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Joint Commission Behavioral Health Update

October 2013         
In This Issue
New Client Welcome!
Survey Scheduling Alert
Joint Commission Requirements for Trauma Assessment
Reminder about Expiration of Multi-Dose Vials
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

It was great to catch up with so many of our California clients at the California Alliance of Child and Family Services Conference last month in San Diego! The agenda was chock full of eminent speakers and it was also a great networking opportunity for everyone.


In our effort to keep you updated on survey compliance issues, we are covering two topics this month that have posed challenges for some organizations on their TJC surveys. Our first article covers the TJC requirements for trauma assessment under the Behavioral Health Standards. Our second article recaps the TJC requirements for expiration dates on multi-dose vials (for organizations that store these types of medications). We have also included information on a possible trend for "early" survey scheduling.


We hope to see many of you at the TJC Behavioral Health Care Conference on October 22nd and 23rd! If you will be attending, please send me an email and we will arrange to meet up with you.


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:


The Source Health and Wellness Treatment Center is a cutting edge organization located in Los Angeles, California that provides two highly specialized programs: a Binge Eating & Food Addiction Program and a Smoking Cessation Program. Both programs are unique in their approach to treatment and include PHP, IOP, and Outpatient levels of care. The Source Health and Wellness Treatment Center is planning for initial Joint Commission accreditation.


ChildNet Youth & Family Services is headquartered in Long Beach, California and provides a diverse and comprehensive continuum of services for the children and families they serve. Their programs include Foster Family Network, Zinsmeyer Academy (a specialized school), Behavioral Health Services, and Wraparound Services. Their mission is "to provide safe homes, education and counseling to vulnerable children and families." ChildNet Youth & Family Services is planning for initial Joint Commission accreditation.

Chart R   .Survey Scheduling Alert


We want to share with our readers an emerging trend that we have seen this year among our clients in terms of the scheduling of their triennial surveys. TJC's official "window" of survey availability is 18 months to 36 months past the organization's previous survey date. However, in the past, the majority of our clients had been surveyed very close to their 36 month anniversary date. This year, that pattern seems to be changing. We have had several clients surveyed between two and five months prior to their 36 month anniversary date. So, in terms of survey readiness, don't count on your triennial survey taking place in the same month it did three years ago. It may well be scheduled a few months prior to that time so keep your survey readiness program in full gear throughout your three year survey cycle.

Discussion - L

 Joint Commission Requirements for Trauma Assessment


We have noticed recently that some behavioral health organizations are being cited on their Joint Commission surveys for not having an adequate process for conducting trauma assessment. The Joint Commission (TJC) standard related to trauma assessment is standard CTS.02.02.05 in the Behavioral Health Manual and was added to the standards in 2011:

"The organization identifies individuals served who may have experienced trauma, abuse, neglect, or exploitation."


The rationale for the standard is that in order for the assessment and treatment planning process to be comprehensive, an individual's experience of trauma, abuse, neglect or exploitation must be considered. There are specific requirements that must be met related to trauma assessment:

  • The organization must educate staff about trauma, abuse, neglect and exploitation.
  • The organization must have a mechanism for identifying individuals who have experienced trauma, abuse, neglect, or exploitation.
  • Staff must be able to screen for trauma, abuse, neglect and exploitation (as indicated by the setting and services.)
  • The organization must assess the individual who has experienced trauma, abuse, neglect or exploitation or refer the individual for this assessment.

An area in which organizations are frequently lacking is that they already cover abuse and neglect in their assessment but have not expanded the assessment to include types of trauma other than abuse and neglect. Beyond abuse and neglect, trauma includes experiences such as crime related events, witnessing violence, natural disasters, man-made disasters and other types of traumatic events. One tool for gathering trauma history is the Trauma History Questionnaire (THQ) available through Dr. Bonnie Green at Georgetown University. It's a 24 item self report measure that collects information about experiences with traumatic events in a variety of categories. 


Many behavioral health organizations have begun to incorporate trauma-informed care into their scope of services. Trauma-informed care is an approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives. It is a model that seeks to change the paradigm from one that asks "What's wrong with you?" to one that asks "What has happened to you?"


So, to be fully compliant with TJC requirements for trauma assessment, we recommend that you determine if the following processes are in place within your organization:

  • Has some type of education been provided to staff about trauma and its potential effect on the clients they serve? If so, where is this education documented? (It should be reflected in their HR file.)
  • Is there a mechanism in place to collect information about an individual's trauma history? Does it include other types of trauma in addition to abuse and neglect?
  • If a trauma history is identified, is there an assessment of the impact of that trauma and the implications for treatment?

A valuable resource on this topic is SAMHSA's National Center for Trauma-Informed Care. It's a technical assistance center with a wealth of resources on various models of trauma-informed care, staff training, and best practices. 

Medical Devices 2 - Right Reminder about Expiration of Multi-Dose Vials


During recent mock surveys, we encountered some organizations that were storing opened vials of insulin but were unaware of the Joint Commission requirement for labeling the open vial with a 28 day expiration date and discarding it at that point. So, let's clarify the TJC requirements for expiration of multi-dose vials.


  • In June, 2010, TJC clarified its requirements for expiration of multi-dose vials. This was based on revisions made by the United States Pharmacopeia (USP) and the Association for Professionals in Infection Control (APIC) to their guidelines for multi-dose vials (in response to outbreaks of infections associated with multi-dose vials).  
  • Standard MM.03.01.01 EP 7 (in the Hospital and Behavioral Health Manuals) requires that all stored medications must be labeled with an expiration date. TJC defines the expiration date as the last date that the product is to be used (also know as a "beyond use date".) 
  • In order to be compliant with this standard, TJC requires that once a multi-dose vial has been opened, it must be labeled with an expiration date that is 28 days after the date on which the vial was opened.

Since medication storage is one of the most frequently cited areas of non-compliance on TJC surveys, it's important to ensure that your existing medication storage procedures are in compliance with this requirement. We recommend that you check on the following issues within your organization:


  • Do you have a written policy/procedure on the labeling of multi-dose vials?
  • Does your procedure specify that the vial must be labeled with a 28 day expiration date once it has been opened?
  • Have you decided if you will label the vial with both an open date and a 28 day expiration date? Be aware that TJC does not require that the vial be labeled with an open date but if your own policy requires it, the surveyor will hold you to your own policy.
  • Has all nursing staff been trained on the procedure for labeling multi-dose vials with a 28 day expiration date?
  • Does your med room inspection process include checking for the 28 day labeling as well as appropriate discarding of any vials after the 28 day expiration date?

To read the original announcement on this requirement from TJC, see the June 2010 TJC Perspectives page 12: "Clarification: Expiration of Multi-Dose Vials".


Also, see our handy Calculation Chart for 28 Day Expiration Dates to help you figure out the right date for labeling the opened vial.

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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.