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

Greetings to Our Colleagues in Behavioral Healthcare!
We hope you've begun to enjoy the summer season in your part of the country!
This month, our first article provides an update on CMS Validation Surveys - an occurrence that some of our psychiatric hospital clients are experiencing. Our second article covers The Joint Commission's recommendations for suicide prevention in non-hospital behavioral health settings, which is a high focus area during surveys. We're also introducing a new associate, Gayle Nash, RN, MPH.

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.

Anne Barrins
Anticipating a TJC Survey in 2019?
Contact us soon to schedule your mock survey. 2018 TJC surveys have been increasingly challenging and are often occurring "early." Be sure to schedule your mock survey soon enough to address our findings and ensure survey success!
Tip of the Month
Be aware there are standards updates going into effect July 1, 2018. These are included in the
E-dition version of the standards manuals available to all accredited organizations on your Joint Commission Connect extranet site. Be sure to check out the updates for changes applicable to your organization.

Why Choose
Barrins & Associates?

We've used Barrins & Associates as Joint Commission consultants for our behavioral health programs throughout Mount Sinai Health System and for some of our acute care services. They're not only experts in TJC standards but also highly skilled at helping us find workable solutions for challenging compliance issues. They've exceeded our expectations and become part of our team. We count on them routinely for their regulatory guidance and expertise." 
Sabina Lim MD MPH
Vice President, Behavioral Health, Mount Sinai Health System,
Chief of Strategy, Behavioral Health, Mount Sinai Health System
19 Years of Service
Psychiatric Hospitals:
As we know, TJC has deeming authority from CMS for both acute care hospitals and psychiatric hospitals. As part of its oversight of TJC's deemed status survey process, CMS conducts validation surveys to assess TJC's performance in evaluating a hospital's compliance with the CMS Conditions of Participation (COPs.)  These validation surveys are conducted within 60 days after a hospital's triennial TJC survey. The annual sample size for these validations surveys ranges from 2% to 5% of deemed hospitals.
Suicide Prevention Recommendations for
Non-Hospital BH Settings
In our January newsletter, we covered the suicide prevention recommendations issued by TJC earlier this year for non-hospital behavioral health settings. These were published in the January 2018 issue of TJC Perspectives and apply to residential, partial hospitalization, day treatment, and intensive outpatient behavioral health programs. (We clarified later with TJC that they also apply to outpatient behavioral health settings.)
Gayle Nash joins Barrins & Associates team
Barrins & Associates is very pleased to welcome a new member to our consulting team! Former Joint Commission surveyor Gayle Nash, RN, MPH recently joined us after 13 years as a surveyor for The Joint Commission. She surveyed acute care hospitals, critical access hospitals, psychiatric hospitals, and ambulatory care centers in the U.S. and internationally. Since leaving TJC, Gayle has consulted with organizations nationwide on TJC and CMS compliance and healthcare quality improvement.

Gayle has over 38 years' experience in nursing, hospital administration, regulatory compliance, and quality management. 
Barrins & Associates is pleased to welcome four new clients:
Blueridge Vista Health & Wellness in Cincinnati, Ohio, Hillside Atlanta in Atlanta, Georgia, UF Health Florida Recovery Center in Gainesville, Florida, and Virginia Beach Psychiatric Center in Virginia Beach, Virginia.
  We are pleased to be working with these clients on accreditation preparation and continuous regulatory readiness. 
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.