Behavioral Health Accreditation & Regulatory Monthly Newsletter

Want to research accreditation and regulatory compliance requirements and survey strategies? Access the Barrins & Associates newsletter archive by month to gain access to insights shared by our team. Also, see behavioral health industry links.

Need to stay informed about TJC, CMS, and other industry leaders behavioral health news, trends, best practices and regulatory changes? Join our mailing list by signing up using in the form in the right column. Email addresses are solely used for our newsletter and not shared outside of Barrins & Associates.

September 2024 

• Strategies for Reducing Youth Suicide: Building Hope and Resilience
• Accreditation and Regulatory Compliance Consultant in New Healthcare Builds
• Supporting the Completion and Implementation of Psychiatric Advance Directives
• Tip of the Month: Integrating Culturally Responsive Care into Suicide Risk Reduction Efforts

August 2024 

• Healthcare Competency Assessments: How to Make them Engaging and Enjoyable
• The Vital Role of a High-Performing Governing Board in Healthcare Success
• Inpatient Psychiatric Prospective Payment System
• Tip of the Month: Texting of Medication Orders

July 2024 

• Staff Effectiveness: A Contributing Factor of Patient/Client Safety Incidents
• Joint Commission Releases New Medications for Opioid Use Requirements
• The Joint Commission Updated Restraint and Seclusion Requirements
• Tip of the Month: Communication

July 2024 

• Accreditor Update
• Tips for Selecting an Electronic Health Record
• The Joint Commission Launches New Telehealth Accreditation
• Tip of the Month: Over-the-Counter Multi-Use Products

May 2024 

• Revolutionizing Behavioral Healthcare: Does AI Have a Vital Role in High Quality Care, Treatment, and Services?
• Navigating Compliance: Optimizing Electronic Health Records (EHRs) for Psychiatric Hospitals and Community Behavioral Health Providers
• Preventable Patient Harm
• Congratulations Corner
• Welcome New Client

April 2024 

• Enhancing Behavioral Healthcare: Implementing Measurement-Based Care
• TJC: New & Revised Workplace Violence Standards
• Texting in Healthcare: Ensuring Compliance & Patient Safety

March 2024 

• The Crucial Role of Safety Culture in Behavioral Healthcare Organizations
• CMS: Strengthening Oversight of Accreditation- A Proposed Rule
• TJC: Field Review of Restraint & Seclusion Requirements

February 2024 

• Ensuring Patient Rights: Understanding Healthcare Organization Complaint Resolution Processes
• TJC: New and Revised Infection Prevention & Control Requirements
• CMS: Top 15 Citations for 2023

January 2024 

• TJC & SAMHSA: Navigating the Revised Requirements for Certified Community Behavioral Health Clinics
• TJC: Insights into ORYX 2024 for Freestanding Psychiatric Hospitals
• TJC: New & Revised Workplace Violence Prevention Requirements

November/December 2023 

• Updates to TJC’s Definition of Sentinel Events Involving Suicide
• CMS Updates Validation Survey Process: What You Need to Know
• Joint Commission: New Eligibility Requirements for Opioid Treatment Programs

October 2023 

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

September 2023 

• CMS Updates Accreditation Processes: What You Need to Know
• Healing with Empathy: The Power of Trauma-Informed Care

August 2023 

• The Joint Commission Standards: What You Need to Know About Workplace Violence
• Five Surprising Joint Commission Standards Frequently Scored High-Risk

July 2023 

• New CMS Memo Impacts Joint Commission Procedures
• Healthcare Construction Risk Assessment

June 2023 

• Joint Commission Accreditation: How to turn a preliminary denial of accreditation into an accreditation
• Joint Commission: Why Do You Need a Mock Survey?

