Barrins Bulletin
August 2026
Greetings to Our Colleagues in Behavioral Health!
Dear Readers,
This month’s accreditation and regulatory updates offer several practical opportunities for behavioral health organizations to look closely at everyday operations.
Joint Commission’s August Environment of Care News takes an extensive look at workplace violence prevention—an issue with particular relevance for psychiatric hospitals, residential programs, and other behavioral health settings. CMS has also released new guidance addressing oversight of Applied Behavior Analysis services, while ACHC is focusing on the connection between assessments, plans of care, documentation, and the services actually provided.
We have also included a new SAMHSA resource that can help organizations evaluate behavioral health and substance-use trends when planning future services.
As always, we encourage readers to look beyond the publication itself and ask: What does this tell us to review within our own organization?
Best Regards,
John Berry
RN, MSN, CPHQ, SQIL
Principal Consultant
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Joint Commission (JC)
Is Your Workplace Violence Prevention Program Focused on Prevention or Response?
The August issue of Environment of Care News provides a useful review of Joint Commission’s workplace violence prevention requirements, along with examples of strategies organizations are using to identify and address risk before incidents escalate.
The definition of workplace violence is broader than physical assaults. It includes verbal, nonverbal, written, and physical aggression as well as threatening, intimidating, harassing, humiliating, bullying, and other concerning behaviors. Joint Commission emphasizes that organizations should monitor and respond to lower-level or emerging aggression rather than waiting until an event requires emergency intervention.
For hospitals, including psychiatric hospitals, the requirements are consolidated in NPG.02.04.01. For the Behavioral Health accredited program the similar expectations are distributed across the Environment of Care, Leadership, and Human Resources chapters. Required program elements include:
- A designated program leader
- Multidisciplinary involvement
- Incident-reporting and trending processes
- Support for those affected by workplace violence
- Governing-body reporting
- Staff education
- An annual worksite analysis
For behavioral health organizations, the most useful takeaway may be to look at the program from a prevention perspective. Are you identifying patterns before they become serious events? Does your annual analysis incorporate actual incidents and near misses? Do staff know how to recognize escalating behavior and when to call for additional help?
The article also provides summary of practical examples from a Vanderbilt publication of verbal de-escalation techniques, including maintaining personal space, using concise communication, active listening, setting limits, knowing when to call for assistance, and debriefing after an event.
Barrins recommends: Review your workplace violence data for the past year and compare it with your annual worksite analysis. Look for recurring locations, times, types of incidents, contributing factors, and staff groups affected. Then ask whether your mitigation strategies and training actually address the risks your own data are identifying.
This is also a good opportunity to evaluate whether frontline staff can describe your organization’s de-escalation approach and reporting expectations—not simply whether they completed annual education.
Source: Workplace Violence Prevention Education – 11 Steps of Verbal De-Escalation
ACHC
Does the Plan of Care Actually Drive Care?
ACHC recently focused on Behavioral Health Standard BH5-3A, which requires a written plan of care for each service recipient. The article is particularly relevant because documentation remains a prominent behavioral health survey issue. Seven (7) of ACHC’s 10 most frequently cited Behavioral Health standards are within Provision of Care and Record Management.
The survey-readiness question isn’t simply whether a plan of care is present. Organizations should be able to demonstrate the connection between:
- The assessment
- Identified needs and goals
- Plan of care
- Services delivered
- Progress documentation
- Updates to the plan
- Eventual discharge planning
A traditional clinical-record audit may confirm that required forms are complete while missing disconnects between them.
Barrins recommends: Conduct a focused clinical record tracer. Begin with the assessment and follow the client’s story through treatment planning, services, progress notes, revisions, and discharge planning. Ask whether the documentation demonstrates that the plan is actually directing care.
Source: Surveyor Volume 2025, No. 2
CMS
New Toolkit Addresses Oversight of Applied Behavior Analysis (ABA) Services
CMS released a Medicaid and CHIP toolkit on August 4 addressing state oversight of Applied Behavior Analysis services for children with autism.
