Barrins & Associates Newsletter Banner

Joint Commission Behavioral Health Update

 July 2014        
In This Issue
New Client Welcome!
Congratulations Corner
"Opportunities for Improvement" Now Included in TJC Survey Reports
Heads up on TJC and CMS Requirement for Treatment Plans in Psychiatric Hospitals
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 this month on two topics of interest.

Our first article covers the topic of the new "Opportunities for Improvement" section that is now included in TJC reports effective July 1, 2014. Our second article is a "heads up" on a survey finding regarding treatment plans that we see coming up for our psychiatric hospital clients.


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. 


Enjoy the rest of your summer and we will be back in touch in September!



Anne Barrins
Newsletter Signup

Welcome - Left  New Client Welcome!    


Barrins & Associates is pleased to welcome our new client A Better Way  located in Berkeley, California. A Better Way offers behavioral health, foster-adoption and parent advocacy services to children and families in the San Francisco Bay area. The organization is a member of the California Alliance of Child and Family Services and is preparing for initial Joint Commission accreditation. We are pleased to be working with A Better Way to achieve that goal!  

 Congratulations Corner      


Congratulations to our client Rock Springs located in Georgetown, Texas who recently achieved initial Joint Commission accreditation and CMS deemed status! Rock Springs is a 72 bed behavioral hospital which opened in February 2014. It provides inpatient and outpatient treatment for seniors, adults, and adolescents and is part of Springstone Inc. headquartered in Louisville, Kentucky. Congratulations to the Rock Springs team on achieving the gold standard of Joint Commission accreditation!

"Opportunities for Improvement" Now Included in TJC Survey Reports


Organizations surveyed after July 1, 2014 will see a change in how their findings are written up in their TJC survey reports. There will now be an Opportunities for Improvement section included in the survey report. Included in this OFI section will be single observations of non-compliance with Category C elements of performance (EPs.)


A bit of explanation regarding scoring: Category C EPs are frequency based requirements and are scored based on the number of times an organization is found not to be compliant with a particular EP. In the past, if a surveyor had only one observation of non-compliance with a Category C EP (such as pain screening), that EP would be scored as 2 (satisfactory compliance) and this finding would NOT be included in the survey report. If there were two observations of non-compliance, that EP would be scored as 1 (partial compliance) and if there were three observations of non-compliance, that EP would be scored as 0 (insufficient compliance.) The findings with scores of 1 (partial compliance) and 0 (insufficient compliance) were included in the survey report.


The change is that now just one observation of non-compliance with a Category C EP will result in a finding that will be included in the survey report as an Opportunity for Improvement. Although the OFI will be included in the survey report, it will not require Evidence of Standards Compliance (ESC) follow-up by the organization. Also, the organization will not be allowed to submit a Clarification to attempt to have the finding removed from the survey report. We have seen survey reports this month with the new OFI section and it is worded as follows:

Opportunities for Improvement

"Observations noted within the Opportunities for Improvement (OFI) section of the report represent single instances of non-compliance noted under a C category Element of Performance. Although these observations do not require official follow up through the Evidence of Standards Compliance (ESC) process, they are included to provide your organization with a robust analysis of all instances of non-compliance noted during survey."

So, the bottom line is that survey reports will have more findings than in the past but the nature of the official response to TJC will not change.

Heads up on TJC and CMS Requirement for Treatment Plans in Psychiatric Hospitals


As we all know, issues with treatment plans are one of the most frequently cited areas of non-compliance on TJC surveys. This is true for both psychiatric hospitals and behavioral health organizations. The problems typically cited are lack of measurability, lack of individualization, and failure to update the treatment plan. Recently, however, we have seen an issue being cited on TJC surveys of psychiatric hospitals that is different from these common issues and relates directly to a CMS requirement for treatment plans. The issue being cited is failure to have the names of the treatment team members listed on the treatment plan. An example of such a surveyor finding is as follows:


"The treatment plan for three patients did not include the responsibilities for each member of the treatment team. Responsibilities must include treatment team members' names and disciplines."


The applicable TJC standard is PC.01.03.01 EP 43 in the Hospital manual which states: "For psychiatric hospitals that use accreditation for deemed status purposes: The plan of care includes the responsibilities of each member of the treatment team."


So, on first reading of this element of performance, it requires that the treatment plan include the responsibilities of the members of the treatment team (i.e. the interventions that they will be providing) but does not indicate that their names need to be included. However, when one reads the corresponding CMS standard and Interpretive Guideline, this requirement becomes explicit. The corresponding Condition of Participation (CoP) is 482.61: Special medical record requirements for psychiatric hospitals. The standard is 482.61(c) (1) (IV); Tag B123. The wording of the CMS standard is as follows:


"The written plan must include the responsibilities of each member of the treatment team."


This wording is almost identical to the wording of the TJC standard. However, the CMS Interpretive Guideline that accompanies this standard is much more explicit. It states that "identification of the staff should be recorded in a manner that includes the name and discipline of the individual."


Clearly, the TJC hospital surveyors are basing their finding on the CMS requirement. However, as we monitor our clients' survey findings, we have not seen this consistently cited by all TJC surveyors. It is, as we often see, surveyor dependent. So, if you are not currently including the names of treatment team members on treatment plans, be aware that this may be an issue on your next survey. Consider whether you want to make the change proactively or wait and see if the issue is identified on your survey and address it at that time.


It should be noted that we have not seen this particular issue regarding treatment planning cited on surveys of organizations/programs accredited under the Behavioral Health standards.
B&A Logo 
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.