May 2023 

• Joint Commission Suicide Risk Reduction NPSG Standard: Using Validated Tools
• The Joint Commission Standards: Supporting the Transformation of the Crisis Services Continuum of Care

April 2023 

• New Joint Commission Standards: Certified Community Behavioral Health Clinics
• Joint Commission February 2023 Standards Updates: What’s New

March 2023 

• Joint Commission Standard: Medication Administration and Patient Preference
• Joint Commission: Mental Health Conditions are the Leading Cause of Pregnancy Related Deaths

February 2023 

• Joint Commission: Health Care Equity Now NPSG
• Joint Commission: Contract Service Requirements

January 2023 

• Joint Commission 2023 Standards: What’s New
• Joint Commission Licensed Practitioner Standard: Change in Timeframe

November/December 2022 

• Joint Commission Sentinel Event Definition Revised
• Joint Commission Safety Briefing: New in 2023

October 2022 

• Joint Commission Health Care Equity Requirements
• Behavioral Healthcare Accreditation Update

September 2022 

• Joint Commission Sentinel Event Data on Suicides
• Joint Commission Orientation Requirements

July/August 2022 

• Environmental Risk Assessment: Non-inpatient Behavioral Health Settings
• Joint Commission Discharge Summary Review: Be Prepared

June 2022 

• Joint Commission Rights Standards: New Requirements
• Joint Commission PI Standards: Data Collection Requirements

May 2022 

• Joint Commission COVID-19 Staff Vaccination Standard
• Joint Commission Performance Improvement Standards 2022

April 2022 

• Joint Commission Surveys Getting Back on Schedule
• Preliminary Denial of Accreditation: How to Respond

March 2022 

• Joint Commission Grievance Review: New Survey Session
• Virtual Joint Commission Surveys Continue for BH Accreditation

February 2022 

• CMS COVID-19 Staff Vaccination Requirements
• NPSG 15 Suicide Prevention: Training & Competency Requirements

January 2022 

• Joint Commission 2022 Standards: What’s New?
• Joint Commission Fire Drill Requirement: Vary the Timing

November/December 2021 

• Behavioral Health Care Accreditation: 2021 Survey Trends
• Joint Commission Tailored Surveys

October 2021 

• New TJC Performance Improvement Requirements
• Joint Commission BH Pain Management Standards: Training Requirements

September 2021 

• New TJC Requirements: Workplace Violence Prevention
• Boarding Psychiatric Patients in the Emergency Department: Joint Commission Recommendations

July/August 2021 

• Onsite Joint Commission Surveys: July 2021 Update
• New Joint Commission Fire Drill Requirements for Behavioral Health Care

June 2021 

• NPSG 15 Suicide Prevention: The Monitoring Requirement
• Falls Now Included as Sentinel Events

May 2021 

• SAFER Dashboard Launched by TJC
• DNV Has Deeming Authority for Psychiatric Hospitals

April 2021 

• Virtual Joint Commission Surveys: What’s the Status?
• New Joint Commission Life Safety Requirements for Business Occupancies

March 2021 

• Onsite Joint Commission Surveys: March 2021 Update
• Joint Commission Document Review 2021: Be Prepared

February 2021 

• Virtual Joint Commission Surveys: Get Prepared
• Joint Commission 2021 Standards: What’s New?

January 2021 

• Joint Commission Behavioral Telehealth Update
• Joint Commission Environment of Care: Different in 2021

November 2020 

• Joint Commission Credentialing & Privileging Tracer: Focus for 2021
• Joint Commission Flu Vaccination Requirements: 90% Goal Eliminated

October 2020 

• Onsite Joint Commission Surveys Resuming
• Joint Commission Heads-Up Reports: A Valuable Tool

September 2020 

• Behavioral Health Tracers: Joint Commission 2020 Survey Update
• CMS Gives TJC 2 Year Deemed Status Approval

July/August 2020 

• Joint Commission Surveys Resume: Update on the Rollout
• Joint Commission Standards: New Substance Use Treatment Requirements

June 2020 

• Joint Commission Surveys Resume in June
• Joint Commission Surveys: Infection Control Focus

May 2020 

• COVID-19: Suicide Risk Monitoring
• COVID-19: Telepsychiatry and CMS Regulation

April 2020 

• The Joint Commission Suspends Surveys
• COVID-19: CMS Surveys and Top Priority Areas
• COVID-19: Behavioral Healthcare Resources

March 2020 

• NPSG 15 Suicide Risk Reduction: Feedback from the Field
• TJC Survey: Changes to the Survey Agenda

February 2020 

• TJC Standards Update: New Requirements for Substance Use Disorder Treatment
• New CMS Survey Process for Psychiatric Hospitals

