Certified Community Behavioral Health Clinics...Note 3: An external organization (for example, a...

Certified Community Behavioral Health Clinics

Certified Community Behavioral Health Clinics Criteria to Joint Commission Behavioral Health Care Standards & EPs

RegulationsJoint Commission

Equivalent NumberJoint Commission Standards and Elements of PerformanceRequirement

1.A TAG: CCBH

1.A: General Staffing Requirements

1.a.1 TAG: CCBH

1.a.1 As part of the process leading to certification, the state will prepare an assessment of the needs of the target consumer population and a staffing plan for prospective CCBHCs. The needs assessment will include cultural, linguistic and treatment needs. The needs assessment is performed prior to certification of the CCBHCs in order to inform staffing and services. After certification, the CCBHC will update the needs assessment and the staffing plan, including both consumer and family/caregiver input. The needs assessment and staffing plan will be updated regularly, but no less frequently than every three years.

LD.03.06.01 Those who work in the organization are focused on improving safety and quality.

Leaders provide for a sufficient number and mix of staff to support safe, quality care, treatment, or services.

EP 3

Those who work in the organization are competent to complete their assigned responsibilities.EP 4

1.a.2 TAG: CCBH

1.a.2 The staff (both clinical and non-clinical) is appropriate for serving the consumer population in terms of size and composition and providing the types of services the CCBHC is required to and proposes to offer.Note: See criteria 4.K relating to required staffing of services for veterans.

LD.01.04.01 A chief executive manages the organization.

The chief executive provides for the following: Recruitment and retention of staff.EP 2

LD.04.01.05 The organization effectively manages its programs or services.

Leaders of the program or service oversee operations.EP 1

Programs or services providing care are directed by one or more qualified professionals or by a qualified licensed independent practitioner with clinical responsibilities.

EP 2

The organization defines, in writing, the responsibility of those with administrative and clinical direction of its programs or services.

EP 3

1.a.3 TAG: CCBH

1.a.3 The Chief Executive Officer (CEO) of the CCBHC maintains a fully staffed management team as appropriate for the size and needs of the clinic as determined by the current needs assessment and staffing plan. The management team will include, at a minimum, a CEO or Executive Director/Project Director, and a psychiatrist as Medical Director. The Medical Director need not be a full-time employee of the CCBHC. Depending on the size of the CCBHC, both positions (CEO/Executive Director/Project Director and the Medical Director) may be held by the same person. The Medical Director will ensure the medical component of care and the integration of behavioral health (including addictions) and primary care are facilitated.Note: If a CCBHC is unable, after reasonable and consistent efforts, to employ or contract with a psychiatrist as Medical Director because of a documented behavioral health professional shortage in its vicinity (as determined by the Health Resources and Services Administration (HRSA) (Health Resources and Services Administration [2015]), psychiatric consultation will be obtained on the medical component of care and the integration of behavioral health and primary care, and a medically trained behavioral health care provider with appropriate education and licensure with prescriptive authority in psychopharmacology who can prescribe and manage medications independently pursuant to state law will serve as the Medical Director.

Page 1 of 124 © 2016 The Joint CommissionOctober 13, 2015


1.a.4

RequirementRegulations

Joint Commission

Equivalent NumberJoint Commission Standards and Elements of Performance

LD.04.01.01 The organization complies with law and regulation.

The organization provides care, treatment, or services in accordance with licensure requirements, laws, and rules and regulations.

EP 2

1.a.4 TAG: CCBH

1.a.4 The CCBHC maintains liability/malpractice insurance adequate for the staffing and scope of services provided.

1.B TAG: CCBH

1.B: Licensure and Credentialing of Providers

HRM.01.01.03 The organization determines how staff function within the organization.

All staff who provide care, treatment, or services possess a current license, certification, or registration, in accordance with law and regulation and organization policy.

EP 1

Staff practice within the scope of their license, certification, or registration and as required by law and regulation and organization policy.

EP 2

Staff practice within the scope of their job description.EP 3

HRM.01.02.01 The organization verifies and evaluates staff qualifications.

The organization performs primary source verification of staff licensure, certification, or registration in accordance with law and regulation and organization policy at the time of hire and the time of renewal. Note 1: A primary verification source may designate another agency to communicate credentials information. The designated agency can then be used as a primary source. Note 2: An external organization (for example, a credentials verification organization [CVO]) may be used to verify credentials information. A CVO must meet the CVO guidelines identified in the Glossary.Note 3: In some instances, a staff member may also work for another Joint Commission–accredited organization. If the other organization has completed primary source verification of the staff member’s license, certification, or registration; can attest to that fact; and is willing to share that information with the behavioral health care organization, then primary source verification does not need to be completed a second time by the behavioral health care organization. The credentialing information would need to be made available upon demand during a Joint Commission survey.

EP 1

1.b.1 TAG: CCBH

1.b.1 All CCBHC providers who furnish services directly, and any Designated Collaborating Organization (DCO) providers that furnish services under arrangement with the CCBHC, are legally authorized in accordance with federal, state and local laws, and act only within the scope of their respective state licenses, certifications, or registrations and in accordance with all applicable laws and regulations, including any applicable state Medicaid billing regulations or policies. Pursuant to the requirements of the statute (PAMA § 223 (a)(2)(A)), CCBHC providers have and maintain all necessary state-required licenses, certifications, or other credentialing, with providers working toward licensure, and appropriate supervision in accordance with applicable state law.



1.b.1


Joint Commission


The organization verifies and documents that the job applicant has the education and experience required by the job duties and responsibilities, unless this information has already been verified by the entity that issued his or her licensure, certification, or registration. Note 1: The verification of required training informs the organization of the knowledge and competencies of staff. Verification of the specific credential must be obtained from the primary source. Primary source includes federal and state licensing boards, letters from professional schools and letters from postgraduate education or postdoctoral programs for completion of training. Designated equivalent sources include, but are not limited to, the following: - State licensing boards- The entity issuing the license, certification, or registration- The American Medical Association (AMA) Physician Masterfile for verification of a physician’s US and Puerto Rico medical school graduation and residency completion - The American Board of Medical Specialties (ABMS) for verification of a physician’s board certification - The Educational Commission for Foreign Medical Graduates (ECFMG) for verification of a physician’s graduation from a foreign medical school - The American Osteopathic Association (AOA) Physician Database for predoctoral education accredited by the AOA Bureau of Professional Education, postdoctoral education approved by the AOA Council on Postdoctoral Training, and Osteopathic Specialty Board Certification - The Federation of State Medical Boards (FSMB) for all actions against a physician’s medical license - The American Academy of Physician Assistants Profile for physician assistant education and National Commission on Certification of Physician Assistants (NCCPA) certification Note 2: A primary source of verified information may designate to an agency the role of communicating credentials information. The designated agency then becomes acceptable to be used as a primary source. Note 3: An external organization (for example, a credentials verification organization [CVO]) or a Joint Commission–accredited health care organization functioning as a CVO may be used to collect credentialing information. Both of these organizations must meet the CVO guidelines listed in the Glossary.

EP 2



EP 2

HRM.01.01.01 The organization develops written job descriptions.

Each job description identifies the minimum qualifications of the position.EP 2

HRM.01.06.03 Staff who assess individuals with substance abuse, dependence, and other addictive

behaviors and who plan services for and deliver services to these individuals have

specific competencies.

For opioid treatment programs: Trained and qualified substance abuse counselors provide services to meet the needs of patients and are sufficient in number to provide reasonable and prompt access by patients to counseling.

EP 6

LD.03.06.01 Those who work in the organization are focused on improving safety and quality.

Leaders provide for a sufficient number and mix of staff to support safe, quality care, treatment, or services.

EP 3

Those who work in the organization are competent to complete their assigned responsibilities.EP 4

1.b.2 TAG: CCBH

1.b.2 The CCBHC staffing plan meets the requirements of the state behavioral health authority and any accreditation standards required by the state, is informed by the state’s initial needs assessment, and includes clinical and peer staff. In accordance with the staffing plan, the CCBHC maintains a core staff comprised of employed and, as needed, contracted staff, as appropriate to the needs of CCBHC consumers as stated in consumers’ individual treatment plans and as required by program requirements 3 and 4 of these criteria. States specify which staff disciplines they will require as part of certification but must include a medically trained behavioral health care provider, either employed or available through formal arrangement, who can prescribe and manage medications independently under state law, including buprenorphine and other medications used to treat opioid and alcohol use disorders. The CCBHC must have staff, either employed or available through formal arrangements, who are credentialed substance abuse specialists. Providers must include individuals with expertise in addressing trauma and promoting the recovery of children and adolescents with serious emotional disturbance (SED) and adults with serious mental illness (SMI) and those with substance use disorders. Examples of staff the state might require include a combination of the following: (1) psychiatrists (including child, adolescent, and geriatric psychiatrists),



1.b.2


Joint Commission




EP 2

LD.04.03.09 Care, treatment, or services provided through contractual agreement are provided

safely and effectively.

The organization describes, in writing, the nature and scope of services provided through contractual agreements.

EP 2

(2) nurses trained to work with consumers across the lifespan, (3) licensed independent clinical social workers, (4) licensed mental health counselors, (5) licensed psychologists, (6) licensed marriage and family therapists, (7) licensed occupational therapists, (8) staff trained to provide case management, (9) peer specialist(s)/recovery coaches, (10) licensed addiction counselors, (11) staff trained to provide family support, (12) medical assistants, and (13) community health workers. The CCBHC supplements its core staff, as necessary given program requirements 3 and 4 and individual treatment plans, through arrangements with and referrals to other providers.Note: Recognizing professional shortages exist for many behavioral health providers: (1) some services may be provided by contract or part-time or as needed; (2) in CCBHC organizations comprised of multiple clinics, providers may be shared among clinics; and (3) CCBHCs may utilize telehealth/ telemedicine and on-line services to alleviate shortages. CCBHCs are not precluded by anything in this criterion from utilizing providers working towards licensure, provided they are working under the requisite supervision.

1.C TAG: CCBH

1.C: Cultural Competence and Other Training

HRM.01.03.01 The organization provides orientation to staff.

The organization determines the key safety content of orientation provided to staff.Note: Key safety content may include specific processes and procedures related to the provision of care, treatment, or services and the environment of care.

EP 1

The organization orients its staff to the key safety content before staff provides care, treatment, or services. Completion of this orientation is documented.

EP 2

The organization orients staff on the following: Policies and procedures related to job duties and responsibilities. Completion of this orientation is documented.

EP 3

The organization orients staff on the following: Their specific job duties and responsibilities. Completion of this orientation is documented. (See also IC.01.05.01, EP 6; IC.02.01.01, EP 7)

EP 4

The organization orients staff on the following: Sensitivity to cultural diversity based on their job duties and responsibilities. Completion of this orientation is documented.Note: Sensitivity to cultural diversity means being aware of and respecting cultural differences. This does not mean that staff have to be conversant with every culture that they may encounter in the organization.

EP 5

The organization orients staff on the following: The rights of individuals served, including the ethical aspects of care, treatment, or services. Completion of this orientation is documented. (See also RI.01.07.03, EP 5)

EP 6

For opioid treatment programs: Before providing patient care, staff receive education specific to the medication-assisted treatment used in the program and tailored to the patient population.

EP 15

HRM.01.05.01 Staff participate in education and training.

Staff participate in education and training to maintain or increase their competency. Staff participation is documented.

EP 1

1.c.1 TAG: CCBH

1.c.1 The CCBHC has a training plan, for all employed and contract staff, and for providers at DCOs who have contact with CCBHC consumers or their families, which satisfies and includes requirements of the state behavioral health authority and any accreditation standards on training which may be required by the state. Training must address cultural competence; person-centered and family-centered, recovery-oriented, evidence-based and trauma-informed care; and primary care/behavioral health integration. This training, as well as training on the clinic’s continuity plan, occurs at orientation and thereafter at reasonable intervals as may be required by the state or accrediting agencies. At orientation and annually thereafter, the CCBHC provides training about: (1) risk assessment, suicide prevention and suicide response; (2) the roles of families and peers; and (3) such other trainings as may be required by the state or accrediting agency on an annual basis. If necessary, trainings may be provided on-line.Cultural competency training addresses diversity within the organization’s service population and, to the extent active duty military or veterans are being served, must include information related to military culture. Examples of cultural competency training and materials include, but are not limited to, those available through the website of the US Department of Health & Human Services (DHHS), the SAMHSA website through the website of the DHHS, Office of Minority Health, or through the website of the DHHS, Health Resources and Services Administration.Note: See criteria 4.K relating to cultural competency requirements in services for veterans.



1.c.1


Joint Commission


Staff participate in education and training whenever changes in their responsibilities require it. Staff participation is documented.Note: Education and training are only required if an assessment of staff skills and competencies indicates a need for their provision.

EP 2

Staff participate in education and training that is specific to the needs of the population(s) served by the organization. Staff participation is documented. (See also RI.03.01.05, EP 7)

EP 3

For organizations that sponsor or offer peer support services: The organization has a process for persons who are providing peer support services to receive education and training that enhances their knowledge and skills.

EP 4

For opioid treatment programs: The program implements an individual annual training plan for each staff member.

EP 5

For opioid treatment programs: The program provides staff with training in the specific characteristics and needs of women participating in their treatment program.

EP 6

For opioid treatment programs: Staff receive education about all forms of viral hepatitis and their effects on the health of the patient.

EP 7

For opioid treatment programs: Staff have resources for problem solving and troubleshooting patient care issues (for example, vomiting medication, aggressive or disruptive behavior).

EP 8

For organizations that elect The Joint Commission Behavioral Health Home option: Staff providing direct care, treatment, or services participate in additional education and training that is specific to the following:- Behavioral health conditions most commonly found in the population(s) served- Chronic physical health conditions most commonly found in the population(s) served- Care, treatment, or services that are centered on the individual served- Strategies for engaging individuals served in participating in their care, treatment, or services- How equipment or technology related to the provision of primary physical health care is used

EP 10



EP 1


EP 2


EP 3

For organizations that sponsor or offer peer support services: The organization has a process for persons who are providing peer support services to receive education and training that enhances their knowledge and skills.

EP 4

For opioid treatment programs: The program implements an individual annual training plan for each staff member.

EP 5

1.c.2 TAG: CCBH

1.c.2 The CCBHC assess the skills and competence of each individual furnishing services and, as necessary, provides in-service training and education programs. The CCBHC has written policies and procedures describing its method(s) of assessing competency and maintains a written accounting of the in-service training provided during the previous 12 months.



1.c.2


Joint Commission


For opioid treatment programs: The program provides staff with training in the specific characteristics and needs of women participating in their treatment program.

EP 6

For opioid treatment programs: Staff receive education about all forms of viral hepatitis and their effects on the health of the patient.

EP 7

For opioid treatment programs: Staff have resources for problem solving and troubleshooting patient care issues (for example, vomiting medication, aggressive or disruptive behavior).

EP 8

For organizations that elect The Joint Commission Behavioral Health Home option: Staff providing direct care, treatment, or services participate in additional education and training that is specific to the following:- Behavioral health conditions most commonly found in the population(s) served- Chronic physical health conditions most commonly found in the population(s) served- Care, treatment, or services that are centered on the individual served- Strategies for engaging individuals served in participating in their care, treatment, or services- How equipment or technology related to the provision of primary physical health care is used

EP 10

HRM.01.06.01 Staff are competent to perform their job duties and responsibilities.

For each of its programs or services, the organization defines the competencies it requires of staff members who provide care, treatment, or services. Note: Competencies may be based on the programs or services provided and the populations served. (See also NPSG.03.06.01, EP 3)

EP 1

Staff with the educational background, experience, or knowledge related to the skills being reviewed assess competence.Note: When a suitable individual cannot be found to assess staff competence, the organization can utilize an outside individual for this task. If a suitable individual inside or outside the organization cannot be found, the organization may consult the competency guidelines from an appropriate professional organization to make its assessment.

EP 2

As part of orientation, the organization conducts an initial assessment of staff competence before they assume their responsibilities. This assessment is documented.

EP 3

The organization assesses staff competence whenever job duties and responsibilities change.EP 4

Staff competence is assessed and documented once every three years, or more frequently as required by organization policy or in accordance with law and regulation.

EP 5

The organization takes action when a staff member’s competence does not meet expectations.Note: Actions may include, but are not limited to, providing additional training or supervision, or modifying job duties and responsibilities.

EP 6

LD.04.01.07 The organization has policies and procedures that guide and support care, treatment,

or services.

Leaders review and approve policies and procedures that guide and support care, treatment, or services.EP 1

The organization manages the implementation of policies and procedures.EP 2

HRM.01.02.01 The organization verifies and evaluates staff qualifications.1.c.3 TAG: CCBH

1.c.3 The CCBHC documents in the staff personnel records that the training and



1.c.3


Joint Commission


For opioid treatment programs: The program maintains individualized personnel files as a record of employment. The personnel files contain the following:- Employment and credentialing data- Employment application data- Date of employment- Up-to-date licensing and credentialing data- Detailed job descriptions- Performance evaluations- Training records

EP 8



EP 1


EP 2


EP 3


As part of orientation, the organization conducts an initial assessment of staff competence before they assume their responsibilities. This assessment is documented.

EP 3

Staff competence is assessed and documented once every three years, or more frequently as required by organization policy or in accordance with law and regulation.

EP 5

demonstration of competency are successfully completed.

HRM.01.01.01 The organization develops written job descriptions.

Each position has a written job description.Note: A written contract may replace a job description. (For more information on contracted services, refer to Standard LD.04.03.09.)

EP 1

Each job description identifies the minimum qualifications of the position.EP 2

Each job description identifies the competencies of the position, which include the minimum skills, knowledge, and experience required for the position.

EP 4

1.c.4 TAG: CCBH

1.c.4 Individuals providing staff training are qualified as evidenced by their education, training and experience.

1.D TAG: CCBH

1.D: Linguistic Competence

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.1.d.1 TAG: CCBH

1.d.1 If the CCBHC serves individuals with Limited English Proficiency (LEP) or with language-based disabilities, the CCBHC takes reasonable steps to provide meaningful access to their services.



1.d.1


Joint Commission


For organizations that elect The Joint Commission Behavioral Health Home option: The organization identifies the verbal and written communication needs of the individual served, including his or her preferred language for discussing health care. Note: Examples of communication needs include the need for personal devices such as hearing aids or glasses, language interpreters, communication boards, and translated or plain language materials.

EP 18

For organizations that elect The Joint Commission Behavioral Health Home option: The organization communicates with the individual served during the provision of care, treatment, or services in a manner that meets his or her verbal and written communication needs.

EP 19

RI.01.01.03 The organization respects the right of the individual served to receive information in a

manner he or she understands.

The organization provides information to the individual served in a manner tailored to his or her language and ability to understand. (See also CTS.06.02.03, EP 9; RI.01.01.01, EP 2)

EP 1



The organization provides interpreting and translation services, as necessary. (See also RI.01.01.01, EP 2)Note: For organizations that elect The Joint Commission Behavioral Health Home option: Language interpreting options may include trained bilingual staff, contract interpreting services, or employed language interpreters. These options may be provided in person or via telephone or video. The documents that are translated, and the languages into which they are translated, are dependent on the population(s) served by the organization.

EP 2

1.d.2 TAG: CCBH

1.d.2 Interpretation/translation service(s) are provided that are appropriate and timely for the size/needs of the LEP CCBHC consumer population (e.g., bilingual providers, onsite interpreters, language telephone line). To the extent interpreters are used, such translation service providers are trained to function in a medical and, preferably, a behavioral health setting.



The organization communicates with the individual served who has vision, speech, hearing, or cognitive impairments in a manner that meets the needs of that individual. (See also RI.01.01.01, EP 2)

EP 3

1.d.3 TAG: CCBH

1.d.3 Auxiliary aids and services are readily available, Americans With Disabilities Act (ADA) compliant, and responsive to the needs of consumers with disabilities (e.g., sign language interpreters, teletypewriter (TTY) lines).




EP 1


EP 2


EP 3

1.d.4 TAG: CCBH

1.d.4 Documents or messages vital to a consumer’s ability to access CCBHC services (for example, registration forms, sliding scale fee discount schedule, after-hours coverage, signage) are available for consumers in languages common in the community served, taking account of literacy levels and the need for alternative formats (for consumers with disabilities). Such materials are provided in a timely manner at intake. The requisite languages will be informed by the needs assessment prepared prior to certification, and as updated.

IM.02.01.01 The organization protects the privacy of health information.1.d.5 TAG: CCBH

1.d.5 The CCBHC’s policies have explicit provisions for ensuring all employees, affiliated



1.d.5


Joint Commission


The organization has a written policy addressing the privacy of health information. (See also RI.01.01.01, EP 7)

EP 1

The organization implements its policy on the privacy of health information. (See also RI.01.01.01, EP 7)EP 2

The organization uses health information only for purposes permitted by law and regulation or as further limited by its policy on privacy. (See also MM.01.01.01, EP 1; RI.01.01.01, EP 7)

EP 3

The organization discloses health information only as authorized by the individual served or as otherwise consistent with law and regulation. (See also RI.01.01.01, EP 7)Note: For opioid treatment programs: Patients in addiction treatment programs and opioid treatment programs have the right to confidentiality in accordance with federal regulations (42 CFR).

EP 4

RI.01.02.01 The organization respects the right of the individual served to collaborate in decisions

about his or her care, treatment, or services.

The individual served has the right to involve his or her family in decisions about care, treatment, or services. When there is a surrogate decision-maker, he or she can exercise the right to involve the family on behalf of the individual served, in accordance with law and regulation. (See also RI.01.07.01, EP 2)

EP 8

providers, and interpreters understand and adhere to confidentiality and privacy requirements applicable to the service provider, including but not limited to the requirements of Health Insurance Portability and Accountability Act (HIPAA) (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state laws, including patient privacy requirements specific to the care of minors. The HIPAA Privacy Rule allows routine – and often critical – communications between health care providers and a consumer's family and friends, so long as the consumer consents or does not object. If a consumer is amenable and has the capacity to make health care decisions, health care providers may communicate with a consumer's family and friends.

2.A TAG: CCBH

2.A: General Requirements of Access and Availability

EC.02.01.01 The organization manages safety and security risks.

The organization identifies safety and security risks associated with the environment of care that could affect individuals served, staff, and other people coming to the organization's facilities. (See also EC.04.01.01, EP 14)Note 1: Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analyses, results of proactive risk assessments of high-risk processes, and from credible external sources such as Sentinel Event Alerts. Note 2: Examples of risks associated with the physical environment include those that might contribute to suicide or acts of violence.

EP 1

The organization takes action to minimize identified safety and security risks associated with the physical environment.

EP 3

The organization maintains all grounds and equipment.EP 5

The organization controls access to and from areas it identifies as security sensitive.EP 8

EC.02.06.01 The organization establishes and maintains a safe, functional environment.

Interior spaces meet the needs of the individuals served for safety and suitability for the care, treatment, or services provided.

EP 1

The organization provides outside areas for use by individuals served, based on the individual's needs and suitable to the individual's age or other characteristics. Note: Outdoor areas may include facility grounds, nearby parks and playgrounds, and adjacent countryside.

EP 4

2.a.1 TAG: CCBH

2.a.1 The CCBHC provides a safe, functional, clean, and welcoming environment, for consumers and staff, conducive to the provision of services identified in program requirement 4.



2.a.1


Joint Commission


Waiting and reception areas are adequate in size and number and staffed according to the needs of the individuals served.

EP 8

Restrooms are adequate in size and number for people using the facility.EP 9

The organization maintains ventilation, temperature, and humidity levels suitable for the care, treatment, or services provided.

EP 13

Drinking fountains or water coolers are available for the individuals served.EP 19

Areas used by individuals served are safe, clean, and comfortable.EP 20

Furnishings and equipment should reflect the ability and needs of the individual served.EP 24

The organization keeps furnishings and equipment safe and in good repair.EP 26

CTS.01.01.01 The organization accepts for care, treatment, or services only those individuals whose

identified care, treatment, or service needs it can meet.

Note 1: For opioid treatment programs: If an individual eligible for treatment applies for

admission to a comprehensive maintenance treatment program but cannot be placed

within 14 days in a program that is within a reasonable geographic area, an opioid

treatment program’s program sponsor may place the individual in interim maintenance

treatment.

Note 2: For opioid treatment programs: There may be individuals in special

populations who have a history of opioid use but are not currently physiologically

dependent. Federal regulations waive the one-year history of addiction for these

special populations, because these individuals are susceptible to relapse to opioid

addiction, leading to high-risk behaviors with potentially life-threatening

consequences. These populations include the following:

- Persons recently released from a penal institution

- Persons recently discharged from a chronic care facility

- Pregnant women

- Previously treated patients

The organization provides information about the locations and hours during which care, treatment, or services are available.

EP 6

For opioid treatment programs: Services are provided during hours that meet the needs of the majority of patients, including before and/or after the traditional 8:00 A.M. to 5:00 P.M. working day, when possible.

EP 10

CTS.04.01.07 For organizations that elect The Joint Commission Behavioral Health Home option: The

organization provides excellent access to integrated care, treatment, or services.

For organizations that elect The Joint Commission Behavioral Health Home option: The organization provides individuals served with the ability to do the following 24 hours a day, 7 days a week: - Contact the behavioral health home to request an appointment - Request prescription renewal - Request clinical advice for urgent health needsNote: This ability may be provided through a number of methods, including telephone, e-mail, flexible hours, websites, and portals.

EP 1

2.a.2 TAG: CCBH

2.a.2 The CCBHC provides outpatient clinical services during times that ensure accessibility and meet the needs of the consumer population to be served, including some nights and weekend hours.



2.a.2


Joint Commission


For organizations that elect The Joint Commission Behavioral Health Home option: The organization offers flexible scheduling to accommodate the individual’s care, treatment, or service needs. Note: This may include open access scheduling, same-day or next available appointments, group visits, expanded hours, and arrangements with other organizations.

