The Joint Commission health care equity standard will become a National Patient Safety Goal effective July 1, 2023. So, why the change from standard to National Patient Safety Goal? Clearly, TJC is emphasizing the importance of health care equity as a quality and...
read moreDavis Regional Medical Center in Statesville, North Carolina is in the process of transitioning to be an inpatient hospital focused on behavioral health services for the adult and geriatric populations. The hospital is Joint Commission accredited and CMS certified....
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The New Year has arrived! So, are you all squared away with the Joint Commission 2023 standards that are effective 1/1/23? Now’s the time for a final check to be sure you’re fully compliant with the new 2023 requirements. Experience tells us when a new year kicks in,...
read moreCongratulations to our client Hidden River Eating Disorder Treatment in Chester, New Jersey who recently achieved initial Joint Commission accreditation under the Behavioral Health Care & Human Services Accreditation Program. Hidden River provides specialized...
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Heads up! The Joint Commission licensed practitioner evaluation timeframe has changed. The previous timeframe was every two years. Effective February 19, 2023, it will be every three years. This change applies to organizations TJC accredits under the Hospital...
read moreAs you know, in August 2022 Barrins & Associates became an affiliate of Healthcare Building Solutions Inc (HBS) and merged operations with Patton Healthcare Consulting. We’re now extremely pleased to announce that HBS has appointed Julia Finken, BSN, MBA, CPHQ,...
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Effective January 1, 2023, there will be a revised Joint Commission Sentinel Event definition. Specifically, TJC is revising the definition of sexual abuse/assault within the Sentinel Event Policy. Current Joint Commission Sentinel Event Definition The current...
read moreLake Behavioral Hospital in Waukegan, Illinois provides inpatient, PHP, and IOP mental health and addiction treatment for adolescents and adults. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with the Lake Behavioral team on...
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Get ready for the new Joint Commission Safety Briefing that becomes a part of the survey agenda in January 2023. This briefing will be a requirement for all accreditation programs, including Hospital and Behavioral Health Care & Human Services. Joint Commission...
read moreTrenton Psychiatric Hospital in Trenton, New Jersey is a state operated psychiatric facility providing inpatient psychiatric treatment for adults. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with the TPH team on ongoing...
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Expands Regulatory Compliance Capabilities into Behavioral Healthcare Healthcare Building Solutions, LLC, (HBS) announced the acquisition of Barrins & Associates, a nationally recognized consulting firm specializing in accreditation and regulatory compliance...
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The new Joint Commission health care equity requirements go into effect January 1, 2023. This promises to be a major Joint Commission focus area. Rightfully so, since research shows disparities in access to health care and disparities in quality of care persist in our...
read moreEast Tennessee Behavioral Health in Knoxville, Tennessee provides inpatient, PHP, and IOP mental health and addiction treatment for adolescents and adults. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with the East Tennessee...
read moreRolling Hills Hospital in Ada, Oklahoma provides inpatient psychiatric treatment for adolescents and adults as well as PHP, IOP, and detox treatment. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with the Rolling Hills team on...
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Leaders of TJC’s Behavioral Healthcare Accreditation Program recently conducted a webinar for the Consultants Forum. They provided an informative update on survey scheduling and other Behavioral Healthcare Accreditation activities. We’re sharing the highlights with...
read moreThornton Heights is a Specialized Mental Health Rehabilitation Facility in Chicago Heights, Illinois. The program provides recovery oriented residential services for adults with serious mental illness. Thornton Heights is Joint Commission accredited and we’re pleased...
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Behavioral healthcare organizations nationwide continue to work diligently on implementing TJC’s National Patient Safety Goal on Suicide Prevention. The latest Joint Commission sentinel event data (including suicides) recently became available. So, now is an opportune...
read moreMontrose Behavioral Health Hospital in Chicago, Illinois is a newly opened psychiatric hospital providing inpatient treatment for adolescents age 13 – 17. The hospital will be seeking initial Joint Commission accreditation and we’re pleased to work with the Montrose...
read moreThe Woods at Sharon is a Specialized Mental Health Rehabilitation Facility in Peoria, Illinois. The program provides recovery oriented residential services for adults with serious mental illness. The Woods at Sharon is Joint Commission accredited and we’re pleased to...
read moreVantage Point of Northwest Arkansas in Fayetteville, Arkansas provides inpatient psychiatric treatment for children and adults as well as drug/alcohol detox treatment. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with the...
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Meeting the Joint Commission’s orientation requirements is critical for a successful survey. Surveyors review your orientation process and related documentation during the Human Resources/Competence Assessment session. Thus, it’s...
read moreVermillion Behavioral Health Systems in Lafayette, Louisiana provides inpatient, PHP, and IOP mental health and addiction treatment for adolescents and adults. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with the Vermillion...
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The Joint Commission recently updated its FAQ on environmental risk assessments in non-inpatient Behavioral Health settings. Their guidance is essentially the same as back in 2018. However, it’s worth reviewing closely since surveyors frequently cite this issue in...
read moreCascade Behavioral Health Hospital in Seattle, WA provides a comprehensive continuum of mental health and addiction services for adults. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with the Cascade Behavioral Health team on...
read moreAncora Psychiatric Hospital in Hammonton, NJ is a state operated facility that provides a wide range of inpatient psychiatric services for adults. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with the Ancora Psychiatric Hospital...
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Joint Commission discharge summary reviews are a standard part of the survey agenda for both psychiatric hospitals and behavioral health organizations. Frequently, surveyors cite deficiencies in this area on the survey report. So, let’s review the key requirements to...
read moreBrunswick Hospital Center in Amityville, NY is a private psychiatric hospital offering inpatient services for adults and adolescents. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with the Brunswick Hospital Center team on...
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Recently, we covered the new Joint Commission PI requirements effective January 2022. We’re now seeing a clear uptick in the amount of attention surveyors are paying to this topic. Moreover, they’re issuing Requirements for Improvement in their survey reports. While...
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Heads up! The Joint Commission Rights standards have new requirements effective July 1, 2022. These new requirements are in both the Hospital and Behavioral Health Care & Human Services standards. So, they apply to both psychiatric hospitals and any...
read moreBarrins & Associates is pleased to welcome our new client Idaho State Hospital North located in Orofino, Idaho. State Hospital North is part of the Idaho Dept. of Health & Welfare and provides inpatient psychiatric treatment for adults. State Hospital North...
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Have you addressed the new Joint Commission Performance Improvement standards that went into effect January 1st? They’re in both the Hospital manual and the Behavioral Health Care & Human Services manual. If not, now’s the time to do so. These new PI requirements...
read moreAppalachian Behavioral Healthcare in Athens, Ohio provides inpatient psychiatric treatment for acutely mentally ill adults from southeastern Ohio. The hospital is part of the Ohio Dept. of Mental Health & Addiction Services and is Joint Commission accredited and...
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Be aware! There’s a new Joint Commission COVID-19 staff vaccination standard effective July 1, 2022. The new standard is in the Infection Control chapter: IC.02.04.02. This Joint Commission standard mirrors the recent CMS COVID-19 staff vaccination requirements which...
read moreBellin Psychiatric Center offers inpatient and outpatient psychiatric services in the Green Bay, Wisconsin area. The hospital is DNV accredited and we’re pleased to work with the Bellin Psychiatric Center team on best practices for patient safety in the behavioral...
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Your Joint Commission survey ended 10 days ago. TJC just posted your final report. The decision is Preliminary Denial of Accreditation (PDA.) Not what you were hoping for. So, what exactly does PDA mean? And, equally important, what should you do next? The good news:...
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Be prepared! Joint Commission surveys are getting back on schedule. The pandemic is easing up in many counties across the country. As a result, TJC is catching up on surveys. Joint Commission Surveys: Current Status TJC is catching up on triennial surveys in all...
read moreIdaho State Hospital West, located in Nampa, Idaho is part of the Idaho Dept. of Health & Welfare and provides inpatient psychiatric treatment to Idaho’s youth ages 12 through 17. Idaho State Hospital West will be seeking initial Joint Commission accreditation and...
read moreClayton Residential Home is a Specialized Mental Health Rehabilitation Facility in Chicago, Illinois. They provide recovery oriented residential services for adults who live with serious mental illness. Clayton Residential Home is Joint Commission accredited and we’re...
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In the Behavioral Health Care and Human Services Accreditation Program, virtual Joint Commission surveys are on the rise. At this point, many of our clients have undergone virtual surveys. So, we checked in with them to see what their experience was like. We’re...
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Heads up! There’s a new session on the Hospital survey agenda in 2022. It’s the Joint Commission Grievance Review session. So, let’s take a look at what’s involved and how you can best prepare. Joint Commission Grievance Review: What’s Included? First, the surveyors...
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As an Accrediting Organization (AO) for CMS, TJC is now surveying deemed status organizations for compliance with the CMS COVID-19 staff vaccination requirements. Specifically, TJC is surveying to the CMS Omnibus COVID-19 Health Care Staff Vaccination interim final...
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As we know, compliance with TJC’s National Patient Safety Goal 15 on Suicide Prevention continues to be a challenge for many organizations. Survey findings related to inadequate suicide risk assessment abound. But what about the requirements for training and...
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The New Year has arrived! So, are you all squared away with the Joint Commission 2022 standards effective 1/1/22? Now’s the time for a final check to be sure you’re fully compliant with the new 2022 requirements. Experience tells us when a new year kicks in, surveyors...
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An important Joint Commission fire drill requirement is you must vary the timing of your drills. Seems simple, right? Surprisingly, many organizations overlook this requirement. As a result, they get a finding on their survey. So, let’s review what’s needed to be in...
read moreSummit Behavioral Healthcare in Cincinnati, Ohio provides inpatient psychiatric treatment for civil and forensic mentally ill adults. The hospital is part of the Ohio Dept. of Mental Health & Addiction Services and is Joint Commission accredited and CMS certified....
read moreSilver Oaks Behavioral Hospital in New Lenox, Illinois provides inpatient mental health and substance use disorder treatment for adolescents and adults. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with the Silver Oaks team on...
read moreHeywood Healthcare in Gardner, Massachusetts provides a wide range of inpatient and outpatient Behavioral Health services at its various locations. The Heywood Healthcare hospitals are Joint Commission accredited and CMS certified. We’re pleased to work with the...
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Does TJC accredit your organization under more than one accreditation manual? If so, that means you get a Joint Commission “tailored survey.” In a tailored survey, TJC applies standards from different accreditation manuals based on your services and settings. For...
read moreNorthcoast Behavioral Healthcare in Northfield, Ohio provides inpatient psychiatric treatment for acutely mentally ill adults from northeastern Ohio. The hospital is part of the Ohio Department of Mental Health & Addiction Services and is Joint Commission...
read moreGalen Hope is a mental health treatment center in Miami, Florida. The program provides treatment for eating disorders and a range of other mental health conditions. Galen Hope is seeking initial Joint Commission accreditation and we’re pleased to work with them on...
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Does The Joint Commission survey your organization under the Behavioral Health Care Accreditation Program (now formally known as Behavioral Health Care & Human Services Accreditation?) If so, we have important feedback about current high focus areas...
read moreCongratulations to our client Memorial Outpatient Behavioral Health Center located in Hollywood, Florida who recently achieved initial Joint Commission accreditation under the Behavioral Health Care & Human Services Accreditation Program. Memorial Outpatient...
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Get Ready! Effective January 1, 2022, new TJC Performance Improvement Requirements go into effect. They’ll be in both the Hospital Standards PI chapter and the Behavioral Health Standards PI chapter. What’s Changed? The new TJC Performance Improvement Requirements...
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Does TJC survey your organization under the Behavioral Health & Human Services standards? If so, it’s important to be aware of the training requirements for the Joint Commission BH pain management standards. We notice organizations sometimes overlook these...
read moreHospital for Behavioral Medicine in Worcester, Massachusetts provides inpatient services for children, adolescents, and adults as well as a PHP/IOP program. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with the Hospital for...
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Get Ready! Effective January 1, 2022, new TJC Workplace Violence Prevention Requirements go into effect. They apply to all TJC accredited hospitals. Currently, the requirements don’t apply to organizations accredited under the Behavioral Health Care standards....
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Boarding psychiatric patients in the Emergency Department is recognized as a significant problem nationwide. Technically, “boarding” is the process of holding an admitted patient in the ED while waiting for an inpatient bed. Best Practices for Boarding Psychiatric...
read moreRidgeview Institute – Monroe located in Monroe, Georgia offers a range of inpatient and outpatient behavioral health and addiction treatment for adolescents, adults, and seniors. The hospital is Joint Commission accredited and CMS certified. We’re pleased to...
read moreRidgeview Institute – Smyrna located in Smyrna, Georgia offers a range of inpatient and outpatient behavioral health and addiction treatment for adolescents, adults, and seniors. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with...
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Heads up! New Life Safety requirements went into effect 7/1/21 for organizations accredited under TJC’s Behavioral Health Care and Human Services program The new requirements apply to residential programs. Specifically, there are two types of buildings covered by the...
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Heads up! There are new fire drill requirements effective 7/1/21. They apply to organizations accredited under the Behavioral Health Care and Human Services standards. The changes better align TJC standards with National Fire Protection Association (NFPA) Life Safety...
read moreBarnes Jewish Hospital in St. Louis, Missouri is an acute care hospital that offers both inpatient psychiatric services and emergency psychiatric services. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with the Barnes Jewish...
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The number of onsite Joint Commission surveys increases each month as we move out of the COVID-19 pandemic. In June 2021, TJC scheduled 784 onsite surveys. That’s the highest number since they resumed limited onsite survey activity in June 2020. In March 2021, they...