The toolkit addresses:
- Individualized treatment and clinical necessity
- Provider qualifications and supervision
- Credentialing and enrollment, treatment intensity
- Utilization management
- Payment methodologies
- Program integrity
CMS notes that the toolkit does not establish new federal requirements; instead, it provides states with approaches they may use in overseeing ABA services.
ABA providers should nevertheless pay attention. The topics CMS identifies are precisely the areas likely to receive continued state oversight: whether treatment is individualized, whether service intensity is supported by the clinical record, whether staff qualifications and supervision are appropriate, and whether documentation supports the services billed.
Barrins recommends: Select several recent ABA cases and trace them from assessment and authorization through the plan of care, services delivered, progress documentation, supervision, and billing. Look for consistency across the entire record rather than auditing each document separately.
Source: Autism Services ABA Toolkit
COA
Medicaid and Funding Changes Remain Important for Community-Based Organizations
Social Current COA continues to highlight Medicaid policy changes, federal grant requirements, workforce pressures, and funding instability as issues requiring attention from human-services organizations. Its recent trend reporting also identifies Medicaid policy changes and their potential effect on community-based organizations as an area to watch.
While there is no new COA accreditation-standard change to report this month, but this information is still relevant for COA-accredited and other community behavioral health organizations that depend significantly on Medicaid and federal funding.
SAMHSA
New National Behavioral Health Data Can Support Service Planning
SAMHSA released the 2025 National Survey on Drug Use and Health in late July. The annual survey includes updated national information on substance use, mental illness, treatment access, and recovery.
This isn’t a new regulatory requirement, but it is a useful planning resource for behavioral health leaders.
Organizations may want to compare national trends with their own utilization, referral patterns, wait lists, community-needs assessments, and service-capacity data. The information can also be useful when developing strategic plans, evaluating unmet needs, or supporting grant applications.
For organizations already seeing increased demand for particular populations or services, national data can provide another point of comparison when considering where future capacity may be needed.
Source: National Survey Drug Use and Health 2025
Don’t Limit Survey Readiness to the Regulatory Team
A short Joint Commission News MythBusters item this month reinforces something Barrins consultants frequently emphasize: survey readiness depends on frontline staff, not just organizational leaders.
Joint Commission notes that surveyors routinely engage directly with frontline caregivers to determine how standards are applied in real-time care.
Try this during your next leadership round: ask several staff members a few simple questions:
- How do you report a safety concern?
- What would you do if a client became increasingly agitated?
- How do you know what is most important in this client’s treatment plan?
- What would you do if you identified an environmental safety concern?
The objective isn’t to develop rehearsed survey answers. You are testing whether policy, practice, staff understanding, and documentation are aligned.
That is continuous readiness.
In this Issue
- New Space Ready for Clients? The Importance of a Behavioral Healthcare Workflow Assessment
- Does Your Budget Reflect Accreditation Survey Readiness?
- Behavioral Health Documentation: If It Isn’t Documented, It Didn’t Happen
- Accreditor Insights & Updates: JC, ACHC, CMS, COA, SAMHSA
- Tip of the Month: Don’t Limit Survey Readiness To The Regulatory Team
- Behavioral Health Documentation: If It Isn’t Documented, It Didn’t Happen
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“We were extremely pleased with the mock survey. The Barrins & Associates consultant team was fabulous. They were knowledgeable, skilled and able to communicate our deficits in ways that will help us to move forward. We are grateful to be working with them and feel very comfortable leaning on their expertise.”
Regulatory, Compliance, & Accreditation Specialist
Psychiatric Hospital
Are You Survey Ready?
At Barrins & Associates, we help behavioral health organizations turn compliance into resilience—strengthening systems, supporting staff, and improving care for every client.
Our consultants support psychiatric hospitals and community behavioral health and human services organizations with accreditation and regulatory readiness across Joint Commission, DNV, CIHQ, ACHC, CARF, COA, QUAD-A, and CMS requirements.
Whether you need a comprehensive mock survey, focused review of a high-risk area, continuous readiness support, or assistance responding to findings, our goal is to provide practical guidance your organization can put into action.
Contact Barrins & Associates to discuss how we can support your accreditation and regulatory readiness.