EP 2

For organizations that elect The Joint Commission Behavioral Health Home option: The organization has a process to respond to an individual’s urgent care needs 24 hours a day, 7 days a week.

EP 3

For organizations that elect The Joint Commission Behavioral Health Home option: The organization facilitates individuals’ online access to their health information within four business days after the information is available to the integrated care team. This information includes diagnostic test results, lab results, summary lists, and medication lists.

EP 4

LD.04.01.11 The organization makes space and equipment available as needed for the provision of

care, treatment, or services.

Note: This standard is applicable only to those settings that are under the control of

the behavioral health care organization.

The arrangement and allocation of space supports safe, efficient, and effective care, treatment, or services.

EP 2

The interior and exterior space provided for care, treatment, or services meets the needs of individuals served.

EP 3

2.a.3 TAG: CCBH

2.a.3 The CCBHC provides services at locations that ensure accessibility and meet the needs of the consumer population to be served.

CTS.04.01.01 The organization coordinates the care, treatment, or services provided to an individual

served as part of the plan for care, treatment, or services and in a manner consistent

with the organization's scope of care, treatment, or services. (For more information,

refer to Standard CTS.03.01.07.)

For organizations that elect The Joint Commission Behavioral Health Home option: When an individual is referred to an external organization, the integrated care team does the following:- Assists the individual with making the referral appointment, when needed- Assists the individual in getting to the appointment, when needed- Tracks whether the individual kept the appointment- Reviews and tracks the care, treatment, or services provided to the individual

EP 17

2.a.4 TAG: CCBH

2.a.4 To the extent possible within the state Medicaid program or other funding or programs, the CCBHC provides transportation or transportation vouchers for consumers.




EP 4

For organizations that elect The Joint Commission Behavioral Health Home option: The organization uses a certified electronic health record to provide appointment reminders to individuals.

EP 5

2.a.5 TAG: CCBH

2.a.5 To the extent possible within the state Medicaid program and as allowed by state law, CCBHCs utilize mobile in-home, telehealth/telemedicine, and on-line treatment services to ensure consumers have access to all required services.

CTS.07.01.01 For organizations that provide prevention and wellness promotion services: The

organization's prevention and wellness promotion services are planned.

For organizations that provide prevention and wellness promotion services: The organization has a written plan for providing prevention and wellness promotion services that are relevant to its mission and the scope of its services.

EP 1

2.a.6 TAG: CCBH

2.a.6 The CCBHC engages in outreach and engagement activities to assist consumers and families to access benefits, and formal or informal services to address behavioral health conditions and needs.



2.a.6


Joint Commission


For organizations that provide prevention and wellness promotion services: The organization seeks input about the needs of the community served relative to prevention and wellness promotion services; the organization uses this information to guide its planning process.

EP 2

For organizations that provide prevention and wellness promotion services: The organization identifies those resources within the community (if any) that will be utilized to support the provision of the organization’s prevention and wellness promotion services.

EP 3



EP 2

Leaders act on or comply with reports or recommendations from external authorized agencies, such as accreditation, certification, or regulatory bodies.

EP 3

2.a.7 TAG: CCBH

2.a.7 Services are subject to all state standards for the provision of both voluntary and court-ordered services.

EM.02.01.01 The organization has an Emergency Management Plan.

Note: The organization’s Emergency Management Plan (EMP) is designed to

coordinate its communications, resources and assets, safety and security, staff

responsibilities, utilities, and clinical and support activities during an emergency (refer

to Standards EM.02.02.01, EM.02.02.03, EM.02.02.05, EM.02.02.07, and EM.02.02.11).

Although emergencies have many causes, the effects on these areas of the

organization and the required response effort may be similar. This "all hazards"

approach supports a general response capability that is sufficiently nimble to address

a range of emergencies of different duration, scale, and cause. For this reason, the

Plan’s response procedures address the prioritized emergencies but are also

adaptable to other emergencies that the organization may experience.

The organization has a written Emergency Management Plan that describes the response procedures to follow when emergencies occur. (See also EM.02.02.11, EP 1; EM.03.01.03, EP 5)Note 1: The response procedures address the prioritized emergencies but can also be adapted to other emergencies that the organization may experience. Response procedures could include the following: - Maintaining or expanding services- Conserving resources- Curtailing services- Supplementing resources from outside the local community- Closing the organization to new individuals for service- Staged evacuation- Total evacuationNote 2: Organizations that do not provide 24-hour care may plan to close in response to an emergency; their activities may be focused on notification and communication to individuals served and strategies for resuming service following the emergency.

EP 2

The organization has a written Emergency Management Plan that describes the recovery strategies, actions, and individual responsibilities necessary to restore the organization’s care, treatment, or services after an emergency.

EP 4

2.a.8 TAG: CCBH

2.a.8 CCBHCs have in place a continuity of operations/disaster plan.



2.a.8


Joint Commission


The Emergency Management Plan describes the processes for initiating and terminating the organization's response and recovery phases of the emergency, including under what circumstances these phases are activated. Note: Mitigation, preparedness, response, and recovery are the four phases of emergency management. They occur over time: Mitigation and preparedness generally occur before an emergency, and response and recovery occur during and after an emergency.

EP 5

The Emergency Management Plan identifies the staff member(s) responsible for activating the response and recovery phases of the emergency response.

EP 6

2.B TAG: CCBH

2.B: Requirements for Timely Access to Services and Initial and Comprehensive Evaluation for New Consumers







treatment.









- Pregnant women


The organization has a written process for determining eligibility of individuals that includes the following:- The criteria to determine eligibility for care, treatment, or services- The information to be collected to determine eligibility for care, treatment, or services- The populations of individuals accepted or not accepted by the organization (for example, programs designed to treat adults that do not treat young children)- The procedures for accepting referrals

EP 1

For organizations that elect The Joint Commission Behavioral Health Home option: The organization defines in writing the population(s) served by the behavioral health home; the population(s) served by the behavioral health home can be a defined subset(s) of the population served by the organization as a whole.

EP 2

The organization screens individuals for eligibility at the point of first contact with the organization, whether by phone, in person, or other.

EP 3

After screening, the organization matches accepted individuals with the care, treatment, or services most appropriate to their needs.

EP 4

2.b.1 TAG: CCBH

2.b.1 All new consumers requesting or being referred for behavioral health services will, at the time of first contact, receive a preliminary screening and risk assessment to determine acuity of needs. That screening may occur telephonically. The preliminary screening will be followed by: (1) an initial evaluation, and (2) a comprehensive person-centered and family-centered diagnostic and treatment planning evaluation, with the components of each specified in program requirement 4. Each evaluation builds upon what came before it. Subject to more stringent state, federal, or applicable accreditation standards:- If the screening identifies an emergency/crisis need, appropriate action is taken immediately, including any necessary subsequent outpatient follow-up.- If the screening identifies an urgent need, clinical services are provided and the initial evaluation completed within one business day of the time the request is made.- If the screening identifies routine needs, services will be provided and the initial evaluation completed within 10 business days.- For those presenting with emergency or urgent needs, the initial evaluation may be conducted telephonically or by telehealth/telemedicine but an in-person evaluation is preferred. If the initial evaluation is conducted telephonically, once the emergency is resolved the consumer must be seen in person at the next subsequent encounter and the initial evaluation reviewed.Subject to more stringent state, federal or applicable accreditation standards, all new consumers will receive a more comprehensive person-centered and family-centered diagnostic and treatment planning evaluation to be completed within 60 calendar days of the first request for services. This requirement that the comprehensive evaluation be completed within 60 calendar days does not preclude either the initiation or completion of the comprehensive evaluation or the provision of treatment during the 60 day period.Note: Requirements for these screenings and evaluations are specified in criteria 4.D.



2.b.1


Joint Commission


CTS.01.03.01 The organization develops a preliminary plan for care, treatment, or services, when

needed.

The organization develops a preliminary plan for care, treatment, or services when care, treatment, or services are initiated prior to completion of the screening and assessment process.

EP 1

The preliminary plan for care, treatment, or services focuses on the individual’s safety.EP 2

The preliminary plan for care, treatment, or services addresses interventions in response to emergency needs, such as an immediate need for placement or danger to self or others.

EP 3


needs, strengths, preferences, and goals of the individual served.

The organization develops a plan for care, treatment, or services that reflects the assessed needs, strengths, preferences, and goals of the individual served.

EP 1

The plan for care, treatment, or services includes the following: - Goals that are expressed in a manner that captures the individual's words or ideas- Goals that build on the individual’s strengths- Factors that support the transition to community integration when identified as a need during assessmentNote 1: Barriers that might need to be considered include co-occurring illnesses, cognitive and communicative disorders, developmental disabilities, vision or hearing disabilities, physical disabilities, and social and environmental factors.Note 2: For opioid treatment programs: For patients receiving interim maintenance treatment, neither an initial treatment plan nor a periodic treatment plan evaluation is required.

EP 2

The organization re-evaluates and, when necessary, revises the goals and objectives of the plan for care, treatment, or services based on change(s) in the individual's needs, preferences, and goals and his or her response to care, treatment, or services. If no change(s) occurs, the goals and objectives are re-evaluated at a specified time interval established by organization policy.

EP 4

Reasons for deferring a goal, or the objectives leading toward or related to a goal, are documented.EP 5

CTS.03.01.09 The organization assesses the outcomes of care, treatment, or services provided to the

individual served.

The organization monitors the individual’s progress in achieving his or her care, treatment, or service goals.

EP 1

The organization evaluates the outcomes of care, treatment, or services provided to the population(s) it serves.

EP 2

2.b.2 TAG: CCBH

2.b.2 The comprehensive person-centered and family-centered diagnostic and treatment planning evaluation is updated by the treatment team, in agreement with and endorsed by the consumer and in consultation with the primary care provider (if any), when changes in the consumer’s status, responses to treatment, or goal achievement have occurred. The assessment must be updated no less frequently than every 90 calendar days unless the state has established a standard that meets the expectation of quality care and that renders this time frame unworkable, or state, federal, or applicable accreditation standards are more stringent.


organization provides excellent access to integrated care, treatment, or services.2.b.3 TAG: CCBH

2.b.3 Outpatient clinical services for established CCBHC consumers seeking an appointment for routine needs must be provided within 10 business days of the requested date for service, unless the state has established a standard that meets the expectation of quality care and that renders this time frame unworkable, or state, federal, or applicable accreditation standards are more stringent. If an established consumer presents with an emergency/crisis need, appropriate action is taken immediately, including any necessary subsequent outpatient follow-up. If an established consumer presents with an urgent



2.b.3


Joint Commission



EP 1

For organizations that elect The Joint Commission Behavioral Health Home option: The organization offers flexible scheduling to accommodate the individual’s care, treatment, or service needs. Note: This may include open access scheduling, same-day or next available appointments, group visits, expanded hours, and arrangements with other organizations.

EP 2


EP 3

CTS.04.03.35 The organization responds to medical emergencies according to organization policy

and procedures.

The organization develops a written policy and procedures for responding to medical emergencies such as respiratory arrest and cardiac arrest.

EP 1

Policy and procedures that address medical emergencies include the following: - Availability of first aid and basic life support services- Emergency transfer to another organization- Placement of a phone call to 911

EP 2

The organization responds to medical emergencies according to organization policy and procedures.EP 3

need, clinical services are provided within one business day of the time the request is made.

2.C TAG: CCBH

2.C: 24/7 Access to Crisis Management Services

CTS.02.01.01 The organization has a screening procedure for the early detection of risk of imminent

harm to self or others.

The screening procedure determines the need for immediate intervention to protect the individual served or others.

EP 1

The organization has a process for responding when an immediate risk of harm is identified.Note: The process may include referring the individual to another organization.

EP 2

The organization responds when it determines the individual served poses an immediate risk of harm to self or others.

EP 3




EP 3

2.c.1 TAG: CCBH

2.c.1 In accordance with the requirements of program requirement 4, the CCBHC provides crisis management services that are available and accessible 24-hours a day and delivered within three hours.



2.c.2


Joint Commission



or services.



LD.04.02.03 Ethical principles guide the organization’s business practices.

Marketing materials accurately represent the organization and address the care, treatment, or services that the organization provides either directly or by contractual arrangement.

EP 4

2.c.2 TAG: CCBH

2.c.2 The methods for providing a continuum of crisis prevention, response, and postvention services are clearly described in the policies and procedures of the CCBHC and are available to the public.

CTS.01.04.01 For organizations that serve adults with serious mental illness: The organization

supports the adult’s decisions (psychiatric advance directive) about how care,

treatment, or services are to be delivered during times when he or she is unable to

make such decisions. (See also RI.01.05.01, EPs 1, 4, 5, 8, 10)

For organizations that serve adults with serious mental illness: The organization documents whether the adult has a psychiatric advance directive.

EP 1

For organizations that serve adults with serious mental illness: Upon request, the organization shares with the adult sources of help in formulating psychiatric advance directives.

EP 2

For organizations that serve adults with serious mental illness: If the adult has a psychiatric advance directive, clinical staff who are involved in the care, treatment, or services provided to that adult are aware that the psychiatric advance directive exists and know how to access it.

EP 3




EP 1


EP 3

For organizations that elect The Joint Commission Behavioral Health Home option: The organization provides individuals with contact information for the team coordinator on their integrated care team. (See also CTS.04.02.27, EP 4)

EP 6

2.c.3 TAG: CCBH

2.c.3 Individuals who are served by the CCBHC are educated about crisis management services and Psychiatric Advanced Directives and how to access crisis services, including suicide or crisis hotlines and warmlines, at the time of the initial evaluation. This includes individuals with LEP or disabilities (i.e., CCBHC provides instructions on how to access services in the appropriate methods, language(s), and literacy levels in accordance with program requirement 1).



2.c.3


Joint Commission


CTS.05.05.01 For organizations that use physical holding on a child or youth: The leaders establish

and communicate the organization’s philosophy on physical holding of children or

youth.

For organizations that use physical holding on a child or youth: At a minimum, the organization's philosophy addresses the following:- Its commitment to minimize the use of physical holding of children or youth- Prevention of emergencies that have the potential to lead to the use of physical holding of children or youth- Non-physical interventions as preferred interventions with input from the child or youth and parent or guardian- Limitation of the use of physical holding of children and youth to emergencies in which there is an imminent risk of a child or youth physically harming himself or herself, staff, or others - Responsibility to facilitate the discontinuation of physical holding of children or youth as soon as possible- Raising awareness among staff about how physical holding of children or youth may be experienced by the child or youth - Preserving the safety and dignity of the child or youth when physical holding is used

EP 1

For organizations that use physical holding on a child or youth: The organization’s philosophy on the use of physical holding of children and youth is communicated to the child or youth served, the parent(s) or guardian, and staff.

EP 2

CTS.05.06.01 For organizations that use restraint or seclusion: The leaders establish and

communicate the organization's philosophy on restraint and seclusion to all staff with

direct care responsibility.

For organizations that use restraint or seclusion: At a minimum, the organization's philosophy addresses the following: - Its commitment to prevent, reduce, and strive to eliminate restraint and seclusion- Prevention of emergencies that have the potential to lead to the use of restraint or seclusion- Nonphysical interventions as preferred interventions- Limitation of the use of restraint and seclusion to emergencies in which there is an imminent risk of an individual physically harming himself or herself, staff, or others- Its responsibility to facilitate the discontinuation of restraint or seclusion as soon as possible- Raising awareness among staff about how restraint or seclusion may be experienced by the individual served - Preserving the safety and dignity of the individual served when restraint or seclusion is used

EP 1

For organizations that use restraint or seclusion: The organization's philosophy on restraint or seclusion is communicated to all members of the organization who have direct care responsibility.

EP 2

For organizations that use restraint or seclusion: The organization's philosophy on restraint or seclusion is communicated to the individual served.

EP 3




EP 2

2.c.4 TAG: CCBH

2.c.4 In accordance with the requirements of program requirement 3, CCBHCs maintain a working relationship with local EDs. Protocols are established for CCBHC staff to address the needs of CCBHC consumers in psychiatric crisis who come to those EDs.



2.c.5


Joint Commission





EP 1


EP 2


EP 3

2.c.5 TAG: CCBH

2.c.5 Protocols, including protocols for the involvement of law enforcement, are in place to reduce delays for initiating services during and following a psychiatric crisis.Note: See criterion 3.c.5 regarding specific care coordination requirements related to discharge from hospital or ED following a psychiatric crisis.

CTS.05.05.17 For organizations that use physical holding on a child or youth: The child or youth and

staff participate in a debriefing about the physical holding episode.

For organizations that use physical holding on a child or youth: The child or youth and involved staff participate in a debriefing following each episode of physical holding.

EP 1

For organizations that use physical holding on a child or youth: The debriefing about each episode of physical holding occurs as soon as possible.

EP 2

For organizations that use physical holding on a child or youth: The debriefing about each episode of physical holding is used to do the following: - Identify what led to the incident and what could have been handled differently.- Ascertain that the physical well-being, psychological comfort, and right to privacy of the child or youth were addressed.- Assess the impact of the holding on the child's or youth’s emotional functioning.- When indicated, modify the child’s or youth’s plan for care, treatment, or services.

EP 3

For organizations that use physical holding on a child or youth: Information obtained and documented from debriefings is used in performance improvement activities.

EP 4

CTS.05.06.31 For organizations that use restraint or seclusion: The individual served and staff

participate in a debriefing about the restraint or seclusion episode.

For organizations that use restraint or seclusion: The individual served and, if appropriate, the individual's family participate with staff members who were involved in the episode and who are available in a debriefing about each episode of restraint or seclusion.

EP 1

For organizations that use restraint or seclusion: The debriefing about each episode of restraint or seclusion occurs as soon as possible, but no longer than 24 hours after the episode.

EP 2

For organizations that use restraint or seclusion: The debriefing about each episode of restraint or seclusion is used to do the following: - Identify what led to the incident and what could have been handled differently- Ascertain that the physical well-being, psychological comfort, and right to privacy of the individual served were addressed- Counsel the individual served for any trauma that may have resulted from the incident- When indicated, modify the individual's plan for care, treatment, or services

EP 3

For organizations that use restraint or seclusion: Information obtained and documented from debriefings is used in performance improvement activities.

EP 4

2.c.6 TAG: CCBH

2.c.6 Following a psychiatric emergency or crisis involving a CCBHC consumer, in conjunction with the consumer, the CCBHC creates, maintains, and follows a crisis plan to prevent and de-escalate future crisis situations, with the goal of preventing future crises for the consumer and their family.Note: See criterion 3.a.4 where precautionary crisis planning is addressed.



2.D


Joint Commission


2.D TAG: CCBH

2.D: No Refusal of Services due to Inability to Pay


Care, treatment, or services are provided based on the needs of individuals served, regardless of compensation or financial risk-sharing with those who work in the organization, including staff.

EP 5

LD.04.02.05 When internal or external review results in the denial of care, treatment, or services, or

payment, the organization makes decisions regarding the ongoing provision of care,

treatment, or services, and discharge or transfer, based on the assessed needs of the

individual served.

Decisions regarding the provision of ongoing care, treatment, or services, discharge, or transfer are based on the assessed needs of the individual served, regardless of the recommendations of any internal or external review.

EP 1

The safety and quality of care, treatment, or services do not depend on the ability of the individual served to pay.

EP 2

LD.04.03.07 Individuals with comparable needs receive the same standard of care, treatment, or

services throughout the organization.

Care, treatment, or services are consistent with the organization’s mission, vision, and goals.EP 2

2.d.1 TAG: CCBH

2.d.1 The CCBHC ensures: (1) no individuals are denied behavioral health care services, including but not limited to crisis management services, because of an individual’s inability to pay for such services (PAMA § 223 (a)(2)(B)), and (2) any fees or payments required by the clinic for such services will be reduced or waived to enable the clinic to fulfill the assurance described in clause (1).


Individuals served receive information about charges for which they will be responsible.EP 7

2.d.2 TAG: CCBH

2.d.2 The CCBHC has a published sliding fee discount schedule(s) that includes all services the CCBHC proposes to offer pursuant to these criteria. Such fee schedule will be included on the CCBHC website, posted in the CCBHC waiting room and readily accessible to consumers and families. The sliding fee discount schedule is communicated in languages/formats appropriate for individuals seeking services who have LEP or disabilities.



EP 2


The organization follows ethical practices for marketing and billing.EP 3

2.d.3 TAG: CCBH

2.d.3 The fee schedules, to the extent relevant, conform to state statutory or administrative requirements or to federal statutory or administrative requirements that may be applicable to existing clinics; absent applicable state or federal requirements, the schedule is based on locally prevailing rates or charges and includes reasonable costs of operation.


or services.




The organization follows ethical practices for marketing and billing.EP 3

2.d.4 TAG: CCBH

2.d.4 The CCBHC has written policies and procedures describing eligibility for and implementation of the sliding fee discount schedule. Those policies are applied equally to all individuals seeking services.



2.E


Joint Commission


2.E TAG: CCBH

2.E: Provision of Services Regardless of Residence



EP 5

2.e.1 TAG: CCBH

2.e.1 The CCBHC ensures no individual is denied behavioral health care services, including but not limited to crisis management services, because of place of residence or homelessness or lack of a permanent address.







treatment.









- Pregnant women



EP 1

For organizations that elect The Joint Commission Behavioral Health Home option: The organization defines in writing the population(s) served by the behavioral health home; the population(s) served by the behavioral health home can be a defined subset(s) of the population served by the organization as a whole.

EP 2


EP 3


EP 4

The organization accepts individuals for care, treatment, or services according to established processes.EP 5



EP 5

2.e.2 TAG: CCBH

2.e.2 CCBHCs have protocols addressing the needs of consumers who do not live close to a CCBHC or within the CCBHC catchment area as established by the state. CCBHCs are responsible for providing, at a minimum, crisis response, evaluation, and stabilization services regardless of place of residence. The required protocols should address management of the individual’s on-going treatment needs beyond that. Protocols may provide for agreements with clinics in other localities, allowing CCBHCs to refer and track consumers seeking non-crisis services to the CCBHC or other clinic serving the consumer’s county of residence. For distant consumers within the CCBHC’s catchment area, CCBHCs should consider use of telehealth/telemedicine to the extent practicable. In no circumstances (and in accordance with PAMA § 223 (a)(2)(B)), may any consumer be refused services because of place of residence.



3.A


Joint Commission


3.A TAG: CCBH

3.A: General Requirements of Care Coordination

CTS.03.01.01 The organization bases the planned care, treatment, or services on the needs,

strengths, preferences, and goals of the individual served.

Note: For opioid treatment programs: Methadone has well-documented effects on

several systems, including the respiratory, nervous, and cardiac systems, and the liver.

Additionally, many medications including methadone can act to increase the QT

interval on an electrocardiogram and potentially lead to torsades de pointes, a

potentially life-threatening cardiac arrhythmia. Therefore, it is important for the

program physician to consider all of the medications the patient is currently taking

(including actual versus prescribed doses, illicit drugs, medically active adulterants

potentially present in illicit substances, and medically active over-the-counter or

natural remedies). Given consideration of this information, the program physician can

determine whether the treatment drug will be methadone, buprenorphine, or another

medication and whether the treatment indicated for the patient is induction,

detoxification, or maintenance.

Planning for care, treatment, or services includes interventions and services necessary to meet the identified goals.

EP 4

For organizations that elect The Joint Commission Behavioral Health Home option: The physical health goals of the individual served are identified based on the screening and assessment and used in the plan for care, treatment, or services.

EP 12

For organizations that elect The Joint Commission Behavioral Health Home option: All physical and behavioral health care, treatment, or service decisions are collaborative and integrated when more than one discipline is involved in the care, treatment, or services provided to the individual served.

EP 13




EP 1


EP 2

The objectives of the plan for care, treatment, or services meet the following criteria:- They include identified steps to achieve the goal(s) (See also CTS.03.01.01, EP 3)- They are sufficiently specific to assess the progress of the individual served - They are expressed in terms that provide indices of progress

EP 3

3.a.1 TAG: CCBH

3.a.1 Based on a person and family-centered plan of care aligned with the requirements of Section 2402(a) of the ACA and aligned with state regulations and consistent with best practices, the CCBHC coordinates care across the spectrum of health services, including access to high-quality physical health (both acute and chronic) and behavioral health care, as well as social services, housing, educational systems, and employment opportunities as necessary to facilitate wellness and recovery of the whole person.Note: See criteria 4.K relating to care coordination requirements for veterans.



3.a.1


Joint Commission



EP 4


The organization provides care, treatment, or services for each individual served according to the plan for care, treatment, or services.

EP 6

For organizations that elect The Joint Commission Behavioral Health Home option: The plan for care, treatment, or services includes the following: - The physical health care needs of the individual- The physical health care goals of the individual- How the organization will meet those needs - How the organization will help the individual to work toward achieving his or her goals

EP 17


EP 18

For organizations that elect The Joint Commission Behavioral Health Home option: The organization works in partnership with the individual served to achieve planned integrated care outcomes.

EP 20

For organizations that elect The Joint Commission Behavioral Health Home option: The individual’s self-management goals related to behavioral and physical health conditions are identified and incorporated into the individual’s plan of care, treatment, or services. (Refer to RI.01.02.01, EP 1)

EP 21

For organizations that elect The Joint Commission Behavioral Health Home option: The organization involves the individual served in the development of his or her plan of care, treatment, or services.

EP 22

CTS.03.01.07 When individuals served need additional care, treatment, or services not offered by the

organization, referrals are made and documented in the clinical/case record. (For more

information, refer to Standard CTS.04.01.01.)

When the organization does not directly provide care, treatment, or services needed by the individual served, it refers the individual to an outside source.

EP 1

Concurrent care, treatment, or services provided by an outside source that are integral to meeting goals and objectives are addressed in the plan for care, treatment, or services.

