TJC and CMS News for Behavioral Healthcare

July 2023

Greetings to Our Colleagues in Behavioral Health!

July is a vibrant and invigorating month that marks the heart of summer in many parts of the world. It is a time when the sun shines brightly, warming the days and encouraging outdoor activities. The warm weather, being outside, taking vacations, longer days, and engaging in activities that promote well-being can have a positive impact on mental health.
It is also a time when behavioral health care construction accelerates and the importance of pre-construction risk assessments (PCRA) and infection control risk assessments (ICRA) processes are established, fully implemented, and sustained. 
With staff on vacation and engaged in outdoor activities, it is easy for organizations to take their eyes off accreditation and regulatory compliance especially new accreditation and CMS requirements that have gone into effect in July. 
Our first topic outlines the information that will be presented by our Barrins Life Safety consultant Domenic Baratta regarding healthcare construction risk assessments. 
Our second article discusses the July CMS memorandum that outlines updates and guidelines for all Accrediting Organizations (AO). The memo, effective from July 14, 2023, includes several important points that will impact AO processes.

We value your feedback on the newsletter. Please send us your comments and tell us what topics you’d like to see in future issues. We look forward to hearing from you! Also, feel free to forward this newsletter to your colleagues.


In a recent email, The Centers for Medicare and Medicaid (CMS) released an important memo that outlines updates and guidelines for all Accrediting Organizations (AO). The memo, effective from July 14, 2023, includes several important points that will impact TJC’s…

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CMS Memo


For licensing purposes, health care facilities are required to have pre-construction risk assessment (PCRA) and infection control risk assessment (ICRA) processes established. But anyone who has tackled a construction project knows that identifying potential…

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construction risk assessment
Barrins & Associates provides Joint Commission and CMS consulting services for the Behavioral Healthcare industry. Our clients include psychiatric hospitals and freestanding Behavioral Healthcare organizations and we specialize in providing Survey Preparation and Continuous Survey Readiness services for the Behavioral Healthcare industry.

Barrins & Associates was founded by Anne Barrins, a Joint Commission surveyor for 13 years and is succeeded by Julia Finken with a 17 year tenure from The Joint Commission as a surveyor, the 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.

Are You Compliant with the New Joint Commission Standards Effective July 1, 2023?

Our Mock Survey is your best preparation. Contact us now to get scheduled and fully prepared for the new 2023 standards and changes to the survey process.

888-742-4621 xt 702


Healthcare Equity Certification Resource Center:

The July Perspectives describes new website content on the TJC site for resources regarding healthcare equity. While this relates to a new optional certification program TJC has developed there are many useful resources on this site that may be helpful in implementing the healthcare equity national patient safety goal, formerly the healthcare equity standards in the leadership chapter. We encourage readers to share this resource with their organization’s identified health equity leader. There is material and ideas on the website that may help get your program moving forward.

Why Choose Barrins & Associates

“Montefiore Health System has used Barrins & Associates as Joint Commission consultants for our Behavioral Health Services since 2004. Their in-depth knowledge of TJC standards and survey process has been instrumental in our survey success over the years. Whether working with our inpatient, outpatient, or opioid treatment programs, their ability to operationalize the standards in a way that supports best practices has been invaluable to us. They’ve truly become part of our team!”

Marguerite Taheri
Director of Regulatory Affairs, Montefiore Medical Center

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