Barrins Bulletin
March 2024
Greetings to Our Colleagues in Behavioral Health!
Welcome to the March Edition of our Behavioral Healthcare Newsletter. As we transition from the winter months into the vibrant colors of spring, we continue to grapple with the ongoing challenges in the realm of behavioral health.
In this edition, we continue to delve into the latest developments shaping the field and provide insights to support clinicians, administrators, and stakeholders as they navigate this ever-evolving terrain. As we commemorate National Social Work Month, we celebrate the indispensable contributions of social workers in supporting individuals and communities facing mental health challenges. Their dedication, compassion, and expertise serve as pillars of strength in our collective pursuit of holistic well-being. Together let us navigate the complexities of behavioral healthcare with empathy, insight, and unrelenting dedication.
This month, we broaden our perspectives by exploring subjects crucial to Accreditors, CMS, Hospitals, Psychiatric Hospitals, Community Behavioral Health, and Human Services providers.
Starting this year, we are expanding our content to encompass insights and updates from additional behavioral health accreditors. We value your feedback on the newsletter. Please share your comments and tell us what you think. We would also like to hear about topics you’d like to see in future issues.
We look forward to hearing from you! Feel free to forward this newsletter to your colleagues, their perspectives are equally important to us.
Best Regards,
Julia Finken, RN, BSN, MBA, CPHQ, CLSSMBB
Senior Vice President
“Diverse Perspectives, Comprehensive Solutions:
Tailoring Standards to Your Organization’s Needs”
Tailoring Standards to Your Organization’s Needs”
In the realm of healthcare, ensuring the safety and well-being of patients is paramount. However, when it comes to behavioral health, where vulnerabilities may be more complex and nuanced, cultivating a culture of safety becomes even more critical.
Safety culture refers to the shared values, attitudes, and practices within an organization that prioritize the protection of patients, staff, and stakeholders from harm. In the context of behavioral healthcare organizations, fostering a robust safety culture is not just desirable – it is essential. Here is why…
In an ongoing effort to ensure the highest standards of quality and safety in healthcare facilities participating in Medicare and Medicaid programs, the Centers for Medicare & Medicaid Services (CMS) has proposed significant changes to enhance its oversight of Accrediting Organizations (AOs)…
The Joint Commission is proposing changes to the restraint, seclusion and physical holding standards in the Behavioral Health Care and Human Services standards manual…
Barrins & Associates and Patton Healthcare Consulting are pleased to welcome our new client CommonSpirit. Common Spirit, formed in 2019 through the alignment of Catholic Health Initiatives (CHI) and Dignity Health, is one of the largest nonprofit health systems in the U.S., with more than 1,000 care sites in 21 states coast to coast, serving 20 million patients in big cities and small towns across America. CommonSpirit is committed to building healthy communities by advocating for those who are poor and vulnerable, and innovating how and where healing can happen.
Barrins & Associates provides Joint Commission and CMS consulting services for the Behavioral Healthcare industry. Our clients include psychiatric hospitals and freestanding Behavioral Healthcare organizations and we specialize in providing Survey Preparation and Continuous Survey Readiness services for the Behavioral Healthcare industry.
Barrins & Associates was founded by Anne Barrins, a Joint Commission surveyor for 13 years and is succeeded by Julia Finken with a 17 year tenure from The Joint Commission as a surveyor, the Associate Director of Business Development for the Home Care Program, and Executive Director of Business Development for the Behavioral Health Care and Psychiatric Hospital Programs.
Are You Compliant with the Most Often Cited High-Risk Standards?
Our Mock Survey is your best preparation for all standards considered at risk. Contact us today to become fully prepared for your next accreditation survey.
888-742-4621 x 702
TIP OF THE MONTH
On January 5, 2018, CMS issued memorandum QSO-18-10-Hospital, CAHs Revised, addressing the use of texting for patient information among healthcare providers in hospitals and critical access hospitals (CAHs). While acknowledging the importance of texting for communication within healthcare teams, CMS highlighted concerns regarding compliance with Conditions of Participation (CoPs), citing issues with record retention, privacy, confidentiality, security, and system integrity.
Recognizing advancements in encryption and application interface capabilities, on February 8, 2024, CMS released a memorandum, QSO-24-05, emphasizing the importance of secure and encrypted systems for texting patient information and orders. In summary, texting patient information and orders among members of the health care team is permissible through a HIPAA compliant secure texting platform (STP) and in compliance with the CoPs. However, Computerized Provider Order Entry (CPOE) remains the preferred method of order entry.
Providers are urged to ensure compliance with HIPAA regulations, routinely assess security and integrity, and implement platforms meeting the requirements of the HIPAA Security Rule and the HITECH Act Amendment 2021. For questions or concerns, please contact QSOG_Hospital@cms.hhs.gov.
Why Choose Us
“The most helpful aspect of the Barrins & Associates consultant was her knowledge of TJC standards and CMS CoPs. She was able to expertly educate and provide suggestions and resources to our organization. She addressed issues in a non-judgmental manner. Consistently using this consultant at all of our hospitals has enabled her to become familiar with our EMR and with our policies and procedures as well as establish a good working relationship with the staff at the facility.”
Barb Walls
VP Performance Improvement, Risk Management, and Compliance
SUN Behavioral Health
Congratulations Corner
Congratulations to Mount Sinai South Nassau for a successful reaccreditation! For over 30 years, Mount Sinai South Nassau’s expert team of specialists has been providing care for people with sudden, short-term crises, as well as ongoing mental health conditions. They offer a wide range of mental health and substance use disorders in settings such as outpatient, partial hospitalization and intensive outpatient programs, inpatient psychiatric services, and outpatient substance abuse programs.
Congratulations to Sunshine Treatment Institute, PLLC for achieving their initial Joint Commission Accreditation! Sunshine Treatment Institute provides Mental Health and Substance Abuse services including detoxification, methadone maintenance, methadone detoxification, and buprenorphine services. Sunshine Treatment Institute is located in Detroit, MI.