EP 2

The organization documents referrals of individuals served to outside sources in the clinical/case record.EP 3





The organization coordinates the care, treatment, or services provided through internal resources to an individual served.

EP 1



3.a.1


Joint Commission


When external resources are needed, the organization participates in coordinating care, treatment, or services with these resources.

EP 5

The organization has a process to receive or share relevant information about the individual served to facilitate coordination and continuity when individuals are referred to other care, treatment, or service providers.

EP 6

For organizations that provide eating disorders care, treatment, or services: If during the course of care, treatment, or services the individual served is transferred to the hospital, the organization maintains communication with the hospital to exchange information relevant to the individual's eating disorder in support of the individual's care, treatment, or services.

EP 7

IM.02.01.01 The organization protects the privacy of health information.


EP 1



EP 3


EP 4

The organization monitors compliance with its policy on the privacy of health information. (See also RI.01.01.01, EP 7)

EP 5

IM.02.01.03 The organization maintains the security and integrity of health information.

The organization has a written policy that addresses the security of health information, including access, use, and disclosure.

EP 1

The organization has a written policy addressing the integrity of health information against loss, damage, unauthorized alteration, unintentional change, and accidental destruction.

EP 2

The organization has a written policy addressing the intentional destruction of health information.EP 3

The organization has a written policy that defines when and by whom the removal of health information is permitted. Note: Removal refers to those actions that place health information outside the organization's control.

EP 4

The organization protects against unauthorized access, use, and disclosure of health information.EP 5

The organization protects health information against loss, damage, unauthorized alteration, unintentional change, and accidental destruction.

EP 6

The organization controls the intentional destruction of health information.EP 7

The organization monitors compliance with its policies on the security and integrity of health information.EP 8

3.a.2 TAG: CCBH

3.a.2 The CCBHC maintains the necessary documentation to satisfy the requirements of HIPAA (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state privacy laws, including patient privacy requirements specific to the care of minors. The HIPAA Privacy Rule allows routine – and often critical – communications between health care providers and a consumer's family and friends. Health care providers may always listen to a consumer’s family and friends. If a consumer consents and has the capacity to make health care decisions, health care providers may communicate protected health care information to a consumer's family and friends. Given this, the CCBHC ensures consumers’ preferences, and those of families of children and youth and families of adults, for shared information are adequately documented in clinical records, consistent with the philosophy of person and family-centered care. Necessary consent for release of information is obtained from CCBHC consumers for all care coordination relationships. If CCBHCs are unable, after reasonable attempts, to obtain consent for any care coordination activity specified in program requirement 3, such attempts must be documented and revisited periodically.



3.a.2


Joint Commission


RC.02.01.01 The clinical/case record contains information that reflects the care, treatment, or

services provided to the individual served.

As needed to provide care, treatment, or services, the clinical/case record contains the following additional information:- Any advance directives- Any informed consent (See also RI.01.03.01, EP 13)- Any documentation of protective services- Any documentation of consent by the individual served, family, or guardian for admission; care, treatment, or services; evaluation; continuing care; or research- Any records of communication with the individual served, such as telephone calls or e-mail- Any documentation of involvement in care, treatment, or services by the individual served and, when necessary, his or her family- Any information on unusual occurrences, such as complications; accidents or injuries to the individual served; procedures that place the individual served at risk or cause pain; other illnesses or conditions that affect care, treatment, or services; or the death of the individual served- Any indications for and episodes of special procedures

EP 4



The organization involves the individual served in making decisions about his or her care, treatment, or services.Note: This involvement goes beyond mere presence at the time of discussion or decision making. Involvement connotes a collaborative process in which the organization actively engages the individual served in decision making regarding his or her care, treatment, or services.

EP 1

When an individual served is unable to make decisions about his or her care, treatment, or services, or chooses to delegate decision making to another, the organization involves the surrogate decision-maker in making these decisions. (See also RI.01.03.01, EP 6; RI.01.01.01, EP 18)

EP 6

When a surrogate decision-maker is responsible for making care, treatment, or services decisions, the organization respects the surrogate decision-maker’s right to refuse care, treatment, or services on behalf of the individual served, in accordance with law and regulation.

EP 7


EP 8






EP 17

3.a.3 TAG: CCBH

3.a.3 Consistent with requirements of privacy, confidentiality, and consumer preference and need, the CCBHC assists consumers and families of children and youth, referred to external providers or resources, in obtaining an appointment and confirms the appointment was kept.



3.a.4


Joint Commission







EP 1


EP 2


EP 3




EP 1


EP 4


EP 6


EP 20


EP 22




EP 1


EP 6


EP 7

3.a.4 TAG: CCBH

3.a.4 Care coordination activities are carried out in keeping with the consumer’s preferences and needs for care and, to the extent possible and in accordance with the consumer’s expressed preferences, with the consumer’s family/caregiver and other supports identified by the consumer. So as to ascertain in advance the consumer’s preferences in the event of psychiatric or substance use crisis, CCBHCs develop a crisis plan with each consumer. Examples of crisis plans may include a Psychiatric Advanced Directive or Wellness Recovery Action Plan.



3.a.4


Joint Commission



EP 8

RI.01.05.01 For organizations that elect The Joint Commission Behavioral Health Home option: The

organization addresses decisions made by the individual served about physical health

care, treatment, or services received at the end of life. (For more information, refer to

Standard CTS.01.04.01.)

For organizations that elect The Joint Commission Behavioral Health Home option: The organization has a written policy on physical health advance directives.

EP 1

For organizations that elect The Joint Commission Behavioral Health Home option: The organization’s written policy specifies whether the organization will honor physical health advance directives.

EP 4

For organizations that elect The Joint Commission Behavioral Health Home option: The organization implements its physical health advance directive policy.

EP 5

For organizations that elect The Joint Commission Behavioral Health Home option: The organization communicates its policy on physical health advance directives to the individuals it serves.

EP 8

For organizations that elect The Joint Commission Behavioral Health Home option: Upon request, the organization shares with the individual possible sources of help in formulating physical health advance directives.

EP 10

For organizations that elect The Joint Commission Behavioral Health Home option: If the individual served has a physical health advance directive, all members of the integrated care team are aware that it exists and know how to access it.

EP 11

NPSG.03.06.01 Maintain and communicate accurate medication information for the individual served.

Obtain and/or update information on the medications the individual served is currently taking. This information is documented in a list or other format that is useful to those who manage medications.Note 1: The organization obtains the individual's medication information during the first contact. The information is updated when the individual's medications change.Note 2: Current medications include those taken at scheduled times and those taken on an as-needed basis. See the Glossary for a definition of medications.Note 3: It is often difficult to obtain complete information on current medications from the individual served. A good faith effort to obtain this information from the individual and/or other sources will be considered as meeting the intent of the EP.

EP 1

Define the types of medication information (for example, name, dose, route, frequency, purpose) to be collected in non–24-hour settings based on situations of individuals served and characteristics of different settings.

EP 2

For organizations that prescribe medications: Compare the medication information the individual served brought to the organization with the medications ordered for the individual by the organization in order to identify and resolve discrepancies.Note: Discrepancies include omissions, duplications, contraindications, unclear information, and changes. A qualified staff member, identified by the organization, does the comparison. (See also HRM.01.06.01, EP 1)

EP 3

3.a.5 TAG: CCBH

3.a.5 Appropriate care coordination requires the CCBHC to make and document reasonable attempts to determine any medications prescribed by other providers for CCBHC consumers and, upon appropriate consent to release of information, to provide such information to other providers not affiliated with the CCBHC to the extent necessary for safe and quality care.



3.a.5


Joint Commission


For organizations that prescribe medications: Provide the individual served (or family as needed) with written information on the medications the individual should be taking at the end of the encounter (for example, name, dose, route, frequency, purpose).Note: When the only additional medications prescribed are for a short duration, the medication information the organization provides includes only those medications. For more information about communications to other providers of care when the patient is discharged or transferred, refer to Standard CTS.06.02.05.

EP 4

For organizations that prescribe medications: Explain the importance of managing medication information to the individual served.Note: Examples include instructing the individual served to give a list to his or her primary care physician; to update the information when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added; and to carry medication information at all times in the event of emergency situations. (For information on education of the individual served, refer to Standard CTS.04.01.03.)

EP 5


organization provides individuals served with information about the functions and

services of the behavioral health home.

For organizations that elect The Joint Commission Behavioral Health Home option: The organization provides information to the individual served and, when needed, his or her family or surrogate decision-maker about: The individual’s responsibilities, including providing his or her health history and current medications, and participating in self-management activities. (Refer to RI.01.01.03, EPs 1–3 and RI.02.01.01, EP 2)Note: Individuals’ responsibilities will vary depending on their abilities and unique circumstances. In some cases, family members or surrogate decision-makers may be able to help individuals meet their responsibilities.

EP 5



For organizations that elect The Joint Commission Behavioral Health Home option: The organization respects the individual’s right and provides him or her the opportunity to do the following: - Obtain care from other clinicians of the individual’s choosing within the behavioral health home - Seek a second opinion from a clinician of the individual’s choosing - Seek specialty care Note: This element of performance does not imply financial responsibility on the part of the organization for any activities associated with these rights.

EP 33




For organizations that elect The Joint Commission Behavioral Health Home option: The organization provides information to the individual served about: How the behavioral health home functions, including the following: - The process for assigning or selecting clinicians- Involving the individual in his or her plan of care, treatment, or services- Obtaining and tracking referrals - Coordinating the individual’s integrated care - Collaborating with clinicians who provide specialty care or second opinions

EP 3

3.a.6 TAG: CCBH

3.a.6 Nothing about a CCBHC’s agreements for care coordination should limit a consumer’s freedom to choose their provider with the CCBHC or its DCOs.



3.a.6


Joint Commission


For organizations that elect The Joint Commission Behavioral Health Home option: The organization provides information to the individual served about: The individual’s right to obtain care from other clinicians within the behavioral health home, to seek a second opinion, and to seek specialty care. (Refer to RI.01.02.01, EPs 9, 31, and 32)

EP 6

3.B TAG: CCBH

3.B: Care Coordination and Other Health Information Systems




EP 4

For organizations that elect The Joint Commission Behavioral Health Home option: The organization uses a certified electronic health record to provide appointment reminders to individuals.

EP 5

IM.01.01.01 The organization plans for managing information.

The organization identifies the internal and external information needed to provide safe, quality care.EP 1

The organization identifies how data and information enter, flow within, and leave the organization.Note: The flow of data and information within the organization includes how it moves into and out of storage.

EP 2

The organization uses the information identified to guide development of processes to manage information.

EP 3

The organization selects staff to participate in the assessment, selection, integration, and use of information management systems for the delivery of care, treatment, or services.

EP 4

For organizations that elect The Joint Commission Behavioral Health Home option: The organization uses health information technology to do the following: - Support the continuity of care and the provision of integrated care, treatment, or services - Document and track care, treatment, or services - Support disease management, including educating the individual about disease management - Support preventive care, treatment, or services - Create reports for internal use and external reporting - Facilitate electronic exchange of information among providers - Support performance improvement

EP 6

3.b.1 TAG: CCBH

3.b.1 The CCBHC establishes or maintains a health information technology (IT) system that includes, but is not limited to, electronic health records. The health IT system has the capability to capture structured information in consumer records (including demographic information, diagnoses, and medication lists), provide clinical decision support, and electronically transmit prescriptions to the pharmacy. To the extent possible, the CCBHC will use the health IT system to report on data and quality measures as required by program requirement 5.

IM.01.01.01 The organization plans for managing information.3.b.2 TAG: CCBH

3.b.2 The CCBHC uses its existing or newly established health IT system to conduct activities such as population health management, quality improvement, reducing disparities, and for research and outreach.



3.b.2


Joint Commission



EP 6

PI.01.01.01 The organization collects data to monitor its performance.

The leaders set priorities for data collection. (See also LD.04.04.01, EP 1)EP 1

The organization identifies the frequency for data collection.EP 2

The organization collects data on the following: Performance improvement priorities identified by leaders. (See also LD.04.04.01, EP 1)

EP 3

The organization collects data on the following: Significant medication errors. (See also LD.04.04.01, EP 2; MM.08.01.01, EP 1)

EP 14

The organization collects data on the following: Significant adverse medication reactions. (See also LD.04.04.01, EP 2; MM.08.01.01, EP 1)

EP 15

The organization collects data on the following: - Whether the individual served was asked about treatment goals and needs- Whether the individual served was asked if his or her treatment goals and needs were met- The view of the individual served regarding how the organization can improve the safety of the care, treatment, or services provided(See also RI.01.01.01, EP 17, for opioid treatment programs)

EP 16

The organization collects data to measure the performance of high-risk, high-volume, problem-prone processes provided to high-risk or vulnerable populations, as defined by the organization. (See also LD.04.04.01, EP 2)Note: Examples of such processes include the use of restraints, seclusion, suicide watch, and behavior management and treatment.

EP 27

The organization considers collecting data on the following:- Staff opinions and needs- Staff perceptions of risk to individuals- Staff suggestions for improving safety of the individuals served- Staff willingness to report adverse eventsNote: If the organization has not collected data on this topic, consideration can be demonstrated through methods such as interviews or meeting minutes.

EP 30

For organizations that elect The Joint Commission Behavioral Health Home option: The organization collects data on the following: Disease management outcomes. (See also LD.04.04.01, EP 24)

EP 40

For organizations that elect The Joint Commission Behavioral Health Home option: The organization collects data on the following: The individual’s access to care within time frames established by the organization.

EP 41



3.b.2


Joint Commission


For organizations that elect The Joint Commission Behavioral Health Home option: The organization collects data on the following: - The individual’s experience and satisfaction related to access to care, treatment, or services and communication - The individual’s perception of the comprehensiveness of care, treatment, or services - The individual’s perception of the coordination of care, treatment, or services - The individual’s perception of the continuity of care, treatment, or services (Refer to PI.01.01.01, EP 16)

EP 42

For organizations that elect The Joint Commission Behavioral Health Home option: All staff who are part of the behavioral health home actively participate in performance improvement activities.

EP 43

PI.02.01.01 The organization compiles and analyzes data.

The organization analyzes and compares internal data over time to identify levels of performance, patterns, trends, and variations.

EP 4

The organization compares data with external sources, when available.Note: Examples of external sources of information include the following:- Recent scientific, clinical, and management literature, including Sentinel Event Alerts- Evidence-based guidelines or parameters- Performance measures- Reference databases- Other organizations with similar processes

EP 5

The organization uses the results of data analysis to identify improvement opportunities. (See also HRM.01.06.05, EP 2; HRM.01.07.01, EP 3; LD.03.02.01, EP 5; PI.03.01.01, EP 1)

EP 8

For organizations that elect The Joint Commission Behavioral Health Home option: The organization uses patient registries, health information technology (HIT), and/or electronic health records (EHRs) to collect, analyze, and compare data in order to improve the outcomes of the individuals served.

EP 9

IM.01.01.01 The organization plans for managing information.


EP 6

IM.02.02.01 The organization effectively manages the collection of health information.

The organization uses uniform data sets to standardize data collection throughout the organization.EP 1

The organization uses standardized terminology, definitions, abbreviations, acronyms, symbols, and dose designations.

EP 2

3.b.3 TAG: CCBH

3.b.3 If the CCBHC is establishing a health IT system, the system will have the capability to capture structured information in the health IT system (including demographic information, problem lists, and medication lists). CCBHCs establishing a health IT system will adopt a product certified to meet requirements in 3.b.1, to send and receive the full common data set for all summary of care records and be certified to support capabilities including transitions of care and privacy and security. CCBHCs establishing health IT systems will adopt a health IT system that is certified to meet the “Patient List Creation” criterion (45 CFR §170.314(a)(14)) established by the Office of the National Coordinator (ONC)7 for ONC’s Health IT Certification Program.



3.b.3


Joint Commission


IM.02.02.03 The organization retrieves, disseminates, and transmits health information in useful

formats.

The organization's storage and retrieval systems make health information accessible when needed for care, treatment, or services of the individual served.

EP 2

The organization disseminates data and information in useful formats within time frames that are defined by the organization and consistent with law and regulation.

EP 3

The organization retains data and information for time frames consistent with law and regulation.EP 12

IM.04.01.01 The organization maintains accurate health information.

The organization has processes to check the accuracy of health information.Note: The organization has the flexibility to determine what health information needs to be checked for accuracy and the frequency with which it will be checked.

EP 1

IM.02.01.01 The organization protects the privacy of health information.


EP 1



EP 3


EP 4

The organization monitors compliance with its policy on the privacy of health information. (See also RI.01.01.01, EP 7)

EP 5

IM.02.01.03 The organization maintains the security and integrity of health information.

The organization has a written policy that addresses the security of health information, including access, use, and disclosure.

EP 1

The organization has a written policy addressing the integrity of health information against loss, damage, unauthorized alteration, unintentional change, and accidental destruction.

EP 2

The organization has a written policy addressing the intentional destruction of health information.EP 3

The organization has a written policy that defines when and by whom the removal of health information is permitted. Note: Removal refers to those actions that place health information outside the organization's control.

EP 4

The organization protects against unauthorized access, use, and disclosure of health information.EP 5

The organization protects health information against loss, damage, unauthorized alteration, unintentional change, and accidental destruction.

EP 6

3.b.4 TAG: CCBH

3.b.4 The CCBHC will work with DCOs to ensure all steps are taken, including obtaining consumer consent, to comply with privacy and confidentiality requirements, including but not limited to those of HIPAA (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state laws, including patient privacy requirements specific to the care of minors.



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Joint Commission


The organization controls the intentional destruction of health information.EP 7

The organization monitors compliance with its policies on the security and integrity of health information.EP 8

LD.04.04.01 Leaders establish priorities for performance improvement. (Refer to the "Performance

Improvement" [PI] chapter.)

Leaders set priorities for performance improvement activities and behavioral health outcomes. (See also PI.01.01.01, EPs 1 and 3)

EP 1

For organizations that elect The Joint Commission Behavioral Health Home option: Leaders set priorities for physical health care performance improvement activities and outcomes. (See also PI.01.01.01, EP 40)Note: As an example, activities and outcomes may be related to individuals with multiple chronic physical health conditions.

EP 24

For organizations that elect The Joint Commission Behavioral Health Home option: Leaders involve individuals served in performance improvement activities related to integrated care. Note: This involvement may include activities such as participating on a quality committee or providing feedback on safety and quality issues.

EP 25

PI.03.01.01 The organization improves performance.

Leaders prioritize the identified improvement opportunities. (See also PI.02.01.01, EP 8)EP 1

The organization takes action on improvement priorities.EP 2

The organization evaluates whether actions taken resulted in improvements.EP 3

The organization takes action when it does not achieve or sustain planned improvements.EP 4

For organizations that elect The Joint Commission Behavioral Health Home option: The organization uses the data it collects on the individual’s perception of the safety and quality of care, treatment, or services to improve its performance. This data includes the following: - The individual’s experience and satisfaction related to access to care, treatment, or services and communication - The individual’s perception of the comprehensiveness of care, treatment, or services - The individual’s perception of the coordination of care, treatment, or services - The individual’s perception of the continuity of care, treatment, or services

EP 11

3.b.5 TAG: CCBH

3.b.5 Whether a CCBHC has an existing health IT system or is establishing a new health IT system, the CCBHC will develop a plan to be produced within the two-year demonstration program time frame to focus on ways to improve care coordination between the CCBHC and all DCOs using a health IT system. This plan shall include information on how the CCBHC can support electronic health information exchange to improve care transition to and from the CCBHC using the health IT system they have in place or are implementing for transitions of care.

3.C TAG: CCBH

3.C: Care Coordination Agreements






EP 5

3.c.1 TAG: CCBH

3.c.1 The CCBHC has an agreement establishing care coordination expectations with Federally-Qualified Health Centers (FQHCs) (and, as applicable, Rural Health Clinics [RHCs]) to provide health care services, to the extent the services are not provided directly through the CCBHC. For consumers who are served by other primary care providers, including but not limited to FQHC Look-Alikes and Community Health Centers, the CCBHC has established protocols to ensure adequate care coordination.Note: If an agreement cannot be established with a FQHC or, as applicable, an RHC (e.g.,



3.c.1


Joint Commission



EP 6


EP 17


organization is accountable for facilitating the provision of integrated care to the

individual served.

For organizations that elect The Joint Commission Behavioral Health Home option: The organization manages transitions in care and facilitates the individual’s access to integrated care, treatment, or services including the following: - Acute care - Management of chronic care - Preventive services that are age- and gender-specific - Behavioral health care needs - Oral health care - Vision care- Urgent and emergent care Note: Some of these services may be obtained through the use of community resources as available, or in collaboration with other organizations.

EP 1

For organizations that elect The Joint Commission Behavioral Health Home option: The integrated care, treatment, or services address various phases of the lifespan of the individuals it serves, including end-of-life care when relevant to the population(s) served. (For more information, refer to Standard RI.01.05.01)

EP 2

For organizations that elect The Joint Commission Behavioral Health Home option: The organization provides disease and chronic care management services to the individuals it serves, as needed or as clinically indicated.

EP 3

For organizations that elect The Joint Commission Behavioral Health Home option: The organization communicates its role in supporting individuals who require specialty physical health assessment, care, treatment, or services to the individual and, as appropriate, his or her family, with the permission of the individual and in accordance with law and regulation.

EP 4

For organizations that elect The Joint Commission Behavioral Health Home option: The organization makes certain that the specialty physical health care, treatment, or services provider receives all the information about the individual’s behavioral and physical health that is needed to facilitate the specialty physical health assessment(s) and care, treatment, or services, with the permission of the individual and in accordance with law and regulation.

EP 5

a provider does not exist in their service area), or cannot be established within the time frame of the demonstration project, justification is provided to the certifying body and contingency plans are established with other providers offering similar services (e.g., primary care, preventive services, other medical care services).Note: CCBHCs are expected to work toward formal contracts with entities with which they coordinate care if they are not established at the beginning of the demonstration project.



3.c.1


Joint Commission



integrated care team works in partnership with the individual served to support the

continuity of care and the provision of comprehensive and coordinated care, treatment,

or services.

For organizations that elect The Joint Commission Behavioral Health Home option: The organization identifies the composition of the integrated care team.

EP 1

For organizations that elect The Joint Commission Behavioral Health Home option: The members of the integrated care team provide comprehensive and coordinated care, treatment, or services and maintain the continuity of care, treatment, or services. Note: The provision of care, treatment, or services may include making internal and external referrals.

EP 2

For organizations that elect The Joint Commission Behavioral Health Home option: The organization designates one member of the integrated care team to serve as team coordinator. This team member is accountable for coordinating the provision and continuity of the integrated care, treatment, or services and facilitating the individual's access to all needed care, treatment, or services, whether behavioral or physical. Note 1: Coordination of integrated care, treatment, or services may include coordinating internal and external referrals and coordinating the development and evaluation of plans of care, treatment, or services.Note 2: Portions of these activities may be delegated to other staff members by the team coordinator, with accountability remaining with the team coordinator.

EP 3

For organizations that elect The Joint Commission Behavioral Health Home option: The integrated care team participates in the development of the individual’s plan of care, treatment, or services.

EP 4

For organizations that elect The Joint Commission Behavioral Health Home option: The integrated care team assesses individuals for health risk behaviors.

EP 5

CTS.06.01.05 For organizations that elect The Joint Commission Behavioral Health Home option:

Case management/care coordination services are based on the needs, preferences,

and goals of the individual served and on the community resources available.

For organizations that elect The Joint Commission Behavioral Health Home option: The individual served and, as appropriate, his or her family are partners with the integrated care team in care, treatment, or service planning.

EP 1



3.c.1


Joint Commission


For organizations that elect The Joint Commission Behavioral Health Home option: With the assistance of the integrated care team, the individual served and, as appropriate, his or her family identify needs, preferences, and goals for the following: - Housing - Employment - Education - Transportation - Crisis support - Integrated health services - Illness self-management (for example, symptom management, medication management), including what to do in case of a health crisis or urgent health problem- Habilitation and rehabilitation services- Financial services and benefits - Assistance with housekeeping - Assistance with personal hygiene - Assistance with the retention and improvement of other skills related to activities of daily living - Social support and adaptive skills - Support of spirituality - Schools - Leisure and recreational activities- Parental support for children and youth - Interaction with the criminal or juvenile justice system, if applicable

EP 2

For organizations that elect The Joint Commission Behavioral Health Home option: The integrated care team assists the individual served in identifying, using, and accessing family, neighborhood, and community supports and services.

EP 3

For organizations that elect The Joint Commission Behavioral Health Home option: The integrated care team supports informed choice by individuals served.

EP 4

For organizations that elect The Joint Commission Behavioral Health Home option: The integrated care team assists the individual served in achieving his or her personal goals of independent living.

EP 5

For organizations that elect The Joint Commission Behavioral Health Home option: The individual served and the integrated care team evaluate all services provided directly or through referral to the individual served on a periodic basis, as defined by the organization.

EP 6

CTS.06.02.01 When an individual served is transferred or discharged, the continuity of care,

treatment, or services is maintained.

The organization has a process for addressing the continuity of care, treatment, or services after discharge or transfer that includes the following:- The transfer of responsibility for care, treatment, or services for the individual served from one staff, organization, organizational program, or service to another- The reason(s) for transfer or discharge when moving from one staff, organization, organizational program, or service to another- Mechanisms for internal and external transfer- Identification of the person who has accountability and responsibility for the safety of the individual served during an external transfer

EP 1




3.c.2 TAG: CCBH

3.c.2 The CCBHC has an agreement establishing care coordination expectations with



3.c.2


Joint Commission




EP 5


EP 6


EP 17



individual served.


