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Joint Commission Behavioral Health Update

September 2014   
In This Issue
New Client Welcome!
Congratulations Corner
Feedback from TJC Hospital Executives Briefings
Suicide Risk Assessment Now #2 in Top Ten Compliance Issues for Behavioral Health
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in
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 support those efforts, we are providing feedback from the recent TJC Hospital Executives Briefing and an update on the top compliance issues for behavioral health organizations.


We look forward to seeing many of you at the TJC Behavioral Health Care Conference on October 15 and 16 in Rosemont, Illinois. Please let us know if you will be attending and we will be sure to find you and catch up!


We enjoyed spending time with many of our California clients at the California Alliance of Child and Family Services Conference earlier this month in Dana Point, California where Barrins & Associates was a premier sponsor. (See photo above.)


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!


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Welcome - Left  New Client Welcome!    


Barrins & Associates welcomes three new clients this month:


Osage Beach Center for Cognitive Disorders is a new twelve bed psychiatric hospital located in Osage Beach, Missouri. The hospital specializes in the treatment of conditions often associated with aging and/or that impact the cognitive abilities or functioning of individuals. OBCCD is located on the campus of Osage Beach Rehabilitation and Health Care Center and is owned by NHC Reliant Psychiatric Services, LLC. The hospital is licensed by the state of Missouri and is seeking initial Joint Commission accreditation. We are pleased to be working with the OBCCD team on achieving that goal!


The Village for Families and Children is located in Hartford, Connecticut and has been serving children and families since 1809. The Village offers a wide range of services including prevention/early intervention, outpatient behavioral health, residential treatment as well as foster care and adoption services. The Village for Families and Children is seeking initial Joint Commission accreditation and we are pleased to be supporting them in that effort!

Rutgers University Behavioral Health Care is a behavioral health system that offers a wide range of behavioral health services throughout New Jersey. Rutgers UBHC is part of the Rutgers University Medical School. Rutgers UBHC offers acute psychiatric services as well as a full continuum of community based services for children, adolescents, and adults. The organization is accredited by The Joint Commission and we are pleased to be working with them in preparation for their upcoming TJC survey.

 Congratulations Corner    


Congratulations to our client Oceanview Psychiatric Health Facility in Long Beach, California who recently achieved initial Joint Commission accreditation and deemed status for their freestanding psychiatric hospital! OPF is part of Collaborative Neuroscience Network (CNS) which is a leading clinical research center in Southern California. CNS specializes in the testing of new medications for a variety of mental health, neurological and general health conditions. Congratulations to Oceanview PHF and CNS on achieving the gold standard of Joint Commission accreditation!


Congratulations to our client Black Bear Lodge who also recently received initial Joint Commission accreditation! Black Bear Lodge is located in the foothills of northern Georgia and offers a holistic model of integrated substance abuse and mental health treatment. The program is part of Foundations Recovery Network  with headquarters in Nashville, Tennessee.  Congratulations to the Black Bear team on achieving the gold standard of Joint Commission accreditation!


Last but not least, we extend Congratulations to our client Dublin Springs Hospital in Dublin, Ohio who recently received Joint Commission accreditation for their Partial Hospital and Intensive Outpatient Service! Dublin Springs is a TJC accredited 72 bed behavioral hospital which opened in 2012. It is part of Springstone Inc. headquartered in Louisville, Kentucky. Congratulations to the Dublin Springs team on achieving the gold standard of Joint Commission accreditation for their PHP/IOP Service! 

Feedback from TJC Hospital Executives Briefings      


We attended the annual TJC Hospital Executives Briefings and CMS Update in New York City earlier this month. It was chock full of information on the latest TJC and CMS compliance issues. It was also a glimpse into what some of the key TJC focus areas will be in 2015. The following are highlights from the conference with more info to follow as these new requirements unfold.

News Item # 1: New Patient Safety Systems chapter coming in 2015


A new chapter will be added to the Hospital Accreditation Manual in 2015. It is titled the Patient Safety Systems chapter. This new chapter will not contain any new standards or requirements per se. Rather, it will describe how existing Joint Commission requirements can be applied to enhance patient safety. Here's an outline of the chapter:

  • Becoming a Learning Organization

  • The Role of Leaders in creating a Fair and Just Safety Culture

  • Data Use and Reporting Systems

  • A Proactive Approach to Preventing Harm

  • Encouraging Patient Activation (helping patients become more actively involved in their own care) 

It was clear from the presentation that while there are no new requirements in this new chapter, its content will be a focus of surveys in 2015 with surveyors zeroing in on leadership's role in this area


News Item # 2: Revised Sentinel Event Policy coming in 2015


TJC has rewritten its Sentinel Event Policy. Some of the key changes are as follows:

  • The policy defines Sentinel Events as just one category of Patient Safety Events. A Patient Safety Event is an event, incident, or condition that could have resulted or did result in harm to a patient. Patient Safety Events also include adverse events, close calls (or near misses), hazardous (or unsafe conditions), and no-harm events.

  • The types of follow-up activities that TJC may require have been expanded. These typically include submitting Measures of Success (MOS) related to the sentinel event or other documentation of sustained improvement.