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As we work with clients on survey readiness, we’re noticing some organizations haven’t updated their Sentinel Event policy to include the Joint Commission definition of falls as sentinel events. The new definition went into effect January 1, 2021. Here’s what you need...
read moreDayton Children’s Hospital in Dayton, Ohio is a pediatric acute care children’s teaching hospital and also offers specialized inpatient and emergency behavioral health services. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work...
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As we know, compliance with the requirements of National Patient Safety Goal (NPSG) 15 on Suicide Prevention continues to be a challenge for many organizations. Survey findings related to inadequate suicide risk assessment abound. But what about the requirement to...
read moreCaroMont Regional Medical Center is a public, not-for-profit, acute care hospital located in Gastonia, North Carolina. The hospital also offers inpatient and emergency behavioral health services for children, adolescents, and adults. We’re pleased to work with the...
read moreAlaska Psychiatric Institute is a state operated inpatient psychiatric hospital in Anchorage, Alaska and provides a full range of inpatient psychiatric treatment for adults. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with the...
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Ever wonder how your survey results stack up against other similar organizations? TJC has made that easier to do with its new SAFER Dashboard. The SAFER Dashboard is a self-serve data analytic tool. It allows organizations to view their survey data and national...
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DNV Healthcare is now the second Accrediting Organization (after The Joint Commission) to receive deeming authority from CMS for psychiatric hospitals to participate in the Medicare or Medicaid programs. CMS granted deeming authority to DNV in July 2020. CMS’s...
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Heads up! There’s are new Joint Commission Life Safety standards for business occupancies effective July 1, 2021. They apply to organizations accredited under both the Hospital Manual and the Behavioral Health & Human Services manual. So, what’s involved and how...
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As we know, once the pandemic hit, TJC launched its virtual survey process. The number of virtual Joint Commission surveys increased dramatically over the past year as the Public Health Emergency continued. Fast forward: TJC reinstituted routine onsite surveys...
read moreProvo Canyon School in Provo, Utah is a psychiatric youth residential treatment center in Provo, Utah. It provides inpatient psychiatric treatment and a full academic program for children and adolescents ages 8 to 18. Provo Canyon School is Joint Commission accredited...
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Whether you have an onsite or a virtual survey, the Joint Commission Document Review is critical. Your documents give surveyors their first impression of your organization. And we all know “You don’t get a second chance...
read moreBernalillo Academy is a residential treatment center in Albuquerque, New Mexico. It serves children ages 4-17 and is part of Sequel Youth and Family Services. The program is Joint Commission accredited and we’re pleased to work with the Bernalillo team on continuous...
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What’s the latest on Joint Commission survey activity? Well, we may soon be seeing a return to business as usual for onsite Joint Commission surveys. As we know, The Joint Commission resumed onsite survey activity on a limited basis in June. Their approach to date has...
read moreSUN Behavioral Delaware in Georgetown, Delaware provides a full range of inpatient and outpatient mental health and substance abuse treatment for adolescents and adults. SUN Delaware is Joint Commission accredited and CMS certified and we’re pleased to work with the...
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Are you all squared away with the Joint Commission 2021 standards that went into effect January 1st? Now is a good time for a final check to be sure you’re fully compliant with all the new 2021 requirements. Our experience is when a new year begins, surveyors often...
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Are you ready for the possibility of a virtual Joint Commission survey? As the pandemic has continued, the number of virtual surveys has steadily increased. The chart below illustrates the pattern of onsite vs. virtual surveys since May 2020. TJC has established a...
read moreNorthwest Ohio Psychiatric Hospital in Toledo, Ohio offers a full range of inpatient psychiatric services for adults as well as a network of community support services. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with the NOPH...
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Get ready! The Joint Commission Environment of Care survey process for hospitals has changed in 2021. Previously, there was a one hour session on the hospital survey agenda dedicated to the Environment of Care review. TJC eliminated that session effective January 1,...
read moreCenterstone Behavioral Hospital & Addiction Center in Bradenton, Florida offers a comprehensive range of behavioral health and addiction services. The organization is Joint Commission accredited and we’re pleased to work with the Centerstone team on continuous...
read moreThe Children’s Center of Hamden in Hamden, CT offers a full range of residential, educational, and day treatment services for youth and families. The organization is Joint Commission accredited and also CMS certified for their psychiatric residential treatment...
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As we’ve all witnessed, the use of behavioral telehealth has increased exponentially during the COVID-19 pandemic. Clearly, it’s proven an important vehicle for delivering services, particularly in the face of the mental health issues the pandemic has created. As a...
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What’s the latest on Joint Commission survey activity? As we know, The Joint Commission resumed onsite survey activity in June. Their approach has been to conduct onsite surveys in counties that are low risk for COVID-19. At the same time, they began conducting a...
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The Joint Commission recently announced elimination of the requirement for a 90% flu vaccination goal effective January 1, 2021. Currently, Infection Control standard IC.02.04.01 Element of Performance # 5 requires organizations to set “incremental influenza...
read moreDelta Specialty Hospital in Memphis, Tennessee offers a full continuum of inpatient psychiatric, dual diagnosis, and PHP/IOP services. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with the Delta team on continuous regulatory...
read moreBehavioral Crossroads Recovery in Egg Harbor Township, New Jersey offers provides mental health and substance abuse treatment in its Partial Hospital and Outpatient Programs and is Joint Commission accredited. We’re pleased to work with the Behavioral Crossroads team...
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As we head into 2021, watch for a more consistent surveyor approach to the Joint Commission Credentialing & Privileging Tracer. In the past, this session has been somewhat surveyor dependent and, thus, has varied in its level of scrutiny. Seems...
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There’s a valuable resource you should know about on your TJC Connect extranet site. It’s the Joint Commission Heads-Up Report. You’ll find it under the Resources & Tools section. Joint Commission Heads-Up Reports TJC produces these reports quarterly for all...
read moreMemorial Outpatient Behavioral Health Center in Hollywood, Florida offers a full continuum of outpatient mental health and substance use disorder treatment services. The Center is part of Memorial Healthcare System and is Joint Commission accredited. We’re pleased to...
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Some of our clients are “back in the saddle again” in terms of onsite Joint Commission surveys. For example, we had several clients undergo their onsite triennial surveys last month. So, what are surveys like these days in light of the COVID-19 reality? We got some...
read moreMingus Mountain Academy is a residential treatment center in Prescott Valley, Arizona and part of Sequel Youth and Family Services. The program serves girls who are emotionally or behaviorally at risk and is Joint Commission accredited. We’re pleased to work with the...
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Have you heard about virtual Joint Commission surveys? TJC began conducting these a few months ago. They’re been limited to hospitals applying for initial CMS deemed status and opioid treatment programs. They’ve just recently begun...
read moreWestborough Behavioral Healthcare Hospital in Westborough, Massachusetts offers a full continuum of psychiatric and dual diagnosis services for youth and adults. The hospital is Joint Commission accredited, CMS certified and licensed by the Massachusetts Dept. of...
read moreLas Vegas Recovery Center in Las Vegas, Nevada provides comprehensive treatment for pain and addiction. The organization is Joint Commission accredited and we’re pleased to support their continuous readiness efforts.
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News Flash: CMS recently granted The Joint Commission a two year approval for its authority to conduct deemed status surveys for hospitals. The previous approval was for six years. So, what’s behind this shorter approval period? Background on Deemed Status CMS grants...
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Wondering what types of behavioral health tracers The Joint Commission is conducting as they resume surveys? By “behavioral health tracers” we mean the tracers done in psychiatric hospitals, behavioral health organizations, and psychiatric units of med/surg hospitals....
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Heads up! Does your organization provide treatment to individuals with addictions? If so, the new Joint Commission standards for substance use disorder treatment apply to you. The new requirements became effective July 1st in the Behavioral Health Care Accreditation...
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As we know, regular Joint Commission surveys resumed in June. So, how’s that going? TJC recently provided an update to our Consultants Forum group. Here’s some important info they shared. Surveys Targeted to Low Risk Areas Currently, TJC is scheduling surveys in...
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Are you aware that TJC has developed new standards specifically geared to the child welfare industry? These new and revised Joint Commission standards for child welfare agencies go into effect September 13, 2020. The new standards are in the Behavioral Health Care...
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As we know, regular Joint Commission surveys are resuming in June. Thus, as you ramp up your survey readiness, it’s important to focus on areas that will be a high priority for TJC. Clearly, in the face of the COVID-19 pandemic, infection control will be one of those...
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It’s official! The Joint Commission announced this week they will resume regular surveys in June. As we know, TJC suspended regular survey activity on March 16th due to the COVID-19 pandemic. Since that time, they have not been conducting routine triennial surveys....
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As we all know, The Joint Commission suspended regular survey activity effective March 16, 2020. We covered questions from our readers on that topic in our post The Joint Commission Suspends Surveys. Since that announcement, TJC has not been conducting routine...
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With the onset of COVID-19, telepsychiatry use has dramatically increased. Clearly, providers are finding it a viable solution for treating patients previously seen in office settings. In response, CMS recently eased several reimbursement requirements for the use of...
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COVID-19 and suicide risk: definitely two challenging patient care issues. Recently, The Joint Commission (TJC) answered a question about monitoring COVID-19 patients who are a high suicide risk. Specifically, the question was whether staff doing a 1:1 observation for...
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In light of COVID-19, CMS has suspended routine surveys. CMS wants to allow healthcare organizations to focus on their top priority – responding to the COVID-19 pandemic. However, that suspension applies only to routine survey activity. It doesn’t mean all CMS surveys...
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Searching for COVID-19 behavioral healthcare resources? We know as a Behavioral Healthcare organization you’re facing some unique challenges with COVID-19 in terms of your patient population and your varied settings. Clearly, you want to continue to provide your...
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The Joint Commission has announced that effective March 16, 2020 they are suspending all “regular surveying.” TJC implemented this survey suspension in light of the declaration of a National Emergency regarding the COVID-19 virus. TJC wants to allow healthcare...
read moreLongleaf Hospital in Alexandria, Louisiana provides inpatient mental health and addiction treatment to adolescents and adults as well as a Military Support Program. Longleaf Hospital is Joint Commission accredited and CMS certified and we’re pleased to work with them...
read moreCumberland Hospital for Children and Adolescents in New Kent, Virginia provides medical, psychotherapeutic, rehabilitative, behavioral, and educational services for young people with complex medical and emotional needs. Cumberland Hospital is Joint Commission...
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Are you ready for the changes TJC has made to the survey agenda? TJC recently announced “minor modifications” to the survey agenda effective March 1st. Although they’re small changes, they do have implications for your onsite survey – and how you manage it. So, best...
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Are you a behavioral health organization that uses restraint or physical holding as interventions? Does TJC survey your organization under the Behavioral Health Care manual? If so, make sure you understand the TJC restraint definition and the distinction between...
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Heads up on a potential TJC tracer to keep on your radar. It’s patients transferred from an inpatient behavioral health setting to the ER. We frequently see TJC (and also CMS) surveyors select this type of case for a tracer. So, what are the key things they’re...
read moreRockford Center in Newark, Delaware offers a full continuum of behavioral health and substance abuse treatment for children, adolescents, adults, and older adults. Rockford Center is Joint Commission accredited and CMS certified and we’re pleased to work with them on...
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It’s now been seven months since the new requirements for NPSG 15 on Suicide Risk Reduction took effect on July 1st. So, how is this important topic playing out on surveys? First, we know surveyors are closely scrutinizing each of the seven elements of performance...
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On January 13, 2020, CMS announced it will change its survey process for psychiatric hospitals. Certainly, this is a significant change so it’s important to understand all the details. New CMS Survey Process: What will be Different? The key difference is how the State...
read moreSUN Behavioral Columbus in Columbus, Ohio provides a full range of inpatient and outpatient mental health and substance abuse treatment for adolescents and adults. SUN Columbus is Joint Commission accredited and CMS certified and we’re pleased to work with them on...
read moreHidden River in Chester, New Jersey provides residential eating disorder treatment for girls and women. The program opened in July 2019 and will be seeking initial Joint Commission accreditation. We’re pleased to be working with Hidden River to help them achieve that...
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Heads up! Does your behavioral health organization/program provide treatment for substance use disorders? If so, you’ll need to address new TJC standards going into effect on July 1, 2020. TJC Standards: Behavioral Health Care Manual TJC accredits opioid treatment...
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Ready for the new focus area that’s now a part of Joint Commission surveys? It’s the Dietary Tracer. TJC now includes a Dietary Tracer on all triennial surveys of hospitals (including psychiatric hospitals) that use Joint Commission accreditation for deemed status....
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Have you seen the latest FAQ from TJC on NPSG.15.01.01 – Suicide Risk Reduction? It’s about monitoring patients at high risk of suicide. Important information for everyone grappling with the new requirements effective 7/1/19. New FAQ: Monitoring High Risk Patients TJC...
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Heads Up! Recently, several of our clients had their unannounced TJC surveys earlier than they anticipated. That includes both psychiatric hospitals and behavioral health organizations. So, is this a trend? Hard to tell but best to be prepared in case you encounter...
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TJC’s SAFER matrix has been around since January 2017. Feedback from the field has been very positive. At the same time, clients often ask just how surveyors make decisions about scoring on the matrix. So, let’s take a closer look at that. SAFER Matrix Decisions TJC...
read moreSt. Anthony’s Behavioral Health Hospitals in Wichita and Olathe, Kansas specialize in providing inpatient and outpatient psychiatric treatment for ages 50 and up. They are Joint Commission accredited and CMS certified. We’re pleased to work with St....