EP 1


EP 2


EP 3


EP 4


EP 5

programs that can provide inpatient psychiatric treatment, with ambulatory and medical detoxification, post-detoxification step-down services, and residential programs to provide those services for CCBHC consumers. The CCHBC is able to track when consumers are admitted to facilities providing the services listed above, as well as when they are discharged, unless there is a formal transfer of care to a non-CCBHC entity. The CCBHC has established protocols and procedures for transitioning individuals from EDs, inpatient psychiatric, detoxification, and residential settings to a safe community setting. This includes transfer of medical records of services received (e.g., prescriptions), active follow-up after discharge and, as appropriate, a plan for suicide prevention and safety, and provision for peer services.Note: For these services, if an agreement cannot be established, or cannot be established within the time frame of the demonstration project, justification is provided and contingency plans are developed and the state will make a determination whether the contingency plans are sufficient or require further efforts.



3.c.2


Joint Commission





or services.


EP 1


EP 2


EP 3


EP 4


EP 5





EP 1



3.c.2


Joint Commission



EP 2


EP 3


EP 4


EP 5


EP 6




EP 1




3.c.3 TAG: CCBH

3.c.3 The CCBHC has an agreement establishing care coordination expectations with a



3.c.3


Joint Commission




EP 5


EP 6


EP 17



individual served.


EP 1


EP 2


EP 3


EP 4


EP 5

variety of community or regional services, supports, and providers. Services and supports to collaborate with which are identified by statute include: - Schools; - Child welfare agencies; - Juvenile and criminal justice agencies and facilities (including drug, mental health, veterans and other specialty courts); - Indian Health Service youth regional treatment centers; - State licensed and nationally accredited child placing agencies for therapeutic foster care service; and - Other social and human services. The CCBHC has, to the extent necessary given the population served and the needs of individual consumers, an agreement with such other community or regional services, supports, and providers as may be necessary, such as the following: - Specialty providers of medications for treatment of opioid and alcohol dependence; - Suicide/crisis hotlines and warmlines; - Indian Health Service or other tribal programs; - Homeless shelters; - Housing agencies; - Employment services systems; - Services for older adults, such as Aging and Disability Resource Centers; and - Other social and human services (e.g., domestic violence centers, pastoral services, grief counseling, Affordable Care Act navigators, food and transportation programs). Note: For these services, if an agreement cannot be established, or cannot be established within the time frame of the demonstration project, justification is provided and contingency plans are developed and the state will make a determination whether the contingency plans are sufficient or require further efforts.



3.c.3


Joint Commission





or services.


EP 1


EP 2


EP 3


EP 4


EP 5





EP 1



3.c.3


Joint Commission



EP 2


EP 3


EP 4


EP 5


EP 6




EP 1




3.c.4 TAG: CCBH

3.c.4 The CCBHC has an agreement establishing care coordination expectations with the



3.c.4


Joint Commission




EP 5


EP 6


EP 17



individual served.


EP 1


EP 2


EP 3


EP 4


EP 5

nearest Department of Veterans Affairs' medical center, independent clinic, drop-in center, or other facility of the Department. To the extent multiple Department facilities of different types are located nearby, the CCBHC should explore care coordination agreements with facilities of each type. Note: For these services, if an agreement cannot be established, or cannot be established within the time frame of the demonstration project, justification is provided and contingency plans are developed and the state will make a determination whether the contingency plans are sufficient or require further efforts.



3.c.4


Joint Commission





or services.


EP 1


EP 2


EP 3


EP 4


EP 5





EP 1



3.c.4


Joint Commission



EP 2


EP 3


EP 4


EP 5


EP 6




EP 1




3.c.5 TAG: CCBH

3.c.5 The CCBHC has an agreement establishing care coordination expectations with



3.c.5


Joint Commission




EP 5


EP 6


EP 17



individual served.


EP 1


EP 2


EP 3


EP 4


EP 5

inpatient acute-care hospitals, including emergency departments, hospital outpatient clinics, urgent care centers, residential crisis settings, medical detoxification inpatient facilities and ambulatory detoxification providers, in the area served by the CCBHC, to address the needs of CCBHC consumers. This includes procedures and services, such as peer bridgers, to help transition individuals from the ED or hospital to CCBHC care and shortened time lag between assessment and treatment. The agreement is such that the CCBHC can track when their consumers are admitted to facilities providing the services listed above, as well as when they are discharged, unless there is a formal transfer of care to another entity. The agreement also provides for transfer of medical records of services received (e.g., prescriptions) and active follow-up after discharge. The CCBHC will make and document reasonable attempts to contact all CCBHC consumers who are discharged from these settings within 24 hours of discharge. For all CCBHC consumers being discharged from such facilities who presented to the facilities as a potential suicide risk, the care coordination agreement between these facilities and the CCBHC includes a requirement to coordinate consent and follow-up services with the consumer within 24 hours of discharge, and continues until the individual is linked to services or assessed to be no longer at risk. Note: For these services, if an agreement cannot be established, or cannot be established within the time frame of the demonstration project, justification is provided and contingency plans are developed and the state will make a determination whether the contingency plans are sufficient or require further efforts.



3.c.5


Joint Commission





or services.


EP 1


EP 2


EP 3


EP 4


EP 5





EP 1



3.c.5


Joint Commission



EP 2


EP 3


EP 4


EP 5


EP 6




EP 1

3.D TAG: CCBH

3.D: Treatment Team, Treatment Planning and Care Coordination Activities



3.d.1


Joint Commission


CTS.02.03.01 For organizations providing care, treatment, or services to a child or youth: The

organization facilitates and coordinates family or guardian involvement throughout the

assessment process.

For organizations providing care, treatment, or services to a child or youth: The organization assesses the family's or legal guardian's expectations for and involvement in the assessment and initial and continuing care, treatment, or services.

EP 1

For organizations providing care, treatment, or services to a child or youth: The organization clearly explains the family’s or legal guardian's role in achieving care, treatment, or service goals.

EP 2

For organizations providing care, treatment, or services to a child or youth: The organization establishes procedures that facilitate ongoing communication with the family or legal guardian about their perceptions of the child’s or youth’s needs and other issues.

EP 3

For organizations providing care, treatment, or services to a child or youth: In conducting the assessment, the organization distinguishes between data provided by the family or legal guardian or referral sources and data based on the organization's interaction with the child or youth.

EP 4















The needs, strengths, preferences, and goals of the individual served are identified based on the screening and assessment and are used in the plan for care, treatment, or services.

EP 1

Care, treatment, or service decisions are collaborative and interdisciplinary when more than one discipline is involved in the care, treatment, or services of the individual served.

EP 2

Planning for care, treatment, or services includes identifying objectives for the identified goals. (See also CTS.03.01.03, EP 3)

EP 3


EP 4


EP 12

3.d.1 TAG: CCBH

3.d.1 The CCBHC treatment team includes the consumer, the family/caregiver of child consumers, the adult consumer’s family to the extent the consumer does not object, and any other person the consumer chooses. All treatment planning and care coordination activities are person-centered and family-centered and aligned with the requirements of Section 2402(a) of the Affordable Care Act. All treatment planning and care coordination activities are subject to HIPAA (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state laws, including patient privacy requirements specific to the care of minors. The HIPAA Privacy Rule does not cut off all communication between health care professionals and the families and friends of consumers. As long as the consumer consents, health care professionals covered by HIPAA may provide information to a consumer’s family, friends, or anyone else identified by a consumer as involved in their care.



3.d.1


Joint Commission



EP 13




EP 1


EP 2


EP 3


EP 4



EP 6


EP 17


EP 18


EP 19



3.d.1


Joint Commission



EP 20


EP 21


EP 22

CTS.03.01.05 The plan for care, treatment, or services addresses the family’s involvement.

The family of the individual served is involved in developing the plan for care, treatment, or services upon consent from the individual (if an adult) or in accordance with law and regulation (if a minor).

EP 1

The plan for care, treatment, or services reflects family participation in care, treatment, or services unless such participation is contraindicated.

EP 2

The organization documents family participation (if any) in the individual’s record of care, treatment, or services.

EP 3
















EP 2




or services.


EP 1


EP 2

3.d.2 TAG: CCBH

3.d.2 As appropriate for the individual’s needs, the CCBHC designates an interdisciplinary treatment team that is responsible, with the consumer or family/caregiver, for directing, coordinating, and managing care and services for the consumer. The interdisciplinary team is composed of individuals who work together to coordinate the medical, psychosocial, emotional, therapeutic, and recovery support needs of CCBHC consumers, including, as appropriate, traditional approaches to care for consumers who may be American Indian or Alaska Native.Note: See criteria 4.K relating to required treatment planning services for veterans.



3.d.2


Joint Commission



EP 3


EP 4


EP 5
















EP 2





EP 1


EP 2


3.d.3 TAG: CCBH

3.d.3 The CCBHC coordinates care and services provided by DCOs in accordance with the current treatment plan.Note: See program requirement 4 related to scope of service and person-centered and family-centered treatment planning.



3.d.3


Joint Commission






The organization coordinates the care, treatment, or services provided through internal resources to an individual served.

EP 1


EP 5


EP 6


EP 17

4.A TAG: CCBH

4.A: General Service Provisions

LD.01.03.01 Governance is ultimately accountable for the safety and quality of care, treatment, or

services.

Governance approves the organization's written scope of services.EP 3



Clinical leaders have an opportunity to provide advice about the sources of clinical services to be provided through contractual agreement.

EP 1


EP 2

Designated leaders approve contractual agreements.EP 3

Leaders monitor contracted services by establishing expectations for the performance of the contracted services. Note: When the organization contracts with another accredited organization for care, treatment, or services to be provided off site, it can do the following:- Verify that all licensed independent practitioners who will be providing care, treatment, or services have appropriate clinical responsibilities by obtaining, for example, a copy of the list of clinical responsibilities.- Specify in the written agreement that the contracted organization will ensure that all contracted services provided by licensed independent practitioners will be within the scope of their clinical responsibilities.

EP 4

4.a.1 TAG: CCBH

4.a.1 CCBHCs are responsible for the provision of all care specified in PAMA, including, as more explicitly provided and more clearly defined below in criteria 4.B through 4.K, crisis services; screening, assessment and diagnosis; person-centered treatment planning; outpatient behavioral health services; outpatient primary care screening and monitoring; targeted case management; psychiatric rehabilitation; peer and family supports; and intensive community-based outpatient behavioral health care for members of the US Armed Forces and veterans. As provided in criteria 4.B through 4.K, many of these services may be provided either directly by the CCBHC or through formal relationships with other providers that are DCOs. Whether directly supplied by the CCBHC or by a DCO, the CCBHC is ultimately clinically responsible for all care provided. The decision as to the scope of services to be provided directly by the CCBHC, as determined by the state and clinics as part of certification, reflects the CCBHC’s responsibility and accountability for the clinical care of the consumers. Despite this flexibility, it is expected CCBHCs will be designed so most services are provided by the CCBHC rather than by DCOs, as this will enhance the ability of the CCBHC to coordinate services.Note: See CMS PPS guidance regarding payment.



4.a.1


Joint Commission


Leaders monitor contracted services by communicating the expectations in writing to the provider of the contracted services. Note: A written description of the expectations can be provided either as part of the written agreement or in addition to it.

EP 5

Leaders monitor contracted services by evaluating these services in relation to the organization's expectations.

EP 6

Leaders take steps to improve contracted services that do not meet expectations. Note: Examples of improvement efforts to consider include the following:- Increase monitoring of the contracted services.- Provide consultation or training to the contractor.- Renegotiate the contract terms.- Apply defined penalties.- Terminate the contract.

EP 7

When contractual agreements are renegotiated or terminated, the organization maintains the continuity of care.

EP 8

Reference and contract laboratory services meet the federal regulations for clinical laboratories and maintain evidence of the same.

EP 10




EP 2


EP 4


EP 5


EP 6


EP 7

4.a.2 TAG: CCBH

4.a.2 The CCBHC ensures all CCBHC services, if not available directly through the CCBHC, are provided through a DCO, consistent with the consumer’s freedom to choose providers within the CCBHC and its DCOs. This requirement does not preclude the use of referrals outside the CCBHC or DCO if a needed specialty service is unavailable through the CCBHC or DCO entities.



4.a.2


Joint Commission


When contractual agreements are renegotiated or terminated, the organization maintains the continuity of care.

EP 8

RI.01.07.01 The individual served and his or her family have the right to have complaints reviewed

by the organization.

The organization establishes a complaint resolution process.EP 1

The organization informs the individual served and his or her family about the complaint resolution process. (See also RI.01.02.01, EP 8)Note: If the individual served has a surrogate decision-maker, he or she will be informed of and involved in the complaint resolution process.

EP 2

The organization reviews and, when possible, resolves complaints from the individual served and his or her family.

EP 4

The organization acknowledges receipt of the complaint and notifies the individual served and, when appropriate, his or her family of the outcome of the complaint.

EP 6

The organization provides the individual served (and when deemed beneficial, his or her family) with the phone number and address needed to file a complaint with the relevant state authority.

EP 7

The organization allows the individual served and his or her family to complain and recommend changes regarding care, treatment, or services without being subject to coercion, discrimination, or reprisals, or to interruptions of care, treatment, or services that could adversely affect the individual served.

EP 10

4.a.3 TAG: CCBH

4.a.3 With regard to either CCBHC or DCO services, consumers will have access to the CCBHC’s existing grievance procedures, which must satisfy the minimum requirements of Medicaid and other grievance requirements such as those that may be mandated by relevant accrediting entities.




EP 2



EP 4


EP 5


EP 6

4.a.4 TAG: CCBH

4.a.4 DCO-provided services for CCBHC consumers must standards as those provided by the CCBHC.



4.a.4


Joint Commission



EP 7


EP 10




EP 2



EP 4


EP 5


EP 6


EP 7


EP 10

4.a.5 TAG: CCBH

4.a.5 The entities with which the CCBHC coordinates care and all DCOs, takenin conjunction with the CCBHC itself, satisfy the mandatory aspects of these criteria.

4.B TAG: CCBH

4.B: Requirement of Person-Centered and Family-Centered Care



4.b.1


Joint Commission

















EP 1


EP 2


EP 3


EP 4


EP 12


EP 13




EP 1


EP 2

4.b.1 TAG: CCBH

4.b.1 The CCBHC ensures all CCBHC services, including those supplied by its DCOs, are provided in a manner aligned with the requirements of Section 2402(a) of the Affordable Care Act, reflecting person and family-centered, recovery-oriented care, being respectful of the individual consumer’s needs, preferences, and values, and ensuring both consumer involvement and self-direction of services received. Services for children and youth are family-centered, youth-guided, and developmentally appropriate.Note: See program requirement 3 regarding coordination of services and treatment planning. See criteria 4.K relating specifically to requirements for services for veterans.



4.b.1


Joint Commission



EP 3


EP 4



EP 6


EP 17


EP 18


EP 19


EP 20


EP 21


EP 22



EP 1


EP 2


EP 3



4.b.1


Joint Commission





EP 1

The organization respects the right of the individual served to refuse care, treatment, or services, in accordance with law and regulation.

EP 3


EP 8

The organization provides the individual served or surrogate decision-maker with the information about the outcomes of care, treatment, or services that the individual needs in order to participate in current and future behavioral health care decisions.

EP 20

For organizations that elect The Joint Commission Behavioral Health Home option: The organization respects the individual’s right to make decisions about the management of his or her care, treatment, or services.

EP 32

RI.01.01.01 The organization respects the rights of the individual served.

The organization treats the individual served in a respectful manner that supports his or her dignity.EP 4

The organization respects the cultural and personal values, beliefs, and preferences of the individual served.

EP 6

4.b.2 TAG: CCBH

4.b.2 Person-centered and family-centered care includes care which recognizes the particular cultural and other needs of the individual. This includes but is not limited to services for consumers who are American Indian or Alaska Native (AI/AN), for whom access to traditional approaches or medicines may be part of CCBHC services. For consumers who are AI/AN, these services may be provided either directly or by formal arrangement with tribal providers.

4.C TAG: CCBH

4.C: Crisis Behavioral Health Services




EP 1


EP 2


EP 3

4.c.1 TAG: CCBH

4.c.1 Unless there is an existing state-sanctioned, certified, or licensed system or network for the provision of crisis behavioral health services that dictates otherwise, the CCBHC will directly provide robust and timely crisis behavioral health services. Whether provided directly by the CCBHC or by a state-sanctioned alternative acting as a DCO, available services must include the following:- 24 hour mobile crisis teams,- Emergency crisis intervention services, and- Crisis stabilization.PAMA requires provision of these three crisis behavioral health services. As part of the certification process, the states will clearly define each term as they are using it but services provided must include suicide crisis response and services capable of addressing crises related to substance abuse and intoxication, including ambulatory and medical detoxification. States may elect to require the employment of peers on crisis teams. CCBHCs will have an established protocol specifying the role of law enforcement during the provision of crisis services.



4.c.1


Joint Commission





EP 1


EP 3

CTS.04.03.35 The organization responds to medical emergencies according to organization policy

and procedures.

The organization develops a written policy and procedures for responding to medical emergencies such as respiratory arrest and cardiac arrest.

EP 1

Policy and procedures that address medical emergencies include the following: - Availability of first aid and basic life support services- Emergency transfer to another organization- Placement of a phone call to 911

EP 2

The organization responds to medical emergencies according to organization policy and procedures.EP 3

For opioid treatment programs: The program’s offices and waiting areas display the names and telephone numbers of whom to contact in case of emergency or 911 or similar local emergency resources.

EP 4

For opioid treatment programs: The program has staff on duty who are trained and proficient in the following: - Cardiopulmonary resuscitation (CPR) through an evidence-based training program- Management of opiate overdose- Management of medical emergencies- Other appropriate techniques

EP 5

EC.02.01.01 The organization manages safety and security risks.

The organization identifies safety and security risks associated with the environment of care that could affect individuals served, staff, and other people coming to the organization's facilities. (See also EC.04.01.01, EP 14)Note 1: Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analyses, results of proactive risk assessments of high-risk processes, and from credible external sources such as Sentinel Event Alerts. Note 2: Examples of risks associated with the physical environment include those that might contribute to suicide or acts of violence.

EP 1

For opioid treatment programs: The organization establishes procedures for handling physical or verbal threats, acts of violence, inappropriate behavior, or other escalating and potentially dangerous situations. This includes situations in which security guards or police need to be summoned.

EP 13

Note: See program requirement 2 related to crisis prevention, response and postvention services and criterion 3.c.5 regarding coordination of services and treatment planning, including after discharge from a hospital or ED following a psychiatric crisis.



4.D


Joint Commission


4.D TAG: CCBH

4.D: Screening, Assessment, and Diagnosis






EP 5


EP 6


services.


4.d.1 TAG: CCBH

4.d.1 The CCBHC directly provides screening, assessment, and diagnosis, including risk assessment, for behavioral health conditions. In the event specialized services outside the expertise of the CCBHC are required for purposes of screening, assessment or diagnosis (e.g., neurological testing, developmental testing and assessment, eating disorders), the CCBHC provides or refers them through formal relationships with other providers, or where necessary and appropriate, through use of telehealth/telemedicine services.Note: See program requirement 3 regarding coordination of services and treatment planning.


needed.


EP 1



EP 3

CTS.02.01.03 The organization performs screenings and assessments as defined by the

organization's policy.

The organization assesses each individual served in accordance with organization policy.EP 1

The organization conducts each individual's assessment within the time frame specified by the needs of the individual served, organization policy, and law and regulation.

EP 2

The organization collects information during screenings and/or assessments about the following: The individual's perceptions of his or her needs, preferences, and goals for care, treatment, or services.

EP 3

The organization collects information during screenings and/or assessments about the following: When indicated and available, the family's perceptions and preferences for care, treatment, or services.

EP 4





The activities detailed in the plan of care, treatment, or services are designed to occur in a time frame that meets the behavioral health needs of the individual served.

EP 8

4.d.2 TAG: CCBH

4.d.2 Screening, assessment, and diagnosis are conducted in a time frame responsive to the individual consumer’s needs and are of sufficient scope to assess the need for all services required to be provided by CCBHCs.



4.d.2


Joint Commission


For organizations that elect The Joint Commission Behavioral Health Home option: The activities detailed in the plan of care, treatment, or services are designed to occur in a time frame that meets the physical health care needs of the individual served.

EP 9







treatment.









- Pregnant women



EP 1


EP 3


EP 4

The organization accepts individuals for care, treatment, or services according to established processes.EP 5


needed.


EP 1



EP 3

4.d.3 TAG: CCBH

4.d.3 The initial evaluation (including information gathered as part of the preliminary screening and risk assessment), as required in program requirement 2, includes, at a minimum, (1) preliminary diagnoses; (2) the source of referral; (3) the reason for seeking care, as stated by the consumer or other individuals who are significantly involved; (4) identification of the consumer’s immediate clinical care needs related to the diagnosis for mental and substance use disorders; (5) a list of current prescriptions and over-the-counter medications, as well as other substances the consumer may be taking; (6) an assessment of whether the consumer is a risk to self or to others, including suicide risk factors; (7) an assessment of whether the consumer has other concerns for their safety; (8) assessment of need for medical care (with referral and follow-up as required); and (9) a determination of whether the person presently is or ever has been a member of the U.S. Armed Services. As needed, releases of information are obtained.



4.d.3


Joint Commission





EP 1


EP 2


EP 3





EP 2

The organization collects information during screenings and/or assessments about the following: The individual's perceptions of his or her needs, preferences, and goals for care, treatment, or services.

EP 3

The organization collects information during screenings and/or assessments about the following: When indicated and available, the family's perceptions and preferences for care, treatment, or services.

EP 4

CTS.02.01.05 For organizations providing care, treatment, or services in non–24-hour settings: The

organization implements a written process requiring a physical health screening to

determine the individual's need for a medical history and physical examination.

Note 1: This standard does not apply to foster care and therapeutic foster care. (See

also CTS.02.04.01, EP 1)

Note 2: This standard does not apply to organizations that provide physical

examinations to all individuals served as a matter of policy or to comply with law and

regulation.

For organizations providing care, treatment, or services in non–24-hour settings: The organization has a written physical health screening process to determine whether an individual served is in need of a medical history and physical examination that is based on the population(s) served and, at a minimum, includes the following:- Data to be collected- Time frame for completion of the screening- Screening triggers that indicate the need for a medical history and physical examination

EP 1

For organizations that elect The Joint Commission Behavioral Health Home option: If the screening triggers indicate the need for a medical history and physical examination, the behavioral health home arranges for the history and physical to occur in a time frame that meets the physical health care needs of the individual served.

EP 2

For organizations providing care, treatment, or services in non–24-hour settings: The organization has a practitioner qualified by the scope of his or her license participate in developing the data to be collected and the physical health screening process.

EP 3



4.d.3


Joint Commission


For organizations providing care, treatment, or services in non–24-hour settings: The organization determines whether the date of the individual’s most recent physical examination exceeds one year. If the date exceeds one year, a medical history and physical examination is performed.Note: Securing the individual’s agreement to receive a medical history and physical examination may be undertaken as a process, and the organization may incorporate this process into the individual’s plan for care, treatment, or services. If performing a medical history and physical examination is not within the organization’s scope of services, it may refer the individual to another organization. (Refer to CTS.03.01.07, EPs 1-3)

EP 4

For organizations providing care, treatment, or services in non–24-hour settings: The organization implements its written process.

EP 5

CTS.02.02.01 The organization collects assessment data on each individual served.

As relevant to care, treatment, or services, the organization collects the following assessment data about each individual served:- Environment and living situation(s)- Leisure and recreational interests- Religion or spiritual orientation- Cultural preferences- Childhood history- Military service history, if applicable- Financial issues- Usual social, peer-group, and environmental setting(s)- Language preference and language(s) spoken- Ability to self-care- Family circumstances, including bereavement- Current and past trauma- Community resources accessed by the individual servedNote 1: Relevance to care, treatment, or services may be determined by the individual's presenting needs and the organization's scope of care, treatment, or services.Note 2: For certain populations, early identification of community resources is important to care, treatment, or services. Such populations include individuals with severe mental illness or disabilities and children and youth. Community resources for these groups encompass a wide range of services. These services are supportive (such as community mental health, sheltered living, day treatment, or activity programs) as well as commonly accessed by the general public (such as public transportation, banking, or retail stores). For youth or children in foster care or in-home services, resources might include community mental health centers, teen centers, YMCAs, or Jewish community centers. These sources of community services may be used as informational, discharge planning, supportive, or continuing care resources.

EP 1

As relevant to care, treatment, or services, the assessment data collected about the individual's emotional and behavioral functioning include at least the following:- History of emotional functioning- History of behavioral functioning- Addictive behaviors as a primary or a co-occurring condition(s), including the use of alcohol, other drugs, gambling, or other addictive behaviors by the individual served and family members- Current emotional functioning- Current behavioral functioning

EP 2

The assessment data collected include the individual’s short- and long-term personal goal(s).EP 3



4.d.3


Joint Commission


When indicated, the following evaluations are conducted:- Mental status- Psychological- Psychiatric- Intellectual and cognitive functioning

EP 4

Family members are invited to participate in the assessment process as relevant to the care, treatment, or services provided, and the age and preference of the individual served.

EP 5

CTS.02.02.05 The organization identifies individuals served who may have experienced trauma,

abuse, neglect, or exploitation.

The organization identifies individuals who may have experienced trauma, abuse, neglect, or exploitation during initial screening and assessment and on an ongoing basis.

EP 2

The organization assesses the individual who may have experienced trauma, abuse, neglect, or exploitation or refers the individual for such assessment.

EP 3

NPSG.03.06.01 Maintain and communicate accurate medication information for the individual served.

Obtain and/or update information on the medications the individual served is currently taking. This information is documented in a list or other format that is useful to those who manage medications.Note 1: The organization obtains the individual's medication information during the first contact. The information is updated when the individual's medications change.Note 2: Current medications include those taken at scheduled times and those taken on an as-needed basis. See the Glossary for a definition of medications.Note 3: It is often difficult to obtain complete information on current medications from the individual served. A good faith effort to obtain this information from the individual and/or other sources will be considered as meeting the intent of the EP.

