Joint Commission Behavioral Health Update
September 2017
In This Issue:

Greetings to Our Colleagues in Behavioral Healthcare!
Now that summer vacations are over, most organizations are returning to their routine flow of business, including regulatory readiness efforts. To support you in that, we are providing information on two topics of interest related to TJC readiness. 

Our first article covers the topic of mental status exams which has been a challenging issue during deemed status psychiatric hospital surveys. Our second article discusses the final round of changes to the Behavioral Health standards that go into effect January 1, 2018.
We look forward to seeing many of you at the annual TJC Behavioral Health Care Conference on October 12 and 13 in Rosemont, Illinois. Please let us know if you will be attending and we will be sure to connect and catch up!

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.

Best regards and enjoy the fall season in your part of the country!

Anne Barrins
Concerned about TJC's Survey of Ligature Risks at Your Facility?
Our customized consultation on ligature risks is conducted by our engineer teamed with a clinical consultant. It delivers technical assistance on risk assessment as well as mitigation strategies - the best preparation for your next survey. Contact us now to schedule your consultation.
Tip of the Month
Getting ready for the new BH requirement for standardized outcome measures effective January 2018? TJC has published a searchable list of outcome measure tools on the TJC website. It's an excellent resource and may help you find the right tool for your program and your population. 
Why Choose
Barrins & Associates?

"Our Barrins & Associates engineer consultant provided outstanding technical assistance on our Environment of Care and Life Safety program. He was not only expert in his area but helpful and friendly and so easy to work with. Just keep him coming back!"

Abby Halloran
Director of Risk Management Haven Behavioral Hospital of Philadelphia
Tips for Documenting the Mental Status Exam
As we know, there is an intense focus now during TJC surveys on compliance with the CMS CoP for Special Medical Records Requirements for Psychiatric Hospitals, i.e. the B Tags. During surveys, there is a session devoted to the review of a sample of medical records for compliance with the specific requirements listed in B Tags 113 and 116. One area that is frequently found noncompliant these days is documentation of the mental status exam. 
Behavioral Health Manual
CHANGES Coming in 2018
The Behavioral Health Care Accreditation manual has undergone some revisions over the past several months as part of TJC's Standards Review Project. The final round of changes is now complete and will be effective January 2018. 
Update from TJC and CMS re Ligature Risks
TJC recently communicated to the field that CMS has agreed to develop guidance in the area of ligature risks; specifically regarding how these risks should be surveyed and cited and what constitutes acceptable mitigation plans. CMS anticipates that this guidance will take approximately six months to develop. In the interim, CMS has indicated that TJC may use its judgment as to what risks are cited, the level of deficiency, and approval of the facilities' mitigation plans.

This is at least a step in the right direction on this complex issue. We will keep you posted on any new developments.
Barrins & Associates is pleased to welcome four new clients:  
University Behavioral Center in Orlando, Florida, Mt. Sinai Beth Israel Hospital in New York City, Maine Medical Center in Portland, Maine, and Diamond Healthcare.
  We are pleased to be working with these clients on continuous regulatory readiness
Congratulations corner!
Congratulations to our clients, Potomac Pathways in Cabin John, Maryland, and Appliedtx in Los Angeles, California, who recently achieved initial Joint Commission 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.