Barrins Bulletin
February 2025
Supporting Mental Health in the Wake of Natural Disasters: A Call to Behavioral Health Providers
Dear Readers,
As February 2025 begins, communities across the country are still reeling from the devastating effects of recent natural disasters—raging wildfires in Los Angeles, destructive hurricanes in the southeast, and widespread flooding in multiple regions. These disasters have left a lasting impact not just on infrastructure and livelihoods, but also on the mental well-being of those affected. The trauma of displacement, loss, and uncertainty can lead to increased anxiety, depression, PTSD, and other behavioral health challenges that require immediate and ongoing support.
For behavioral health providers, this moment presents both a challenge and an opportunity—to step up as a crucial support system for individuals and families struggling to process their experiences. Whether through crisis intervention, trauma-informed care, or long-term therapy, providers can play a vital role in fostering resilience, helping individuals regain a sense of stability, and ensuring that no one has to navigate the aftermath alone.
Behavioral health providers are on the frontlines, offering critical support to individuals and communities affected by these devastating events. Your dedication to trauma-informed care, crisis intervention, and long-term healing is invaluable during these challenging times. As natural disasters continue to impact lives, your role in fostering resilience, providing hope, and guiding recovery is more essential than ever. We are truly grateful for your unwavering commitment to the well-being of those you serve.
As always, we appreciate your input on the newsletter. Please take a moment to share your comments and let us know your thoughts. Additionally, we welcome suggestions for topics you would like to see covered in future issues. We eagerly anticipate hearing from you! Don’t hesitate to forward this newsletter to your colleagues; their insights are invaluable to us as well.
Protecting Financial Stability: Mitigating Risks Through Compliance and Excellence
A Tribute: Remembering Mary Cesare-Murphy, PhD
Beyond her professional accomplishments, Mary was a trusted friend and mentor to many of us, sharing her wisdom, kindness, and generosity of spirit. Her guidance and passion inspired all who had the privilege of working alongside her, and her influence will continue to shape our work and values for years to come.
Mary’s loss is deeply felt by her family, colleagues, and the many individuals whose lives she touched. We extend our heartfelt condolences to her loved ones during this difficult time. Mary’s legacy of compassion, dedication, and leadership will remain a source of inspiration and strength for all who knew her. She will be profoundly missed.
In today’s rapidly evolving healthcare landscape, the demand for safe, effective, and reliable care has never been higher—especially in the realm of behavioral health and medications for opioid use disorder (MOUD). Achieving consistently high levels of safety and…
For over 25 years, Barrins & Associates has partnered with psychiatric hospitals and behavioral health and human services providers, guiding them through the complex terrain of accreditation and compliance. With expertise spanning more than 350 organizations…
A CEO transition is a pivotal moment for any psychiatric hospital, behavioral health, or human services organization. In healthcare, this leadership change can ripple through all facets of the institution, including the critical areas of accreditation and regulatory…
TJC has updated their Survey Process and Report Design. The Survey Report modifications include:
- Findings are sorted by priority on the SAFER™ Matrix
- The SAFER™ Matrix now includes EP number and descriptive text
- A benchmarking tool is available on your extranet site to enable organizations to compare performance against similar organizations. There is a caveat – the benchmarking data cannot be used for marketing
TJC Process changes involve for-cause surveys; they will:
- Provide the general reason for the survey
- Inform the organization of the areas they wish to survey and will provide the general
- Provide a verbal overview of the findings from the survey
- Allow for questions
TJC New Document Upload Tool is available on the extranet site. This tool allows organizations to upload documents they want to share with surveyors.
CIHQ has published an article outlining 6 Tips for Managing After-Hour Access to the Hospital Pharmacy. This article discusses the role of access, training, second checks, pharmacist coverage, quality assurance and corrective action(s) in effectively managing the hospital pharmacy after-hours.
DNV has launched a Digital Accreditation Platform, effective April 15, 2025, designed to streamline the accreditation process for healthcare organizations. This platform offers real-time tracking of compliance metrics and provides resources for continuous improvement.
ACHC has published their Surveyor, Quality Review Edition. This informs behavioral health organizations regarding the top accreditation deficiencies and how to avoid them. The information includes an overview of standard requirements, common reasons for citations, frequency of citations, essential tips for compliance, and examples of survey findings.
CARF has developed interdisciplinary, field driven standards for Shelters. These standards were released in January 2025. The standards apply to Shelter programs from drop-in overnight to longer lengths of stay. These standards focus on services, supports and resources, environment, personnel training, safe space, and food safety. Organizations that achieve Shelter Program accreditation demonstrate that they offer a comprehensive array of services and supports.