EP 1

Define the types of medication information (for example, name, dose, route, frequency, purpose) to be collected in non–24-hour settings based on situations of individuals served and characteristics of different settings.

EP 2

For organizations that prescribe medications: Compare the medication information the individual served brought to the organization with the medications ordered for the individual by the organization in order to identify and resolve discrepancies.Note: Discrepancies include omissions, duplications, contraindications, unclear information, and changes. A qualified staff member, identified by the organization, does the comparison. (See also HRM.01.06.01, EP 1)

EP 3

For organizations that prescribe medications: Provide the individual served (or family as needed) with written information on the medications the individual should be taking at the end of the encounter (for example, name, dose, route, frequency, purpose).Note: When the only additional medications prescribed are for a short duration, the medication information the organization provides includes only those medications. For more information about communications to other providers of care when the patient is discharged or transferred, refer to Standard CTS.06.02.05.

EP 4



4.d.3


Joint Commission


For organizations that prescribe medications: Explain the importance of managing medication information to the individual served.Note: Examples include instructing the individual served to give a list to his or her primary care physician; to update the information when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added; and to carry medication information at all times in the event of emergency situations. (For information on education of the individual served, refer to Standard CTS.04.01.03.)

EP 5




EP 2





The activities detailed in the plan of care, treatment, or services are designed to occur in a time frame that meets the behavioral health needs of the individual served.

EP 8

For organizations that elect The Joint Commission Behavioral Health Home option: The activities detailed in the plan of care, treatment, or services are designed to occur in a time frame that meets the physical health care needs of the individual served.

EP 9

HRM.01.01.03 The organization determines how staff function within the organization.

All staff who provide care, treatment, or services possess a current license, certification, or registration, in accordance with law and regulation and organization policy.

EP 1

Staff practice within the scope of their license, certification, or registration and as required by law and regulation and organization policy.

EP 2

Staff practice within the scope of their job description.EP 3

4.d.4 TAG: CCBH

4.d.4 As required in program requirement 2, a comprehensive person-centered and family-centered diagnostic and treatment planning evaluation is completed within 60 days by licensed behavioral health professionals who, in conjunction with the consumer, are members of the treatment team, performing within their state’s scope of practice. Information gathered as part of the preliminary screening and initial evaluation may be considered a part of the comprehensive evaluation. This requirement that the comprehensive evaluation be completed within 60 calendar days does not preclude either the initiation or completion of the comprehensive evaluation or the provision of treatment during the intervening 60 day period.



EP 2

4.d.5 TAG: CCBH

4.d.5 Although a comprehensive diagnostic and treatment planning evaluation is required for all CCBHC consumers, the extent of the evaluation will depend on the individual consumer and on existing state, federal, or applicable accreditation standards. As part of certification, states will establish the requirements for these evaluations; factors states should consider requiring include: (1) reasons for seeking services at the CCBHC, including information regarding onset of symptoms, severity of symptoms, and circumstances leading to the consumer’s presentation to the CCBHC; (2) a psychosocial evaluation including housing, vocational and educational status, family/caregiver and social support, legal issues, and insurance status; (3) behavioral health history (including trauma history and previous therapeutic interventions and hospitalizations); (3) a diagnostic assessment, including current mental status, mental health (including depression screening) and substance use disorders (including tobacco, alcohol, and other drugs); (4) assessment of imminent risk (including suicide risk, danger to self or others, urgent or critical medical conditions, other immediate risks including threats from another person); (5) basic competency/cognitive impairment screening (including the consumer’s



4.d.5


Joint Commission


ability to understand and participate in their own care); (6) a drug profile including the consumer’s prescriptions, over-the-counter medications, herbal remedies, and other treatments or substances that could affect drug therapy, as well as information on drug allergies; (7) a description of attitudes and behaviors, including cultural and environmental factors, that may affect the consumer’s treatment plan; (8) the consumer’s strengths, goals, and other factors to be considered in recovery planning; (9) pregnancy and parenting status; (10) assessment of need for other services required by the statute (i.e., peer and family/caregiver support services, targeted case management, psychiatric rehabilitation services, LEP or linguistic services); (11) assessment of the social service needs of the consumer, with necessary referrals made to social services and, for pediatric consumers, to child welfare agencies as appropriate; and (12) depending on whether the CCBHC directly provides primary care screening and monitoring of key health indicators and health risk pursuant to criteria 4.G, either: (a) an assessment of need for a physical exam or further evaluation by appropriate health care professionals, including the consumer’s primary care provider (with appropriate referral and follow-up), or (b) a basic physical assessment as required by criteria 4.G. All remaining necessary releases of information are obtained by this point.



EP 2

4.d.6 TAG: CCBH

4.d.6 Screening and assessment by the CCBHC related to behavioral health include those for which the CCBHC will be accountable pursuant to program requirement 5 and Appendix A of these criteria. The CCBHC should not take non-inclusion of a specific metric in Appendix A as a reason not to provide clinically indicated behavioral health screening or assessment and the state may elect to require specific other screening and monitoring to be provided by the CCBHCs beyond those listed in criterion 4.d.5 or Appendix A.




4.d.7 TAG: CCBH

4.d.7 The CCBHC uses standardized and validated screening and assessment tools and, where appropriate, brief motivational interviewing techniques.

RI.01.01.01 The organization respects the rights of the individual served.

The organization respects the cultural and personal values, beliefs, and preferences of the individual served.

EP 6




EP 1


EP 2


EP 3

4.d.8 TAG: CCBH

4.d.8 The CCBHC uses culturally and linguistically appropriate screening tools, and tools/approaches that accommodate disabilities (e.g., hearing disability, cognitive limitations), when appropriate.



4.d.9


Joint Commission




EP 2

CTS.02.03.07 For organizations providing care, treatment, or services to individuals with addictions:

The assessment includes the individual's history of addictive behaviors.

For organizations providing care, treatment, or services to individuals with addictions: The organization obtains the individual's history of alcohol use, drug use, nicotine use, and other addictive behaviors. The history includes the following information:- Age of onset- Duration- Patterns of use (for example, continuous, episodic, binge)

EP 1

For organizations providing care, treatment, or services to individuals with addictions: The organization obtains the individual's history of mental, emotional, behavioral, legal, and social consequences of dependence or addiction.

EP 2

For organizations providing care, treatment, or services to individuals with addictions: The organization obtains information related to the consequences of dependence or addiction (for example, legal problems, divorce, loss of family members or friends, job-related incidents, financial difficulties, blackouts, memory impairment).

EP 3

For organizations providing care, treatment, or services to individuals with addictions: The organization obtains the individual's history of physical problems associated with substance abuse, dependence, and other addictive behaviors.

EP 4

For organizations providing care, treatment, or services to individuals with addictions: The organization obtains the history of the use of alcohol and other drugs, and other addictive behaviors by the individual's family.

EP 5

For organizations providing care, treatment, or services to individuals with addictions: The organization obtains the individual's perception of the role of spirituality or religion in his or her life.

EP 6

For organizations providing care, treatment, or services to individuals with addictions: Assessments of the individual served contain information about previous care, treatment, or services.

EP 7

For organizations providing care, treatment, or services to individuals with addictions: Assessments of the individual served contain information about the individual's response to previous care, treatment, or services.

EP 8

For organizations providing care, treatment, or services to individuals with addictions: Assessments of the individual served contain information about the individual's relapse history.

EP 9

4.d.9 TAG: CCBH

4.d.9 If screening identifies unsafe substance use including problematic alcohol or other substance use, the CCBHC conducts a brief intervention and the consumer is provided or referred for a full assessment and treatment, if applicable.



4.E


Joint Commission


4.E TAG: CCBH

4.E: Person-Centered and Family-Centered Treatment Planning


services.


4.e.1 TAG: CCBH

4.e.1 The CCBHC directly provides person-centered and family-centered treatment planning or similar processes, including but not limited to risk assessment and crisis planning. Person-centered and family-centered treatment planning satisfies the requirements of criteria 4.e.2 – 4.e.8 below and is aligned with the requirements of Section 2402(a) of the Affordable Care Act, including consumer involvement and self-direction.Note: See program requirement 3 related to coordination of care and treatment planning.

CTS.02.02.03 A complete and accurate assessment drives the identification and delivery of the care,

treatment, or services needed by the individual served.

The organization collects information about the individual’s emotional and behavioral functioning and his or her needs, strengths, preferences, and goals.

EP 1

The needs of the individual served are identified based on information from the assessment.EP 2

In collaboration with the individual served and, as appropriate, his or her family, the organization makes care, treatment, or service decisions that are based on information it has collected about the individual’s needs, strengths, preferences, and goals.

EP 3

The organization matches the individual with care, treatment, or services that will meet his or her needs, strengths, preferences, and goals.

EP 4
















EP 1


EP 2


EP 3

4.e.2 TAG: CCBH

4.e.2 An individualized plan integrating prevention, medical and behavioral health needs and service delivery is developed by the CCBHC in collaboration with and endorsed by the consumer, the adult consumer’s family to the extent the consumer so wishes, or family/caregivers of youth and children, and is coordinated with staff or programs necessary to carry out the plan.Note: States may wish to access additional resources related to person-centered treatment planning found in the CMS Medicaid Home and Community Based Services regulations at 42 C.F.R. Part 441, Subpart M, or in the CMS Medicare Conditions of Participation for Community Mental Health Centers regulations at 42 C.F.R. Part 485.



4.e.2


Joint Commission



EP 4


EP 12


EP 13

CTS.02.02.03 A complete and accurate assessment drives the identification and delivery of the care,

treatment, or services needed by the individual served.

The organization collects information about the individual’s emotional and behavioral functioning and his or her needs, strengths, preferences, and goals.

EP 1

The needs of the individual served are identified based on information from the assessment.EP 2

In collaboration with the individual served and, as appropriate, his or her family, the organization makes care, treatment, or service decisions that are based on information it has collected about the individual’s needs, strengths, preferences, and goals.

EP 3

The organization matches the individual with care, treatment, or services that will meet his or her needs, strengths, preferences, and goals.

EP 4

4.e.3 TAG: CCBH

4.e.3 The CCBHC uses consumer assessments to inform the treatment plan and services provided.




EP 1


EP 2


EP 3


EP 4

4.e.4 TAG: CCBH

4.e.4 Treatment planning includes needs, strengths, abilities, preferences, and goals, expressed in a manner capturing the consumer’s words or ideas and, when appropriate, those of the consumer’s family/caregiver.



4.e.4


Joint Commission




EP 6


EP 17


EP 18


EP 19


EP 20


EP 21


EP 22
















EP 1


EP 2

4.e.5 TAG: CCBH

4.e.5 The treatment plan is comprehensive, addressing all services required, with provision for monitoring of progress towards goals. The treatment plan is built upon a shared decision-making approach.



4.e.5


Joint Commission



EP 3


EP 4


EP 12


EP 13





EP 1


EP 2




individual served.


EP 4


EP 5

4.e.6 TAG: CCBH

4.e.6 Where appropriate, consultation is sought during treatment planning about special emphasis problems, including for treatment planning purposes (e.g., trauma, eating disorders).






EP 1


EP 2

4.e.7 TAG: CCBH

4.e.7 The treatment plan documents the consumer’s advance wishes related to treatment and crisis management and, if the consumer does not wish to share their preferences, that decision is documented.



4.e.7


Joint Commission



EP 3




EP 4


organization addresses decisions made by the individual served about physical health

care, treatment, or services received at the end of life. (For more information, refer to

Standard CTS.01.04.01.)

For organizations that elect The Joint Commission Behavioral Health Home option: The organization has a written policy on physical health advance directives.

EP 1

For organizations that elect The Joint Commission Behavioral Health Home option: The organization’s written policy specifies whether the organization will honor physical health advance directives.

EP 4

For organizations that elect The Joint Commission Behavioral Health Home option: The organization implements its physical health advance directive policy.

EP 5

For organizations that elect The Joint Commission Behavioral Health Home option: The organization communicates its policy on physical health advance directives to the individuals it serves.

EP 8

For organizations that elect The Joint Commission Behavioral Health Home option: Upon request, the organization shares with the individual possible sources of help in formulating physical health advance directives.

EP 10

For organizations that elect The Joint Commission Behavioral Health Home option: If the individual served has a physical health advance directive, all members of the integrated care team are aware that it exists and know how to access it.

EP 11



EP 2

4.e.8 TAG: CCBH

4.e.8 Consistent with the criteria in 4.e.1 through 4.e.7, states should specifyother aspects of consumer, person-centered and family-centered treatmentplanning they will require based upon the needs of the population served.Treatment planning components that states might consider include:



4.e.8


Joint Commission


prevention; community inclusion and support (housing, employment, socialsupports); involvement of family/caregiver and other supports; recoveryplanning; safety planning; and the need for specific services required by thestatute (i.e., care coordination, physical health services, peer and familysupport services, targeted case management, psychiatric rehabilitationservices, accommodations to ensure cultural and linguistically competentservices).

4.F TAG: CCBH

4.F: Outpatient Mental Health and Substance Use Services






EP 5


EP 6

LD.04.04.09 For organizations that elect The Joint Commission Behavioral Health Home option: The

organization uses clinical practice guidelines and/or evidence-based practices to

evaluate and treat specific diagnoses, conditions, or symptoms for both physical and

behavioral health care.

Note: Clinical practice guidelines and evidence-based practices include both nationally

recognized guidelines and practices and guidelines and practices developed by

individual organizations to address their particular circumstances.

For organizations that elect The Joint Commission Behavioral Health Home option: The organization identifies clinical practice guidelines and/or evidence-based practices to evaluate and treat specific diagnoses, conditions, or symptoms for both physical and behavioral health care that are relevant to the population(s) served by the behavioral health home.

EP 1

For organizations that elect The Joint Commission Behavioral Health Home option: The organization uses clinical practice guidelines and/or evidence-based practices to evaluate and treat specific diagnoses, conditions, or symptoms for both physical and behavioral health care.

EP 2

For organizations that elect The Joint Commission Behavioral Health Home option: The organization manages and evaluates the implementation of clinical practice guidelines and/or evidence-based practices that have been selected to evaluate and treat specific diagnoses, conditions, or symptoms for both physical and behavioral health care.

EP 3

For organizations that elect The Joint Commission Behavioral Health Home option: The leaders of the organization review and approve the clinical practice guidelines and/or evidence-based practices that have been selected to evaluate and treat specific diagnoses, conditions, or symptoms for both physical and behavioral health care.

EP 4

For organizations that elect The Joint Commission Behavioral Health Home option: The organization monitors and reviews, then modifies as necessary, its clinical practice guidelines and/or evidence-based practices for continued applicability and effectiveness.

EP 5

4.f.1 TAG: CCBH

4.f.1 The CCBHC directly provides outpatient mental and substance use disorder services that are evidence-based or best practices, consistent with the needs of individual consumers as identified in their individual treatment plan. In the event specialized services outside the expertise of the CCBHC are required for purposes of outpatient mental and substance use disorder treatment (e.g., treatment of sexual trauma, eating disorders, specialized medications for substance use disorders), the CCBHC makes them available through referral or other formal arrangement with other providers or, where necessary and appropriate, through use of telehealth/telemedicine services. The CCBHC also provides or makes available through formal arrangement traditional practices/treatment as appropriate for the consumers served in the CCBHC area. Note: See also program requirement 3 regarding coordination of services and treatment planning.



4.f.2


Joint Commission




EP 2

4.f.2 TAG: CCBH

4.f.2 Based upon the findings of the needs assessment as required in program requirement 1, states must establish a minimum set of evidence-based practices required of the CCBHCs. Among those evidence-based practices states might consider are the following: Motivational Interviewing; Cognitive Behavioral individual, group and on-line Therapies (CBT); Dialectical Behavior Therapy (DBT); addiction technologies; recovery supports; first episode early intervention for psychosis; Multi-Systemic Therapy; Assertive Community Treatment (ACT); Forensic Assertive Community Treatment (F-ACT); evidence-based medication evaluation and management (including but not limited to medications for psychiatric conditions, medication assisted treatment for alcohol and opioid substance use disorders (e.g., buprenorphine, methadone, naltrexone (injectable and oral), acamprosate, disulfiram, naloxone), prescription long-acting injectable medications for both mental and substance use disorders, and smoking cessation medications); community wrap-around services for youth and children; and specialty clinical interventions to treat mental and substance use disorders experienced by youth (including youth in therapeutic foster care). This list is not intended to be all-inclusive and the states are free to determine whether these or other evidence-based treatments may be appropriate as a condition of certification.



EP 1

4.f.3 TAG: CCBH

4.f.3 Treatments are provided that are appropriate for the consumer’s phase of life and development, specifically considering what is appropriate for children, adolescents, transition age youth, and older adults, as distinct groups for whom life stage and functioning may affect treatment. Specifically, when treating children and adolescents, CCHBCs provide evidenced-based services that are developmentally appropriate, youth guided, and family/caregiver driven with respect to children and adolescents. When treating older adults, the individual consumer’s desires and functioning are considered and appropriate evidence-based treatments are provided. When treating individuals with developmental or other cognitive disabilities, level of functioning is considered and appropriate evidence-based treatments are provided. These treatments are delivered by staff with specific training in treating the segment of the population being served.



4.f.3


Joint Commission



EP 2

The assessment data collected include the individual’s short- and long-term personal goal(s).EP 3

When indicated, the following evaluations are conducted:- Mental status- Psychological- Psychiatric- Intellectual and cognitive functioning

EP 4

Family members are invited to participate in the assessment process as relevant to the care, treatment, or services provided, and the age and preference of the individual served.

EP 5

For organizations that elect The Joint Commission Behavioral Health Home option: The assessment data collected include the individual’s short- and long-term physical health care goals.

EP 6


organization assesses the needs of children or youth.

For organizations providing care, treatment, or services to a child or youth: Assessment information defined by the organization to be collected during the initial assessment of a child or youth includes the following, as relevant to care, treatment, or services: - Legal custody status, including the clear identification of the legal guardian(s)- The use of a developmental perspective in evaluating all aspects of functioning, including the child’s or youth’s physical, emotional, cognitive, educational, nutritional, and social development- Assessment of normative development as related to chronological age- The child's or youth's leisure and recreational interests- The family history and current living situation- The family dynamics and their impact on the child’s or youth’s current needs- Family factors that should be considered in discharge planning

EP 1

For organizations providing care, treatment, or services to a child or youth: When a physical health examination is done for a child or youth, it addresses the following: - Motor development and functioning- Sensorimotor functioning - Speech, hearing, and language functioning- Visual functioning- Immunization status- Oral health and oral hygiene(For more information about the physical health assessment, refer to Standard CTS.02.01.07.)

EP 2



4.f.3


Joint Commission


CTS.02.03.05 For organizations providing care, treatment, or services to individuals with intellectual

and developmental disabilities: The organization assesses the needs of the individual.

For organizations providing care, treatment, or services to individuals with intellectual and developmental disabilities: The organization bases the individual's care, treatment, or services on his or her assessed needs and functioning.

EP 1

For organizations providing 24-hour care, treatment, or services to individuals with intellectual and developmental disabilities: The individual served receives at least an annual physical examination.

EP 2

For organizations providing 24-hour care, treatment, or services to individuals with intellectual and developmental disabilities: The physical examination includes the following:- Motor development and functioning- Sensorimotor functioning- Speech, hearing, and language functioning- Visual functioning- Immunization status- Oral health and oral hygiene(Refer to Standard CTS.02.01.07 for more information)Note: The physical examination can be performed by the organization or another provider.

EP 3

For organizations providing care, treatment, or services to individuals with intellectual and developmental disabilities: The assessment includes the following:- Social history- Cognitive functioning- Family support- Support to family- Presenting conditions- Other disabilities- When possible, the causes of the individual's disabilities- Additional needs related to age, such as senior services or early childhood intervention services(Refer to Standard CTS.02.02.01 for more information)

EP 4

For organizations providing care, treatment, or services to individuals with intellectual and developmental disabilities: The emotional and behavioral functioning assessment also includes the following: - Adaptive behavior- Social functioning- Independent living skills- Talents, aptitudes, and interests- Need for assistive functioning(Refer to Standard CTS.02.02.01 for more information)

EP 5

For organizations providing care, treatment, or services to individuals with intellectual and developmental disabilities: The vocational functioning assessment of older youth and adults also includes the following:- Vocational training history - Work history - Work interests - Work skills - Work-related behaviors(Refer to Standard CTS.02.01.17 for more information)Note: The assessments can be provided by the organization or another provider.

EP 6



4.f.3


Joint Commission


For organizations providing care, treatment, or services to individuals with intellectual and developmental disabilities: The educational assessment also includes the following:- Reading and math levels- Educational status/history- Intelligence testing- The current level of concrete and abstract reasoning(Refer to Standard CTS.02.01.13 for more information)Note: The assessments can be provided by the organization or another provider.

EP 7

For organizations providing 24-hour care, treatment, or services to individuals with intellectual and developmental disabilities: Individuals are reassessed when there are changes in their functioning or living situation. The reassessment includes those elements of the assessment that are relevant to the changes identified.

EP 8

CTS.04.01.03 The individual served receives education and training specific to the individual's needs

and abilities consistent with the care, treatment, or services provided.

Note: This standard does not apply to academic education.

Education provided is based on the needs and abilities of the individual served.EP 1

The assessment of learning needs addresses the individual's cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations, and barriers to communication.

EP 2

Education provided to the individual served is coordinated among the disciplines providing care, treatment, or services.

EP 3

Based on the assessed needs and abilities of the individual served and the organization’s scope of care, treatment, or services, the individual is educated about the following:- The plan for care, treatment, or services- Basic health practices and safety- The safe and effective use of medications- Nutrition interventions, modified diets, and oral health, as needed- Habilitation or rehabilitation techniques to help him or her reach the maximum level of independence possible

EP 4

The content of the education provided to the individual served is presented in an understandable manner.EP 5

Teaching methods accommodate various learning styles.EP 6

The individual's comprehension of the education provided is evaluated.EP 7

CTS.04.02.01 For organizations providing care, treatment, or services to individuals with intellectual

and developmental disabilities: The organization recognizes and addresses the

personal preferences of the individual served.

Note: The personal preferences of the individual served are addressed by the

organization to the extent feasible.

For organizations providing care, treatment, or services to individuals with intellectual and developmental disabilities: The organization's philosophy is to recognize and support the preferences of each individual served.

EP 1



4.f.3


Joint Commission


For organizations providing care, treatment, or services to individuals with intellectual and developmental disabilities: To the extent feasible for each individual served, the organization fosters a quality of life comparable to that experienced by most people.

EP 2

For organizations providing care, treatment, or services to individuals with intellectual and developmental disabilities: The setting of care, treatment, or services supports the personal experiences, appearance, and behavior of each individual served.

EP 3

For organizations providing care, treatment, or services to individuals with intellectual and developmental disabilities: The social and living environment offers the individual a variety of social and community experiences that facilitate the development of self-awareness, independence, and use of personal strengths and skills.

EP 4

For organizations providing care, treatment, or services to individuals with intellectual and developmental disabilities: The individual served participates in formulating policies that affect his or her living and social environment.

EP 5



individual served.


EP 1


EP 2


EP 3


EP 4


EP 5



4.f.3


Joint Commission



For each of its programs or services, the organization defines the competencies it requires of staff members who provide care, treatment, or services. Note: Competencies may be based on the programs or services provided and the populations served. (See also NPSG.03.06.01, EP 3)

EP 1

HRM.01.06.05 Staff who provide care, treatment, or services to children or youth have specific

competencies.

Staff who provide care, treatment, or services to children or youth demonstrate an understanding of the developmental milestones of children or youth.

EP 1

When assessing staff competence, supervisors use the findings from performance improvement activities when it relates to competence of staff. (See also PI.02.01.01, EP 8)

EP 2

The person responsible for administrative and clinical direction of care, treatment, or services provided to children or youth is qualified by training, experience, or documented competence.

EP 3

HRM.01.06.09 For organizations that provide care, treatment, or services to individuals with

intellectual and/or developmental disabilities: Staff responsible for providing services

for persons with intellectual disabilities have specific competencies.

For organizations that provide care, treatment, or services to individuals with intellectual and/or developmental disabilities: In accordance with the needs of the population served, staff are trained in proper feeding techniques.

EP 1

For organizations that provide care, treatment, or services to individuals with intellectual and/or developmental disabilities: In accordance with the needs of the population served, staff are educated in the following: Communication with nonverbal individuals or individuals with limited verbal skills.

EP 2

For organizations that provide care, treatment, or services to individuals with intellectual and/or developmental disabilities: In accordance with the needs of the population served, staff are educated in the following: Prevention and management of behavior that is harmful to self or others.

EP 3

For organizations that provide care, treatment, or services to individuals with intellectual and/or developmental disabilities: In accordance with the needs of the population served, staff are educated in the following: Teaching activities of daily living and life domain skills.

EP 4

For organizations that provide care, treatment, or services to individuals with intellectual and/or developmental disabilities: In accordance with the needs of the population served, staff are educated in the following: Adherence to the principles of normalization.

EP 5

For organizations that provide care, treatment, or services to individuals with intellectual and/or developmental disabilities: A qualified intellectual and/or developmental disabilities professional is responsible for coordinating services for each individual served.

EP 6

For organizations that provide care, treatment, or services to individuals with intellectual and/or developmental disabilities: The qualified intellectual and/or developmental disabilities professional who is responsible for coordinating services for each individual served understands their needs and the range, intensity, and duration of care, habilitation, or rehabilitation they require.

EP 7



4.f.4


Joint Commission



organization facilitates and coordinates family or guardian involvement throughout the

assessment process.

For organizations providing care, treatment, or services to a child or youth: The organization assesses the family's or legal guardian's expectations for and involvement in the assessment and initial and continuing care, treatment, or services.