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Has your organization addressed the new NPSG.15.01.01.01 requirement for counseling and follow-up care at discharge? It went into effect July 1st. Interestingly, we find many clients focusing on the suicide risk assessment component but paying little attention to this...
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Fifth in our series on TJC Survey Management Strategies You’re coming down the home stretch of your survey. Now it’s time for the TJC System Tracer on Data Management. So, what’s this tracer all about these days? And how best to prepare? Let’s take a look at the...
read moreRiver Park Hospital in Huntington, West Virginia provides a range of inpatient, residential, and PHP/IOP services for children, adolescents, and adults. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with them on continuous...
read moreWe are very pleased to welcome a new member to our consulting team! Lee Fraser, RN-BC, MA has joined us directly from the Joint Commission surveyor cadre. She surveyed in both the Hospital and Behavioral Health accreditation programs and was part of the surveyor group...
read moreCongratulations to our client Families for Children in Inglewood, California who recently achieved initial Joint Commission accreditation. The program provides substance abuse and mental health outpatient and IOP services. Kudos to the Families for Children team on...
read moreCongratulations to our client NUWAY in Minneapolis, Minnesota who recently achieved initial Joint Commission accreditation. NUWAY provides residential and outpatient care to individuals recovering from co-occurring substance abuse and mental health disorders. Kudos to...
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Be prepared! TJC’s new requirements for the National Patient Safety Goal on Suicide Risk Reduction (NPSG.15.01.01) officially went into effect July 1st. As anticipated, surveyors are closely evaluating compliance with the seven new requirements. We analyzed our...
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Is your psychiatric hospital feeling the burden of CMS regulations? If so, you’re not alone. The National Association for Behavioral Healthcare (NABH) recently released a report on this important topic: The High Cost of Compliance: Assessing the Regulatory Burden on...
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Wonder how your TJC survey results compare with other organizations across the country? At our recent Consultants Forum meeting in Chicago, TJC COO Mark Pelletier shared data on survey results for 2019. Take a look at the trends across the country. We did a breakdown...
read moreEpworth Children and Family Services in St. Louis, Missouri provides a range of residential, clinical, and prevention services to children and families and is Joint Commission accredited. We’re pleased to support Epworth’s ongoing survey readiness efforts.
read moreSanford Health in Fargo, North Dakota offers inpatient psychiatric services and emergency psychiatric services at its three med/surg hospitals. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with them on continuous regulatory...
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It’s official! The new requirements for TJC’s National Patient Safety Goal NPSG.15.01.01 on Suicide Risk Reduction became effective July 1st. Predictably, surveyors are focusing intensely on these new requirements. We’ve seen survey reports that cite all seven...
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Fourth in our series on TJC Survey Management Strategies It’s Day 3 of your TJC survey. Time for the TJC Competence Assessment Session. Surveyors have given you a list of staff names. Now they’ll review your Human Resource and Staff...
read moreSequel Pomegranate Health Systems in Columbus, Ohio provides residential and inpatient psychiatric services for youth aged 12 to 17. The program is Joint Commission accredited and CMS certified. We’re pleased work with Sequel Pomegranate on continuous regulatory...
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Has your psychiatric hospital been put in Immediate Jeopardy by CMS? Or, had a CMS survey with Condition level findings? Either way, you need to prepare for your CMS resurvey. So, it’s time to shift into high gear. In our last article Immediate Jeopardy and CMS...
read moreThe Brook Hospital – Dupont in Louisville, Kentucky provides a range of inpatient and PHP/IOP services for children, adolescents, and adults. The hospital is Joint Commission accredited and CMS certified. We’re pleased to work with them on continuous regulatory...
read moreRogers Behavioral Health, headquartered in Oconomowoc, Wisconsin, provides a wide range of inpatient, residential, PHP/IOP and outpatient services for children, adolescents, and adults. They provide services throughout Wisconsin and also in California, Florida,...
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Has your psychiatric hospital been cited by CMS for an Immediate Jeopardy situation? If so, “Immediate Jeopardy” can be a somewhat frightening term. What exactly does it mean and what are the implications? Most importantly, how should you respond? In this article, we...
read moreTwin Valley Behavioral Healthcare Hospital in Columbus, Ohio provides inpatient psychiatric treatment for adults on its civil forensic and acute care units. The hospital is operated by Ohio Mental Health and Addiction Services and is Joint Commission accredited and...
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Third in our series on TJC Survey Management Strategies Don’t think you can fly on auto-pilot for the TJC Medical Staff Credentialing & Privileging Session. Yes, it’s been a standard part of hospital surveys for a long time. Yet, we still see a significant number...
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Have you seen The Joint Commission’s two new FAQs on suicide risk reduction? The first one relates to monitoring of patients at high risk for suicide. The second FAQ clarifies the requirement for self-closing and self-locking doors. Both are critically important. Get...
read moreLandmark Recovery in Louisville, Kentucky provides a full spectrum of medical detoxification, residential treatment, PHP, and IOP services and is Joint Commission accredited. We’re pleased to support Landmark Recovery’s ongoing survey readiness efforts.
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Second in our series on TJC Survey Management Strategies The TJC Medication Management Tracer has been part of the survey process for awhile. For this reason, some organizations underestimate its importance. Don’t make that mistake. Safe medication...
read moreRiver Oaks Hospital in New Orleans, Louisiana provides a range of inpatient and outpatient services to adults and adolescents. The hospital is Joint Commission accredited and CMS certified and we’re pleased to work with them on continuous regulatory readiness.
read moreAvera Behavioral Health in Sioux Falls, South Dakota provides a continuum of inpatient and outpatient services and is Joint Commission accredited and CMS certified. We’re pleased to be working with them on the development of their new residential program at Avera...
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The countdown is on. July 1st is when the new Joint Commission requirements for suicide risk reduction go into effect. The revised National Patient Safety Goal NPSG.15.01.01 has seven new and revised elements of performance. We do a lot of education on the new...
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First in our series on TJC Survey Management Strategies “You don’t get a second chance to make a first impression.” We’ve all heard that. You can be sure it applies to your Joint Commission survey. And certainly to the TJC Document Review Session. You know the drill....
read moreCongratulations to our client Sunrise Recovery in Clarksville, Indiana who recently achieved initial TJC accreditation! The program provides medical detoxification, partial hospitalization, and residential treatment services. Congratulations to the Sunrise Recovery...
read moreAusten Riggs Center in Stockbridge, Massachusetts provides a continuum of inpatient, residential and outpatient services. The hospital is Joint Commission accredited and we’re pleased to work with them on implementation of their electronic medical record.
read moreHill Crest Behavioral Health Services in Birmingham, Alabama provides a range of inpatient, residential, and outpatient services to children, adolescents, and adults. The hospital is Joint Commission accredited and CMS certified and we’re pleased to work with them on...
read moreNew Beginnings Counseling Centers in Las Vegas, Nevada offers outpatient medically supervised substance abuse treatment. New Beginnings will be seeking Joint Commission accreditation and we’re pleased to support them in achieving that goal.
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Intimidating behavior has been called the “healthcare equivalent of road rage.” As more and more healthcare organizations work on building a Culture of Safety, they’re forced to address this issue head on. Intimidating Behavior and a Culture of Safety A hallmark of a...
read moreWhite Shield Center in Portland, Oregon is operated by The Salvation Army and provides residential treatment for adolescent girls. White Shield Center will be seeking initial Joint Commission accreditation and we’re pleased to support them in achieving that...
read moreCongratulations to our client Fort Behavioral Health in Fort Worth, Texas who recently achieved initial TJC accreditation! The organization provides detox and residential addiction treatment as well as treatment for autism and spectrum disorders. Congratulations to...
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Are you ready for the new Joint Commission requirements effective July 1, 2019 for suicide risk assessment? TJC has revised National Patient Safety Goal (NPSG) 15.01.01. There are seven new and revised elements of performance. We covered this topic in previous posts...
read moreHigh Point Hospital is a freestanding psychiatric hospital located in Middleborough, Massachusetts and serves adults and adolescents. The hospital is Joint Commission accredited and CMS certified and we are pleased to work with them on continuous regulatory...
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Are you up to speed on how CMS is instructing its surveyors to cite Immediate Jeopardy? Effective March 5, 2019, CMS revised its surveyor guidelines for citing cases of Immediate Jeopardy. The goal is to make decisions about Immediate Jeopardy more consistent across...
read moreKindred Hospital – Chicago North in Chicago, Illinois is a transitional care hospital which includes a Behavioral Health Unit. The hospital is Joint Commission accredited and CMS certified and we are pleased to work with them on continuous regulatory...
read moreTimberline Knolls Residential Treatment Center in Lemont, Illinois provides treatment for eating disorders, addictions, mood disorders and trauma. The program is Joint Commission accredited and we are pleased to work with them on ongoing accreditation compliance and...
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Heads up for behavioral healthcare organizations surveyed under the Behavioral Health Care standards! TJC just issued an important clarification on revised National Patient Safety Goal 15.01.01 for non-inpatient BH settings. Revised NPSG.15.01.01 The revised National...
read moreBrookhaven Hospital in Tulsa, Oklahoma provides a range of inpatient behavioral and neuro-behavioral health programs and services. The hospital is Joint Commission accredited and CMS certified and we are pleased to work with them on continuous regulatory...
read moreThe Motion Picture and Television Fund Center for Behavioral Health in Woodland Hills, CA provides inpatient behavioral health treatment for older adults. MPTF’s core constituency is the entertainment community but services are also available to the community at...
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Is your organization surveyed under The Joint Commission’s Behavioral Health Care standards? If so, be aware of new requirements effective July 1, 2019 related to pain assessment and pain management. First, let’s review the current...
read moreSunrise Recovery in Clarksville, Indiana provides medical detoxification, partial hospitalization, and residential treatment services. Sunrise Recovery is seeking initial Joint Commission accreditation and we are pleased to support them in achieving that goal.
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Have you seen The Joint Commission’s latest FAQs on ligature risks? In January, TJC published three new FAQs on this topic. One is particularly noteworthy since it involves somewhat of an easing of TJC’s original position. So, let’s cover that one first. Ligature...
read moreWellpath Recovery Solutions headquartered in Nashville, Tennessee, provides medical and behavioral healthcare through a family of local and state providers in correctional facilities, state psychiatric hospitals, forensic treatment facilities and civil commitment...
read moreKingwood Pines Hospital in Houston, Texas offers inpatient psychiatric and chemical dependency services as well as partial hospitalization and outpatient programs. The hospital is Joint Commission accredited and CMS certified and we are pleased to work with them on...
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Wondering how The Joint Commission’s emphasis on a culture of safety will impact your survey? We’re getting feedback on recent surveys and it’s clear this is a top priority for TJC. Culture of Safety: Important Focus Area TJC is actively promoting the establishment of...
read moreNUWAY in Minneapolis, Minnesota serves individuals recovering from co-occurring substance abuse and mental health disorders. NUWAY offers residential and outpatient care and is pursuing initial Joint Commission accreditation. We are pleased to support them in...
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In our last post, TJC Survey Outcomes: Update on 2018 Trends, we gave you the scoop on the 2018 survey outcomes for psychiatric hospitals. This time, we’re sharing similar data for behavioral healthcare organizations surveyed under the Behavioral Healthcare Standards...
read moreCongratulations to our client CenterPointe Hospital Columbia in Columbia, Missouri who recently achieved initial TJC accreditation! The hospital provides inpatient psychiatric and substance abuse services for adolescents and adults. Congratulations to the CenterPointe...
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So, you survived your latest TJC survey! You’ll tackle your deficiencies and maybe prepare for a follow-up survey. But you’re curious how your results compare to other organizations. TJC recently shared updated aggregate data with members of the Consultants Forum....
read moreCongratulations to our client Rainier Springs in Vancouver, Washington who recently achieved initial TJC accreditation! The hospital provides inpatient, PHP, and IOP services and is part of Springstone Inc. Congratulations to the Rainier Springs team on achieving the...
read moreUniversity of Maryland Medical System – Capital Region Health provides behavioral health services at UM Prince George’s Hospital Center and UM Laurel Medical Center. The hospitals are TJC accredited and CMS certified and we’re pleased to work with their BH programs on...
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“Oh, no! The surveyors cited us again for treatment planning.” It’s an all-too-common refrain following a Joint Commission or CMS survey. Sure, it’s frustrating and, yes, there is surveyor variability. But if you tackle the the most common pitfalls,...
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Is your organization ready for the revised NPSG.15.01.01 effective July 1, 2019? There are new and expanded requirements you’ll need to address. We reviewed these in our recent post NPSG.15.01.01: Changes Coming in 2019. This month, we’re responding to questions from...
read moreNorth Spring Behavioral Healthcare in Leesburg, VA provides a full continuum of services including inpatient acute, residential, PHP, and IOP. North Spring is TJC accredited and licensed by Virginia Department of Behavioral Health and Developmental Services. We’re...
read moreRainier Springs is a newly opened behavioral hospital in Vancouver, Washington providing inpatient, PHP, and IOP services. Rainier Springs is part of Springstone, Inc. with headquarters in Louisville, Kentucky. We’re pleased to have worked with Rainier Springs on...