January 2020 

• Unannounced Surveys: Are You Prepared for an “Early Survey?”
• TJC Tracer Update: Focus on Dietary Services

November 2019 

• NPSG.15.01.01.01 Suicide Risk Reduction: Safety Planning at Discharge
• TJC System Tracer on Data Management: Survey Management Strategies

October 2019 

• TJC Survey Outcomes: 2019 Trends
• NPSG.15.01.01 Suicide Risk Reduction: Feedback from Surveys

September 2019 

• NPSG.15.01.01 Suicide Risk Reduction: Get Clear on New Requirements
• TJC Competence Assessment Session: Survey Management Strategies

July 2019 

• Suicide Risk Reduction: Two New FAQs from TJC
• TJC Medical Staff Credentialing & Privileging: Survey Management Strategies

June 2019 

• Suicide Risk Reduction: Be Clear on TJC’s New July 1 Requirements
• TJC’s Medication Management Tracer: Survey Management Strategies

May 2019 

• Intimidating Behavior Undermines a Culture of Safety
• TJC Document Review Session: Survey Management Strategies

April 2019 

• Suicide Risk Assessment: Q&A on July 1 Revisions to NSPG 15.01.01
• CMS Immediate Jeopardy: Revised Guidelines for Surveyors

March 2019 

• National Patient Safety Goal NPSG 15.01.01: Clarification from TJC
• Pain Management: New Requirements in TJC BH Standards

February 2019 

• Ligature Risks: New FAQs From TJC
• Culture of Safety: Now Part of Your TJC Survey

January 2019 

• TJC Survey Outcomes: Update on 2018 Trends for Psychiatric Hospitals
• TJC Survey Outcomes: Update on 2018 Trends for BH Organizations

November 2018 

• Suicides in Hospitals: New Study Provides Data
• CMS Complaint Surveys: Results on New Website
• National Patient Safety Goal NPSG 15.01.01

October 2018

• CMS Validation Survey: New Process Being Piloted
• TJC Survey Outcomes: 2018 Trends
• Joint Commission Surveys: High Risk Areas

September 2018

• Joint Commission Puts Infection Control Issues High on Radar
• Trauma Assessment: Feedback From Recent Surveys
• Closed Medical Records Reviews: TJC Survey Feedback

July 2018

• The Joint Commission Suicide Risk Recommendation FAQs
• Ligature Risks: Recommendations for Inpatient Detox Units
• Deemed Status for Psychiatric Hospitals: You Must Notify TJC If CMS Removes Your Deemed Status

June 2018

• Psychiatric Hospitals: Be Prepared for CMS Validation Surveys
• Suicide Prevention Recommendations for Non-Hospital BH Settings
• Barrins & Associates Welcomes New Associate

May 2018

• Be Ready for the Program-Specific Tracer on Suicide Prevention
• Evaluating Your Culture of Safety

April 2018

• Proposed Revisions to National Patient Safety Goal on Suicide Risk Assessment
• How One Organization is Meeting the New Outcomes Measurement Requirements

March 2018

• Survey Findings Related to Ligature Risks
• New 2018 BH Requirements Now Being Surveyed

February 2018

• Feedback from TJC Consultants Forum
• Increased Scrutiny of Hand Hygiene During Surveys

January 2018

• Guidance from CMS and TJC Regarding Surveying Ligature Risks
• New Pain Management Standards for Hospitals

November 2017

• Guidance from The Joint Commission Regarding Ligature Risks

October 2017

• BH Conference Update: Expectations for Outcomes Measurement in 2018
• Update from TJC BH Conference: Surveying of Ligature Risks

September 2017

• Tips for Documenting the Mental Status Exam
• Behavioral Health Manual Changes Coming in 2018
• Update from TJC and CMS re Ligature Risks

July 2017

• Field Feedback on Surveying of Ligature Risks

June 2017

• Update on TJC Surveying of Ligature Risks
• TJC HR Requirement: Competence Assessment by a Qualified Individual

May 2017

• Psychiatric Hospitals: Top Ten Compliance Issues on the SAFER Matrix
• Environment of Care Updates: Exit Signs and Fire Drills

April 2017

• Proposed Revisions to National Patient Safety Goal on Suicide Risk Assessment
• Psychiatric Advance Directives in Behavioral Healthcare

