TJC and CMS News for Behavioral Healthcare
Greetings to our Colleagues in Behavioral Health!
Summer is here. The longer days and warmer weather inspire us to venture outdoors, enjoy vacations, and get together with family and friends. For individuals with behavioral health issues who cannot embrace what June has to offer, it can be a month where individuals feel isolated, left behind, and forgotten. As a result, the month of June also serves as a reminder of the importance of prioritizing mental health, fostering understanding, and creating a supportive environment for those navigating behavioral health issues.
June can be a challenging month for behavioral health providers as census rises, staff take vacations, and accreditation and regulatory surveys continue. Additionally, Barrins & Associates has continued to see a marked increase in requests for assistance with Joint Commission and CMS adverse decisions in June.
Our first topic outlines the steps organizations can take to respond effectively to a Joint Commission preliminary denial of accreditation decision.
Our second article discusses how mock surveys are one tool that Risk, Compliance, Legal and even Financial departments use to improve patient safety, adhere to the ever-changing compliance mandates, attain, or maintain Joint Commission Accreditation, CMS, and state regulatory compliance, and save money.
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.
Joint Commission accreditation is not only a mark of excellence but also a requirement for deemed providers receiving CMS funding and demonstrating commitment to patient safety. However, the accreditation process can be rigorous, and a denial decision from the Joint Commission can have serious consequences………..
When it comes to the essential services a hospital needs to elevate patient safety and maintain compliance, where do you draw the line on what to keep and what to cut? Mock surveys are one tool that Risk, Compliance, Legal and even financial departments use to improve patient safety, adhere to the ever-changing compliance mandates, attain, or maintain Joint Commission Accreditation, CMS, and state regulatory compliance, and save money. Here are 7 reasons why a mock survey is essential to your organization……….
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.
TIP OF THE MONTH
This is an update to the May Tip provided by Joint Commission
Day rooms do not need to have self-closing doors on inpatient psych units. The group rooms, day rooms, and other non-locked group spaces that are not ligature resistant need self-closing and self-locking doors and a staff member needs to always be present in the room when a patient is in the room.
“The office, if it is in a locked behavioral unit and accessible by patients, needs to be both self-locking and self-closing.”
If you have a ligature resistant day room with no identified safety or self-harm risks, that room does not need to have a self-closing, self-locking door.
Why Choose Barrins & Associates
“Thank you so, so much for everything this week, as well as over the past year so far. I’ve been reflecting on how much we’ve learned, how far we’ve come, and how well-equipped we feel to get to where we need to go, and it’s honestly amazing the difference between today vs the first time you were here. This is in very large part due to all of your help and encouragement.
I also just really appreciate your style; you two are fun, smart, and say what needs to be said. It’s always a pleasure!”
Teresa I. Shackelford
Administrator, State Hospital North