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The Joint Commission’s SAFER matrix – that colorful grid displaying survey findings – we’ve all become accustomed to it. But how does it impact the survey process? And how is the scoring shaking out for psychiatric hospitals and behavioral...
read moreMesilla Valley Hospital in Las Cruces, New Mexico provides a full continuum of mental health and addiction treatment to adults and adolescents. The hospital is Joint Commission accredited and CMS certified and we are pleased to work with them on continuous regulatory...
read moreMontefiore Nyack Hospital in Nyack, New York is an acute care hospital that offers addiction treatment and behavioral health services. The hospital is Joint Commission accredited and CMS certified and we are pleased to work with them on continuous regulatory...
read moreWhiting Forensic Hospital n Middletown, Connecticut specializes in providing inpatient services to individuals involved in the criminal justice system. The hospital is licensed by the State Department of Public Health and we are pleased to work with them on...
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A new study provides the first data driven estimate of the number of suicides in hospitals in the U.S. The study – “Incidence and Method of Suicide in Hospitals in the U.S.”– analyzed national data sets to establish an evidence based estimate of suicides in hospitals...
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Be aware! CMS will now post CMS complaint survey results on their new website. CMS communicated this in their memo QSO-19-01 on October 4th. This means if CMS conducts a complaint survey at an accredited hospital, they will post their official report of findings (the...
read moreCongratulations to our client University of Florida Health – Florida Recovery Center in Gainesville, Florida, who recently achieved initial Joint Commission accreditation. UF Health Florida Recovery Center provides detox, rehab, and PHP/IOP...
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As we know, suicide risk assessment continues to be a high focus area for The Joint Commission. (See our recent posts Suicide Risk Reduction Tracer and High Risk Areas for Joint Commission Surveys.) Accordingly, TJC will further strengthen its approach to suicide...
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At the Consultants Forum meeting in Chicago, Joint Commission COO Mark Pelletier announced an interesting new approach TJC and CMS are piloting. It’s a concurrent validation survey process. This means CMS surveyors conduct their CMS validation survey at the same time...
read moreSUN Behavioral Houston is a 148-bed psychiatric hospital located in the Texas Medical Center in Houston, Texas. The hospital provides a continuum of mental health and substance use services for children, adolescents and adults. SUN Behavioral Houston is Joint...
read moreFort Behavioral Health is a newly opening 125-bed behavioral healthcare facility located in Fort Worth, Texas, and is part of Vizion Health headquartered in Charlotte, North Carolina. Fort Behavioral Health will seek Joint Commission accreditation and we are pleased...
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The Joint Commission has changed its process for complaint reporting. Effective September 1, a Joint Commission employee will no longer answer the complaint line at TJC’s Office of Quality and Patient Safety. Instead, there will be an automated message. Over the...
read moreCenterPointe Hospital in St. Louis, Missouri, provides a continuum of inpatient, residential, and outpatient psychiatric and substance abuse services for adolescents, adults, and seniors. CenterPointe Hospital is TJC accredited and CMS certified and we are pleased to...
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You just received the TJC survey report for your hospital. You have two Condition-Level Deficiencies, and you’re getting a follow-up survey in 45 days. Of course, you’ll develop your Joing Commission corrective action plans and implement the needed fixes. But your...
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Did you know Dr. Mark Chassin, President and CEO of The Joint Commission, recently sent a letter to CEOs of accredited organizations about four areas surveyors will closely scrutinize during Joint Commission surveys? The June 19 letter identifies “four high-risk areas...
read moreBarrins & Associates was pleased to once again attend the Joint Commission Consultants Forum in August at TJC headquarters in Oakbrook Terrace, Illinois. This invitational meeting has now become a twice-yearly event. This time, there were 10 consulting firms in...
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Joint Commission surveys of deemed status psychiatric hospitals include a session for B Tag Medical Record Reviews. In this session, surveyors review a sample of closed medical records to evaluate compliance with the CMS Special Medical Record Requirements for...
read moreCongratulations to our client Generations Behavioral Health in Youngstown, Ohio, who recently achieved initial Joint Commission accreditation. Generations Behavioral Health Youngstown provides inpatient psychiatric services for adults, geriatrics and patients with...
read moreOakwood Springs in Oklahoma City, Oklahoma, is operated by Springstone and provides inpatient and outpatient mental health and addiction treatment for adults and adolescent. Oakwood Springs is TJC accredited and CMS certified. We are pleased to work with our...
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Are you a behavioral healthcare organization or a behavioral healthcare program within a hospital that is surveyed under TJC’s Behavioral Healthcare standards? If so, you should have updated your nutrition screening tool by now to comply with the new 2018...
read moreWindmoor Healthcare in Clearwater, Florida, provides inpatient and outpatient services for adults dealing with behavioral health disorders or substance abuse issues. The hospital is Joint Commission accredited and CMS certified and we are pleased to work with them on...
read moreBon Secours Charity Health System, headquartered in Suffern, New York, includes Bon Secours Community Hospital, Good Samaritan Hospital, and St. Anthony Community Hospital. All hospitals are Joint Commission accredited and CMS certified and we are pleased to work with...
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Infection control issues are high on The Joint Commission’s radar these days. While psychiatric hospitals and behavioral health organizations admittedly do not have the same types of infection control challenges as med/surg hospitals, there are...
read moreAlbert J. Solnit Psychiatric Center – South Campus in Middletown, Connecticut, provides comprehensive care to children and adolescents with severe mental illness and related behavioral problems. Solnit Center – South is Joint Commission accredited and CMS certified...
read moreAcadia Hospital in Bangor, Maine, provides inpatient and outpatient services for children, adolescents, and adults. The hospital is Joint Commission accredited and CMS certified and is a member of Eastern Maine Healthcare Systems. We are pleased to work with Acadia...
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As we track survey results for our clients, we are seeing a recent trend related to trauma assessment and want to make you aware of it. The Joint Commission standard on trauma assessment is in the Behavioral Health manual. It’s standard CTS.02.02.05: “The...
read moreCongratulations to our client True Life Center in San Diego, California, who recently achieved initial Joint Commission accreditation. True Life Center offers an integrative approach to mental health and addiction treatment through its PHP and IOP programs....
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In the July issue of The Joint Commission Perspectives, responses to frequently asked questions from the field were published, relating to the suicide risk recommendations issued over the past several months. Since we’ve received numerous questions from readers...
read moreCongratulations to our client Clifford Beers Clinic in New Haven, Connecticut, who recently achieved initial Joint Commission accreditation. Clifford Beers Clinic provides outpatient mental health services, school-based clinics, and a specialized program for military...
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The Joint Commission recently clarified some of its recommendations regarding ligature risks in the hospital environment. In the July issue of TJC Perspectives, they published responses to a set of FAQs received from the field. Most of the responses are essentially...
read moreWindsor Laurelwood Center for Behavioral Medicine in Willoughby, Ohio offers inpatient psychiatric and chemical dependency services as well as PHP and IOP programs. The hospital is Joint Commission accredited and CMS certified and we are pleased to work with them on...
read moreLinden Oaks Behavioral Health in Naperville, Illinois, provides inpatient and outpatient treatment plus recovery programs for depression, substance abuse, and eating disorders. The hospital is Joint Commission accredited and CMS certified and we are pleased to work...
read moreDenver Springs is a 96-bed behavioral hospital located in Englewood, Colorado. The hospital, operated by Springstone, opened in July 2017 and offers inpatient and outpatient mental health and addiction treatment for adults and adolescents. Denver Springs is TJC...
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Are you a psychiatric hospital that uses your Joint Commission accreditation for deemed status to satisfy Medicare certification requirements? If so, there’s an important new TJC Accreditation Participation Requirement for you to be aware of. Effective July 1, 2018,...
read moreAs we know, TJC has deeming authority from CMS for both acute care hospitals and psychiatric hospitals. As part of its oversight of TJC’s deemed status survey process, CMS conducts validation surveys to assess TJC’s performance in evaluating a hospital’s compliance...
read moreIn our January newsletter, we covered the suicide prevention recommendations issued by TJC earlier this year for non-hospital behavioral health settings. These were published in the January 2018 issue of TJC Perspectives and apply to residential, partial...
read moreBarrins & Associates is very pleased to welcome a new member to our consulting team! Former Joint Commission surveyor Gayle Nash, RN, MPH recently joined us after 13 years as a surveyor for The Joint Commission. She surveyed acute care hospitals, critical access...
read moreVirginia Beach Psychiatric Center in Virginia Beach, Virginia, offers inpatient psychiatric and chemical dependency services as well as a PHP/IOP program. The hospital is Joint Commission accredited and CMS certified and we are pleased to work with them on continuous...
read moreUF Health Florida Recovery Center is an addiction treatment program in Gainesville, Florida, and offers detox, rehab, PHP, and IOP services. UF Health Florida Recovery Center is pursuing initial Joint Commission accreditation and we are pleased to support them in...
read moreHillside Atlanta in Atlanta, Georgia, offers a full continuum of behavioral health services including residential, outpatient, educational, and foster care. Hillside Atlanta is pursuing initial Joint Commission accreditation and we are pleased to support them in...
read moreBlueridge Vista Health & Wellness in Cincinnati, Ohio, is a behavioral health hospital serving the adult and senior population. The hospital is Joint Commission accredited and CMS certified and we are pleased to work with them on continuous regulatory...
read moreWe all know the topic of suicide risk assessment is an important focus of TJC surveys in behavioral health settings — whether it’s an inpatient psychiatric unit or a community-based behavioral health program. You may not, however, be aware that surveyors are...
read moreAre you expecting a TJC survey in 2018? If so, be ready for surveyors to explore how your organization has evaluated its Culture of Safety and what you’ve done with the results of that evaluation. We’ve already seen this occurring in 2018 surveys based on feedback...
read moreBrook Lane in Hagerstown, Maryland, provides a continuum of mental health services for children, adolescents and adults, including inpatient, PHP, outpatient and residential services. The hospital is Joint Commission accredited and CMS certified and we are pleased to...
read moreGreen Hill Recovery in Raleigh, North Carolina, offers integrated sober living and intensive outpatient clinical services to support emerging adults in early recovery as they continue their academic pursuits. Green Hill Recovery is pursuing initial Joint Commission...
read moreTJC has proposed revisions to the current National
read moreMany organizations and programs accredited under TJC’s Behavioral Healthcare standards are striving to implement the new outcomes measurement requirements effective January 2018. (See our October 2017 newsletter.) Several readers have asked what instruments folks are...
read moreWyoming State Hospital in Evanston, Wyoming, provides inpatient psychiatric and medical services for adults as well as criminal justice treatment services. We are pleased to be assisting the hospital with compliance with CMS regulations applicable to its patient...
read moreNewport News Behavioral Health Center in Newport News, Virginia, provides both acute care and residential treatment for children and adolescents including a specialized program for sexually abusive adolescent males. Newport News BH Center is TJC accredited and we are...
read moreWithin its scope of acute care services, MaineGeneral Health provides inpatient psychiatric services at MaineGeneral Medical Center and specialized behavioral health emergency services at two other locations. The hospital is Joint Commission accredited and CMS...
read moreFieldview at Holland is a new substance abuse treatment center opening in Wichita, Kansas, and will provide detox, residential, PHP/IOP, and outpatient services. Fieldview at Holland plans to seek Joint Commission accreditation, and we are pleased to support them in...
read moreIntense scrutiny on ligature risks continues for inpatient psychiatric units, both in freestanding psychiatric hospitals and inpatient psychiatric units of med/surg hospitals. As the field continues to work toward making these settings ligature resistant, it’s...
read moreFor those of you who have organizations and programs surveyed under TJC’s Behavioral Health Care manual, remember there are new requirements effective January 1, 2018, now being surveyed by the BH surveyors. We’ve discussed these in past issues and are summarizing...
read moreSaint Simons By-The-Sea in St. Simons Island, Georgia, is a behavioral health/substance abuse hospital serving adults and young adults. The hospital is Joint Commission accredited and CMS certified, and we are pleased to be working with them on continuous regulatory...
read moreUT Health Harris County Psychiatric Center is part of the University of Texas Health Science Center in Houston. UT Health HCPC provides inpatient and outpatient services and is the largest provider of psychiatric care in Houston. The hospital is Joint Commission...
read moreOak Hills Behavioral Center in Jackson, Tennessee, is operated by WoodRidge Behavioral Care and provides inpatient psychiatric services to senior adults and now to children and adolescents as well in its new child/adolescent unit. The hospital is Joint Commission...
read moreRiverVista Health & Wellness in Columbus, Ohio, is a new behavioral health hospital planning to open in spring 2018. The hospital will serve adults and seniors, and we are pleased to work with them in preparation for TJC accreditation.
read moreClearVista Health & Wellness in Lorain, Ohio, is a behavioral health hospital serving the adult and senior population. The hospital is Joint Commission accredited and CMS certified and we are pleased to be working with them on continuous regulatory...
read moreWe were pleased to once again attend the TJC Consultants Forum last month at their headquarters in Oakbrook Terrace, Illinois. The meeting is an annual invitational event and there were 12 consulting firms represented. We heard several informative updates on TJC...
read moreBe prepared for increased scrutiny and more stringent scoring of hand hygiene compliance during your next TJC survey. Effective January 1, 2018, if a surveyor observes an individual staff person failing to perform hand hygiene during direct patient care, this single...
read moreSierra Vista Hospital in Sacramento, California, provides a full range of inpatient and outpatient psychiatric services for adolescents and adults as well as an inpatient alcohol detox program. The hospital is Joint Commission accredited and CMS certified and we are...
read moreGenerations Behavioral Health in Youngstown, Ohio, is a newly opening psychiatric hospital and will have 76 beds serving geriatric, adult, and dual diagnosis patients. Generations BH is seeking initial TJC accreditation and we are pleased to support them in achieving...