March 2017

• Increased Scrutiny of Environmental Safety Risks in Psychiatric Hospitals
• TJC Updates: Behavioral Health Care Accreditation Program

February 2017

• Revisions to BH Standards (Effective July 1, 2017)
• Compliance Catch Up

January 2017

• TJC Approves Revisions to Behavioral Health Outcome Measures Standard
• Prepare for Focus on Antimicrobial Stewardship during 2017 Hospital Surveys

November 2016

• Behavioral Health Organizations: New SAFER Matrix (Effective Jan. 2017)
• Changes to TJC Clarification Process (Effective Jan. 2017)

October 2016

• Psychiatric Hospitals: Prepare for New Antimicrobial Stewardship Standard
• Survey of Sober Living Houses in Behavioral Health Organizations

September 2016

• Update on Medication Ordering and Therapeutic Duplication for Psychiatric Hospitals
• Influenza Vaccination: Important Compliance Issue for BH Organizations

July 2016

• Recent Psychiatric Hospital Surveys: Strong CMS Focus
• Proposed Standards Revision for Behavioral Health Outcome Measures

June 2016

• Surveying Active Treatment in Psychiatric Hospitals
• Trauma Assessment: Survey Findings and Resources

May 2016

• TJC Introduces New SAFER Matrix Scoring Methodology
• TJC Update on Texting of Orders

April 2016

• Changes to TJC Survey Process for Psychiatric Hospitals
• Sentinel Event Policy Update
• Kevin Huckshorn Joins Barrins & Associates

March 2016

• Changes to TJC Accreditation Process for Psychiatric Hospitals
• Update on TJC Topics of Interest

February 2016

• Oro 2.0 High Reliability Organizational Assessment
• New Behavioral Health Care Standards for Permanent Housing Support Services
• Barrins & Associates Attends TJC Consultants Forum

January 2016

• New Requirements for Eating Disorder Programs
• Responding to Changes in a Patient’s Condition

November 2015

• Heads Up on Survey Findings
• New Requirements for Clinical Alarm Management in Psychiatric Hospitals

October 2015

• Survey Strategy: Preparation of Documents
• Cleaning of Medical Equipment: Top Ten Compliance Issue for Hospitals

September 2015

• Environmental Risk Assessment in Behavioral Health Settings
• Prepare for Closed Record Review during Your Next Survey

July 2015

• TJC Proposed Standards for Eating Disorder Programs
• Competency Assessment for Group Facilitators

June 2015

• Introducing New Associate: Mark Halal, LCSW
• Refresher on Waived Testing Requirements

May 2015

• Psychiatric Hospitals: Study the CMS Worksheets
• The Life Events Checklist: A Resource for Trauma Assessment
• RiverMend Health engages Barrins & Associates

April 2015

• A Closer Look at a Suicide Prevention Tracer
• TJC Top Standards Compliance Data for 2014
• TJC Quick Safety Article: Preventing Copy-and-Paste Errors in EHRs
• TJC Newsletter for Chief Medical Officers

March 2015

• Patient Safety: Evaluating the Culture of Safety and Quality in Your Organization
• Q&A on the New Behavioral Healthcare Human Resources Management Chapter

February 2015

• Patient Safety Systems New Chapter
• Provision of Care Chapter: Highlights from 2014 TJC Surveys
• NAPHS Annual Meeting: Barrins & Associates Gold Sponsor
• Barrins & Associates Attends TJC Consultants Forum

January 2015

• Revised Requirements for Psychiatric Hospitals with Deemed Status
• New Sentinel Event Chapter

November 2014

• National Patient Safety Goal on Alarm Management: Relevance for Psychiatric Hospitals
• Q&A on Behavioral Health Human Resource Standards and Requirements

October 2014

• Changes to Behavioral Health Human Resources Chapter
• TJC Behavioral Health Home Certification

September 2014

• Feedback from TJC Hospital Executives Briefings
• Suicide Risk Assessment Now #2 in Top Ten Compliance Issues for Behavioral Health

July 2014

• “Opportunities for Improvement” Now Included in TJC Survey Reports
• Heads up on TJC and CMS Requirement for Treatment Plans in Psychiatric Hospitals

