Barrins Bulletin
November 2025
Greetings to Our Colleagues in Behavioral Health!
Dear Readers,
As we head into year’s end, thank you for your continued commitment to safe, high-quality care and true continuous readiness.
At Barrins & Associates, we’re inspired by the leadership and resilience we see every day—staying ahead of evolving accreditation requirements, using data to drive improvement, and balancing innovation (AI, telehealth, digital tools) with regulatory expectations.
This month, we’re focusing on how to turn regulatory pressure into a strategic advantage by building a continuous-readiness approach so your organization doesn’t just respond to change, but leads it.
Inside this issue, we share practical strategies for strengthening resilience, highlight key survey trends we’re seeing in the field, and offer a brief “Tip of the Month” you can put into practice before year-end.
As you look toward 2026, consider: What is one process you can redesign so the safer path becomes the default—and how are you equipping emerging leaders to sustain that change?
Thank you for inviting Barrins & Associates to be part of your journey. We remain committed to providing the clarity, perspective, and tools you need.
Your Path to Accreditation Success: Our Experts Know Every Step!
Best Regards,
Yvonne Rockwood
MBA, MHA, CPHQ
Senior Vice President
Expert Support for CMS Systems Improvement Agreements (SIA)
Protect Your Medicare Certification with Proven Guidance
Is your psychiatric hospital navigating the intense scrutiny of a potential or current Centers for Medicare & Medicaid Services (CMS) Systems Improvement Agreement (SIA)? Don’t go it alone. At Barrins & Associates, our SIA services are purpose-built for hospitals like yours — combining hands-on expertise and CMS-approved credentials to safeguard your Medicare certification and reimbursement.
Why this matters:
When an Immediate Jeopardy or repeated Condition-level findings threaten your path, the SIA offers a strategic alternative to decertification — giving you the time and structure to rebuild and reform your system. But to make it work, you’ll need the right partners. You’ll need deep regulatory know-how, a corrective-action mindset, and a guide who can walk that journey with you.
What we deliver:
- A comprehensive gap analysis of your compliance with CMS Conditions of Participation (CoPs)
- Root cause identification that gets beneath the surface of non-compliance
- Development of a corrective action plan that meets CMS expectations
- Technical assistance and readiness support ahead of your resurvey
- A mock resurvey — your final rehearsal before the real deal
Why choose us:
We’re not just consultants — we’re CMS-approved experts for SIAs. Our team has partnered with psychiatric hospitals nationwide to help them emerge from SIAs stronger and operationally resilient. We lean into your team, collaborate side-by-side, and aim for long-term system improvement — not just a quick fix.
Take action now:
If your hospital is considering or already under an SIA, don’t wait. Partnering with us early gives you the best chance at a successful resurvey and uninterrupted Medicare reimbursement. Contact us right away to learn how we can help you navigate this critical pathway.
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Joint Commission (JC)
2025 Hospital Breakfast Briefings; Safety & EOC series
- The series is a webinar-based educational offering (“Breakfast Briefings”), designed specifically for hospitals (i.e., accredited organizations under the Comprehensive Accreditation Manual for Hospitals, CAMH)
- The purpose: to help hospital leaders, accreditation teams, quality/safety/risk personnel understand the latest changes/updates in standards, survey process, and compliance — including the upcoming changes (notably those related to the 2026 survey cycle)
DNV
The 14th annual, 2026 DNV Healthcare Symposium
- October 26-29 in Wisconsin Dells, Wisconsin.
- The purpose: to bring together hospital, ASC, and other patient care leaders to share best practices in quality improvement and patient safety. The event features education sessions, networking, and opportunities for sponsors and exhibitors to connect with healthcare organizations
ACHC
ACHCU Academy 2026 (March 2–4, 2026, Amelia Island, FL)
- A live, in-person, multi-track educational event hosted by Accreditation Commission for Health Care/ACHCU designed for healthcare professionals across settings (hospitals, home health, hospice, pharmacy, etc.).