read moreDorothea Dix Psychiatric Center in Bangor, Maine, is a 51-bed, state-operated, inpatient psychiatric hospital serving adults with serious, persistent mental illness. The hospital is Joint Commission accredited and CMS certified and we are pleased to be working with...
read moreCMS Memo As you are well aware, psychiatric hospitals and inpatient psychiatric units of med/surg hospitals continue to grapple with the challenge of eliminating suicide risks in their environment and how this will be evaluated during TJC surveys. TJC has been working...
read moreTJC’s new pain management standards are effective January 1, 2018, for all hospitals including psychiatric hospitals. As the 2018 surveys unfold, we expect to see significant emphasis on these new requirements. The following is a summary of key...
read moreCongratulations to our client Riverside Recovery in Tampa, Florida, who recently achieved initial Joint Commission accreditation. Riverside Recovery is a newly opened substance abuse treatment center serving individuals with chemical dependency and co-occurring mental...
read moreSobriety Solutions offers evidence-based, intensive outpatient addiction treatment at its two locations in Plymouth Meeting, Pennsylvania, and Sicklerville, New Jersey. Sobriety Solutions is seeking initial TJC accreditation and we are pleased to support them in...
read moreThe Pavilion at Williamsburg Place is a 57-bed, inpatient psychiatric hospital serving adults and older adults in their Acute Program and Mood Disorders Program. The hospital is Joint Commission accredited and CMS certified and we are pleased to be working with them...
read moreRiverview Psychiatric Center in Augusta, Maine, is a 92-bed, state-operated inpatient psychiatric hospital serving adults with serious, persistent mental illness and co-occurring substance use disorders. The hospital is Joint Commission accredited and CMS certified...
read moreGenerations Healthcare Network, headquartered in Lincolnwood, Illinois, operates five Specialized Mental Health Rehabilitation facilities in the Chicago area which provide long term mental health care for adults. These five facilities are seeking initial TJC...
read moreCedar Springs Hospital in Colorado Springs, Colorado, provides acute and residential inpatient psychiatric treatment as well as partial hospitalization and intensive outpatient programs and serves children, adolescents, adults, and seniors. The hospital is Joint...
read moreAnchor Hospital in Atlanta, Georgia, is a 122-bed psychiatric hospital specializing in the treatment of behavioral health and addiction disorders for adults and older adults. The hospital is Joint Commission accredited and CMS certified and we are pleased to be...
read moreThe topic of ligature risks in inpatient psychiatric settings has been a significant challenge for the industry over the past several months following TJC’s increased scrutiny of this issue since March 1st. The latest development is that TJC has now published official...
read moreCongratulations to our client Monarch in North Carolina who recently achieved initial Joint Commission accreditation. Monarch provides services statewide to people with developmental disabilities, mental illness, and substance use disorders. Impressively, 142...
read moreAxis Mental Health in Newport Beach, California, provides a wide range of outpatient mental health services for adults. Axis Mental Health is seeking initial TJC accreditation and we are pleased to support them in achieving that goal.
read moreWellBridge Hospital Fort Worth in Fort Worth, Texas, provides inpatient and IOP services for seniors as well as mental health services in skilled nursing facilities. The hospital is Joint Commission accredited and CMS certified and we are pleased to be working with...
read moreChicago Behavioral Hospital in Des Plaines, Illinois, provides inpatient mental health and substance services as well as IOP services. The hospital is Joint Commission accredited and CMS certified and we are pleased to be working with them on continuous regulatory...
read moreRiverside Recovery in Tampa, Florida, is a newly opened substance abuse treatment center serving individuals with chemical dependency and co-occurring mental health disorders. Riverside Recovery is seeking initial TJC accreditation and we are pleased to support them...
read moreMaine Behavioral Healthcare provides a continuum of inpatient and outpatient behavioral health services throughout the state. We are pleased to be working with Spring Harbor Hospital and the inpatient services at Pen Bay Medical Center, Southern Maine Healthcare, and...
read moreMt. Sinai Hospital, Mt. Sinai West, and Mt. Sinai St. Luke’s in New York City provide inpatient psychiatric services and psychiatric emergency services as part of the Mt. Sinai Behavioral Health System. The hospitals are Joint Commission accredited and CMS certified...
read moreA significant topic of interest at the annual TJC Behavioral Healthcare Conference in Chicago this month was the new requirements going into effect in January 2018 related to outcomes measurement. These requirements apply to organizations and programs surveyed under...
read moreA hot topic at the annual Behavioral Healthcare Conference in Chicago this month was TJC’s update on how they are surveying ligature risks in psychiatric hospitals and psychiatric units of med/surg hospitals. As readers know from our newsletter articles and their own...
read moreCongratulations to our client La Luna Center in Boulder, Colorado who recently achieved initial Joint Commission accreditation. La Luna is a specialized eating disorder treatment center and provides IOP and outpatient services. Congratulations to the La Luna team on...
read moreCongratulations to our client Enterhealth Ranch Addiction Treatment in Dallas, Texas who recently achieved initial Joint Commission accreditation. Enterhealth provides science-based addiction treatment in its residential and outpatient programs. Congratulations to the...
read moreCongratulations to our client Clearview Treatment Programs in Venice, California who recently achieved initial Joint Commission accreditation. Clearview offers residential and day treatment as well as outpatient services for a variety of addiction and mental health...
read moreRidgeview Institute in Smyrna, Georgia, provides a continuum of inpatient and outpatient mental health and addiction services to adolescents, adults and senior adults. The hospital is Joint Commission accredited and CMS certified and we are pleased to be working with...
read moreFairmount Behavioral Health System in Philadelphia, Pennsylvania, offers a range of inpatient psychiatric and chemical dependency services as well as PHP services for children, adolescents, and adults. The hospital is Joint Commission accredited and CMS certified and...
read morePeople Encouraging People (PEP) in Baltimore, Maryland, is a non-profit behavioral healthcare organization providing rehabilitation and support services to individuals who are disabled or disadvantaged. PEP is Joint Commission accredited and we are pleased to be...
read moreFremont Hospital in Fremont, California, offers a continuum of inpatient, PHP, and IOP services for children, adolescents, and adults. The hospital is Joint Commission accredited and CMS certified and we are pleased to be working with them on continuous regulatory...
read moreSmokey Point Behavioral Hospital in Maryville, Washington, opened in June 2017 and provides behavioral health and addiction treatment services to children, adolescents, adults and senior adults. The hospital is Joint Commission accredited and CMS certified and we are...
read moreAs we know, there is currently an intense focus during TJC surveys on compliance with the CMS CoP for Special Medical Records Requirements for Psychiatric Hospitals (B Tags.) During surveys of psychiatric hospitals, there is a session designated for review of a sample...
read moreThe Behavioral Health Care Accreditation manual has undergone some revisions over the past several months as part of TJC’s Standards Review Project. The final round of changes is now complete and will be effective January 2018. Highlights of these final revisions are...
read moreCongratulations to our client Appliedtx in Los Angeles, California who recently achieved initial Joint Commission accreditation. Appliedtx provides addiction and dual diagnosis outpatient treatment for adults with substance abuse and co-occurring disorders....
read moreCongratulations to our client Potomac Pathways in Cabin John, Maryland who recently achieved initial Joint Commission accreditation. Potomac Pathways offers treatment programs for young adults facing substance abuse and mental health challenges. Congratulations to the...
read moreDiamond Healthcare, headquartered in Richmond, Virginia, provides a wide variety of management and consulting services for the behavioral healthcare industry. We are pleased to be working with the Diamond Healthcare leadership team to support the services they provide...
read moreMaine Medical Center in Portland, Maine, provides inpatient psychiatric services on its specialized geropsychiatric unit and is part of Maine Behavioral Healthcare. Maine Medical Center is Joint Commission accredited and CMS certified and we are pleased to be working...
read moreMt. Sinai Beth Israel Hospital in New York City provides inpatient psychiatric services and a Comprehensive Psychiatric Emergency Program and is part of the Mt. Sinai Behavioral Health System. The hospital is Joint Commission accredited and CMS certified and we are...
read moreUniversity Behavioral Center in Orlando, Florida, provides intensive mental health services for children, adolescents, and adults as well as detox and substance abuse programs for adults. The hospital is Joint Commission accredited and CMS certified and we are pleased...
read moreAs many of you know, the surveying of ligature risks in psychiatric hospitals has almost taken on a life of its own over the past four months. So, in follow-up to our June article on ligature risks, we’re providing some timely feedback from clients about how this...
read moreCongratulations to our client Beachside Recovery in Newport Beach, California, who recently achieved initial Joint Commission accreditation. Beachside Recovery provides a full range of detox, inpatient, and outpatient substance abuse treatment. Congratulations to the...
read moreSpring Harbor Hospital in Westbrook, Maine, offers inpatient psychiatric services for children, adolescents, and adults as well as outpatient services. The hospital is Joint Commission accredited and CMS certified and we are pleased to be working with the Spring...
read moreIf you are a psychiatric hospital anticipating a TJC survey, it’s important to know the details of how TJC is currently surveying ligature risks. They recently provided an update for the field on this topic in follow-up to their March 2017 communication on the scoring...
read moreTwenty-two percent of behavioral health organizations surveyed in 2016 received a survey finding related to competence assessment. Frequently, the finding relates to a staff person or contractor not having their clinical competence assessed by an individual qualified...
read moreCongratulations to our client Casa de Amparo in San Diego, California, who recently achieved initial Joint Commission accreditation. The organization provides child abuse prevention services through its residential, counseling, family visitation, and other support...
read moreBarrins & Associates is pleased to be working in partnership with DCCS Consulting to support the regulatory readiness needs of their client Anoka-Metro Regional Treatment Center in Anoka, Minnesota. AMRTC is a state operated psychiatric hospital providing...
read moreQuail Run Behavioral Health in Phoenix, Arizona, offers inpatient psychiatric treatment for adolescents, adults, and older adults. The hospital is Joint Commission accredited and CMS certified and we are pleased to be working with them on continuous regulatory...
read moreValley Hospital in Phoenix, Arizona, offers inpatient and PHP/IOP mental health and chemical dependency services for adults, including a military program and a specialized women’s unit. The hospital is Joint Commission accredited and CMS certified and we are pleased...
read morePsychiatric hospitals that use TJC accreditation for CMS deemed status were the first organizations to experience the SAFER (Survey Analysis for Evaluating Risk) methodology starting in June 2016. TJC recently published six months of compliance data for these...
read moreAs you know, TJC began surveying to the 2012 edition of the National Fire Protection Life Safety Code in November 2016. Resulting changes to the Environment of Care and Life Safety standards went into effect January 2017. (See the November 2016 issue of TJC...
read moreCongratulations to our client The Foundry Treatment Center in Steamboat Springs, Colorado, who recently achieved initial Joint Commission accreditation. The program offers a holistic approach to addiction treatment and provides detox, residential, and outpatient...
read moreWellbridge Hospital of Plano in Plano, Texas provides inpatient psychiatric services for adults age 50 and over. The hospital is Joint Commission accredited and CMS certified and we are pleased to be working with them on continuous regulatory readiness.
read moreHorsham Clinic in the Philadelphia area offers inpatient and PHP mental health and chemical dependency treatment services for children, adolescents, and adults. The hospital is Joint Commission accredited and CMS certified and we are pleased to be working with them on...
read moreThe Discovery House is a full service drug addiction treatment center in Los Angeles that serves individuals struggling with drug and alcohol addiction. The Discovery House is Joint Commission accredited and we are pleased to be working with them on continuous...
read moreTJC has published proposed revisions to the National Patient Safety Goal (NPSG) on suicide risk assessment for both the Hospital Accreditation Program and the Behavioral Health Care Accreditation Program. The proposed revisions are out for field comment which ends on...
read moreAs we review survey results for our clients surveyed under TJC’s Behavioral Health standards, we see the issue of psychiatric advance directives (PADs) being cited more frequently so thought it was time for a refresher on this topic. The standard regarding PADs is in...
read moreCongratulations to our client Sober College in Woodland Hills, California, who recently achieved initial Joint Commission accreditation. Sober College provides detox, residential, outpatient, and sober living services for young adults. Congratulations to the Sober...
read moreCongratulations to Oakwood Springs Hospital who recently achieved initial Joint Commission accreditation. Oakwood Springs is a 72-bed behavioral hospital in Oklahoma City, Oklahoma providing inpatient and outpatient treatment for adults and seniors. The hospital is...
read moreSacred Oak Medical Center is a newly opening psychiatric hospital in Houston, Texas. The hospital will provide inpatient psychiatric and chemical dependency treatment as well as PHP and IOP services. Sacred Oak Medical Center will be seeking TJC accreditation and we...
read moreSana Behavioral Health in Las Vegas, Nevada is a newly opening psychiatric hospital. The hospital is managed by ER Hospitals and will provide inpatient psychiatric services for older adults. Sana Behavioral Health will be seeking TJC accreditation and we are pleased...
read moreMillwood Hospital in Arlington, Texas, offers inpatient, PHP, and IOP mental health and chemical dependency treatment services for children, adolescents, and adults. The hospital is Joint Commission accredited and CMS certified and we are pleased to be working with...
read moreCopper Springs is a 72-bed behavioral hospital located in the Phoenix, Arizona area. The hospital, operated by Springstone, opened in May 2016 and offers inpatient and outpatient mental health and addiction treatment to adults and seniors. Copper Springs is TJC...
read moreThe Joint Commission recently announced that it is increasing scrutiny during surveys on ligature, suicide and self-harm risks in psychiatric hospitals and inpatient psychiatric units of med/surg hospitals. Specifically, TJC surveyors will document in their report all...
