TJC and CMS News for Behavioral Healthcare

October 2023

Greetings to Our Colleagues in Behavioral Health!

As the leaves turn brilliant shades of red and gold and the days grow shorter, October arrives with its own unique charm. It’s a month filled with pumpkin patches, apple picking, and the excitement of Halloween costumes. But beyond the fall festivities, October holds a special significance: it is also Mental Health Awareness Month.

The season is changing and so are we. Starting in October, we are sending a link to our blog posts in an email to our subscribers. We will continue to send an email with a link to our newsletter each month. We will be posting two blogs each month to our website and one Newsletter with the exception of July/August and November/December in which we will post two blogs and one Newsletter for the two months combined. We want to leave time for our readers to enjoy what the summer and the holiday season have to offer.

So, as you sip your warm apple cider and watch the leaves fall, let’s take a moment to reflect on the importance of behavioral health and all it encompasses. Join us in this October edition of our Newsletter as we dive into three important topics to further your journey toward providing higher quality and safer care, treatment, and services to the individuals you serve.

Our first article highlights the strategies to implement when individuals do not attend group therapy. The second focuses on key strategies to reduce the use of restraints and seclusion in behavioral health settings, and our third topic explores the most challenging physical environment of care standard for behavioral health organizations.

We value your feedback on the newsletter. Please send us your comments and tell us what topics you’d like to see in future issues. We look forward to hearing from you! Also, feel free to forward this newsletter to your colleagues.

Tackling the Challenge of Non-Attendance at Group Therapy

Non-attendance of treatment groups is a common phenomenon in mental health care settings, and it can have negative consequences for both the individuals served and the service provider. According to some studies, non-attendance can lead to financial costs for the program, worsened outcomes for the individuals, and disrupted group processes for the therapists and other participants.

According to the Joint Commission, failure to provide alternative treatment and update the plan for care, treatment and services is one of the top non-compliance findings for Joint Commission Accredited Hospitals and Behavioral Health Care organizations.

In the course of this article, we are going to discuss the:

Potential Barriers to Group Therapy,
Strategies to Enhance Group Therapy Attendance, and
Alternative Treatment Options.

And how you can:

Meet Accreditation and Regulatory Requirements,
Initiate and Maintain Patient-Centered Care Plans, and
Improve Staff Training and Documentation for Enhanced Compliance.

Reducing Restraints and Seclusion in Behavioral Health Settings

The Joint Commission places a strong emphasis on reducing the use of restraints and seclusion in psychiatric hospitals and behavioral health care organizations. These settings play a vital role in offering care and support to individuals facing behavioral health challenges. However, the ethical concerns and potential harm…

Addressing the Top Physical Environment Challenges in Behavioral Health Care Organizations

In the realm of Behavioral Health Care (BHC) organizations, creating a safe and supportive environment is paramount. However, the physical environment poses several challenges…

NEW CLIENTS

Barrins & Associates is pleased to welcome and honored to work with Montgomery County Emergency Services, a private, not-for-profit, psychiatric hospital in West Norriton, Montgomery County, Pennsylvania.

MCES and its talented team of more than 200 professionals provide a range of behavioral health services from its 73-bed facility in the Delaware Valley. For more than 35 years, they have been building better tomorrows by providing the following critical behavioral health services for individuals, families, and organizations:

Inpatient Program
Outpatient Program
Crisis Residential Program
Criminal Justice Program
Crisis Intervention
Suicide Prevention

As a nationally recognized leader for its work in behavioral health, MCES has been recognized by the American Psychiatric Association, the U.S. Department of Justice, the Law Enforcement Assistance Agency, and the Public Citizen’s Health Research Group.

Our Clients >

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.

In this Issue

Tackling the Challenge of Non-Attendance at Group Therapy
Reducing Restraints and Seclusion in Behavioral Health Care Settings
Addressing Top Physical Environment Challenges in Behavioral Health Care Organizations

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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.

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TIP OF THE MONTH

The Joint Commission standard EC.02.05.01 requires the hospital to label utility system controls to facilitate partial or complete emergency shutdowns. The scoring frequency for EP 9 of this standard is huge with 56% of the hospitals surveyed in 2022 failing to comply with this requirement. EP 9 requires the hospital to label utility system controls to facilitate partial or complete emergency shutdowns.

One very common finding is that some circuit breaker is unlabeled and in the on position, or labeled as a spare and in the on position which means it may actually be powering some section or device and no one knows exactly what it is powering.

The scoring frequency for this EP is so large that this would be an ideal issue to include in your own EC rounding process to open and inspect electrical panels to verify you don’t have unlabeled or spare breakers in the on position. See The Joint Commission’s October 2023 Perspectives for the full article.

Why Choose Us

We were extremely pleased with the mock survey. The Barrins & Associates consultant team was fabulous. They were knowledgeable, skilled and able to communicate our deficits in ways that will help us to move forward. We are grateful to be working with them and feel very comfortable leaning on their expertise.”

Susan R. Niemitz, LCSW
Quality Assurance Director
Capitol Region Mental Health Center