  • A new term "Comprehensive Systematic Analysis" is used (for identifying the causal and contributory factors) with Root Cause Analysis identified as the most common example.  

News Item # 3: Top Hospital Standards Compliance Issues for First Half of 2014


One of the favorite sessions at this conference is listening to the details of the current top standards compliance issues. While the Top Ten compliance issues were also published in the September 2014 issue of TJC Perspectives, Executive Briefings goes twice as deep and identifies the Top Twenty compliance issues. This is particularly helpful since eight of the Top Ten compliance issues for hospitals are in the areas of Environment of Care or Life Safety. So, here's a summary of the non-EOC/Life Safety issues that fall into the Top Twenty and how we see these playing out in psychiatric hospitals:


Infection Control Chapter: Reducing risk of infections associated with medical equipment (IC.02.02.01); 50% of hospitals cited. Issues are:

  • Lack of staff training re disinfection of medical equipment

  • Failure to follow procedures

  • Inadequate supervision  

Record of Care Chapter: Complete and accurate medical records (RC.01.01.01); 49% of hospitals cited. Issues are:

  • Timing and dating of entries

  • Lack of information to promote continuity of care (Lack of alignment between assessments and treatment plans is frequently cited.) 

Medication Management Chapter


Safe medication storage (MM.03.01.01); 32% of hospitals cited. Issues are:

  • Medication storage area not secure

  • Expired medications

  • Opened multi-dose vials not labeled with 28 day expiration date 

Unclear medication orders (MM.04.01.01); 24% of hospitals cited. Issues are:

  • Unclear medication orders (e.g. PO/IM or 1-2 tablets every 4 hours) 

Pharmacy review of medication orders (MM.05.01.01); 20% of hospital cited. Most common issue is no review for therapeutic duplication:

  • Multiple PRNs without clear guidelines when one is to be selected over another

  • Multiple pain medications

  • Multiple benzodiazepines for anxiety 

Provision of Care Chapter


Treatment Planning (PC.01.03.01); 29% of hospitals cited. Issues are:

  • Problems identified in assessment not address in treatment plans (e.g. medical issues)

  • Lack of revision to tx plans based on progress or lack of progress 

Pre and Post Anesthesia Assessment (for hospitals doing ECT) (PC.03.01.03); 24% of hospitals cited. Most common issue is that the assessment does not contain all the TJC required components.


Leadership Chapter


Management of programs and services (LD.04.01.05); 22% of hospitals cited. Most commonly cited issue is "Staff are held accountable for their responsibilities." Surveyors cite this when they conclude that leadership has allowed non-compliance to exist without correction.


We recommend that you incorporate review of these "Hot Spots" into your Continuous Readiness Program. Include these topics in your medical record audits, your tracers, and consider conducting a time limited study on a particular topic to see if it's a trouble spot for your organization.

Discussion - R

Suicide Risk Assessment Now # 2 in Top Ten Compliance Issues for Behavioral Health 


TJC recently published the Top Ten Standards Compliance Issues for the First Half of 2014. (See table below.) There is not much new or different from previous years but it's worth noting that suicide risk assessment has now climbed to the # 2 spot on the list with 21% of behavioral health organizations found non-compliant on their TJC surveys. The most frequent issues that we see cited on surveys are the following:

  • The suicide risk assessment lacks specific characteristics of the client and environmental features that would increase or decrease the risk for suicide. (Essentially, the assessment is too brief and/or too general in its evaluation of suicide risk.)

  • The suicide risk assessment does not include protective factors that could potentially decrease the risk for suicide.

  • Suicide risk is identified in the assessment but there is no carry-through to the treatment plan in terms of interventions, a safety plan, etc.

  • Suicide risk is assessed at the time of admission but there are no clear guidelines for when suicide risk should be reassessed.

  • There is no competency assessment for clinical staff conducting suicide risk assessments.

So, we encourage you to review your process for suicide risk assessment and make sure it's addressing these particular areas. Also, TJC has published a Standards BoosterPak for Suicide Risk. It's an excellent resource that includes a thorough explanation of the standards as well as helpful tips, FAQs, a comprehensive bibliography and an extensive listing of other resources. It's worth checking out. You can access it on your TJC Connect extranet site. Click on Resources & Tools; then click on Standards BoosterPaks and you will see the one titled Suicide Risk.








Treatment Plans

Objectives not stated in behavioral terms such that progress can be measured; not individualized, not updated


Suicide Risk Assessment

Not addressing specific risk factors; no protective factors; lack of interventions; no reassessment; lack of staff training


Clinical Responsibilities for LIPs

Lack of peer review data or National Practitioner Data Bank query; not done every two years


Verifying Staff Qualifications

Lack of primary source verification of licensure, certification, or education


Safe, Functional Environment

Safety and cleanliness issues identified in the environment of care


Competency Assessment

Lack of assessment of clinical competencies; competencies not defined for specific populations


Nutritional Screening

No clear criteria for referral for nutritional assessment; nutritional risk identified but no follow-up


Clinical Record

Missing, incomplete or late assessments


Medication Storage

Lack of security for medications; expired medications; problems with medication refrigerator monitoring


Flu Vaccination

Lack of implementation of annual flu vaccination program

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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.