read moreHere’s some news and updates to keep you informed on what’s going on in the BHC Accreditation Program: New Executive Director Julia Finken, BSN, MBA, CPHQ, CSSBB is the new Executive Director of Behavioral Health Care and Psychiatric Hospital Accreditation for TJC....
read moreCongratulations to our client, GenPsych, who recently achieved initial Joint Commission accreditation. GenPsych offers mental health and substance abuse services including Partial Care, IOP, and outpatient services at four locations throughout New Jersey. Kudos to the...
read moreStuyvesant Square Chemical Dependency Service at Mt. Sinai Beth Israel Medical Center in New York City provides inpatient detox and rehabilitation services as well as ambulatory detox and day treatment services. The program is TJC accredited and we are pleased to be...
read moreLaurel Heights Hospital in Atlanta, Georgia, is a child/adolescent behavioral health facility offering residential treatment, inpatient acute services, and therapeutic foster care. Laurel Heights is TJC accredited and CMS certified and we are pleased to be working...
read moreThe Kiloby Center for Recovery in Rancho Mirage, California, provides detox, day treatment, and intensive outpatient services. They are TJC accredited and we are pleased to be working with them on continuous readiness.
read moreThe Sanctuary at the Woodlands in Cullman, Alabama, is a freestanding psychiatric hospital providing inpatient treatment for adults and geriatrics. The hospital is CMS certified and is pursing initial TJC accreditation. We are pleased to support them in achieving that...
read moreBe aware there are some revisions coming to the Care, Treatment, and Services chapter of the Behavioral Health Care Manual effective July 1, 2017. One is a fairly substantive addition to treatment planning requirements and the other is a wording clarification...
read moreFrom time to time, we update our readers on standards compliance requirements related to commonly challenging issues we see coming up on surveys. So, take a look at the following and make sure these don’t become survey pitfalls for you: Vaccine Storage TJC agrees with...
read moreCongratulations to our client A Mission for Michael in San Clemente, California, who recently achieved initial Joint Commission accreditation. AMFM is a dual diagnosis substance abuse treatment center providing a continuum of addiction treatment services for men....
read moreFirst Steps Recovery in Clovis, California, offers drug/alcohol detox and residential services through its Wilderness Treatment Services. First Steps Recovery is pursuing initial TJC accreditation and we are pleased to support them in achieving that goal.
read moreTaraVista Behavioral Health Center in Devens, Massachusetts, is a freestanding psychiatric hospital providing inpatient treatment for adults. The hospital recently received its TJC accreditation and we are pleased to be working with them on continuous readiness and...
read moreTJC has approved revisions to the standard in the Behavioral Health manual related to outcomes measurement. The revisions require BH organizations/programs to assess outcomes of care, treatment or services by using a standardized tool and go into effect January 1,...
read moreIn our October 2016 newsletter, we covered the new TJC requirements on antimicrobial stewardship. Now, it’s clear that TJC is incorporating a significant emphasis on this topic into the 2017 survey process for hospitals. The recently released 2017 Survey Activity...
read moreCongratulations to our client ASAP Rehab in Pasadena, California, who recently achieved initial Joint Commission accreditation! ASAP Rehab provides detox and residential alcohol and substance abuse treatment services. Kudos to the ASAP Rehab team on achieving the gold...
read moreShoreline Treatment in San Clemente, California, offers residential detox services. Shoreline Treatment is pursuing initial TJC accreditation and we are pleased to support them in achieving that goal.
read moreBeach City Treatment in Huntington Beach, California, offers residential detox services. Beach City Treatment is pursuing initial TJC accreditation and we are pleased to support them in achieving that goal.
read moreMichigan Modern Psychology offers psychological evaluations and outpatient therapy for all age groups at its five locations in southeastern Michigan. Michigan Modern Psychology is pursuing initial TJC accreditation and we are pleased to support them in achieving that...
read moreThere are some significant changes to survey reports, scoring of standards, and the post-survey response process that go into effect in January 2017 for behavioral health organizations. These changes have been in effect for psychiatric hospitals since June 2016 and...
read moreFor many years, TJC has had a process whereby an organization can request to “clarify” a survey finding. The clarification process is used when the organization believes that it was actually in compliance with the applicable standard at the time of the survey and thus...
read moreCongratulations to our client NorthStar Transitions who recently achieved initial Joint Commission accreditation! NorthStar Transitions is a young adult extended care substance abuse treatment and sober living program serving the Boulder and Denver, Colorado,...
read moreCarrier Clinic in Belle Mead, New Jersey, offers a full continuum of inpatient, residential, and outpatient psychiatric and substance abuse services to adolescents and adults. The hospital is TJC accredited and CMS certified and we are pleased to work with the Carrier...
read moreCottonwood Springs is a newly constructed, 72-bed behavioral hospital in Olathe, Kansas. The hospital provides a full continuum of inpatient and outpatient mental health and substance abuse treatment for adults and their families. The hospital is TJC accredited and...
read moreIn July, 2016 TJC introduced its new standard on antimicrobial stewardship. The standard is contained in the Medication Management chapter (MM.09.01.01) of the Hospital manual and goes into effect January 1, 2017. At first, it might seem that this new standard...
read moreMany substance abuse programs across the country operate sober living houses as part of their continuum of care. A sober living house is commonly defined as an alcohol and drug free living environment for individuals attempting to maintain abstinence from alcohol and...
read moreCongratulations to our client Surf City Recovery in Huntington Beach, California, who recently received initial Joint Commission accreditation! Surf City Recovery offers drug rehabilitation services including PHP, IOP, and an outpatient program. Kudos to the Surf City...
read moreTwo Rivers Behavioral Health System in Kansas City, Missouri, offers inpatient psychiatric and chemical dependency treatment for children, adolescents and adults as well as PHP and IOP services. Two Rivers Behavioral Health System is TJC accredited and CMS certified...
read moreREBOS in Los Angeles, California, provides PHP, IOP, and Outpatient substance abuse services as well as two sober living homes. REBOS is Joint Commission accredited and we are pleased to support their continuous readiness program!
read moreEnterhealth Ranch Addiction Treatment is located in Van Alstyne, Texas (north of Dallas), and offers science-based addiction treatment in its residential and outpatient programs. Enterhealth is pursuing initial Joint Commission accreditation and we are pleased to...
read moreEffective August 1, 2016, TJC added three additional policies to the list of documents required for hospitals on the first day of survey. These have been added to the Hospital Accreditation Program Document List in the updated Survey Activity Guide and are...
read moreThe Joint Commission requirements for behavioral health organizations to implement influenza vaccination programs went into effect in 2012 and were expanded in 2013. Most BH organizations now have a process for offering influenza vaccination and educating staff about...
read moreCongratulations to our client, Renaissance Ranch Outpatient Treatment in Salt Lake City, Utah, who recently achieved initial Joint Commission accreditation! Renaissance Ranch provides IOP, sober living, and a family program. Kudos to Renaissance Ranch on achieving the...
read moreCongratulations to our client, The Teen Project in Rancho Santa Margarita, California, who recently achieved initial Joint Commission accreditation! The Teen Project serves teens aging out of the foster care system. Kudos to The Teen Project on achieving the gold...
read moreCongratulations to our client, Steps to Recovery in Levittown, Pennsylvania, who recently achieved initial Joint Commission accreditation! StR offers detox, residential, PHP, and extended care options. Kudos to the StR team on achieving the gold standard of TJC...
read moreMonarch is headquartered in Albemarle, North Carolina, and provides mental health services and intellectual/developmental disabilities services to multiple counties throughout the state. Monarch is pursuing initial Joint Commission accreditation and we are pleased to...
read moreRiver Point Behavioral Health in Jacksonville, Florida, offers inpatient psychiatric and chemical dependency treatment for adolescents and adults as well as PHP and ECT services. River Point Behavioral Health is TJC accredited and CMS certified and we are pleased to...
read moreThe Foundry Treatment Center in Steamboat Springs, Colorado, offers a holistic approach to addiction treatment and provides detox, residential, and outpatient services. The Foundry is pursuing initial Joint Commission accreditation and we are pleased to support them...
read morePotomac Pathways in Cabin John, Maryland, offers a variety of clinical treatment programs for teens and young adults facing substance abuse and mental health challenges. Potomac Pathways is pursuing initial Joint Commission accreditation and we are pleased to support...
read moreIf you are a psychiatric hospital using TJC accreditation for deemed status, you know that TJC recently implemented some significant changes to its survey process and scoring methodology. These include closer scrutiny of the two Special Conditions of Participation...
read moreTJC has published proposed standards revisions related to outcomes measurement for the Behavioral Health Accreditation Program . Currently, there is one standard in the Behavioral Health manual related to outcomes. That standard is CTS.03.01.09 which requires BH...
read moreCongratulations to our client Sobertec in San Clemente, California, who recently achieved initial Joint Commission accreditation! Sobertec offers detox, transitional living, and IOP services. Kudos to Sobertec on achieving the gold standard of TJC...
read moreArbour Health System in Massachusetts offers a full continuum of psychiatric services and all AHS hospitals are TJC accredited and CMS certified. We are pleased to be working with Arbour Hospital, Pembroke Hospital, Lowell Treatment Center, and Westwood Lodge on...
read moreSober College in Woodland Hills Los Angeles, California, provides drug and alcohol treatment services for young adults and offers detox, residential, outpatient, and sober living services. Sober College is pursuing initial Joint Commission accreditation and we are...
read moreFairfax Hospital in Kirkland, Washington, offers a full continuum of inpatient and PHP services for adolescents and adults. Fairfax Hospital is TJC accredited and CMS certified, and we are pleased to be working with them on continuous regulatory readiness.
read morePsychiatric hospitals that use TJC accreditation for deemed status and have been surveyed in the last few months have experienced a shift in focus. Many report that their recent TJC survey felt more like a CMS survey. That’s because TJC surveyors now have a mandate to...
read moreAs we track survey results for our clients, we see that some behavioral health organizations continue to be challenged by the TJC requirements for trauma assessment. There have been several survey findings on this topic in 2015 and 2016. So, let’s recap the...
read moreCongratulations to our client Halcyon Horizons, who recently achieved initial Joint Commission accreditation! Halcyon Horizons offers detox, bio-physical cleansing, as well as therapy and life skills training in its residential programs in Santa Cruz and South Lake...
read moreSunspire Health Astoria Pointe in Astoria, Oregon, provides detox, residential, PHP, and IOP services for substance abuse and co-occurring mental health disorders. Sunspire Astoria Pointe is part of Sunspire Health, a national network of addiction treatment providers....
read moreD’Veal Family & Youth Services in Pasadena, California, provides mental health services, family preservation services, and a specialized Fatherhood program. D’Veal is pursuing initial Joint Commission accreditation and we are pleased to support them in achieving...
read moreClifford Beers Clinic in New Haven, Connecticut, offers outpatient mental health services, school based clinics, and a specialized program for military families. Clifford Beers Clinic is pursuing initial Joint Commission accreditation and we are pleased to support...
read moreCasa de Amparo in San Diego, California, provides child abuse prevention services through its residential, counseling, family visitation, and other support services and programs. Casa de Amparo is pursuing initial Joint Commission accreditation and we are pleased to...
read moreIn recent newsletters, we’ve been keeping you updated on changes to the scoring methodology and survey process for psychiatric hospitals that use TJC accreditation for deemed status. (See our March and April newsletters.) As previously discussed, the changes to the...
read moreUp until now, it has been TJC’s position that the texting of orders did not meet TJC standards. Effective May, 2016, TJC has updated this position and will now allow the texting of orders provided that certain features are in place. First and foremost, the text...
read moreCongratulations to our client CASA Recovery in San Juan Capistrano, California who recently achieved initial Joint Commission accreditation! CASA Recovery offers detox, residential, counseling, holistic treatment, specialized tracks, and outpatient services. Hats off...
read moreCongratulations to our client A Better Way in Berkeley, California who recently achieved initial Joint Commission accreditation! A Better Way offers behavioral health, foster-adoption, family strengthening, and parent advocacy services to children and families in the...
read moreShadow Mountain Behavioral Health System in Tulsa, Oklahoma, offers a full continuum of inpatient and outpatient psychiatric services as well as residential treatment, ECT and therapeutic foster care. SMBHS is TJC accredited and CMS certified and we are pleased to be...
read moreThe Peninsula Regional Medical Center Behavioral Health Program (operated by Adventist Behavioral Health) in Salisbury, Maryland, provides inpatient psychiatric services, a PHP, and evaluation services in the Emergency Department. PRMC is TJC accredited and we are...
read moreCasa Pacifica Centers for Children & Families in Camarillo, California, provides a wide range of residential, therapeutic, and educational services to children and families in both community based and in-home settings. Casa Pacifica is pursuing initial Joint...
read moreAs reported in our March newsletter, significant changes are occurring to the TJC accreditation process for psychiatric hospitals. TJC recently sent an email to all psychiatric hospitals that use accreditation for deemed status. It outlined the changes to survey...
read moreDuring recent consultations, we’ve noticed that some organizations haven’t updated their sentinel event policy to include all the current TJC requirements. So, the following is a recap of TJC requirements related to sentinel events. In 2013, TJC expanded its Sentinel...
read moreBarrins & Associates is very pleased to welcome Dr. Kevin Huckshorn as a new member of our consulting team! Dr. Huckshorn’s experience includes her six-year tenure as Director of the Division of Substance Abuse and Mental Health for the state of Delaware. She...
