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Behavioral Health TJC and CMS Monthly Newsletter

Want to research TJC and CMS 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.

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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!

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