June 2014

• TJC Changes to PFIs and Life Safety Equivalencies
• Heads Up on Battery Operated Smoke Detectors in BH Residential Settings
• Revisions to TJC BH Opioid Treatment Standards

May 2014

• High Reliability: Important Topic for TJC Leadership Interview
• Competence Assessment in Behavioral Health

April 2014

• Suicide Risk Assessment: Patient Bathrooms
• Medication Instructions at Discharge
• No More Complimentary Standards Manuals

March 2014

• Competence Assessment by a Qualified
• Barrins & Associates Attends TJC Consultants Forum

February 2014

• Proposed Revisions to Behavioral Health Human Resources Chapter
• Clarification: Current TJC Requirements for FMEAs

January 2014

• Use Our Updated Tracer Tools for 2014
• Sign Up for Our 2014 TJC Update Sessions

November 2013

• TJC Behavioral Health Home Certification Available in January 2014

October 2013

• Survey Scheduling Alert
• Joint Commission Requirements for Trauma Assessment
• Reminder about Expiration of Multi-Dose Vials

September 2013

• Psychiatric Advance Directives

July 2013

• Determining Client Competency to Self Administer Medication
• Proposed New TJC Requirements for Sample Medications
• TJC Survey Activity Guide Updated July 1, 2013

June 2013

• BH Organizations: Additional Flu Vaccination Requirements Effective 7/1/13
• Managing Contracted Clinical Services

May 2013

• TJC to Offer New Certification for Behavioral Health Home
• Conducting and Documenting Risk Assessments

April 2013

• Joint Commission Requirements for Spiritual Assessment in Behavioral Health
• Have you Updated Your Sentinel Event Policy?

March 2013

• Visit Us at the National Council for Behavioral Health Conference
• Update on CMS Activities
• Back to Basics: Survey Management 101

February 2013

• Credentialing and Assigning Clinical Responsibilities under the Behavioral Health Standards
• QPRT: A Resource for Suicide Risk Assessment

January 2013

• Use Our Updated Tracer Tools for 2013
• Sign Up for Our 2013 TJC Update Sessions

November 2012

• Primary Source Verification under the Behavioral Health Standards
• Heads Up: Survey Scrutiny on Food Storage

October 2012

• Feedback from Fall 2012 Joint Commission Conferences
• New Focused Standards Assessment Identifies Risk Related Standards

September 2012

• CMS Requires HBIPS Reporting for Inpatient Psychiatric Facilities
• Behavioral Health Standards for Peer Support Services
• Two Important Joint Commission Conferences Coming Up!

July 2012

• Easing Up of Waived Testing Requirements
• Disaster Privileging: Make Sure Your Process is in Order

June 2012

• CMS Eases Verbal Order and Nursing Care Plan Requirements for Hospitals
• New Prevention and Wellness Promotion Standards for Behavioral Healthcare

May 2012

• TJC BH Manual Identifies Standards Applicable to Adoption Services
• Psychiatric Hospitals: Scrutinize your Medical Staff Bylaws!

April 2012

• Update on TJC’s “Integrated Survey Process” for Psychiatric Hospitals
• Behavioral Health Organizations/Programs: Does your Health Screening Process Meet the New 2012 Requirements?

March 2012

• Increased Focus on Discharge Planning in Psychiatric Hospital Surveys
• BH Organizations: Prepare for New Flu Vaccination Requirements

February 2012

• Survey Tip: Renewed Interest in Eyewash Stations
• Refresher on Waived Testing Requirements

January 2012

• Use Our Updated Tracer Tools for 2012!
• Which New 2012 TJC Requirements Affect You?

November 2011

• Change to BH Health Screening Requirements Effective January 2012
• Psychiatric Hospitals: Do You Have All the Documents You Need for Your Survey?

