TJC and CMS News for the Behavioral Healthcare Industry
July 2018
In This Issue:

Greetings to Our Colleagues in Behavioral Healthcare!
Now that summer has reached its peak, we trust many of you are taking some well-deserved vacation. To keep you informed even in this more leisurely season, we're providing updates this month on CMS validation surveys and TJC's recently released FAQs on its Suicide Risk Recommendations.

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

Enjoy the rest of your summer and we'll be back in touch with our September newsletter.

Anne Barrins
Patient Safety Consultations
Are you ready for how patient safety will be evaluated on your next survey? Our patient safety consultation covers both environmental risks and the clinical suicide risk assessment process to  ensure compliance with TJC and CMS requirements. Contact us now to schedule this customized consultation!
Tip of the Month
The Documents List for Hospitals and Behavioral Health organizations now requires a copy of the organization's Safety Culture survey results. So, be sure to add that to your list as you prepare your documents for your next survey. Even more importantly, be prepared to speak to how you're responding to the survey results. (See our May, 2018 article Evaluating Your Culture of Safety.)
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
19 Years of Service
The Joint Commission Suicide Risk Recommendation FAQs
In the July issue of The Joint Commission Perspectives, responses to frequently asked questions from the field were published, relating to the suicide risk recommendations issued over the past several months.  Since we've received numerous questions from readers regarding these recommendations, we're providing a few of the responses in this article.
Ligature RiskS:
Recommendations for Inpatient Detox Units
The Joint Commission recently clarified some of its recommendations regarding ligature risks in the hospital environment. In the July issue of TJC Perspectives, they published responses to a set of FAQs received from the field. Most of the responses are essentially clarifications of their  initial recommendations published in November 2017However, one clarification is particularly noteworthy. It relates to the requirements for inpatient detox units.
Are you a psychiatric hospital that uses your Joint Commission accreditation for deemed status to satisfy Medicare certification requirements? If so, there's an important new TJC Accreditation Participation Requirement for you to be aware of.  Effective July 1, 2018, any hospital that loses its deemed status following a CMS complaint survey or CMS validation survey must immediately notify The Joint Commission.
Barrins & Associates is pleased to welcome three new clients:
Denver Springs, in Englewood, ColoradoLinden Oaks Behavioral Health in Naperville, Illinois, and Windsor Laurelwood Center for Behavioral Medicine in Willoughby, Ohio.
  We are pleased to be working with these clients on accreditation preparation and continuous regulatory readiness. 
Congratulations Corner
Congratulations to our clients, Clifford Beers Clinic in New Haven, Connecticut, and True Life Center in San Diego, California, on achieving the gold standard of TJC accreditation!
Barrins & Associates provides Joint Commission and CMS consulting services for the Behavioral Healthcare industry. Our clients include psychiatric hospitals and freestanding Behavioral Healthcare organizations. We specialize in providing Survey Preparation and Continuous Survey Readiness services for the Behavioral Healthcare industry. Barrins & Associates was founded by Anne Barrins who was a Joint Commission surveyor for 13 years.