COA, a subsidiary of Social Current, is seeking submissions for its 2025 Innovative Impact Award. This award recognizes Social Current network organizations that innovate strategies that create lasting positive change with families and communities. Online submissions are due by March 24, 2025.
With the recent surge in natural disasters, psychiatric hospitals should reaffirm their commitment to Emergency Preparedness accreditation and regulatory standards.
Some key compliance actions for February 2025 include:
- Review & Update the Emergency Operations Plan
- Conduct an Emergency Drill including an after action report
- Validate Backup Communication Systems
- Ensure Staff Training & Competency
- Inventory and Restock Emergency supplies
Now is the time to act – before the next emergency arises!
Thankfully, the fires in Los Angeles are now contained, but dealing with the aftermath of the fires remains a challenge. ACHC has posted information from HHS ASPR, about section 1135 waivers that are already available for hospitals in the affected areas. Use this link to learn more – ACHC HHS ASPR 1135 Waivers California Fires.
As of January 2025, DNV has not publicly announced specific updates to their healthcare standards for the year. However, DNV continues to emphasize a risk-based approach to patient safety and quality of care, integrating ISO 9001 Quality Management System principles into their accreditation programs.
In November 2024, DNV achieved a significant milestone by accrediting its 1,000th healthcare organization in the United States, reflecting the growing adoption of their standards and commitment to continuous improvement in patient safety.
CARF International has released the 2025 Behavioral Health Standards Manual, which includes several key updates to enhance service quality and organizational performance. Carf Bookstore
Key Updates in the 2025 Standards:
- Accreditation Policies and Procedures: Revised to streamline processes and clarify requirements for behavioral health service providers.
- Applicable Standards: Updated to reflect current best practices and emerging trends in behavioral health care.
- Intent Statements: Enhanced to provide clearer guidance on demonstrating conformance to the standards.
- Appendices: Expanded to include detailed information on required written documentation and operational timelines, aiding organizations in compliance and implementation.
- CARF Glossary: Updated with new terminology and definitions relevant to the evolving field of behavioral health.
Additionally, CARF has introduced accreditation standards for Certified Community Behavioral Health Clinics (CCBHCs), reflecting the growing emphasis on integrated, comprehensive care models.
We were founded by Anne Barrins, former Joint Commission surveyor, and are succeeded by Julia Finken, former Joint Commission surveyor, Associate Director of Business Development for the Home Care Program, and Executive Director of Business Development for the Behavioral Health Care and Psychiatric Hospital Programs.
- Transforming Care Delivery: The Path to High Reliability in Medications for Opioid Use Disorder Treatment
- The Hidden Value of Compliance Services: Why Investing in Accreditation and Regulatory Compliance is Essential
- The Crucial Role of Accreditation and Regulatory Support After a CEO Transition
- Accreditor Insights & Updates: TJC, CIHQ, DNV, ACHC, CARF, COA
- Tip of the Month: Emergency Preparedness
Congratulations Corner
We congratulate our clients who have recently and successfully completed their Joint Commission Psychiatric Hospital and/or Behavioral Health & Human Services accreditation.
SUN Behavioral Delaware
Georgetown, Delaware
Northwest Ohio Behavioral Healthcare
Toledo, Ohio
Hear What Our Clients Say
“My name is Alexander Male, and I am the Clinical Director at Caritas Treatment and Wellness Center. As we approach our upcoming accreditation survey, I wanted to take a moment to personally acknowledge and express my gratitude for the outstanding support that the Barrins & Associates consultant has provided throughout this process.
From the very beginning, your consultant has been an invaluable resource, guiding us through policy development, brainstorming solutions, and ensuring we stay on track. Her knowledge, patience, and ability to provide clear, actionable guidance have been instrumental in our preparation.
Whether it was offering halftime speeches to keep us motivated or helping us tackle complex compliance issues, she has gone above and beyond in every way.
Personally, I have learned a tremendous amount from this experience, and much of that is due to her expertise and dedication. Her contributions have not only prepared us for the survey but have also strengthened our organization for the long term.
I truly appreciate the opportunity to work with your consultant, and I wanted to ensure her hard work and commitment do not go unnoticed.”
Alexander Male, MSW, LISW-S
Clinical Director
Caritas Treatment & Wellness Center
Is Your Physical Environment Safe and Survey Ready?
At Barrins & Associates we can assist you to achieve and sustain accreditation and regulatory compliance in adherence to the TJC, DNV, CHIQ, ACHC, CARF, COA, and CMS, standards for psychiatric hospitals and community behavioral health and human services providers.
We have a highly skilled team of Life Safety Code engineers ready to support your compliance with the accreditation and regulatory requirements for Environment of Care, Life Safety, and Emergency Management. Inquire today about our consulting services.
Inquire today about our consulting services.
We continue to support your journey toward accreditation and regulatory compliance.