read moreClearview Treatment Programs in Venice, California, offers residential and day treatment as well as outpatient services for a variety of addiction and mental health disorders. Clearview is pursuing initial Joint Commission accreditation and we are pleased to support...
read moreEl Paso Behavioral Health System in El Paso, Texas, offers a full continuum of inpatient and outpatient psychiatric and substance abuse treatment as well as ECT services. The hospital is TJC accredited and CMS certified and we are pleased to be working with them on...
read moreBancroft Rehabilitation Services in Cherry Hill, New Jersey, offers a residential behavioral stabilization program and a pediatric transitional program for children with developmental disabilities. Bancroft Rehabilitation Services is TJC accredited and we are pleased...
read moreIf you are a psychiatric hospital that uses TJC accreditation for deemed status, you probably received an email communication recently from TJC entitled “Important Update on The Joint Commission Accreditation Process for Psychiatric Hospitals.” This notification...
read moreScheduling of Behavioral Health Surveys Initial Surveys The TJC BH Accreditation Program has seen a significant increase in applications for BH accreditation. In speaking recently with Tracy Collander Executive Director of the BH Accreditiaotn Program, she indicated...
read moreCongratulations to our client Positive Sobriety Institute in Chicago, Illinois, who recently achieved initial Joint Commission accreditation! Positive Sobriety Institute, a program of RiverMend Health, provides addiction assessment, rehabilitation, and recovery...
read moreCongratulations to our client Bluff Plantation in Augusta, Georgia, who recently achieved initial Joint Commission accreditation! Bluff Plantation, a program of RiverMend Health, is a comprehensive residential addiction recovery program. Kudos to RiverMend Health and...
read moreCongratulations to our client Akua Mind and Body in Orange County, California who recently achieved initial Joint Commission accreditation! Akua Mind & Body provides comprehensive, holistic addiction treatment including detox, day treatment, IOP, and sober living...
read moreRenaissance Ranch Outpatient Treatment in Salt Lake City, Utah, offers intensive outpatient substance abuse treatment including specialized programs for men and women, a family program, and a sober living home. We are pleased to be working with this organization on...
read moreBehavioral Health Partners of Frederick is a joint program of Sheppard Pratt Health System and Frederick Regional Health System and offers outpatient mental health services at three clinics in Frederick County, Maryland. We are pleased to be working with this...
read moreBeachside Recovery is located in Newport Beach, California, and provides a full range of detox, inpatient and outpatient substance abuse treatment. We are pleased to be working with Beachside on Joint Commission readiness!
read moreThe Joint Commission Center for Transforming Healthcare recently made available the Oro 2.0 High Reliability Organizational Assessment. The assessment is an online tool designed to assist hospitals in evaluating their progress toward high reliability and support them...
read moreEffective July 1, 2016, TJC’s Behavioral Health Care Accreditation Program will include standards for case management services provided to individuals being served in a Housing First program. The new standards are designed to assist individuals with serious mental...
read moreWe were pleased to attend the 2016 Consultants Forum sponsored by TJC last month at their headquarters in Oakbrook Terrace, Illinois. The meeting is an invitational event and there were 12 consulting firms represented. We were briefed on the latest TJC initiatives and...
read moreCongratulations to our client SoCal Detox in San Clemente, California, who recently achieved initial Joint Commission accreditation! SoCal Detox provides medically managed detoxification services in two residential settings. Kudos to the SoCal team on achieving the...
read moreCongratulations to our client Silver Rock Recovery in Las Vegas, Nevada, who recently achieved initial Joint Commission accreditation! Silver Rock Recovery is a specialized men’s addiction treatment program that offers detox, residential treatment, PHP, IOP, and...
read moreThe Teen Project is located in Rancho Santa Margarita, California, and serves teens aging out of the foster care system. Services include a residential program, a drop-in center, and other supports and resources to help clients transition into a successful adult life....
read moreAffinity Recovery is a substance abuse program located in Orange County, California. The program provides clinically managed detox services in a residential setting. Affinity Recovery is pursuing initial Joint Commission accreditation and we are pleased to support...
read moreLa Luna Center is an eating disorder program with locations in Boulder and Fort Collins, Colorado. The program has been in operation for eleven years and offers IOP and outpatient services. La Luna Center is pursuing initial Joint Commission accreditation and we are...
read moreThe Joint Commission has finalized new requirements for accredited behavioral health organizations that treat individuals with eating disorders. The new requirements go into effect July 1, 2016. They are the result of collaboration between the TJC Behavioral Health...
read moreIn working with our psychiatric hospital clients, we have noted a standard in the Hospital manual which sometimes gets overlooked. That standard is PC.02.01.19 in the Provision of Care chapter: “The hospital recognizes and responds to changes in a patient’s...
read moreCongratulations to our client Simple Recovery in Huntington Beach, CA who recently achieved initial Joint Commission accreditation! Simple Recovery is a specialized drug and alcohol addiction treatment center that offers a Men’s Residential Program and a Co-ed...
read moreWellmore Behavioral Health in Waterbury, Connecticut, offers a full range of behavioral health services for children, adolescents, and adults including early intervention, residential, outpatient, and case management services. Wellmore Behavioral Health is seeking...
read moreSurf City Recovery in Huntington Beach, California, offers drug rehabilitation services including PHP, IOP, and an outpatient program. Surf City Recovery is seeking initial TJC accreditation and we are pleased to support them in achieving that goal!
read moreIdeal Option in Spokane, Washington, is a full service addiction medicine clinic that includes a Suboxone program for patients with opioid addiction problems. Ideal Option is seeking initial TJC accreditation and we are pleased to support them in achieving that...
read moreSteps to Recovery is located in Levittown, Pennsylvania, and offers detoxification, residential treatment, partial hospitalization with a residence, and extended care options. Steps to Recovery is seeking initial TJC accreditation and we are pleased to support them in...
read moreAlcohol and Substance Abuse Programs is located in Pasadena, California, and offers a full continuum of detox, residential, and outpatient services. as well as a specialized dual diagnosis program. ASAP is seeking initial TJC accreditation and we are pleased to...
read moreSobertec is a substance abuse treatment program in San Clemente, California, that offers detox, transitional living, and IOP services. Sobertec is seeking initial TJC accreditation and we are pleased to support them in achieving that goal!
read moreWest Oaks Hospital in Houston, Texas, offers a full range of inpatient, partial hospitalization, and IOP services for children, adolescents, and adults. West Oaks is TJC accredited and CMS certified and we are pleased to support their continuous readiness...
read moreAs the year winds down, we thought it would be useful to review the top compliance issues encountered by psychiatric hospitals and behavioral healthcare organizations in 2015. However, truth is that the Top Ten list hasn’t changed much and the topics are quite...
read moreEffective January 1, 2016 The National Patient Safety Goal on Alarm Management (NPSG.06.01.01) went into effect in January, 2014 for hospitals. TJC defines a clinical alarm as “A component of some medical devices that is designed to notify caregivers of an important...
read moreCongratulations to our client Transformations Drug and Alcohol Treatment Center in Delray Beach, Florida who recently achieved their initial, three-year Joint Commission accreditation! Transformations offers a full range of residential services, IOP, and community...
read moreLaurel Ridge Treatment Center in San Antonio, Texas provides inpatient, residential and outpatient services as well as specialized services for the military community. Laurel Ridge is TJC accredited and CMS certified and we are pleased to support their continuous...
read moreMesa Springs is a 72-bed behavioral hospital in Fort Worth, Texas. The hospital is TJC accredited and CMS certified and provide inpatient, PHP, and IOP treatment for mental health and chemical dependency. We are pleased to be working with our Springstone partners on...
read moreGenPsych offers mental health and substance abuse services including Partial Care, IOP, and outpatient services at four locations throughout New Jersey. GenPsych is pursuing initial Joint Commission accreditation and we are pleased to support them in achieving that...
read moreBluff Plantation in Augusta, Georgia provides specialized residential substance abuse services. The program is part of RiverMend Health, a nationwide provider of evidence-based, scientifically driven addiction medicine. Bluff Plantation is pursuing initial Joint...
read moreThe Arroyos Treatment Centers in Pasadena, California offer IOP, day treatment, outpatient, and transitional living for individuals coping with a psychological disorder or substance abuse problem. The Arroyos Treatment Centers is pursuing initial Joint Commission...
read moreThe Document Review session has always been a component of TJC surveys. Years ago, it meant the surveyors spent hours poring over documents and, consequently, less time out visiting programs and units. Once the tracer methodology came along, that emphasis shifted...
read moreTJC recently published data on the “Top Ten” compliance issues for the first half of 2015. For hospitals, it was notable that the # 2 issue is the improper cleaning and disinfection of medical equipment, devices, and supplies. 54% of hospitals were cited for this...
read moreCongratulations to our client Sunspire Health Hyde Park in Tampa, Florida who recently achieved initial Joint Commission accreditation! The program serves women with substance abuse, co-occurring mental health disorders, and eating disorders and provides residential,...
read moreThe Senior Behavioral Center of Mayo Clinic Health System in Waycross, Georgia offers inpatient psychiatric services for seniors. The SBC is Joint Commission accredited and we are pleased to support their continuous readiness efforts!
read morePositive Sobriety Institute is located in Chicago, IL and specializes in addiction assessment, rehabilitation and recovery services to healthcare and other professionals. The program offers intensive partial hospital and outpatient services and is part of RiverMend...
read moreHalcyon Horizons is an alternative to 12 step program and offers detoxification, bio-physical cleansing, therapy and life skills training. Halcyon Horizons runs residential programs in Santa Cruz and South Lake Tahoe, CA. Halcyon Horizons is pursuing initial Joint...
read moreSoCal Detox is a specialized drug detoxification program located in San Clemente, CA. The program provides medically managed detoxification services in two residential settings. SoCal Detox is pursuing initial Joint Commission accreditation and we are pleased to...
read moreAs we monitor TJC survey reports, we continue to see surveyors cite environmental safety risks in behavioral health settings including psychiatric hospitals, psychiatric units in acute care hospitals and sometimes in BH residential settings. Examples of issues cited...
read moreAlthough it is not a part of the formal agenda, most TJC surveys typically include a review of a sample of closed records in addition to the open record review that takes place during tracer activities. There are specific elements that surveyors are evaluating when...
read moreCongratulations also to our client, Bx Healthcare Systems in Atlanta, Georgia, on achieving initial Joint Commission accreditation! Bx Healthcare Systems provides outpatient detox, addiction intervention, individual/group/family counseling and family workshops. Bx...
read moreCongratulations to our client, The Village for Families and Children in Hartford, Connecticut, for recently achieving initial Joint Commission accreditation! The Village for Families and Children has been serving children and families since 1809 and offers a wide...
read moreSober Living Outpatient is located in Delray Beach, Florida and offers evidence-based outpatient drug and alcohol treatment. Sober Living Outpatient is pursuing initial Joint Commission accreditation and we are pleased to support them in achieving that goal!
read moreAkua Mind & Body is located in Orange County, California and offers comprehensive, holistic addiction treatment including detox, day treatment, IOP, and sober living programs. Akua Mind & Body is pursuing initial Joint Commission accreditation and we are...
read moreCedar Creek Recovery is a specialized women’s addiction treatment program located in Austin, Texas. Cedar Creek Recovery offers detoxification, residential treatment, PHP, IOP, and Continuing Care. The program is part of Solid Landings Behavioral Health which operates...
read moreHaven Behavioral Hospital of Albuquerque is a freestanding psychiatric hospital located in Albuquerque, New Mexico which specializes in providing inpatient psychiatric treatment to older adults. The hospital is part of Haven Behavioral Healthcare Inc., which...
read more“How do you know this clinician is competent to run these groups?” That was the question asked by the nurse surveyor during the Human Resources interview on a psychiatric hospital survey. She was reviewing the file of an inpatient therapist who was a licensed clinical...
read moreThe Joint Commission has published proposed standards (PDF, 225KB) for accredited behavioral health organizations providing services to individuals with eating disorders. The proposed standards are the result of collaboration between the TJC Behavioral Health Care...
read moreCongratulations to our client Challenges Relapse Prevention Program in Margate, Fla., who recently achieved initial Joint Commission accreditation! Challenges offers evidence-based substance abuse treatment and a holistic addiction treatment approach and operates PHP,...
read moreCongratulations also to our new client Oak Hills Behavioral Center who recently received initial TJC accreditation for their new freestanding psychiatric hospital in Jackson, Tennessee. Oak Hills Behavioral Center is a specialized senior adult psychiatric hospital for...
read moreSilver Rock Recovery is a specialized men’s addiction treatment program located in Las Vegas, Nevada. Silver Rock Recovery offers detoxification, residential treatment, PHP, IOP, and Continuing Care. The program is part of Solid Landings Behavioral Health, which...
read moreTransformations Drug and Alcohol Treatment Center is an addiction treatment program specializing in integrated natural and holistic protocols. Transformations offers a full range of detoxification, residential services, IOP, and community housing at their two campuses...
read moreA Mission for Michael is a dual diagnosis substance abuse treatment center located in Orange County, California. AMFM operates a continuum of addiction treatment services for men including PHP, IOP, and sober living facilities. AMFM is pursuing initial TJC...
read moreWe still sometimes see organizations (both psychiatric hospitals and behavioral health organizations) receiving TJC survey findings related to waived testing. So, this month, we are recapping the requirements for waived testing and answering some frequently asked...
read moreBarrins & Associates is very pleased to welcome a new member to our consulting team! Former TJC surveyor Mark Halal, LCSW, recently joined us and has hit the ground running in the last month, working with clients all across the country. Mark spent the last six...
