TJC and CMS News for Behavioral Healthcare

May 2023

Greetings to our Colleagues in Behavioral Health!

May is a captivating month, full of beautiful blossoms and joyous holiday celebrations.  It also serves as an introspective period, marked by the observance of Mental Health Awareness Month.  During this time, we commemorate the remarkable strides we have made in destigmatizing mental health challenges and fostering emotional wellness.  Moreover, it is an opportune moment to contemplate our trajectory towards eradicating stigma and advancing mental well-being for all.

In support of advancing mental well-being, The Joint Commission continues to emphasize standards to provide a framework for organizations to improve the care, treatment, and services to those individuals seeking high quality behavioral health treatment. To support those efforts, we’re covering two important topics this month. 

Our first topic covers suicide risk reduction using validated tools for suicide risk assessment.  By using validated tools, your behavioral health professionals can ensure a systematic and consistent evaluation process

Our second article is about how the Joint Commission standards support the delivery of high-quality crisis services.  You might be surprised to learn how the existing Joint Commission standards provide a robust framework for the continuum of crisis services.   

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 Suicide Risk Reduction NPSG Standard: Using Validated Tools

Take note, to improve patient safety and enhance the quality of care provided by healthcare organizations, the Joint Commission continues to emphasize NPSG which is focused on suicide risk reduction. This standard highlights the importance of identifying and effectively managing patients at risk of self-harm or suicide.

Be aware, this standard is scored frequently for both Hospitals  and  Behavioral Health Care organizations. Utilization of validated tools for assessing suicide risk is a key component to successfully complying with this standard

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suicide risk reduction standard

The Joint Commission Standards: Supporting the Transformation of the Crisis Services Continuum of Care

​Did you know that the Joint Commission has standards that support the provision of high-quality crisis services in both Hospital and Behavioral Health settings?  In fact, the Joint Commission has had these standards for years.  However, these standards have never been as important as they are now and here is why…….

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crisis services
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.

Plan for your Next TJC Survey Now

We are receiving more than normal numbers of calls from clients requesting help with Joint Commission adverse decisions. We recommend that all organizations are proactive by seeking Barrins & Associates consultation during their preparation for an upcoming survey or sustaining compliance rather than having to seek recovery assistance. Being proactive in maintaining compliance and preparing for upcoming surveys decreases leader and staff stress and reduces the cost of engaging consulting services. ​

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Self-Closing Doors

All the offices and 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.