program for special needs students with significant behavioral difficulties. Bayes Achievement Center is accredited by the Council on Accreditation (COA) and is planning for initial Joint Commission accreditation.


Michael's House is located in Palm Springs, California and provides specialized treatment services for individuals dealing with chemical dependency and mental health issues. Services are provided at four campuses that include a Men's Center, a Women's Center, a Stabilization Center, and an Outpatient Program. Michael's House is part of Foundations Recovery Network and is accredited by the Council on Accreditation of Rehabilitation Facilities (CARF).

  Congratulations Corner


Congratulations to our client Castlewood Treatment Center in St. Louis, Missouri who achieved initial Joint Commission accreditation this month! 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.

nullPsychiatric Advance Directives


Heads up for organizations and programs surveyed under TJC's Behavioral Health standards: We have noted that the topic of psychiatric advance directives is receiving increased scrutiny during Behavioral Health surveys.




The standard regarding psychiatric advance directives is in the Care, Treatment, and Services chapter of the 2013 BH manual and was added in 2011:


CTS.01.04.01 The organization supports the adult's decisions (psychiatric advance directives) about how care, treatment, or services are to be delivered during times when he or she is unable to make such decisions.


This standard applies only to organizations that serve adults with serious mental illness. The elements of performance require the following:

  1. The organization documents whether the adult has a psychiatric advance directive.
  2. Upon request, the organization shares with the adult sources of help in formulating psychiatric advance directives.
  3. If the adult has a psychiatric advance directive, clinical staff who are involved in the care, treatment, or services provided to that adult are aware that the psychiatric advance directive exists and how to access it.


Survey Scrutiny


Recently, surveyors have been asking BH organizations that serve the SMI population what their process is for determining if a client has a psychiatric advance directive (PAD) and what resources they provide to clients who are interested in developing one. Surveyors have also reviewed records to find documentation of this process. Organizations have been cited for the following issues:

  • Not having a policy/procedure on psychiatric advance directives
  • No documentation in the chart that the client had been asked about psychiatric advance directives
  • Staff unaware of any process for discussing psychiatric advance directives with clients


Interestingly, there is not a standard specific to PADs in the TJC Hospital Manual under which psychiatric hospitals are surveyed. There is, of course, a Hospital standard on advance directives (RI.01.05.01) as they relate to care received at the end of life. Thus, all psychiatric hospitals are required to have a policy on advance directives related to medical care. Some psychiatric hospitals broaden this policy to address PADs as well.


One complicating issue is that although TJC specifies that this standard applies only to "organizations that serve adults with serious mental illness", they do not provide a definition of "serious mental illness" (SMI). While definitions vary, the National Institute for Mental Health (NIMH) has used the following definition of SMI:

  • A mental, behavioral, or emotional disorder (excluding developmental and substance use disorders)
  • Diagnosable currently or within the past year
  • Of sufficient duration to meet diagnostic criteria specified within the DSM-IV.
  • Resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.
  • Note: Serious functional impairment has been further defined as impairment equivalent to a Global Assessment of Functioning (GAF) score of less than 60 (Endicott, Spitzer, Fleiss, & Cohen, 1976).

Most BH organizations serve both adults who would qualify as SMI and adults who would not. Thus, a key decision when developing a PADs policy is whether to apply the process to all clients or just those who qualify as SMI. Understandably, it's often easier to implement the policy for all adults served.


State-by-State Variability


One of the challenges in formulating a policy on psychiatric advance directives is that laws governing these directives vary from state to state. There are 25 states that have specific PAD statutes. All states provide health care power of attorney which clients can use to plan for their psychiatric as well as medical treatment. Thus, it's critical to research and determine your state laws re PADs in order to develop a policy that is compliant with state statute. The National Resource Center on Psychiatric Advance Directives provides state by state information on the different state laws pertaining to PADs and is an excellent resource on this subject.


Compliance Tips


So, in order to be fully compliant with the BH standard on PADs, we recommend the following steps:

  • Research your state law on PADs.
  • Research the resources that you can provide to your clients about PADs.
  • Develop a written policy/procedure. Be sure to address:
    • The specific process for having a discussion with the client about PADs (who, when, etc)
    • How this should be documented in the record.
    • The specific resources to be shared with clients who want more information about PADs.
  • Educate staff about your PADs policy and their role in the process.
  • Monitor your records for compliance with documentation of the PADs process.




In addition to the National Resource Center on Psychiatric Advance Directives, another good resource is the presentation Integrating Psychiatric Advance Directives into Clinical Practice by Dr. Eric Elbogen of University of North Carolina-Chapel Hill School of Medicine.

News Items


New BH Executive Director at TJC  

TJC has named a new executive director for the Behavioral Healthcare Accreditation Program in follow-up to the recent retirement of Dr. Mary Cesare-Murphy. Tracy Griffin Collander, LCSW has been appointed as the new executive director. She will lead the program's operations, development, and strategic planning and will serve as liaison to national BH professional and provider organizations. Ms. Griffin Collander was previously executive director of Gateway Foundation, a BH organization outside of Chicago. For the full press release, click on the TJC Announcement.


null California Alliance of Child and Family Services Conference  

 The Fall 2013 Executive Conference of California Alliance of Child and Family Services will be held in Del Mar, CA on September 18 - 20, 2013. Barrins & Associates has been pleased to work with many Alliance members on Joint Commission accreditation. We are a premier sponsor of the conference and look forward to touching base with many of our California clients at the conference!


TJC Annual Behavioral Health Care Conference     null

The 2013 Behavioral Health Care Conference is set for October 22 and 23, 2013 in Rosemont, Illinois. The conference is titled The Next Generation: Leadership and Services. It will highlight national perspectives and best practices in behavioral health as well as provide updates on the latest standards and requirements for BH providers. Similar to least year, the conference will have two tracks: one for organizations/programs surveyed under the BH Accreditation Manual and one for those surveyed under the Hospital Accreditation Manual. Check out the conference details.


We look forward to seeing many of you at the conference so if you will be attending, please let us know and we will arrange to touch base!

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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.