read moreCongratulations to our client Edgewood Center for Children and Families in San Francisco, Calif., who recently achieved initial Joint Commission accreditation! Edgewood provides community based, residential, school based and youth support services for children and...
read moreNuLife Treatment Centers offer residential substance abuse treatment in Woodland Hills, Calif., as well as intensive outpatient drug treatment services in Southern California. The program offers a wide variety of evidence based and holistic treatments for men and...
read moreChamberlain’s Children Center is located in Hollister, Calif., and provides residential treatment for children who are victims of child abuse. They also operate a non-public school and a Wellness Center. Chamberlain’s Children Center is preparing for its...
read moreSatori Waters is located in Fort Lauderdale, Fla., and treats men and women with substance abuse and mental health disorders. Satori Waters provides day/night treatment with community housing and utilizes both traditional and evidence based interventions. The...
read moreSunspire Health Spring Hill is a private, residential treatment facility for men and women with substance abuse, chemical dependency and co-occurring mental health disorders. The program is located in Ashby, Mass., and is part of Sunspire Health, which operates a...
read moreIn October 2014, CMS distributed the final version of the three worksheets to be used by the State Survey Agencies (SAs) when conducting their surveys. The worksheets are for Infection Control, Discharge Planning, and Quality Assessment/Performance Improvement (QAPI)....
read moreAs discussed in previous articles, the TJC Behavioral Health standards have a specific standard in the Care, Treatment, and Services chapter on trauma assessment. It is standard CTS.02.02.05 (added in 2011): “The organization identifies individuals served who...
read moreWe are pleased to announce that RiverMend Health has engaged Barrins & Associates to provide Joint Commission readiness consultation for their programs nationwide. RiverMend Health is a premier provider of evidence-based, scientifically driven addiction medicine...
read moreSunspire Health Hyde Park serves women with substance abuse, co-occurring mental health disorders, and eating disorders and provides residential, PHP, and IOP services. The program is located in Tampa, Fla., and is part of Sunspire Health, which operates a national...
read moreStrategic Behavioral Center – Charlotte is a 60-bed adolescent psychiatric residential treatment facility in Charlotte, North Carolina. Strategic Behavioral Center – Charlotte is part of Strategic Behavioral Health LLC, which operates psychiatric hospitals,...
read moreMontevista Hospital is a TJC accredited acute behavioral health hospital serving children, adolescents, adults and seniors located in Las Vegas, Nev. Montevista Hospital is part of Strategic Behavioral Health LLC, which operates psychiatric hospitals, residential...
read moreBeckett Springs is a 48-bed behavioral hospital located in West Chester, Ohio. The hospital opened in July 2013 and provides inpatient and outpatient mental health and addiction treatment to adults and their families. Beckett Springs is part of Springstone Inc. with...
read moreThe April issue of TJC Perspectives has the Top 10 compliance issues for all programs including hospitals and behavioral health organizations. There are no surprises here. For hospitals, once again, the majority of findings are in the Life Safety and Environment of...
read moreTJC now publishes Quick Safety. It’s a brief informational posting on patient safety issues. Issue 10 has an article that’s relevant as many organizations transition to an electronic health record. The topic is the practice of “copying and pasting” in EHRs. It...
read moreTJC publishes a monthly e-newsletter titled Physician Leader Monthly. The target audience is Chief Medical Officers and the topics are geared toward physician leaders. So, check it out and see if it might be a good resource for your CMO. To subscribe, go to the TJC...
read moreBx Healthcare Systems is part of the Acorn Team of Recovery Companies in Atlanta, Georgia. Their services include outpatient detox, addiction intervention, individual/group/family counseling and family workshops. The program specializes in treating dual diagnosis...
read moreChallenges Addiction Treatment Center in Fort Lauderdale, Florida, offers evidence based substance abuse treatment and a holistic addiction treatment approach. Services include a partial hospitalization program, intensive outpatient program and community based...
read moreFor a few years now, TJC surveyors have been conducting suicide prevention tracers when applicable to the setting they are surveying. This is known as a “program specific tracer.” We recently had a client that had this type of tracer during their survey. We talked...
read moreCasa Recovery Residential Treatment Program is a small, private comprehensive addiction treatment center located in San Juan Capistrano, Calif. The program offers detoxification, therapy, counseling, holistic treatment and substance abuse education. In addition to...
read moreSimple Recovery is a specialized drug and alcohol addiction treatment center located in Huntington Beach, Calif. Its primary treatment programs are the Men’s Residential Program and the Co-ed Outpatient Program. In addition, Simple Recovery offers the following...
read moreMore Q&A on the New BH Human Resources Management Chapter As reported in earlier editions of our newsletter, the standards in the new Human Resources Management chapter in the 2015 Behavioral Health Care manual went into effect on January 1. Since then, many...
read moreEvaluating the Culture of Safety and Quality in your Organization Since 2009, the TJC Leadership chapter has contained the requirement for organizations to evaluate their culture of safety and quality. The standard is LD.03.01.01 Element of Performance #1 in both the...
read moreCongratulations to our client Remi Vista Youth and Family Services in Redding, Calif., who recently achieved initial Joint Commission accreditation! Remi Vista Youth and Family Services provides foster care, residential services, mental health services, wraparound...
read moreAdventist HealthCare Behavioral Health & Wellness Services is located in Cambridge, Md., and is the most comprehensive provider of behavioral health services in the National Capital area. They offer acute inpatient treatment, a partial hospitalization program, and...
read moreSolid Landings Behavioral Health is a private, for-profit corporation located in Costa Mesa, Calif. It stands as the flagship brand and managing organization for its core and affiliate centers: Sure Haven Addiction Treatment and Rock Solid Recovery. Solid Landings...
read moreWe were pleased to attend the 2015 Consultants Forum sponsored by TJC last month at their headquarters in Oakbrook Terrace, Illinois. The meeting is an invitational event and there were 14 healthcare consultants in attendance. We were briefed on the latest TJC...
read moreBarrins & Associates is pleased to be a gold sponsor for the annual meeting of the National Association of Psychiatric Health Systems (NAPHS) to be held in Washington D.C. on March 16th to 18th. This year’s meeting promises to be an exciting one with...
read moreFindings in the Provision of Care chapter typically account for a significant number of Requirements for Improvement (RFIs) on surveys for both psychiatric hospitals and behavioral health organizations/programs. These findings relate primarily to assessment, treatment...
read moreThere is a new Patient Safety Systems Chapter in the 2015 Hospital Accreditation Manual. There are no new standards in this chapter. Rather, it describes how existing standards can be used to build an integrated patient safety system. While this new chapter exists...
read moreHaven Behavioral Hospital of Frisco is a 36 bed psychiatric hospital located in Frisco, Texas. The hospital provides inpatient psychiatric treatment to adults aged 55 and older and specializes in the treatment of dementia and Alzheimer’s disease. Haven Behavioral...
read moreBienvenidos Children’s Center is headquartered in Los Angeles, California. Bienvenidos provides a wide range of mental health, community services, foster care and medical services to children and families at 11 locations in the greater Los Angeles area....
read more[lead]With the start of the new year, we are introducing a major redesign of our brand, including a new logo, Website and other materials. The result is exciting![/lead] What’s new online? A cleaner design It’s been about 8 years since our last redesign. The Web has...
read moreEffective February 1, 2015, revised requirements go into effect for psychiatric hospitals that use Joint Commission accreditation for deemed status. TJC added one new requirement and revised nine elements of performance in order to ensure alignment with the CMS...
read moreBe aware that TJC has revised its Sentinel Event Policy and the Sentinel Event chapter in both the Hospital and Behavioral Health manuals. The revisions were effective January 1, 2015. While the essential components of the Sentinel Event Policy have not changed, there...
read moreSierra Vista Child & Family Services is based in Modesto, California and has served children and families in California’s Central Valley since 1972. Sierra Vista provides a wide array of community based services including counseling, family support, mental...
read moreChildNet Youth & Family Services is headquartered in Long Beach, California and provides a comprehensive continuum of services for children and families. Their programs include Foster Family Network, Zinsmeyer Academy (a specialized school), Behavioral Health...
read moreWestpark Springs Hospital in Richmond, Texas is a newly constructed 72 bed behavioral hospital that opened in October 2014. The hospital provides inpatient and outpatient mental health and addiction treatment to adults and their families. Westpark Springs is part of...
read moreBarrins & Associates is pleased to welcome two new clients that are part of the Springstone system of behavioral hospitals. Carrollton Springs is a 45 bed behavioral hospital in Carrollton, Texas. The hospital provides a full continuum of inpatient psychiatric...
read moreAs reported in our October newsletter, there are revisions to the standards in the Behavioral Health Human Resources chapter (effective January 2015) that will make the process for “credentialing and privileging” of licensed independent practitioners...
read moreIn January 2014, TJC introduced the National Patient Safety Goal on Alarm Management (NPSG.06.01.01) for hospitals and critical access hospitals. Since psychiatric hospitals are surveyed under the Hospital standards, this National Patient Safety Goal is applicable in...
read moreCongratulations to our client WestCoast Children’s Clinic in Oakland, California who recently achieved initial Joint Commission accreditation! WestCoast Children’s Clinic provides clinic based, school based and home based therapy services to children and...
read moreWestpark Springs is a newly constructed, state-of-the-art 72 bed behavioral hospital located near Houston in Richmond, Texas. The hospital opened in October 2014 and provides inpatient and outpatient mental health and addiction treatment to adults and their families....
read moreElmhurst Professionals Program is located near Chicago in Elmhurst, Illinois and is a member of the Achieve Network. The program offers holistic recovery treatment with a specialty in treating professionals. Elmhurst Professionals Program is planning to pursue TJC...
read moreAnother highlight of the Annual Behavioral Health Care Conference in Chicago last week was the presentation on TJC’s new Behavioral Health Home Certification. Several BH organizations have achieved this exciting new certification option! So, here’s some...
read moreAt the TJC Annual Behavioral Health Conference in Chicago last week, a key presentation focused on the revisions to the Human Resources chapter in the Behavioral Health Manual that go into effect on January 1, 2015. So, what are the changes and what do you need to do...
read moreCongratulations to Haven Behavioral Hospital of Southern Colorado in Pueblo, Colorado who recently achieved Joint Commission accreditation and CMS deemed status! The hospital provides specialized inpatient psychiatric services to military personnel and veterans. Also...
read moreBarrins & Associates is pleased to welcome our new client Grafton Integrated Health Network with headquarters in Winchester, Virginia Grafton provides a broad continuum of services including residential treatment, education, clinical services, early intervention,...
read moreTJC 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...
read moreCongratulations 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....
read moreRutgers 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...
read moreWe 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....
read moreCongratulations 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....
read moreThe 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...
read moreCongratulations 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...
read moreOsage 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...
read moreAs 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...
read moreOrganizations 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...
read moreCongratulations 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...
read moreBarrins & 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...
read moreIf 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...
read moreOne 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...
read more[thumbnail alt=”Tim O’Rourke, CHFM” type=”img-thumbnail” alignment=”alignright” image=”http://barrins.a3creativeloft.com/wp-content/uploads/TimOrourke-219×300.jpg” ]Tim O’Rourke, CHFM, B&A...
read moreBarrins & 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...
read moreDuring surveys of both psychiatric hospitals and behavioral health organizations, issues continue to arise around how the organization is assessing the competence of its clinical staff. We have seen several survey findings for organizations not clearly defining...
read moreThe TJC focus on the discharge process continues in 2014. During surveys, surveyors will frequently request a sample of closed records. In the past, the focus for closed records was on determining if the discharge summary had been completed on time. More recently,...
read moreFor several years, the common topic for the leadership interview on the last day of the survey was the five “pillars of leadership” as described in standards LD.03.01.01 – LD.03.06.01: Using data Planning Communicating Changing Performance Staffing...
read moreCongratulations to our client Bayes Achievement Center located in Huntsville, Texas who recently underwent their highly successful initial survey from The Joint Commission! Bayes Achievement Center provides a full continuum of prevention services, residential...
read moreBarrins & Associates is pleased to welcome our new client Black Bear Lodge located in the foothills of northern Georgia. Black Bear Lodge offers a holistic model of integrated substance abuse and mental health treatment and is working toward initial Joint...
read moreBe aware that effective January 2014 TJC will no longer be mailing complimentary hard copies of the standards manuals and standards updates to accredited organizations. Standards manuals and standards updates will be available to accredited organizations via E-dition...
read moreDuring surveys of inpatient psychiatric units (and sometimes in residential programs) TJC surveyors continue to cite suicide risks they identify in the environment. Commonly occurring issues are plastic trash can liners, loopable hardware in bedrooms and bathrooms,...
read moreBarrins & Associates is pleased to welcome our new client Haven Behavioral Hospital of Philadelphia which offers specialized inpatient psychiatric treatment for older adults. The hospital is part of Haven Behavioral Healthcare Inc. which specializes in the...
read moreWe were pleased to represent Barrins & Associates at The Joint Commission’s first forum for consultants who work with healthcare organizations. The Consultants Forum was held on February 13th at TJC headquarters in Oakbrook Terrace, Illinois. The focus of...
read moreThere is a standard tucked into the TJC Human Resources chapter that seems innocuous at first reading but frequently causes challenges on surveys. The standard is HR.01.06.01 Element of Performance # 3 in both the Behavioral Health and Hospital manuals: “Staff...
read moreBienvenidos Children’s Center is headquartered in Los Angeles, California. Bienvenidos provides a wide range of mental health, community services, foster care and medical services to children and families at 11 locations in the greater Los Angeles area....
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