Barrins Bulletin
January 2025
Greetings to Our Colleagues in Behavioral Health!
Happy New Year! As we welcome 2025, we’re excited to bring you insights into some critical updates and emerging trends shaping healthcare and behavioral health services. This month, we’ve curated topics that address regulatory requirements, standards updates, and evolving care models—all aimed at equipping you with the knowledge to enhance patient outcomes and organizational performance.
In this edition, we’ll clarify The Joint Commission’s requirement to include patient impact in the evidence of compliance document, offering practical guidance to ensure your organization aligns with this important mandate. Additionally, we’ll explore updated infection prevention and control standards, highlighting key changes and strategies for implementation to safeguard patient safety and improve overall compliance.
Finally, we’ll delve into the nuances of integrated care with a comparative analysis of Integrated Behavioral Health, Behavioral Health Home, and the Certified Community Behavioral Health Clinic (CCBHC) models of care. This exploration will provide you with a deeper understanding of how these approaches align with your organization’s goals and the needs of the populations you serve.
We hope this newsletter inspires thoughtful dialogue and action within your teams as you navigate the year ahead. Thank you for your continued commitment to improving healthcare delivery and outcomes. Let’s make 2025 a year of innovation, collaboration, and progress!
Our newsletter is designed to support behavioral health organizations by offering clear, straightforward regulatory and accreditation updates, along with practical compliance tips to help navigate these challenges smoothly. We also share creative strategies for making accreditation and regulatory compliance more engaging and enjoyable, so that sustaining compliance becomes less of a task and more of an opportunity to grow. We hope this edition is both informational and actionable – so keep reading for insights that can lighten the load and enhance your compliance journey.
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.
Efficient Compliance, Smart Resource Allocation: Reduce Accreditation and Regulatory Costs with Our Solutions!
Best Regards,
Upon completion of a psychiatric hospital or behavioral health and human services Joint Commission survey, organizations receive a final report of findings approximately 10 business days after the survey’s conclusion. This report outlines areas requiring improvement…
On December 18, 2024, the Centers for Medicare & Medicaid Services (CMS) announced the selection of Michigan, New York, Oklahoma, and South Carolina state Medicaid agencies to participate in the Innovation in Behavioral Health Model (IBH). This initiative, which…
The January issue of EC News highlights a crucial reminder about keeping your organization’s life safety drawings accurate and up-to-date. All too often, these documents fail to reflect how spaces are currently being used, leading to potential compliance gaps. Additionally, staff responsible for understanding these drawings sometimes struggle to identify the essential elements required by the standards. Key features that must be included are:
- Areas that are fully sprinklered, if the building is only partially sprinklered
- All hazardous storage areas
- All fire rated barriers
- All smoke related barriers
- Sleeping and nonsleeping suite boundaries, including the size of suites
- Designated smoke compartments
- Chutes and shafts
- Any approved equivalencies or waivers
Make it a priority in 2025 and beyond to maintain accurate, up-to-date life safety drawings and ensure staff are fully equipped to identify and understand the essential elements outlined in the standards.
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.
- Clarifying Joint Commission Requirements: Highlighting Patient Impact in Evidence of Standards Compliance
- Innovation in Behavioral Health Model (IBH): How the IBH Model Differs from the BHH and CCBHC Models
- Joint Commission: New & Revised Infection Prevention and Control Requirements for Behavioral Health and Human Services
- Tip of the Month: Life Safety Drawings
- Accreditor Insights & Updates: ACHC, DNV, & CARF
Congratulations Corner
Congratulations to our clients who have recently, successfully completed their Joint Commission Psychiatric Hospital and/or Behavioral Health & Human Services accreditation.
- Haven Behavioral Hospital of Dayton
- Village for Families & Children
- Mingus Mountain Youth Treatment Center
- Ohio Hospital for Psychiatry (OHP)
Welcome New Clients!
Barrins & Associates welcomes the following new clients:
- Skyland Trail
- Gap Solutions, Inc.
- Good Landing Recovery
- North Dakota State Hospital
- Swedgwick County Mental Health Hospital
Why Choose Us
“I want to thank you for all your efforts in making this mock survey for NDSH possible. The impact you are making in the quality of care for the entire State of ND is impressive. Your engagement, style and competency brings the strength to an organization to make the challenging changes needed going forward. Please extend our thanks and gratitude to you and your team for the excellent work provided and the impact you are making on quality patient care.”
Debbie Linne, Partner, Chief Operating Officer
DCCS
Are You 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. Inquire today about our consulting services.
Inquire today about our consulting services.
We continue to support your journey toward accreditation and regulatory compliance.