EP 1

For organizations providing care, treatment, or services to a child or youth: The organization clearly explains the family’s or legal guardian's role in achieving care, treatment, or service goals.

EP 2

For organizations providing care, treatment, or services to a child or youth: The organization establishes procedures that facilitate ongoing communication with the family or legal guardian about their perceptions of the child’s or youth’s needs and other issues.

EP 3

For organizations providing care, treatment, or services to a child or youth: In conducting the assessment, the organization distinguishes between data provided by the family or legal guardian or referral sources and data based on the organization's interaction with the child or youth.

EP 4


organization assesses the needs of children or youth.

For organizations providing care, treatment, or services to a child or youth: Assessment information defined by the organization to be collected during the initial assessment of a child or youth includes the following, as relevant to care, treatment, or services: - Legal custody status, including the clear identification of the legal guardian(s)- The use of a developmental perspective in evaluating all aspects of functioning, including the child’s or youth’s physical, emotional, cognitive, educational, nutritional, and social development- Assessment of normative development as related to chronological age- The child's or youth's leisure and recreational interests- The family history and current living situation- The family dynamics and their impact on the child’s or youth’s current needs- Family factors that should be considered in discharge planning

EP 1

For organizations providing care, treatment, or services to a child or youth: When a physical health examination is done for a child or youth, it addresses the following: - Motor development and functioning- Sensorimotor functioning - Speech, hearing, and language functioning- Visual functioning- Immunization status- Oral health and oral hygiene(For more information about the physical health assessment, refer to Standard CTS.02.01.07.)

EP 2

CTS.04.02.11 For organizations providing care, treatment, or services to children or youth: The plan

for care, treatment, or services reflects needed educational services for every child or

youth whose care, treatment, or services cause a significant absence from school.

For organizations providing care, treatment, or services to children or youth: An individual education plan is developed for each child or youth whose care, treatment, or services cause a significant absence from school.

EP 1

4.f.4 TAG: CCBH

4.f.4 Children and adolescents are treated using a family/caregiver-driven, youth guided and developmentally appropriate approach that comprehensively addresses family/caregiver, school, medical, mental health, substance abuse, psychosocial, and environmental issues.



4.f.4


Joint Commission


For organizations providing care, treatment, or services to children or youth: Qualified individuals provide educational services to children and youth whose care, treatment, or services cause a significant absence from school.

EP 2

CTS.04.02.13 For organizations providing care, treatment, or services to children or youth: The

organization provides academic education to children and youth as needed.

For organizations providing care, treatment, or services to children or youth: The organization defines the length of stay and absence from school that would require providing educational services in accordance with applicable law and regulation.

EP 1

For organizations providing care, treatment, or services to children or youth: The organization has a written policy that addresses the role of education as a therapeutic activity and protects children and youth from losing ground academically while receiving care, treatment, or services.

EP 2

CTS.04.02.15 For organizations providing care, treatment, or services to children or youth: The

organization facilitates educational continuity for children and youth.

For organizations providing care, treatment, or services to children or youth: The organization facilitates communication with the child’s or youth’s school about past academic functioning and achievement.

EP 1

For organizations providing care, treatment, or services to children or youth: The organization promotes regular communication among teachers, clinical and child-care staff, and parent or guardian.

EP 2

For organizations providing care, treatment, or services to children or youth: The organization provides consistent intervention between teachers and clinical and child-care staff, as defined in the plan for care, treatment, or services.

EP 3

CTS.04.02.19 The organization provides basic prevention, screening, and physical health care

services.

Note: This standard is applicable only to organizations that directly provide primary

physical health care either at their own facility or by contracting with another

organization to provide primary physical health care on behalf of the behavioral health

care organization. It applies whether the organization provides this service to all the

individuals it serves or to only a distinct population of individuals.

For organizations that directly provide primary physical health care to individuals served: The organization provides education to the individual served on the value of prevention, screening, and routine physical health care. (For more information, refer to Standard RI.01.01.03)

EP 1

For organizations that directly provide primary physical health care to individuals served: The organization provides prevention, screening, and primary physical health care services that are appropriate to the age, gender, and needs of the individual.

EP 2

For organizations that directly provide primary physical health care to individuals served: The organization communicates its role in supporting individuals in receiving primary physical health care to the individual and, as appropriate, his or her family.

EP 3

For organizations that directly provide primary physical health care to individuals served: The organization makes available to the primary physical health care provider the individual’s needs, strengths, preferences, and goals and other information needed to facilitate physical health care, with the permission of the individual and in accordance with law and regulation.

EP 4



4.f.4


Joint Commission


For organizations that directly provide primary physical health care to individuals served: The organization provides for physical health care, treatment, and services not directly provided by the organization through a referral (for example, diagnostic and laboratory tests).

EP 5

For organizations that directly provide primary physical health care to individuals served: The organization provides education to the individual on the self-management of a physical illness or condition when indicated by the physical health care needs of the individual. (For more information, refer to Standard RI.01.01.03)

EP 6

For organizations that directly provide primary physical health care to individuals served: With the permission of the individual served, the organization supports the individual in receiving primary physical health care which, at a minimum, includes helping the individual to do the following:- Follow up on tests, medications, and treatments- Manage any fear or reluctance about receiving physical health care- Obtain and keep appointmentsNote: Helping the individual to obtain and keep appointments may include accompanying the individual to appointments, calling the individual to remind him or her of appointments, providing transportation to and from appointments, and other activities within the scope of the organization's resources.

EP 7

For organizations that directly provide primary physical health care to individuals served: The organization maintains communication between itself and the primary physical health care provider regarding the individual's care, treatment, or services, with the permission of the individual and in accordance with law and regulation.

EP 8

For organizations that directly provide primary physical health care to individuals served: The organization educates its primary physical health care staff on how to interact with the behavioral health population(s) it serves.

EP 9


services to individuals served through a referral agreement with a primary physical

health care provider.

Note: This standard is applicable only to organizations that have a formal agreement to

refer individuals to a particular organization for primary physical health care. It applies

whether the organization provides this service to all the individuals it serves or to only

a distinct population of individuals.

For organizations that refer individuals served to another organization for primary physical health care: The organization informs the individual served of the value of prevention, screening, and routine physical health care. (For more information, refer to Standard RI.01.01.03)

EP 1

For organizations that refer individuals served to another organization for primary physical health care: The organization refers the individual for prevention, screening, and primary physical health care services that are appropriate to the age, gender, and needs of the individual.

EP 2

For organizations that refer individuals served to another organization for primary physical health care: The organization communicates its role in supporting individuals who are referred for primary physical health care to the individual and, as appropriate, his or her family.

EP 3

For organizations that refer individuals served to another organization for primary physical health care: The organization shares with the primary physical health care provider the individual’s needs, strengths, preferences, and goals and other information needed to facilitate physical health care, with the permission of the individual and in accordance with law and regulation.

EP 4



4.f.4


Joint Commission




individual served.


EP 1

4.G TAG: CCBH

4.G: Outpatient Clinic Primary Care Screening and Monitoring

CTS.02.01.05 For organizations providing care, treatment, or services in non–24-hour settings: The

organization implements a written process requiring a physical health screening to

determine the individual's need for a medical history and physical examination.

Note 1: This standard does not apply to foster care and therapeutic foster care. (See

also CTS.02.04.01, EP 1)



regulation.

For organizations providing care, treatment, or services in non–24-hour settings: The organization has a written physical health screening process to determine whether an individual served is in need of a medical history and physical examination that is based on the population(s) served and, at a minimum, includes the following:- Data to be collected- Time frame for completion of the screening- Screening triggers that indicate the need for a medical history and physical examination

EP 1

For organizations that elect The Joint Commission Behavioral Health Home option: If the screening triggers indicate the need for a medical history and physical examination, the behavioral health home arranges for the history and physical to occur in a time frame that meets the physical health care needs of the individual served.

EP 2

For organizations providing care, treatment, or services in non–24-hour settings: The organization has a practitioner qualified by the scope of his or her license participate in developing the data to be collected and the physical health screening process.

EP 3

4.g.1 TAG: CCBH

4.g.1 The CCBHC is responsible for outpatient clinic primary care screening and monitoring of key health indicators and health risk. Whether directly provided by the CCBHC or through a DCO, the CCBHC is responsible for ensuring these services are received in a timely fashion. Required primary care screening and monitoring of key health indicators and health risk provided by the CCBHC include those for which the CCBHC will be accountable pursuant to program requirement 5 and Appendix A of these criteria. The CCBHC should not take non-inclusion of a specific metric in Appendix A as a reason not to provide clinically indicated primary care screening and monitoring and the state may elect to require specific other screening and monitoring to be provided by the CCBHCs. The CCBHC ensures children receive age appropriate screening and preventive interventions including, where appropriate, assessment of learning disabilities, and older adults receive age appropriate screening and preventive interventions. Prevention is a key component of primary care services provided by the CCBHC. Nothing in these criteria prevent a CCBHC from providing other primary care services.Note: See also program requirement 3 regarding coordination of services and treatment planning.



4.g.1


Joint Commission


For organizations providing care, treatment, or services in non–24-hour settings: The organization determines whether the date of the individual’s most recent physical examination exceeds one year. If the date exceeds one year, a medical history and physical examination is performed.Note: Securing the individual’s agreement to receive a medical history and physical examination may be undertaken as a process, and the organization may incorporate this process into the individual’s plan for care, treatment, or services. If performing a medical history and physical examination is not within the organization’s scope of services, it may refer the individual to another organization. (Refer to CTS.03.01.07, EPs 1-3)

EP 4

For organizations providing care, treatment, or services in non–24-hour settings: The organization implements its written process.

EP 5

CTS.02.01.06 For organizations providing residential care: The organization screens all individuals

served to determine the individual’s need for a medical history and physical

examination.

Note 1: This standard does not apply to foster care, therapeutic foster care, and

emergency shelters. (See CTS.02.04.01, EP 1)



regulation.

Note 3: "Residential care" includes residential settings, group home settings, and 24-

hour therapeutic schools.

For organizations providing residential care: The organization has a written screening process to determine whether an individual served is in need of a medical history and physical examination that is based on the population(s) served and, at a minimum, includes the following:- Data to be collected- Time frame for completion of the screening- Screening triggers that indicate the need for a medical history and physical examination

EP 1

For organizations providing residential care: A practitioner qualified by the scope of his or her license approves the organization’s screening process.

EP 2

For organizations providing residential care: Individuals for whom a physical examination conducted by a practitioner qualified by the scope of his or her license is indicated are either examined by the organization or referred to an outside source within 30 calendar days after admission, or sooner if warranted by the individual’s physical health needs, and in accordance with law and regulation.

EP 3

For organizations providing residential care: When a physical examination has been completed by a practitioner qualified by the scope of his or her license within the 12 months prior to the individual’s admission and the organization accepts this in lieu of conducting another physical examination, the organization notes any changes to the individual’s physical health condition and documents it in the individual’s clinical/case record. If any changes(s) to the individual’s physical health condition prompts any of the screening process triggers, a new medical history and physical examination is conducted.

EP 4

For organizations providing residential care: The organization determines whether the date of the individual’s most recent physical examination exceeds one year. If the date exceeds one year, a medical history and physical examination is performed.

EP 5



4.g.1


Joint Commission


CTS.02.01.07 The organization completes a physical health assessment, including a medical history

and physical examination.

Note: This standard does not apply to foster care and therapeutic foster care. (Refer to

CTS.02.04.01, EP 1 for more information)

For inpatient crisis stabilization: A physical health examination is performed by a licensed independent practitioner within 24 hours of admission.Note 1: Some physical health needs require completion of a physical health assessment within a shorter time frame.Note 2: If a medical history and physical examination has been completed by a licensed independent practitioner within 30 days before admission, a legible copy of this report may be used in the clinical/case record as the physical health assessment. Changes to the condition of the individual served since completion of the history and physical are recorded at the time of admission.

EP 1

For organizations that conduct outdoor/wilderness experiences: A physical health examination is performed by a licensed independent practitioner within 30 days prior to participating in an outdoor/wilderness experience.Note 1: Some physical health needs require completion of a physical health assessment within a shorter time frame.Note 2: If a medical history and physical examination has been completed by a licensed independent practitioner within 30 days before participating in an outdoor/wilderness experience, a legible copy of this report may be used in the clinical/case record as the physical health assessment. Changes to the condition of the individual served since completion of the history and physical are recorded at the time of admission to the program.

EP 2




EP 17


EP 18


EP 19


EP 20


EP 21



4.g.1


Joint Commission



EP 22


services.

Note: This standard is applicable only to organizations that directly provide primary

physical health care either at their own facility or by contracting with another

organization to provide primary physical health care on behalf of the behavioral health

care organization. It applies whether the organization provides this service to all the

individuals it serves or to only a distinct population of individuals.

For organizations that directly provide primary physical health care to individuals served: The organization provides education to the individual served on the value of prevention, screening, and routine physical health care. (For more information, refer to Standard RI.01.01.03)

EP 1

For organizations that directly provide primary physical health care to individuals served: The organization provides prevention, screening, and primary physical health care services that are appropriate to the age, gender, and needs of the individual.

EP 2

For organizations that directly provide primary physical health care to individuals served: The organization communicates its role in supporting individuals in receiving primary physical health care to the individual and, as appropriate, his or her family.

EP 3

For organizations that directly provide primary physical health care to individuals served: The organization makes available to the primary physical health care provider the individual’s needs, strengths, preferences, and goals and other information needed to facilitate physical health care, with the permission of the individual and in accordance with law and regulation.

EP 4

For organizations that directly provide primary physical health care to individuals served: The organization provides for physical health care, treatment, and services not directly provided by the organization through a referral (for example, diagnostic and laboratory tests).

EP 5

For organizations that directly provide primary physical health care to individuals served: The organization provides education to the individual on the self-management of a physical illness or condition when indicated by the physical health care needs of the individual. (For more information, refer to Standard RI.01.01.03)

EP 6

For organizations that directly provide primary physical health care to individuals served: With the permission of the individual served, the organization supports the individual in receiving primary physical health care which, at a minimum, includes helping the individual to do the following:- Follow up on tests, medications, and treatments- Manage any fear or reluctance about receiving physical health care- Obtain and keep appointmentsNote: Helping the individual to obtain and keep appointments may include accompanying the individual to appointments, calling the individual to remind him or her of appointments, providing transportation to and from appointments, and other activities within the scope of the organization's resources.

EP 7

For organizations that directly provide primary physical health care to individuals served: The organization maintains communication between itself and the primary physical health care provider regarding the individual's care, treatment, or services, with the permission of the individual and in accordance with law and regulation.

EP 8



4.g.1


Joint Commission


For organizations that directly provide primary physical health care to individuals served: The organization educates its primary physical health care staff on how to interact with the behavioral health population(s) it serves.

EP 9


services to individuals served through a referral agreement with a primary physical

health care provider.

Note: This standard is applicable only to organizations that have a formal agreement to

refer individuals to a particular organization for primary physical health care. It applies

whether the organization provides this service to all the individuals it serves or to only

a distinct population of individuals.

For organizations that refer individuals served to another organization for primary physical health care: The organization informs the individual served of the value of prevention, screening, and routine physical health care. (For more information, refer to Standard RI.01.01.03)

EP 1

For organizations that refer individuals served to another organization for primary physical health care: The organization refers the individual for prevention, screening, and primary physical health care services that are appropriate to the age, gender, and needs of the individual.

EP 2

For organizations that refer individuals served to another organization for primary physical health care: The organization communicates its role in supporting individuals who are referred for primary physical health care to the individual and, as appropriate, his or her family.

EP 3

For organizations that refer individuals served to another organization for primary physical health care: The organization shares with the primary physical health care provider the individual’s needs, strengths, preferences, and goals and other information needed to facilitate physical health care, with the permission of the individual and in accordance with law and regulation.

EP 4



individual served.


EP 1


EP 2


EP 3



4.g.1


Joint Commission



EP 4


EP 5

4.H TAG: CCBH

4.H: Targeted Case Management Services

CTS.06.01.01 For organizations providing case management/care coordination services: Case

management/care coordination services are based on the individual's needs,

preferences, goals, and community resources available to the individual.

For organizations providing case management/care coordination services: The individual served and, as appropriate, his or her family are partners with organization staff in service planning.

EP 1

For organizations providing case management/care coordination services: With the assistance of staff, the individual served and, as appropriate, his or her family, identify needs, preferences, and goals for the following: - Housing - Employment - Education - Transportation - Crisis support - Health care and behavioral health services (for example, medication, therapy) - Financial services and benefits - Assistance with housekeeping - Assistance with personal hygiene - Assistance with the retention and improvement of other skills related to activities of daily living- Social support and adaptive skills - Support of spirituality - Schools- Leisure and recreational activities for children, youth, and adults - Parental support for children and youth - Interaction with the criminal or juvenile justice system, if applicable

EP 2

For organizations providing case management/care coordination services: Staff coordinating case management/care coordination services assist the individual served in identifying, using, and accessing family, neighborhood, and community supports and services.

EP 3

For organizations providing case management/care coordination services: Staff coordinating case management/care coordination services support informed choice by individuals served.

EP 4

For organizations providing case management/care coordination services: Staff coordinating case management/care coordination services assist the individual served in achieving the individual's personal goals of independent living.

EP 5

4.h.1 TAG: CCBH

4.h.1 The CCBHC is responsible for high quality targeted case management services that will assist individuals in sustaining recovery, and gaining access to needed medical, social, legal, educational, and other services and supports. Targeted case management should include supports for persons deemed at high risk of suicide, particularly during times of transitions such as from an ED or psychiatric hospitalization. Based upon the needs of the population served, states should specify the scope of other targeted case management services that will be required, and the specific populations for which they are intended.



4.h.1


Joint Commission


For organizations providing case management/care coordination services: The individual served and staff coordinating case management/care coordination services evaluate all services provided directly or through referral to the individual served on a periodic basis, as defined by the organization.

EP 6

CTS.06.01.03 For organizations providing community integration services: The individual served,

with assistance from the organization, determines his or her needs and wants for

education, training, and support to help him or her progress toward independent living

and community integration.

For organizations providing community integration services: Needs, preferences, and goals of the individual served guide the following:- The type of education, training, and support provided- The intensity of education, training, and support provided- The duration of education, training, and support provided

EP 1

For organizations providing community integration services: Needs, preferences, and goals of the individual served, and the organization’s scope of services, guide the provision to the individual of educational opportunities about the following:- Personal grooming and hygiene- Housekeeping - Shopping for necessities- Meal preparation and healthy eating- Budgeting- Banking- Accessing public transportation - Use of community resources - Communication skills- Social skills- Leisure and recreational activities for children, youth, and adults- Volunteer activity- Illness self-management (for example, symptom management, medication management), including what to do in case of a crisis or health problem

EP 2





EP 1



4.h.1


Joint Commission



EP 2


EP 3


EP 4


EP 5


EP 6


individual served, with assistance from the organization, determines his or her needs,

preferences, and goals regarding training and support to help him or her progress

toward independent living and community integration.

For organizations that elect The Joint Commission Behavioral Health Home option: Needs, preferences, and goals of the individual served guide the following: - The type of training and support provided - The intensity of training and support provided - The duration of training and support provided

EP 1



4.h.1


Joint Commission


For organizations that elect The Joint Commission Behavioral Health Home option: Needs, preferences, and goals of the individual served and the organization’s scope of services guide the provision of training and support opportunities regarding the following: - Personal grooming and hygiene - Housekeeping - Shopping for necessities - Meal preparation and healthy eating - Money management- Accessing public transportation - Use of community resources - Communication skills - Social skills - Leisure and recreational activities for children, youth, and adults - Volunteer activity - Illness self-management (for example, symptom management, medication management), including what to do in case of a health crisis or urgent health problem

EP 2

CTS.06.03.01 For organizations that provide care, treatment, or services to young adults with life

transition needs: The organization assists young adults with their life transitions in

accordance with their needs.

For organizations that provide care, treatment, or services to young adults with life transition needs: The organization addresses life transition needs of young adults.Note: An organization may address the needs for transition services through referral or discharge planning based on the organization's scope of care, treatment, or services.

EP 1

For organizations that provide care, treatment, or services to young adults with life transition needs: Organizations that provide young adult life transition services assess the young adult's needs related to independent functioning in the following areas:- Handling finances- Finding employment- Receiving and completing education- Finding housing- Receiving health care- Engaging in social support- Any other needs as determined by the organization

EP 2

For organizations that provide care, treatment, or services to young adults with life transition needs: Organizations that provide young adult life transition services provide assistance based on the individual's assessed needs.

EP 3

4.I TAG: CCBH

4.I: Psychiatric Rehabilitation Services

CTS.04.01.03 The individual served receives education and training specific to the individual's needs

and abilities consistent with the care, treatment, or services provided.

Note: This standard does not apply to academic education.

Education provided is based on the needs and abilities of the individual served.EP 1

The assessment of learning needs addresses the individual's cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations, and barriers to communication.

EP 2

4.i.1 TAG: CCBH

4.i.1 The CCBHC is responsible for evidence-based and other psychiatric rehabilitation services. States should specify which evidence-based and other psychiatric rehabilitation services they will require based upon the needs of the population served. Psychiatric rehabilitation services that might be considered include: medication education; self-management; training in personal care skills; individual and family/caregiver psycho-education; community integration services; recovery support services including Illness Management & Recovery; financial management; and dietary and wellness education.



4.i.1


Joint Commission


Education provided to the individual served is coordinated among the disciplines providing care, treatment, or services.

EP 3

Based on the assessed needs and abilities of the individual served and the organization’s scope of care, treatment, or services, the individual is educated about the following:- The plan for care, treatment, or services- Basic health practices and safety- The safe and effective use of medications- Nutrition interventions, modified diets, and oral health, as needed- Habilitation or rehabilitation techniques to help him or her reach the maximum level of independence possible

EP 4

The content of the education provided to the individual served is presented in an understandable manner.EP 5

Teaching methods accommodate various learning styles.EP 6

The individual's comprehension of the education provided is evaluated.EP 7

CTS.04.03.01 For organizations providing employment assistance: The organization assists the

individual served in preparing for, gaining, maintaining, and/or improving employment,

in accordance with the plan for care, treatment, or services.

For organizations providing employment assistance: The organization assists the individual served in determining his or her desire to work.

EP 1

For organizations providing employment assistance: The organization assists the individual served in identifying his or her personal interests, values, and vocational preferences.

EP 2

For organizations providing employment assistance: The organization assists the individual served in identifying his or her employment needs.

EP 3

For organizations providing employment assistance: The organization assists the individual served in identifying or refining his or her employment goals.

EP 4

For organizations providing employment assistance: The organization assists the individual served in identifying employment opportunities (for example, reviewing employment ads, browsing the Internet) and in preparations to secure employment (for example, preparing resumes, completing applications).

EP 5

For organizations providing employment assistance: The organization assists the individual served in developing the skills and supports needed to maintain employment.

EP 6

CTS.04.03.03 For organizations that provide vocational rehabilitation services: The organization

monitors changes in the local job market to facilitate employment of the individual

served.

For organizations that provide vocational rehabilitation services: The organization establishes and maintains relationships with other agencies providing employment services, vocational rehabilitation, and state vocational rehabilitation departments. Note: Vocational rehabilitation is defined as a service or program designed to attain, retain, or restore vocational skills of persons experiencing limited functioning. Vocational rehabilitation services may include vocational evaluation services, employment skills training, work activities, and supportive employment.

EP 1

States also may wish to require the provision of supported services such as housing, employment, and education, the latter in collaboration with local school systems.Note: See program requirement 3 regarding coordination of services and treatment planning.



4.i.1


Joint Commission


For organizations that provide vocational rehabilitation services: The organization establishes and maintains relationships with the business community.

EP 2

For organizations that provide vocational rehabilitation services: The organization makes staff available to employers upon request to address stigma issues and concerns (for example, speakers, educators, referrals).

EP 3

For organizations that provide vocational rehabilitation services: The organization monitors employment and unemployment trends in the community.

EP 4

For organizations that provide vocational rehabilitation services: The organization makes improvements to service design and offerings in response to employers’ changing personnel and skill needs.

EP 5


assists the individual served in determining his or her desire for training and

assessing needs, strengths, preferences, and goals related to training.

For organizations that provide vocational rehabilitation services: The organization assists the individual served in determining his or her desire for training.

EP 1

For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her potential for the following: Pre-employment education/training.

EP 2

For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her potential for the following: Training and education at the work site.

EP 3

For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her potential for the following: Skill building, both pre-employment and at the work site.

EP 4

For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her potential for the following: Assistance coaching.

EP 5

For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her potential for the following: Long-term training and support needs.

EP 6

For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her potential for the following: Peer and family support in these endeavors.

EP 7


assists the individual served in assessing his or her needs related to securing and

maintaining employment.

For organizations that provide vocational rehabilitation services: The organization assists the individual served in determining his or her need for help with the following: Personal grooming and appearance.

EP 1

For organizations that provide vocational rehabilitation services: The organization assists the individual served in determining his or her need for help with the following: Assistive technologies or accommodations.

EP 2

For organizations that provide vocational rehabilitation services: The organization assists the individual served in determining his or her need for help with the following: Transportation.

EP 3



4.i.1


Joint Commission


For organizations that provide vocational rehabilitation services: The organization assists the individual served in determining his or her need for help with the following: Clothing.

EP 4

For organizations that provide vocational rehabilitation services: The organization assists the individual served in determining his or her need for help with the following: Benefits counseling and management of wages.

EP 5

For organizations that provide vocational rehabilitation services: The organization assists the individual served in determining his or her need for help with the following: Social/cultural concerns.

EP 6

For organizations that provide vocational rehabilitation services: The organization assists the individual served in determining his or her need for help with the following: Safety risks.

EP 7

For organizations that provide vocational rehabilitation services: The organization assists the individual served in determining his or her need for help with the following: Flexibility in terms of scheduling and transportation.

