JC-Standards Overview Behavioral Health Care - Joint Commission

© Copyright, The Joint Commission 

Joint Commission 

Behavioral Health Care Accreditation 

August 07, 2012 

Standards Overview 

Peggy Lavin, LCSW 

Senior Associate Director Behavioral Health Program 

Cynthia Leslie, APRN, BC, MSN 

Associate Director, Standards Interpretation Group 

Evelyn Choi, MS 

Senior Accreditation Specialist


The Joint Commission: 

Independent, not for profit, non-governmental 

organization 

Accrediting behavioral health organizations since 1969 

Over 1,900 behavioral health organizations accredited 

Our focus: helping organizations help the individuals 

they serve 

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Behavioral Health Care 

Accreditation Program 

‣ Requirements found in Comprehensive Accreditation 

Manual for Behavioral Health Care (CAMBHC) 

‣ Based on a Recovery/Resilience Concepts 

‣ Accredited organizations range from small single- service 

to complex multiple-service providers 

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State Recognitions for 

Joint Commission’s 


• 189 Distinct administrative agencies within 48 states 

and District of Columbia 

• Examples: 

– Oklahoma 

– Ohio 

– North Carolina 

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Accreditation Requirements 

Guidance for Good Practices 

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Accreditation Requirements 

Includes: 

Accreditation Participation Requirements 

National Patient Safety Goals 

Standards and Elements of Performance 

Sentinel Event Policy 

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Specific requirements: 

For participation in the accreditation process 

For maintaining an accreditation award 

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Examples of 


When requested, organization provides official 

report of licensing body 

Organization notifies consumers and staff that they 

may contact The Joint Commission with concerns 

about safety or quality of care, treatment or services 

of individuals served 

Organization does not misrepresent information 

provided in the accreditation process 

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National Safety Goals 

Requirements that highlight problematic areas in 

behavioral health care 

Applicability determined by care, treatment, or 

services provided 

Goal applicable to organizations accredited 

under the Comprehensive Behavioral Health 

Care Accreditation Manual: 

– Two identifiers of individual 

– Medication reconciliation 

– Hand hygiene 

– Suicide risk assessment 

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Behavioral Health 

Standards Development 

Standards represent a national consensus 

Expert panels provide feedback 

– Professional and Technical Advisory Committee 

– Advisory Councils 

Web-based field review of standards changes 

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Standards 

Standards are: 

General performance expectations 

General structure or process 

Goal 

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Elements of Performance 

How standards are evaluated: 

Specific performance expectation 

Specific structure/process 

Objectives 

Scored during the On-Site Survey 

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Standard Scoring 

Elements of Performance are scored 

An organization is either in compliance 

or not in compliance with a standard 

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Standards Applicability Process 

Common Standards apply to all organizations 

Specific Program/Setting Standards differ from 

program/setting to program/setting 

Specific Population/Service Standards differ from 

population to population 

Medication Management Standards are specific to 

each organization’s level of involvement 

Applicability grids are in the accreditation 

manual – print or electronic 

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Specific Programs and Settings 

Addictions 

Case management 

Corrections 

Crisis stabilization 

Family pres/wraparound 

Forensics 

Foster care 

Therapeutic foster care 

Community Support 

Therapeutic schools 

Eating Disorders 

Outpatient 

Day programs 

Transitional/Supervised living 

Residential/Group homes 

Outdoor 

Technology-based 

Opioid treatment 

Adult day care 

Vocational rehab. 

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Electronic Manual 

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© Copyright, The Joint Commission

© Copyright, The Joint Commission


View a short video that will walk you 

through these steps: 

http://www.jcrinc.com/BHC-Service-Profile/ 

For organizations that are not yet accredited, 

please contact Evelyn Choi for complimentary 

access 

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Required Written Documentation 

 

 

 

“RWD” Chapter found in CAMBHC print and electronic 

manual 

Identifies accreditation requirements requiring written 

documentation (policies, procedures, criteria, guidelines) 

Can be used as a checklist to achieve or maintain 

compliance 

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Required Written Documentation 

Documentation icon D also found next to all Elements 

of Performance that require written documentation 

This icon appears in all versions of the Accreditation 

Manual (print, on-line, standards-only spiral-bound) 

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Top Compliance Issues 

CTS.02.01.09 The organization screens 

all individuals served for physical pain.


CTS.02.01.11 The organization The 

organization screens all individuals 

served for their nutritional status. 

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CTS.03.01.03 The organization has a 

plan for care, treatment, or services 

that reflects the assessed needs, 

strengths, preferences, and goals of 

the individual served. 

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CTS.04.03.33 For organization 

providing food services: The 

organization has a process for 

preparing and/or distributing food and 

nutrition products. 

