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Joint Commission Behavioral Health Update

 June 2014       
In This Issue
New Client Welcome!
TJC Changes to PFIs and Life Safety Equivalencies
Heads Up on Battery Operated Smoke Detectors in BH Residential Settings
Revisions to TJC BH Opioid Treatment Standards
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare!  


Now that summer has come to all parts of the country, we trust that many of you are planning some well deserved vacation time. To support your survey readiness efforts even during this more leisurely season, we are providing information on three topics of interest.


Our first article is for our psychiatric hospital clients who are surveyed under the TJC Hospital standards. It covers TJC's new process for addressing Plans for Improvement on your Statement of Conditions as well as their new process for approving equivalencies to the Life Safety Code. Our second article deals with the requirements for battery operated smoke detectors in residential behavioral health settings. Our last article provides an update on the recently revised Behavioral Health standards for opioid treatment programs. 


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 Haven Behavioral Healthcare Inc. which offers specialized psychiatric services in Colorado, New Mexico, Ohio, Pennsylvania, and Arizona. Haven Behavioral Healthcare hospitals provide inpatient psychiatric stabilization and treatment to senior adults.  The Haven Behavioral Military Services Davison offers specialized services to meet the unique needs of Armed Forces service members and their families. We are pleased to be working with Haven to support their continuous survey readiness program!

 TJC Changes to PFIs and Life Safety Equivalencies


Barrins & Associates engineer Tim O'Rourke, CHFM has an alert for our psychiatric hospital clients surveyed under Joint Commission Hospital standards. Tim has worked with many of you over the years on mock surveys and compliance with the Life Safety and Environment of Care standards. He wants you to be aware of upcoming changes to the TJC survey process and survey report. These changes relate to two areas:

  • Plans for Improvement (PFIs) that hospitals develop when they identify an area of non-compliance with the Life Safety Code that cannot be resolved within 45 days.
  • The approval process for Life Safety Code equivalencies

TJC is making these changes to align with CMS requirements and maintain its deeming authority to survey hospitals for compliance with the CMS Conditions of Participation for Medicare and Medicaid. The table below summarizes the current process and the changes that go into effect July 1, 2014.

For more detail on how TJC will be handling overdue PFIs, see the Joint Commission Online article "Notice: Overdue PFIs previously accepted during survey must be addressed by July 1, 2014

Tim recommends that you share this important information immediately with your leaders and managers responsible for EOC and Life Safety compliance at your hospital. You can also contact Tim directly with any questions you have about these changes and how they affect your hospital:


Change to TJC Survey Report

Current Process

Change effective July 1, 2014

Added a new section: Open Plans For Improvement (PFIs)



The organization creates a PFI to address noncompliance with life safety requirements


The open PFI does not appear in the decision report.

The organization completes the work identified in the PFI.

Open PFIs will be listed in the decision report.

ESC follow-up is not required for open PFIs, however, the organization will still need to complete any required work identified in a PFI.

Failure to resolve a PFI may result in an on-site survey.

Life Safety Code® equivalencies to be approved by the CMS Regional Office

Equivalencies are used when an organization uncovers an existing Life Safety Code® deficiency that cannot be corrected without major construction. In these cases, the organization may ask for approval of an "equivalency" by demonstrating that alternative building features exist that comply with the intent of the Life Safety Code. 


The Joint Commission reviews and approves equivalency requests.   

The Joint Commission will review the equivalency request and forward it to the CMS Regional Office for final action.


The organization and The Joint Commission will receive a response to the request from the CMS Regional Office.


Appropriate Interim Life Safety Measures (ILSM) will need to be in effect until the final response from the CMS Regional Office is received.




Heads Up on Battery Operated Smoke Detectors in Behavioral Health Residential Settings 


One of our clients that operates a residential treatment program recently underwent their initial TJC survey. They were surveyed under the Life Safety Code Residential Occupancy requirements for Lodging and Rooming Houses that have from 4 to 16 occupants. The organization had a finding that we had never seen before in the Life Safety chapter and thus wanted to share with our readers. The finding related to the battery operated smoke detectors in clients' bedrooms. The surveyor cited the organization for not having a written policy describing how the smoke detectors are tested and maintained and the procedure for replacing batteries. Here's the details:


Standard: LS.04.01.30: The organization maintains and protects vertical openings, fire alarm systems, and separation of sleeping rooms.

Element of Performance #5: Sleeping rooms have approved, single station smoke alarms powered by the building's electrical service.

Note: Existing buildings may have battery powered smoke detectors as long as a written policy exists with procedures defining testing, maintenance, and battery replacement. These activities are documented.


Surveyor Finding: "There was no written policy at time of survey which outlined the testing, maintenance, and battery replacement of battery operated smoke detectors. The organization documents weekly testing of the devices but has not developed a plan for maintenance and battery replacement."


We were well aware that any program using battery operated smoke detectors needs to maintain and test them and replace the batteries on a regular schedule. However, we had not taken note that a written policy is required for this process. In addition, we have never in 15 years of consulting seen a surveyor cite an organization for lack of such a written policy.


So, heads up if you have battery operated smoke detectors. Take the time to develop a simple written policy that describes the procedures for testing, maintenance and battery replacement and save yourself an RFI on your next survey!

Revisions to TJC Behavioral Health Opioid Treatment Standards 

If your organization operates an Opioid Treatment Program (OTP), be sure to review the recent changes to the TJC Behavioral Health standards that apply to these programs. There are some changes to the following chapters:

  • Care, Treatment and Services

  • Medication Management

  • Information Management

  • Rights and Responsibilities of the Individual

Although the changes are not extensive, you should review them carefully to determine if any changes to your processes or policies are needed. To review the full text of the changes, see the June 2014 Joint Commission Perspectives article Revisions to Opioid Treatment Program Requirements.

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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.