EP 8

For organizations that provide vocational rehabilitation services: The organization assists the individual served in determining his or her need for help with the following: Assessment and support planning coordination with other service providers.

EP 9

For organizations that provide vocational rehabilitation services: The organization assists the individual served in determining his or her need for help with the following: Family or community support.

EP 10


assists the individual served in assessing his or her skills and supports related to

securing and maintaining employment.

For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her skills and supports through a review of the following: Previous work history including volunteer activities.

EP 1

For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her skills and supports through a review of the following: Skills and experiences in seeking employment (for example, completing applications, interviewing).

EP 2

For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her skills and supports through a review of the following: Current work skills and the potential for improving skills or developing new ones.

EP 3

For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her skills and supports through a review of the following: Educational background.

EP 4

For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her skills and supports through a review of the following: Cognitive skills and abilities.

EP 5

For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her skills and supports through a review of the following: Physical abilities.

EP 6



4.i.1


Joint Commission


For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her skills and supports through a review of the following: Work habits related to tardiness, absenteeism, dependability, honesty, and relations with coworkers and supervisors.

EP 7


assists the individual served in assessing his or her interests related to securing and

maintaining employment.

For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her own expectations for the personal, financial, and social benefits of working.

EP 1

For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her own aptitudes, interests, and motivations toward involvement in various job-related activities.

EP 2

For organizations that provide vocational rehabilitation services: The organization assists the individual served in assessing his or her own desire for career planning assistance.

EP 3


assists the individual served to gain employment if such a goal is part of his or her

plan for care, treatment, or services.

For organizations that provide vocational rehabilitation services: The organization assists the individual served in developing a plan for employment that focuses on the individual’s employment goals and objectives.

EP 1

For organizations that provide vocational rehabilitation services: The organization develops a written employment plan that is specific to the individual served.

EP 2

For organizations that provide vocational rehabilitation services: The written employment plan includes the following: - The types of employment, school, and/or training for which the individual served is qualified or interested- The goals of the individual served - Barriers to employment (for example, transportation, written or verbal communication skills, child care needs)- Resources available to address barriers - Assessment of employment opportunities available to the individual served based on preferences, barriers, and available positions within the local job market - A description of how wages may impact existing benefits- Alternatives to any lost benefits

EP 3

For organizations that provide vocational rehabilitation services: The organization documents decisions that the individual served has made regarding accepting or declining employment opportunities.

EP 4

For organizations that provide vocational rehabilitation services: The organization reviews opportunities and procedures for requesting changes to the employment plan with the individual served.

EP 5

For organizations that provide vocational rehabilitation services: Once employment has occurred, the organization assesses the individual's satisfaction with his or her employment on a timetable established by the organization.

EP 6

For organizations that provide vocational rehabilitation services: The organization monitors employer satisfaction with an individual that they employ, according to a schedule determined by the organization.

EP 7



4.i.1


Joint Commission


CTS.06.01.01 For organizations providing case management/care coordination services: Case

management/care coordination services are based on the individual's needs,

preferences, goals, and community resources available to the individual.

For organizations providing case management/care coordination services: The individual served and, as appropriate, his or her family are partners with organization staff in service planning.

EP 1

For organizations providing case management/care coordination services: With the assistance of staff, the individual served and, as appropriate, his or her family, identify needs, preferences, and goals for the following: - Housing - Employment - Education - Transportation - Crisis support - Health care and behavioral health services (for example, medication, therapy) - Financial services and benefits - Assistance with housekeeping - Assistance with personal hygiene - Assistance with the retention and improvement of other skills related to activities of daily living- Social support and adaptive skills - Support of spirituality - Schools- Leisure and recreational activities for children, youth, and adults - Parental support for children and youth - Interaction with the criminal or juvenile justice system, if applicable

EP 2

For organizations providing case management/care coordination services: Staff coordinating case management/care coordination services assist the individual served in identifying, using, and accessing family, neighborhood, and community supports and services.

EP 3

For organizations providing case management/care coordination services: Staff coordinating case management/care coordination services support informed choice by individuals served.

EP 4

For organizations providing case management/care coordination services: Staff coordinating case management/care coordination services assist the individual served in achieving the individual's personal goals of independent living.

EP 5

For organizations providing case management/care coordination services: The individual served and staff coordinating case management/care coordination services evaluate all services provided directly or through referral to the individual served on a periodic basis, as defined by the organization.

EP 6

CTS.06.01.03 For organizations providing community integration services: The individual served,

with assistance from the organization, determines his or her needs and wants for

education, training, and support to help him or her progress toward independent living

and community integration.

For organizations providing community integration services: Needs, preferences, and goals of the individual served guide the following:- The type of education, training, and support provided- The intensity of education, training, and support provided- The duration of education, training, and support provided

EP 1



4.i.1


Joint Commission


For organizations providing community integration services: Needs, preferences, and goals of the individual served, and the organization’s scope of services, guide the provision to the individual of educational opportunities about the following:- Personal grooming and hygiene- Housekeeping - Shopping for necessities- Meal preparation and healthy eating- Budgeting- Banking- Accessing public transportation - Use of community resources - Communication skills- Social skills- Leisure and recreational activities for children, youth, and adults- Volunteer activity- Illness self-management (for example, symptom management, medication management), including what to do in case of a crisis or health problem

EP 2





EP 1


EP 2


EP 3



4.i.1


Joint Commission



EP 4


EP 5


EP 6


individual served, with assistance from the organization, determines his or her needs,

preferences, and goals regarding training and support to help him or her progress

toward independent living and community integration.

For organizations that elect The Joint Commission Behavioral Health Home option: Needs, preferences, and goals of the individual served guide the following: - The type of training and support provided - The intensity of training and support provided - The duration of training and support provided

EP 1

For organizations that elect The Joint Commission Behavioral Health Home option: Needs, preferences, and goals of the individual served and the organization’s scope of services guide the provision of training and support opportunities regarding the following: - Personal grooming and hygiene - Housekeeping - Shopping for necessities - Meal preparation and healthy eating - Money management- Accessing public transportation - Use of community resources - Communication skills - Social skills - Leisure and recreational activities for children, youth, and adults - Volunteer activity - Illness self-management (for example, symptom management, medication management), including what to do in case of a health crisis or urgent health problem

EP 2

4.J TAG: CCBH

4.J: Peer Supports, Peer Counseling and Family/Caregiver Supports

CTS.02.04.03 For foster and/or respite care: The agency develops criteria to match a foster or respite

home to an individual.

For foster and/or respite care: The agency develops criteria to match a foster or respite home to an individual that is based on an assessment to identify the needs of the individual and an assessment of the qualities of the foster or respite family.

EP 1

For foster and/or respite care: The agency uses the criteria to match a foster or respite home to an individual.

EP 2

4.j.1 TAG: CCBH

4.j.1 The CCBHC is responsible for peer specialist and recovery coaches, peer counseling, and family/caregiver supports. States should specify the scope of peer and family services they will require based upon the needs of the population served. Peer services that might be considered include: peer-run drop-in centers, peer crisis support services, peer bridge services to assist individuals transitioning between residential or inpatient settings to the community, peer trauma support, peer support for older adults or youth, and other peer recovery services. Potential family/caregiver support services that might be considered include: family/caregiver psycho-education, parent training, and family-to-family/caregiver support services.



4.j.1


Joint Commission


For foster and/or respite care: The agency develops criteria to address emergency placements of individuals.

EP 3

For foster and/or respite care: The agency uses the criteria to address emergency placements of individuals.

EP 4

For foster and/or respite care: The assessment for emergency placement in foster or respite care contains basic information essential to the safety of the individual and the family.

EP 5

CTS.02.04.05 For foster and/or respite care: The agency assesses each prospective foster parent or

respite caregiver to determine whether he or she is eligible to be a foster parent or

respite caregiver.

For foster and/or respite care: Each prospective foster parent or respite caregiver receives an assessment of his or her capability that includes the following: Physical health.

EP 1

For foster and/or respite care: Each prospective foster parent or respite caregiver receives an assessment of his or her capability that includes the following: Emotional capacity.

EP 2

For foster and/or respite care: Each prospective foster parent or respite caregiver receives an assessment of his or her capability that includes the following: Interpersonal relationships.

EP 3

For foster and/or respite care: Each prospective foster parent or respite caregiver receives an assessment of his or her capability that includes the following: Knowledge of developmental needs.

EP 4

For foster and/or respite care: Each prospective foster parent or respite caregiver receives an assessment of his or her capability that includes the following: Financial stability.

EP 5

For foster and/or respite care: Each prospective foster parent or respite caregiver receives an assessment of his or her capability that includes the following: Cultural and linguistic evaluations.

EP 6

For foster and/or respite care: Each prospective foster parent or respite caregiver receives an assessment of his or her capability that includes the following: A willingness to be educated.

EP 7

For foster and/or respite care: Each prospective foster parent or respite caregiver receives an assessment of his or her capability that includes the following: Criminal background checks, including background checks on any adult living in the home.

EP 8

For foster and/or respite care: The assessment of a prospective foster parent or respite caregiver establishes the following:- That the prospective foster parent or respite caregiver is free from any diseases or physical conditions that have been determined to be a detriment to the welfare of the individual in foster or respite care- That the prospective foster parent or respite caregiver has the ability to nurture and provide care and supervision to the individual in foster or respite care- That the prospective foster parent or respite caregiver demonstrates mental and emotional stability

EP 9

For foster and/or respite care: The agency assesses a foster parent or respite caregiver on an ongoing basis, but no less than annually.Note: This assessment may occur at various times throughout service as a foster parent or respite caregiver, such as at license renewal, when a new individual is placed in the home, when physical arrangements change in the home, or when background checks are necessary for any new adult who moves into the home.

EP 10

Note: See program requirement 3 regarding coordination of services and treatment planning.



4.j.1


Joint Commission


CTS.02.04.11 For foster and/or respite care: The agency defines and uses criteria to determine the

need for foster and/or respite care services.

For foster and/or respite care: The agency defines written criteria to determine the appropriateness of foster and/or respite care for an individual served.

EP 1

For foster and/or respite care: The agency uses its criteria to determine the appropriateness of foster and/or respite care for an individual served.

EP 2

For foster and/or respite care: At a minimum, criteria to determine the appropriateness of foster and/or respite care include the following: Safety.

EP 3

For foster and/or respite care: At a minimum, criteria to determine the appropriateness of foster and/or respite care include the following: The need for care for adults and care and protection for children and youth.

EP 4

For foster and/or respite care: At a minimum, criteria to determine the appropriateness of foster and/or respite care include the following: Any need for intensive out-of-home care beyond foster and/or respite care.

EP 5

For foster and/or respite care: At a minimum, criteria to determine the appropriateness of foster and/or respite care include the following: The inability of family or friends to care for the individual.

EP 6

For foster and/or respite care: At a minimum, criteria to determine the appropriateness of foster and/or respite care include the following: The benefits to the individual of family-based care.

EP 7

For foster and/or respite care: Agencies accepting referrals receive and review information from the public or custodial agency as part of intake.

EP 8

For foster and/or respite care: Agencies accepting referrals determine if they can meet the needs of the individual.

EP 9

CTS.02.04.13 For foster and/or respite care: The agency defines and uses criteria to identify

prospective foster parents and/or respite caregivers.

For foster and/or respite care: The agency defines written criteria to identify prospective foster parents and/or respite caregivers.

EP 1

For foster and/or respite care: The agency uses its written criteria to identify and select prospective foster parents and/or respite caregivers.

EP 2

For foster and/or respite care: The agency determines a recruitment plan that includes targeting and marketing to attract prospective foster parents or respite caregivers.

EP 3



4.j.1


Joint Commission


CTS.02.04.15 For foster and/or respite care: The agency develops and uses criteria to determine the

number of individuals that can be placed in each foster and/or respite care home.

For foster and/or respite care: The agency develops written criteria to determine the number of individuals in foster care that can be placed in each foster and/or respite care home.Note: Criteria may include the following:- The individual’s needs (emotional, developmental, psychological, behavioral, age-related, history of legal involvement, history of mental health needs, special restrictions, special physical care needs) - Resources available to the foster parent and/or respite caregiver (education, respite)- Support services (for example, extended family support, church support, community support) - Anticipated length of placement - Special-needs training for foster parents and/or respite caregivers - Prior experience as a foster care and/or respite caregiver - For children and youth, the number of biological children and number of siblings

EP 1

For foster and/or respite care: The agency uses its criteria to determine the number of individuals in foster and/or respite care that can be placed in each home.

EP 2

For foster and/or respite care: The maximum number of individuals living in each home complies with state and federal law and regulation.

EP 3

CTS.02.04.19 For foster and/or respite care: The agency determines the competence of and how to

select foster parents and/or respite caregivers.

For foster and/or respite care: The agency develops a process to determine the competence and selection of foster parents and/or respite caregivers.

EP 1

For foster and/or respite care: The agency follows its process to determine the competence and selection of foster parents and/or respite caregivers.

EP 2

For foster and/or respite care: When determining competence and selection of foster parents and/or respite caregivers, the agency uses the following:- The application- The applicant's references- Criminal background checks for all adults in the household- Child abuse registry checks for children and youth- Physical examinations- Home inspection reports- Language of the family- Interviews with foster parents and/or respite caregivers

EP 3

For foster and/or respite care: When determining competence and selection of foster parents and/or respite caregivers, the agency uses criteria based on the applicant’s ability to care for individuals with special needs, such as physical or intellectual and developmental disabilities or emotional disturbances.

EP 4

For foster and/or respite care: When determining competence and selection of foster parents and/or respite caregivers, the agency uses criteria based on competencies that match the level or type of foster and/or respite care.

EP 5

For foster and/or respite care: The agency has a written policy for circumstances under which unlicensed alternative care providers must have a safety check. The policy takes into consideration the level of risk involved with the situation.

EP 6



4.j.1


Joint Commission


CTS.04.02.09 For respite care: The respite caregiver receives information needed to meet the needs

of the individual placed in his or her care.

For respite care: The information provided by the organization to each respite caregiver includes the following:- Needs, strengths, and preferences of the individual served- Medication(s) for the individual served- First aid- Safety- Provision of emergency medical care- Specific health conditions of the individual served

EP 1

CTS.04.03.27 For organizations providing family support services: The plan for care, treatment, or

services identifies the role of families.

Note: Family support is distinct from family therapy and family counseling.

For organizations providing family support services: The individual served determines the role of family members and their access to information in accordance with his or her age, and law and regulation.

EP 1

For organizations providing family support services: Family members providing support are involved in developing the plan for care, treatment, or services when indicated by the individual served.

EP 2

For organizations providing family support services: The plan for care, treatment, or services reflects the roles and participation of family members designated by the individual served to provide support.

EP 3

CTS.04.03.29 For organizations providing family support services: Family members are offered

information, assistance, and education as needed to facilitate their roles and

participation in meeting the needs of the individual served.

Note: Family support is distinct from family therapy and family counseling.

For organizations providing family support services: Family members providing support are offered information, assistance, and education as needed from the organization on at least the following: Their roles and responsibilities.

EP 1

For organizations providing family support services: Family members providing support are offered information, assistance, and education as needed from the organization on at least the following: Crisis recognition.

EP 2

For organizations providing family support services: Family members providing support are offered information, assistance, and education as needed from the organization on at least the following: Available community resources to respond to a crisis.

EP 3

CTS.04.03.31 For organizations providing peer support: The plan for care, treatment, or services

addresses the involvement of peer support when provided.

For organizations providing peer support: The individual served determines the amount of information that can be accessed by, and the involvement of, peers providing support.

EP 1

For organizations providing peer support: Peers providing support assist in developing the plan for care, treatment, or services, when indicated by the individual served.

EP 2

For organizations providing peer support: The plan for care, treatment, or services reflects the inclusion of peer support, as determined by the individual served.

EP 3



4.K


Joint Commission


4.K TAG: CCBH

4.K: Intensive, Community-Based Mental Health Care for Members of the Armed Forces and Veterans



EP 2

4.k.1 TAG: CCBH

4.k.1 The CCBHC is responsible for intensive, community-based behavioral health care for certain members of the U.S. Armed Forces and veterans, particularly those Armed Forces members located 50 miles or more (or one hour’s drive time) from a Military Treatment Facility (MTF) and veterans living 40 miles or more (driving distance) from a VA medical facility, or as otherwise required by federal law. Care provided to veterans is required to be consistent with minimum clinical mental health guidelines promulgated by the Veterans Health Administration (VHA), including clinical guidelines contained in the Uniform Mental Health Services Handbook of such Administration. The provisions of these criteria in general and, specifically, in criteria 4.K, are designed to assist CCBHCs in providing quality clinical behavioral health services consistent with the Uniform Mental Health Services Handbook. Note: See program requirement 3 regarding coordination of services and treatment planning.







treatment.









- Pregnant women



EP 1


EP 3


EP 4

4.k.2 TAG: CCBH

4.k.2 All individuals inquiring about services are asked whether they have ever served in the U.S. military. Current Military Personnel: Persons affirming current military service will be offered assistance in the following manner: (1) Active Duty Service Members (ADSM) must use their servicing MTF, and their MTF Primary Care Managers (PCMs) are contacted by the CCBHC regarding referrals outside the MTF. (2) ADSMs and activated Reserve Component (Guard/Reserve) members who reside more than 50 miles (or one hour’s drive time) from a military hospital or military clinic enroll in TRICARE PRIME Remote and use the network PCM, or select any other authorized TRICARE provider as the PCM. The PCM refers the member to specialists for care he or she cannot provide; and works with the regional managed care support contractor for referrals/authorizations. (3) Members of the Selected Reserves, not on Active Duty (AD) orders, are eligible for TRICARE Reserve Select and can schedule an appointment with any TRICARE-authorized provider, network or non-network. Veterans: Persons affirming former military service (veterans) are offered assistance to enroll in VHA for the delivery of health and behavioral health services. Veterans who decline or are ineligible for VHA services will be served by the CCBHC consistent with minimum clinical mental health guidelines promulgated by the VHA, including clinical guidelines contained in the Uniform Mental Health Services Handbook as excerpted below (from VHA Handbook 1160.01, Principles of Care found in the Uniform Mental Health Services in VA Centers and Clinics). Note: See also program requirement 3 requiring coordination of care across settings and providers, including facilities of the Department of Veterans Affairs.



4.k.2


Joint Commission




EP 1



EP 2
















EP 1

4.k.3 TAG: CCBH

4.k.3 In keeping with the general criteria governing CCBHCs, CCBHCs ensure there is integration or coordination between the care of substance use disorders and other mental health conditions for those veterans who experience both and for integration or coordination between care for behavioral health conditions and other components of health care for all veterans.



4.k.3


Joint Commission



EP 2


EP 3


EP 4


EP 13




EP 1


EP 2


EP 3


EP 4



EP 6


EP 17

4.k.4 TAG: CCBH

4.k.4 Every veteran seen for behavioral health services is assigned a Principal Behavioral Health Provider. When veterans are seeing more than one behavioral health provider and when they are involved in more than one program, the identity of the Principal Behavioral Health Provider is made clear to the veteran and identified in the medical record. The Principal Behavioral Health Provider is identified on a consumer tracking database for those veterans who need case management. The Principal Behavioral Health Provider ensures the following requirements are fulfilled:(1) Regular contact is maintained with the veteran as clinically indicated as long as ongoing care is required.(2) A psychiatrist, or such other independent prescriber as satisfies the current requirements of the VHA Uniform Mental Health Services Handbook, reviews and reconciles each veteran’s psychiatric medications on a regular basis.(3) Coordination and development of the veteran’s treatment plan incorporates input from the veteran (and, when appropriate, the family with the veteran’s consent when the veteran possesses adequate decision-making capacity or with the veteran’s surrogate decision-maker’s consent when the veteran does not have adequate decision-making capacity).(4) Implementation of the treatment plan is monitored and documented. This must include tracking progress in the care delivered, the outcomes achieved, and the goals attained.(5) The treatment plan is revised, when necessary.(6) The principal therapist or Principal Behavioral Health Provider communicates with the veteran (and the veteran's authorized surrogate or family or friends when appropriate and when veterans with adequate decision-making capacity consent) about the treatment plan, and for addressing any of the veteran’s problems or concerns about their care. For veterans who are at high risk of losing decision-making capacity, such as those with a diagnosis of schizophrenia or schizoaffective disorder, such communications need to include discussions regarding future behavioral health care treatment (see information regarding Advance Care Planning Documents in VHA Handbook 1004.2).(7) The treatment plan reflects the veteran’s goals and preferences for care and that the veteran verbally consents to the treatment plan in accordance with VHA Handbook 1004.1, Informed Consent for Clinical Treatments and Procedures. If the Principal Behavioral Health Provider suspects the veteran lacks the capacity to make a decision about the mental health treatment plan, the provider must ensure the veteran’s decision-making capacity is formally assessed and documented. For veterans who are determined to lack capacity, the provider must identify the authorized surrogate and document the surrogate’s verbal consent to the treatment plan.



4.k.4


Joint Commission



EP 18


EP 19


EP 20


EP 21


EP 22



EP 1


EP 2


EP 3


individual served.


EP 1


EP 2



For organizations that elect The Joint Commission Behavioral Health Home option: The organization provides individuals with contact information for the team coordinator on their integrated care team. (See also CTS.04.02.27, EP 4)

EP 6



4.k.4


Joint Commission





or services.


EP 1


EP 2


EP 3


EP 4


EP 5



The clinical/case record contains the following demographic information:- The name, address, date of birth, and sex of the individual served - The name and contact information for the individual's family and any legally authorized representative- The preferred language and any special communication needs of the individual servedNote: Special communication needs may include sign language.

EP 1



4.k.4


Joint Commission


The clinical/case record of the individual served contains the following clinical information:- The reason(s) for admission for care, treatment, or services- The initial diagnosis, diagnostic impression(s), or condition(s)- Any findings of assessments and reassessments - Any allergies to food- Any allergies to medications- Any conclusions or impressions drawn from the medical history and physical examination- Any diagnoses or conditions established during the course of care, treatment, or services- Any consultation reports- Any observations relevant to care, treatment, or services- The response to care, treatment, or services- Any emergency care, treatment, or services provided prior to arrival- Any progress notes- Any medications ordered or prescribed- Any medications administered, including the strength, dose, and route- Any access site for medication, administration devices used, and rate of administration (for intravenous therapy)- Any adverse drug reactions- Treatment goals, plan of care, and revisions to the plan of care, treatment, or services - Orders for diagnostic and therapeutic tests and procedures and their results

EP 2


EP 4

For organizations that elect The Joint Commission Behavioral Health Home option: The clinical/case record of the individual served contains the following behavioral and physical health information:- All behavioral and physical health diagnoses and conditions that have required care, treatment, or services- All hospital admissions - All hospital re-admissions - All urgent care and emergency department visits (Refer to RC.02.01.01, EP 2)

EP 28

For organizations that elect The Joint Commission Behavioral Health Home option: The clinical/case record includes the individual’s self-management goals related to integrated care and the individual’s progress toward achieving those goals.

EP 30



4.k.4


Joint Commission





EP 1

The organization respects the right of the individual served to refuse care, treatment, or services, in accordance with law and regulation.

EP 3


EP 6


EP 7


EP 8

The organization provides the individual served or surrogate decision-maker with the information about the outcomes of care, treatment, or services that the individual needs in order to participate in current and future behavioral health care decisions.

EP 20

The organization informs the individual served or surrogate decision-maker about unanticipated events that relate to sentinel events as defined by The Joint Commission. (Refer to the Glossary for a definition of sentinel event.)

EP 21

For organizations that elect The Joint Commission Behavioral Health Home option: The organization respects the individual’s right and provides him or her the opportunity to do the following: - Obtain care from other clinicians of the individual’s choosing within the behavioral health home - Seek a second opinion from a clinician of the individual’s choosing - Seek specialty care Note: This element of performance does not imply financial responsibility on the part of the organization for any activities associated with these rights.

EP 33

RI.01.03.01 The organization honors the right of the individual served to give or withhold informed

consent.

The organization's written policy identifies the specific care, treatment, or services that require informed consent, in accordance with law and regulation.

EP 2

The organization's written policy describes circumstances that would allow for exceptions to obtaining informed consent.Note: Such circumstances may include situations involving threat of harm to self or others, child abuse, or elder abuse.

EP 3

The organization’s written policy describes when a surrogate decision-maker may give informed consent. (See also RI.01.02.01, EP 6)

EP 6



4.k.4


Joint Commission


The informed consent process includes a discussion about the proposed care, treatment, or services for the individual served.

EP 7

The informed consent process includes a discussion with the individual served about the goals and potential benefits and risks of the proposed care, treatment, or services.

EP 9

The informed consent process includes a discussion about reasonable alternatives to the individual's proposed care, treatment, or services. The discussion encompasses risks and benefits related to the alternatives and the risks related to not receiving the proposed care, treatment, or services.

EP 11

The informed consent process includes a discussion about any circumstances under which information about the individual served must be disclosed or reported. Note: Such circumstances may include situations involving threat of harm to self or others, child abuse, or elder abuse.

EP 12

Informed consent is obtained in accordance with the organization's policy and processes. (See also RC.02.01.01, EP 4)

EP 13




For organizations that elect The Joint Commission Behavioral Health Home option: The organization provides information to the individual served about: How the behavioral health home functions, including the following: - The process for assigning or selecting clinicians- Involving the individual in his or her plan of care, treatment, or services- Obtaining and tracking referrals - Coordinating the individual’s integrated care - Collaborating with clinicians who provide specialty care or second opinions

EP 3

For organizations that elect The Joint Commission Behavioral Health Home option: The organization provides information to the individual served and, when needed, his or her family or surrogate decision-maker about: The individual’s responsibilities, including providing his or her health history and current medications, and participating in self-management activities. (Refer to RI.01.01.03, EPs 1–3 and RI.02.01.01, EP 2)Note: Individuals’ responsibilities will vary depending on their abilities and unique circumstances. In some cases, family members or surrogate decision-makers may be able to help individuals meet their responsibilities.