October 2011

• Feedback for Psychiatric Hospitals from the TJC 2012 Hospital Executive Briefings

September 2011

• Psychiatric Hospitals: Additional Survey Days for Deemed Status for CMS Special Conditions of Participation
• Coming in 2012: Easing of Physical Exam Requirements for Behavioral Health Residential Programs

July 2011

• TJC Releases New BoosterPak on Suicide Risk Assessment
• 2011 Behavioral Health Standards on Physical Holding of Children and Youth

June 2011

• Psychiatric Hospitals: How CMS Impacts Your Joint Commission Survey
• Incorporate Tracers into Your Continuous Readiness Program

May 2011

• Managing Contracted Clinical Services
• Clarification on Medication Reconciliation in the Outpatient Setting

April 2011

• Update on TJC’s Deemed Status for Psychiatric Hospitals
• Feedback from Surveys: 1st Quarter 2011

March 2011

• It’s Official: TJC Has Deemed Status for Psychiatric Hospitals
• Clarification Regarding Announced Surveys for Behavioral Health Organizations

February 2011

• The Joint Commission Seeks Deemed Status for Psychiatric Hospitals
• Check out TJC’s Leading Practice Library
• New 2011 Survey Activity Guide

January 2011

• Effective January 1, 2011: Surveyors Begin Applying the New Care, Treatment, and Services Standards
• New In 2011: Patient-Provider Communication Requirements for Hospitals

November 2010

• Psychiatric Hospitals: Be Ready for Increased Survey Focus on Cleaning of Medical Equipment
• Infection Control now in Top 10 Standards Compliance Issues for Behavioral Health
• New Resource for Residential Treatment Centers

October 2010

• Change to Requirement for Monitoring Response to First Dose of a New Medication
• Additional Day of Life Safety Code Surveyor for Hospitals in 2011
• Sentinel Event Alert: “Preventing Violence in the Health Care Setting

September 2010

• Hospital Based Inpatient Services (HBIPS) Core Measures Now Mandatory for Freestanding Psychiatric Hospitals
• Nutrition Screening Still a Challenge for Behavioral Health Programs

July 2010

• New Care, Treatment, and Services Chapter for Behavioral Health
• Change to Requirement for History & Physical Exam in BH Residential Programs

June 2010

• New Requirements for Psychiatric Hospitals
• TJC Clarifies 28 Day Expiration Date for Multi-dose Vials
• Do We Need Self Closing Doors in our Residential Program?

May 2010

• Psychiatric Hospitals: Get Ready to Implement Core Measures
• New Provision of Care Chapter to be Released for the Behavioral Health Program
• Clarification from TJC: An Approved Abbreviations List is Not Required

April 2010

• Feedback from Surveys: 1st Quarter 2010

March 2010

• Assess Your Environment of Care for Suicide Risks
• Heads Up on Labeling of Multi-Dose Vials

February 2010

• Make Sure You Have a Process for High-Alert Meds
• Take Note: New PI Requirement for Behavioral Health

January 2010

• 2010 E-dition Available on you TJC Extranet Site
• The Handy Portable Version of the Standards
• New Medication BoosterPak Published by TJC
• New Process for Survey Agendas in 2010
• News Flash from the TJC Annual Behavioral Healthcare Conference

November 2009

• Top Compliance Issues for First Half of 2009
• Psychiatric Hospitals: Take Note of Changes to Your Survey Report Format
• New Requirement for Submitting Evidence of Standards Compliance
• New 2010 Behavioral Health Standards Still Available Online

October 2009

• Feedback From Recent Surveys
• Psychiatric Hospitals: Findings From Life Safety Code Surveys

September 2009

• National Patient Safety Goals Revised for 2010: Some Changes Effective Immediately
• Top 10 Standards Compliance Issues for 2008
• New 2010 Behavioral Health Standards Available Online
• Staffing Effectiveness Data No Longer Required

July 2009

• Modifying the Treatment Plan following Restraint or Seclusion
• Heads Up: Be Sure to Align your Emergency Management Drills with your Hazard Vulnerability Analysis

June 2009

• Effective July 1, 2009: New Restraint and Seclusion Requirements for Hospitals Take Full Effect
• Periodic Performance Review Pitfalls and Strategies

May 2009

• FMEAS For Partial Hospital Programs: A Clarification
• Don’t Overlook Your Public Notice About Contacting TJC
• Sample Public Notice for Reporting Concerns to The Joint Commission

April 2009

• Get Out Your Yardstick: How to Evaluate the Culture of Safety and Quality in your Organization
• Changes to Unannounced Surveys for Behavioral Health: New 7 Days Notice for Many Organizations!