- The purpose: designed to help attendees learn, connect and recharge: network with peers, engage with industry experts, and walk away with actionable insights for quality, risk, and accreditation readiness.
CARF
Live learning events (onsite, virtual, or blended) such as interactive sessions, break-outs, subject‐matter expert consultations.
- The purpose: CARF’s webinars are designed to help organizations understand, prepare for, and excel in the CARF accreditation process
COA
Intensive Accreditation Training (IAT) – December 1, from 10:00 a.m. – 1:00 p.m. EST. This is a paid training.
- The IAT session is designed to prepare new and incoming organizations for the COA Accreditation process: includes an overview of milestones, standards, rating indicators, how survey decisions are made, and how to get organized for the site visit
Introduction to COA Accreditation – December 10 at 1:00 p.m. EST. A free 30-minute webinar designed for organizations new to COA Accreditation
- The Intro to COA webinar is geared toward organizations just starting accreditation or considering it: provides high-level understanding of what accreditation means, the process steps, and benefits.
QUAD-A
Accreditation Strategy Webinar Dec 10, 12:30–1:30 PM (Central time)
- Free live webinar; after registration you’ll receive the recording and slides even if you can’t attend live
- The purpose: to show organizations how to use accreditation as a strategic advantage to build trust, strengthen quality, and support organizational growth.
Build a 15-Minute Weekly “Micro-Rounding” Habit
- Pick one standard or risk-prone process each week and walk it with your frontline teams. This small cadence reveals gaps early, strengthens a culture of readiness, and prevents year-end surprises during surveys.
- For example: Choose Medication Room Readiness as your micro-rounding focus.
- Spend 15 minutes with the charge nurse and tech to check expiration dates, sample storage, temperature logs, and separation of look-alike/sound-alike meds.
- Note one quick fix you can implement the same day (e.g., relabeling a drawer or updating the bin map).
- Repeat with a new standard or process next week to build steady, low-burden continuous readiness.
Barrins & Associates provides regulatory and accreditation consulting services for the Behavioral Healthcare industry, including psychiatric hospitals and freestanding BH organizations. We specialize in providing survey preparation and continuous survey readiness services to help you provide safe and compliant care.
Founded in 1999 by Anne Barrins, former Joint Commission (JC) surveyor and succeeded by Julia Finken, former JC 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 and Yvonne Rockwood, former Regional Associate Director for the Eastern Business Development Division at the JC for Community Behavioral Health Care Services.
- RThe ROI of Accreditation — When Quality Pays for Itself
- Beyond Discharge — Psychiatric Hospitals Demonstrate Compliance in Continuity of Care
- Behavioral Health Staff Education — How to Make Learning Stick
- Accreditor Insights & Updates: JC, DNV, CIHQ, ACHC, CARF, COA, QUAD-A
- Tip of the Month: Build a 15-Minute Weekly “Micro-Rounding” Habit
Congratulations Corner
We applaud our clients who have recently and successfully completed their Joint Commission Behavioral Health and Human Services and/or Hospital Accreditation Program Survey.
The achievement of such indicates an aptitude for quality and safety of care. Congratulations to your organization and staff!
Ohio Department of Behavioral Health
- Central Ohio Behavioral Healthcare
- Appalachian Behavioral Healthcare
Why Choose Us?
“The consultant created a trusting and collaborative feel to the audit. The team felt safe asking sensitive questions that we needed clarification regarding grey areas due to the subjectiveness in the clinical interpretation of standards.”
Chief Operating Officer
Organization
Welcome New Clients
Barrins & Associates welcomes the following new clients:
New Jersey Department of Health
- Greystone Park Psychiatric Hospital
Are You Survey Ready?
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. We continue to support your journey toward accreditation and regulatory compliance.
Inquire today about our consulting services.
We continue to support your journey toward accreditation and regulatory compliance.