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EC.02.06.01 The organization 

establishes and maintains a safe, 

functional environment. 

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HR.01.06.01 Staff are competent to 

perform their responsibilities. 

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HR.02.01.03 The organization assigns 

initial, renewed, or revised clinical 

responsibilities to staff who are 

permitted by law and the organization 

to practice independently 

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MM.03.01.01 The organization safely 

stores medications. 

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NPSG15.01.01 Identify individuals at 

risk for suicide 

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RC.01.01.01 The organization 

maintains complete and accurate 

clinical/case records. 

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NPSG15.01.01 

The organization identifies safety risks 

inherent in the population of the 

individuals it serves. 

Identify individuals at risk for suicide. 

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EP1 Conduct a risk assessment that 

identifies specific characteristics of 

children/youth and environmental 

features that may increase or 

decrease the risk of suicide/harm to 

self. 

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Screening = Process of determining 

whether child/youth has certain risk 

factors requiring assessment. 

Trained staff 

Date to be collected 

Trigger points 

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What questions do you want to ask to 

determine if a child/youth is in danger 

of harm to self? 

Many tools – Choose questions that 

apply to your agency 

Consider a standardized tool 

Is the assessment age appropriate? 

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2012 Upcoming 

Complimentary Webinars* 

September 11 - How to Achieve Accreditation 

November 13 - The On-site Survey Process 

December 11 – Provider Roundtable 

* Already conducted 2012 webinars posted on BHC website 

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The Joint Commission’s Gold Seal of Approval TM means 

your organization has reached for and achieved the highest 

level of performance recognition available in the behavioral 

health field. 

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Behavioral Health Care Accreditation Team 

Mary Cesare-Murphy, PhD 

Executive Director 

mcesaremurphy@jointcommission.org 

630/792-5790 

David Wadner, PhD 

Field Director 

dwadner@jointcommission.org 

630/792-5788 

Peggy Lavin, LCSW 

Senior Associate Director 

plavin@jointcommission.org 

630/792-5411 

Cynthia Leslie, APRN, BC, MSN 

Standards Interpretation Group 

630/792-5982 

Evelyn Choi, MS 

Senior Accreditation Specialist 

echoi@jointcommission.org 

630/792-5866 

Merlin Wessels, LCSW 

Standards Interpretation Group 

630/792-5899 

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What do our accredited customers say? 

“We are under constant pressure to do more with 

less. Joint Commission requirements are the 

standards we use to assure we don’t sacrifice 

quality or safety as we change to meet new 

demands. They are the center around which we 

organize our systems.” 

Susan Rushing, Ph.D. 

CEO 

Burke Center, Lufkin, TX 

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What do our accredited organizations say? 

“The Joint Commission’s self-assessment process 

makes us take a close look at the uniformity of care and 

services. It makes us confident that patients receive 

the same quality care regardless of site, setting, or level 

of care. It helps you find real areas of improvement and 

stay survey-ready all the time.” 

Diane Buchter 

Senior VP, COO 

The Renfrew Center, Philadelphia, PA 

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“We chose The Joint Commission because we felt 

they are the best accrediting agency available. The 

Joint Commission name is powerful and that gives 

us an advantage with licensure, insurance, referrals 

and our reputation in general.” 

Michael Berrett, PhD 

CEO, President 

The Center for Change 

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“The Joint Commission has been very user-friendly, 

more so than other organizations I’ve worked with. 

They have a lot of good resources. And our account 

executives have been wonderful at getting back to us 

quickly whenever we have questions. They’ve been a 

great support throughout the entire process.” 

Gina Palmer 

Compliance Coordinator 

Magnolia Creek Treatment Center 

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“I am always impressed by the experience, patience, 

and thoroughness of our surveyors. With The Joint 

Commission as a partner, I feel like we have a wise 

mentor prodding us to do better, to think more clearly, 

and to be more efficient.” 

Dustin Tibbitts, 


InnerChange New Haven, Provo, UT 

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“We have made several very positive changes as a 

result of opportunities identified in our survey. And 

the surveyors’ willingness to respond to questions 

and share “best practices” observed in other 

accredited facilities enhances the value of the 

survey process.” 

Andrew L Braun, MBA 


Eating Recovery Center 

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“The Joint Commission Gold Seal tells our staff, our 

consumers, our payers, and our contractors that we 

mean business, that we mean quality. That by coming 

to us, they can expect a standard of excellence that’s 

driven by an organization that is synonymous for 

quality not only in our country, but around the world.” 

Michael Flora 

President and CEO 

Ben Gordon Center, DeKalb, IL 

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JC-Standards Overview Behavioral Health Care - Joint Commission

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