EP 5

For organizations that elect The Joint Commission Behavioral Health Home option: The organization provides information to the individual served about: The individual’s right to obtain care from other clinicians within the behavioral health home, to seek a second opinion, and to seek specialty care. (Refer to RI.01.02.01, EPs 9, 31, and 32)

EP 6









4.k.5 TAG: CCBH

4.k.5 In keeping with the general criteria governing CCBHCs, behavioral health services are recovery-oriented. The VHA adopted the National Consensus Statement on Mental Health Recovery in its Uniform Mental Health Services Handbook. SAMHSA has since developed a working definition and set of principles for recovery updating the Consensus Statement. Recovery is defined as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full



4.k.5


Joint Commission









EP 1


EP 2


EP 3


EP 4




EP 1


EP 2


EP 3


EP 4



EP 6

potential.” The following are the 10 guiding principles of recovery: - Hope - Person-driven - Many pathways - Holistic - Peer support - Relational - Culture - Addresses trauma - Strengths/responsibility - Respect (Substance Abuse and Mental Health Services Administration [2012]). As implemented in VHA recovery, the recovery principles also include the following: - Privacy - Security - Honor Care for veterans must conform to that definition and to those principles in order to satisfy the statutory requirement that care for veterans adheres to guidelines promulgated by the VHA.



4.k.5


Joint Commission



EP 17


EP 20


services.


Governance works with other leaders to annually evaluate the organization’s performance in relation to its mission, vision, and goals.

EP 6

LD.02.01.01 The mission, vision, and goals of the organization support the safety and quality of

care, treatment, or services.

Leaders work together to create the organization’s mission, vision and goals.EP 1

The organization's mission, vision, and goals guide the actions of leaders.EP 2

Leaders communicate the mission, vision, and goals to staff and the population(s) the organization serves.

EP 3

HRM.01.03.01 The organization provides orientation to staff.

The organization determines the key safety content of orientation provided to staff.Note: Key safety content may include specific processes and procedures related to the provision of care, treatment, or services and the environment of care.

EP 1

The organization orients its staff to the key safety content before staff provides care, treatment, or services. Completion of this orientation is documented.

EP 2

The organization orients staff on the following: Policies and procedures related to job duties and responsibilities. Completion of this orientation is documented.

EP 3

The organization orients staff on the following: Their specific job duties and responsibilities. Completion of this orientation is documented. (See also IC.01.05.01, EP 6; IC.02.01.01, EP 7)

EP 4

The organization orients staff on the following: Sensitivity to cultural diversity based on their job duties and responsibilities. Completion of this orientation is documented.Note: Sensitivity to cultural diversity means being aware of and respecting cultural differences. This does not mean that staff have to be conversant with every culture that they may encounter in the organization.

EP 5

The organization orients staff on the following: The rights of individuals served, including the ethical aspects of care, treatment, or services. Completion of this orientation is documented. (See also RI.01.07.03, EP 5)

EP 6

4.k.6 TAG: CCBH

4.k.6 In keeping with the general criteria governing CCBHCs, all behavioral health care is provided with cultural competence. (1) Any staff who is not a veteran has training about military and veterans’ culture in order to be able to understand the unique experiences and contributions of those who have served their country. (2) All staff receives cultural competency training on issues of race, ethnicity, age, sexual orientation, and gender identity.



4.k.6


Joint Commission


For organizations that elect The Joint Commission Behavioral Health Home option: The organization orients staff on the following:- Behavioral health conditions most commonly found in the population(s) served- Chronic physical health conditions most commonly found in the population(s) served

EP 16

For organizations that elect The Joint Commission Behavioral Health Home option: If the organization sponsors or offers peer support services, it orients staff providing peer support services to their roles and responsibilities as members of the integrated care team (for example, participating in activities that promote healthy choices and lifestyles).

EP 17



EP 1


EP 2


EP 3
















EP 1


EP 2


EP 3


EP 4

4.k.7 TAG: CCBH

4.k.7 In keeping with the general criteria governing CCBHCs, there is a behavioral health treatment plan for all veterans receiving behavioral health services. (1) The treatment plan includes the veteran’s diagnosis or diagnoses and documents consideration of each type of evidence-based intervention for each diagnosis. (2) The treatment plan includes approaches to monitoring the outcomes (therapeutic benefits and adverse effects) of care, and milestones for reevaluation of interventions and of the plan itself. (3) As appropriate, the plan considers interventions intended to reduce/manage symptoms, improve functioning, and prevent relapses or recurrences of episodes of illness. (4) The plan is recovery oriented, attentive to the veteran’s values and preferences, and evidence-based regarding what constitutes effective and safe treatments. (5) The treatment plan is developed with input from the veteran, and when the veteran consents, appropriate family members. The veteran’s verbal consent to the treatment plan is required pursuant to VHA Handbook 1004.1.



4.k.7


Joint Commission



EP 12


EP 13




EP 1


EP 2


EP 3


EP 4



EP 6


EP 17


EP 18



4.k.7


Joint Commission



EP 19


EP 20


EP 21


EP 22



EP 1


EP 2


EP 3





EP 1


EP 2



individual served.


EP 1


EP 2

5.A TAG: CCBH

5.A: Data Collection, Reporting and Tracking

PI.01.01.01 The organization collects data to monitor its performance.

The leaders set priorities for data collection. (See also LD.04.04.01, EP 1)EP 1

5.a.1 TAG: CCBH

5.a.1 The CCBHC has the capacity to collect, report, and track encounter, outcome, and quality data, including but not limited to data capturing: (1) consumer characteristics; (2)



5.a.1


Joint Commission


The organization identifies the frequency for data collection.EP 2

The organization collects data on the following: Performance improvement priorities identified by leaders. (See also LD.04.04.01, EP 1)

EP 3

The organization collects data on the following: Significant medication errors. (See also LD.04.04.01, EP 2; MM.08.01.01, EP 1)

EP 14

The organization collects data on the following: Significant adverse medication reactions. (See also LD.04.04.01, EP 2; MM.08.01.01, EP 1)

EP 15

The organization collects data on the following: - Whether the individual served was asked about treatment goals and needs- Whether the individual served was asked if his or her treatment goals and needs were met- The view of the individual served regarding how the organization can improve the safety of the care, treatment, or services provided(See also RI.01.01.01, EP 17, for opioid treatment programs)

EP 16

The organization collects data to measure the performance of high-risk, high-volume, problem-prone processes provided to high-risk or vulnerable populations, as defined by the organization. (See also LD.04.04.01, EP 2)Note: Examples of such processes include the use of restraints, seclusion, suicide watch, and behavior management and treatment.

EP 27

The organization considers collecting data on the following:- Staff opinions and needs- Staff perceptions of risk to individuals- Staff suggestions for improving safety of the individuals served- Staff willingness to report adverse eventsNote: If the organization has not collected data on this topic, consideration can be demonstrated through methods such as interviews or meeting minutes.

EP 30

For organizations that elect The Joint Commission Behavioral Health Home option: The organization collects data on the following: Disease management outcomes. (See also LD.04.04.01, EP 24)

EP 40

For organizations that elect The Joint Commission Behavioral Health Home option: The organization collects data on the following: The individual’s access to care within time frames established by the organization.

EP 41

For organizations that elect The Joint Commission Behavioral Health Home option: The organization collects data on the following: - The individual’s experience and satisfaction related to access to care, treatment, or services and communication - The individual’s perception of the comprehensiveness of care, treatment, or services - The individual’s perception of the coordination of care, treatment, or services - The individual’s perception of the continuity of care, treatment, or services (Refer to PI.01.01.01, EP 16)

EP 42

For organizations that elect The Joint Commission Behavioral Health Home option: All staff who are part of the behavioral health home actively participate in performance improvement activities.

EP 43

staffing; (3) access to services; (4) use of services; (5) screening, prevention, and treatment; (6) care coordination; (7) other processes of care; (8) costs; and (9) consumer outcomes. Data collection and reporting requirements are elaborated below and in Appendix A.



5.a.2


Joint Commission



The organization compiles data into formats that enable them to be analyzed.EP 1

The organization identifies the frequency for data analysis.EP 2


EP 4


EP 5


EP 8


EP 9

5.a.2 TAG: CCBH

5.a.2 Reporting is annual and data are required to be reported for all CCBHC consumers, or where data constraints exist (for example, the measure is calculated from claims), for all Medicaid enrollees in the CCBHCs.





EP 4


EP 5


EP 8


EP 9

5.a.3 TAG: CCBH

5.a.3 To the extent possible, these criteria assign to the state responsibility for data collection and reporting where access to data outside the CCBHC is required. Data to be collected and reported and quality measures to be reported, however, may relate to services CCBHC consumers receive through DCOs. Collection of some of the data and quality measures that are the responsibility of the CCBHC may require access to data from DCOs and it is the responsibility of the CCBHC to arrange for access to such data as legally permissible upon creation of the relationship with DCOs and to ensure adequate consent as appropriate and that releases of information are obtained for each affected consumer.



5.a.4 TAG: CCBH

5.a.4 As specified in Appendix A, some aspects of data reporting will be the responsibility of the state, using Medicaid claims and encounter data. States must provide CCHBC-level Medicaid claims or encounter data to the evaluators of this demonstration program



5.a.4


Joint Commission




EP 4


EP 5


EP 8


EP 9

PI.03.01.01 The organization improves performance.

Leaders prioritize the identified improvement opportunities. (See also PI.02.01.01, EP 8)EP 1

The organization takes action on improvement priorities.EP 2

The organization evaluates whether actions taken resulted in improvements.EP 3

The organization takes action when it does not achieve or sustain planned improvements.EP 4

For organizations that elect The Joint Commission Behavioral Health Home option: The organization uses the data it collects on the individual’s perception of the safety and quality of care, treatment, or services to improve its performance. This data includes the following: - The individual’s experience and satisfaction related to access to care, treatment, or services and communication - The individual’s perception of the comprehensiveness of care, treatment, or services - The individual’s perception of the coordination of care, treatment, or services - The individual’s perception of the continuity of care, treatment, or services

EP 11

annually. At a minimum, consumer and service-level data should include a unique consumer identifier, unique clinic identifier, date of service, CCBHC-covered service provided, units of service provided and diagnosis. These data must be reported through MMIS/T-MSIS in order to support the state’s claim for enhanced federal matching funds made available through this demonstration program. For each consumer, the state must obtain and link the consumer level administrative Uniform Reporting System (URS) information to the claim (or be able to link by unique consumer identifier). CCBHC consumer claim or encounter data must be linkable to the consumer’s pharmacy claims or utilization information, inpatient and outpatient claims, and any other claims or encounter data necessary to report the measures identified in Appendix A. These linked claims or encounter data must also be made available to the evaluator. In addition to data specified in this program requirement and in Appendix A that the state is to provide, the state will provide such other data, including Treatment Episode Data Set (TEDS) data and data from comparison settings, as may be required for the evaluation to HHS and the national evaluation contractor annually. To the extent CCBHCs are responsible for provision of data, the data will be provided to the state and, as may be required elsewhere, to HHS and the evaluator. If requested, CCBHCs will participate in discussions with the national evaluation team.



EP 5


EP 8

5.a.5 TAG: CCBH

5.a.5 CCBHCs annually submit a cost report with supporting data within six months after the end of each demonstration year to the state. The state will review the submission for completeness and submit the report and any additional clarifying information within nine months after the end of each demonstration year to CMS. Note: In order for a clinic to receive payment using the CCBHC PPS, it must be certified as a CCBHC.



5.B


Joint Commission


5.B TAG: CCBH

5.B: Continuous Quality Improvement (CQI) Plan

LD.04.04.01 Leaders establish priorities for performance improvement. (Refer to the "Performance

Improvement" [PI] chapter.)

Leaders set priorities for performance improvement activities and behavioral health outcomes. (See also PI.01.01.01, EPs 1 and 3)

EP 1

Leaders give priority to high-volume, high-risk, or problem-prone processes for performance improvement activities. (See also PI.01.01.01, EPs 14, 15, 27)

EP 2

Leaders reprioritize performance improvement activities in response to changes in the internal or external environment.

EP 3

Performance improvement occurs organizationwide.EP 4

For organizations that elect The Joint Commission Behavioral Health Home option: Leaders set priorities for physical health care performance improvement activities and outcomes. (See also PI.01.01.01, EP 40)Note: As an example, activities and outcomes may be related to individuals with multiple chronic physical health conditions.

EP 24

For organizations that elect The Joint Commission Behavioral Health Home option: Leaders involve individuals served in performance improvement activities related to integrated care. Note: This involvement may include activities such as participating on a quality committee or providing feedback on safety and quality issues.

EP 25

5.b.1 TAG: CCBH

5.b.1 The CCBHC develops, implements, and maintains an effective, CCBHC-wide data-driven continuous quality improvement (CQI) plan for clinical services and clinical management. The CQI projects are clearly defined, implemented, and evaluated annually. The number and scope of distinct CQI projects conducted annually are based on the needs of the CCBHC’s population and reflect the scope, complexity and past performance of the CCBHC’s services and operations. The CCBHC-wide CQI plan addresses priorities for improved quality of care and client safety, and requires all improvement activities be evaluated for effectiveness. The CQI plan focuses on indicators related to improved behavioral and physical health outcomes, and takes actions to demonstrate improvement in CCBHC performance. The CCBHC documents each CQI project implemented, the reasons for the projects, and the measurable progress achieved by the projects. One or more individuals are designated as responsible for operating the CQI program.

LD.04.04.05 The organization has an organizationwide, integrated safety program for individuals

served.

The leaders implement an organizationwide safety program for individuals served.EP 1

One or more qualified persons manage the safety program.EP 2

The scope of the safety program includes the full range of safety issues, from potential or no-harm errors (sometimes referred to as near misses, close calls, or good catches) to hazardous conditions and sentinel events.

EP 3

All programs and services within the organization participate in the safety program.EP 4

As part of the safety program, the leaders create procedures for responding to system or process failures.Note 1: Responses might include continuing to provide care, treatment, or services to those affected, containing the risk to others, and preserving factual information for subsequent analysis.Note 2: For opioid treatment programs: Examples of reportable patient deaths include the following:- Drug-related deaths- Methadone or buprenorphine deaths- Unexpected or suspicious deaths- Treatment-context deaths that raise individual, family, community, or public concern

EP 5

5.b.2 TAG: CCBH

5.b.2 Although the CQI plan is to be developed by the CCBHC and reviewed and approved by the state during certification, specific events are expected to be addressed as part of the CQI plan, including: (1) CCBHC consumer suicide deaths or suicide attempts; (2) CCBHC consumer 30 day hospital readmissions for psychiatric or substance use reasons; and (3) such other events the state or applicable accreditation bodies may deem appropriate for examination and remediation as part of a CQI plan.



5.b.2


Joint Commission


The leaders provide and encourage the use of systems for blame-free internal reporting of a system or process failure, or the results of a proactive risk assessment. (See also LD.03.01.01, EP 8; LD.03.04.01, EP 5; LD.04.04.03, EP 3)Note: This EP is intended to minimize staff reluctance to report errors in order to help an organization understand the source and results of system and process failures. The EP does not conflict with holding individuals accountable for their blameworthy errors.

EP 6

The leaders define patient safety event and communicate this definition throughout the organization. Note: At a minimum, the organization's definition includes those events subject to review in the "Sentinel Events" (SE) chapter of this manual. The definition may include any process variation that does not affect the outcome or result in an adverse event, but for which a recurrence carries significant chance of resulting in a serious adverse outcome or an adverse event, often referred to as a close call or near miss.

EP 7

The organization conducts thorough and credible comprehensive systematic analyses (for example, root cause analyses) in response to sentinel events as described in the "Sentinel Events" (SE) chapter of this manual.

EP 8

The leaders make support systems available for staff who have been involved in an adverse or sentinel event. Note: Support systems recognize that conscientious health care workers who are involved in sentinel events are themselves victims of the event and require support. Support systems provide staff with additional help and support as well as additional resources through the human resources function or an employee assistance program. Support systems also focus on the process rather than blaming the involved persons.

EP 9

To improve safety, the organization analyzes and uses information about system or process failures and, when conducted, the results of proactive risk assessments. (See also LD.04.04.03, EP 3)

EP 11

The leaders disseminate lessons learned from comprehensive systematic analyses (for example, root cause analyses), system or process failures, and the results of proactive risk assessments to all staff who provide services for the specific situation. (See also LD.03.04.01, EP 5)

EP 12

6.A TAG: CCBH

6.A: General Requirements of Organizational Authority and Finances


The organization is licensed, is certified, or has a permit, in accordance with law and regulation, to provide the care, treatment, or services for which the organization is seeking accreditation from The Joint Commission. (See also WT.01.01.01, EP 1; WT.04.01.01, EP 1)

EP 1


EP 2


EP 3

6.a.1 TAG: CCBH

6.a.1 The CCBHC maintains documentation establishing the CCBHC conforms to at least one of the following statutorily established criteria:- Is a non-profit organization, exempt from tax under Section 501(c)(3) of the United States Internal Revenue Code;- Is part of a local government behavioral health authority;- Is operated under the authority of the Indian Health Service, an Indian tribe, or tribal organization pursuant to a contract, grant, cooperative agreement, or compact with the Indian Health Service pursuant to the Indian Self-Determination Act (25 U.S.C. 450 et seq.);- Is an urban Indian organization pursuant to a grant or contract with the Indian Health Service under Title V of the Indian Health Care Improvement Act (25 U.S.C. 1601 et seq.).Note: A CCBHC is considered part of a local government behavioral health authority when a locality, county, region or state maintains authority to oversee behavioral health services at the local level and utilizes the clinic to provide those services.



6.a.2


Joint Commission


CTS.07.01.01 For organizations that provide prevention and wellness promotion services: The

organization's prevention and wellness promotion services are planned.

For organizations that provide prevention and wellness promotion services: The organization seeks input about the needs of the community served relative to prevention and wellness promotion services; the organization uses this information to guide its planning process.

EP 2

For organizations that provide prevention and wellness promotion services: The organization identifies those resources within the community (if any) that will be utilized to support the provision of the organization’s prevention and wellness promotion services.

EP 3

LD.02.03.01 Leaders regularly communicate with each other on issues of safety and quality.

The organization establishes time frames for the discussion of issues that affect the organization and the population(s) it serves.

EP 2

6.a.2 TAG: CCBH

6.a.2 To the extent CCBHCs are not operated under the authority of the Indian Health Service, an Indian tribe, or tribal or urban Indian organization, states, based upon the population the prospective CCBHC may serve, should require CCBHCs to reach out to such entities within their geographic service area and enter into arrangements with those entities to assist in the provision of services to AI/AN consumers and to inform the provision of services to those consumers. To the extent the CCBHC and such entities jointly provide services, the CCBHC and those collaborating entities shall, as a whole, satisfy the requirements of these criteria.

LD.04.01.03 The organization develops an annual operating budget and, when needed, a long-term

capital expenditure plan.

The operating budget reflects the organization’s goals and objectives.EP 3

Governance monitors or approves an annual operating budget and, when needed, a long-term capital expenditure plan.

EP 4

Leaders monitor the implementation of the budget and long-term capital expenditure plan.EP 5

The organization has a process that provides for an annual objective evaluation of its financial ability to provide care, treatment, or services. Note: A full audit need not take place, but key measures that support sound financial practices or reveal warning signs requiring a follow-up are to be used. Examples of such measures include cash flow, accounts receivable, and current ratio.

EP 7

6.a.3 TAG: CCBH

6.a.3 An independent financial audit is performed annually for the duration of the demonstration in accordance with federal audit requirements, and, where indicated, a corrective action plan is submitted addressing all findings, questioned costs, reportable conditions, and material weakness cited in the Audit Report.

6.B TAG: CCBH

6.B: Governance

LD.01.01.01 The organization has a leadership structure.

The organization identifies those responsible for governance.EP 1

Governance identifies those responsible for planning, management, and operational activities.EP 2

Governance identifies those responsible for the provision of care, treatment, or services.EP 3

6.b.1 TAG: CCBH

6.b.1 As a group, the CCBHC’s board members are representative of the individuals being served by the CCBHC in terms of demographic factors such as geographic area, race, ethnicity, sex, gender identity, disability, age, and sexual orientation, and in terms of types of disorders. The CCBHC will incorporate meaningful participation by adult consumers with mental illness, adults recovering from substance use disorders, and family members of CCBHC consumers, either through 51 percent of the board being families, consumers or people in recovery from behavioral health conditions, or through a substantial portion of the governing board members meeting this criteria and other specifically described methods for consumers, people in recovery and family members to provide meaningful input to the board about the CCBHC’s policies, processes, and services.


services.

Governance provides for organization management and planning.EP 2

6.b.2 TAG: CCBH

6.b.2 The CCBHC will describe how it meets this requirement or develop a transition plan with timelines appropriate to its governing board size and target population to meet this requirement.



6.b.3


Joint Commission




EP 2


EP 3

6.b.3 TAG: CCBH

6.b.3 To the extent the CCBHC is comprised of a governmental or tribal entity or a subsidiary or part of a larger corporate organization that cannot meet these requirements for board membership, the state will specify the reasons why the CCBHC cannot meet these requirements and the CCBHC will have or develop an advisory structure and other specifically described methods for consumers, persons in recovery, and family members to provide meaningful input to the board about the CCBHC's policies, processes, and services.



EP 2


EP 3

6.b.4 TAG: CCBH

6.b.4 As an alternative to the board membership requirement, any organization selected for this demonstration project may establish and implement other means of enhancing its governing body’s ability to insure that the CCBHC is responsive to the needs of its consumers, families, and communities. Efforts to insure responsiveness will focus on the full range of consumers, services provided, geographic areas covered, types of disorders, and levels of care provided. The state will determine if this alternative approach is acceptable and, if it is not, will require that additional or different mechanisms be established to assure that the board is responsive to the needs of CCBHC consumers and families. Each organization will make available the results of their efforts in terms of outcomes and resulting changes.

LD.01.01.01 The organization has a leadership structure.

The organization identifies those responsible for governance.EP 1

Governance identifies those responsible for planning, management, and operational activities.EP 2

Governance identifies those responsible for the provision of care, treatment, or services.EP 3

6.b.5 TAG: CCBH

6.b.5 Members of the governing or advisory boards will be representative of the communities in which the CCBHC's service area is located and will be selected for their expertise in health services, community affairs, local government, finance and banking, legal affairs, trade unions, faith communities, commercial and industrial concerns, or social service agencies within the communities served. No more than one half (50 percent) of the governing board members may derive more than 10 percent of their annual income from the health care industry.



EP 2


EP 3

6.b.6 TAG: CCBH

6.b.6 States will determine what processes will be used to verify that these governance criteria are being met.

6.C TAG: CCBH

6.C: Accreditation


The organization is licensed, is certified, or has a permit, in accordance with law and regulation, to provide the care, treatment, or services for which the organization is seeking accreditation from The Joint Commission. (See also WT.01.01.01, EP 1; WT.04.01.01, EP 1)

EP 1

6.c.1 TAG: CCBH

6.c.1 CCBHCs will adhere to any applicable state accreditation, certification, and/or licensing requirements.

APR.01.01.01 The organization submits information to The Joint Commission as required.6.c.2 TAG: CCBH

6.c.2 States are encouraged to require accreditation of the CCBHCs by an appropriate nationally-recognized organization (e.g., the Joint Commission, the Commission on



6.c.2


Joint Commission


The organization meets all requirements for timely submissions of data and information to The Joint Commission.Note 1: The Joint Commission will impose the following consequence for failure to comply with this APR:If the organization consistently fails to meet the requirements for the timely submission of data and information to The Joint Commission, the organization will be required to undergo an Accreditation with Follow-up Survey. Failure to resolve this issue at the time of the Accreditation with Follow-up Survey may result in an accreditation decision change.Note 2: The proposed consequences address only compliance with the requirement itself. They do not address the content of the organization’s submissions to The Joint Commission. For example, if information in an organization’s electronic application for accreditation (E-App) leads to inaccuracies in the appropriate length of the survey and a longer survey is required, the organization will incur the additional costs of the longer survey. In addition, if there is evidence that the organization has intentionally falsified the information submitted to The Joint Commission, the requirement at APR.01.02.01, EP 1 and its consequences will apply. (See also APR.01.02.01, EP 1)

EP 1

APR.01.02.01 The organization provides accurate information throughout the accreditation process.

The organization provides accurate information throughout the accreditation process. (See also APR.01.01.01, EP 1)Note 1: Information may be received in any of the following ways:- Provided verbally- Obtained through direct observation by, or in an interview or any other type of communication with, a Joint Commission employee- Derived from documents supplied by the organization to The Joint Commission- Submitted electronically by the organization to The Joint CommissionNote 2: For the purpose of this requirement, falsification is defined as the fabrication, in whole or in part, and through commission or omission, of any information provided by an applicant or accredited organization to The Joint Commission. This includes redrafting, reformatting, or deleting document content. However, the organization may submit supporting material that explains the original information submitted to The Joint Commission. These additional materials must be properly identified, dated, and accompanied by the original documents.

EP 1

APR.01.03.01 The organization reports any changes in the information provided in the application for

accreditation and any changes made between surveys.

The organization notifies The Joint Commission in writing within 30 days of a change in ownership, control, location, capacity, or services offered.Note: When the organization changes ownership, control, location, capacity, or services offered, it may be necessary for The Joint Commission to survey the organization again. If the organization does not provide written notification to The Joint Commission within 30 days of these changes, the organization could lose its accreditation.

EP 1

APR.02.01.01 The organization permits the performance of a survey at The Joint Commission's

discretion.

The organization permits the performance of a survey at The Joint Commission's discretion.EP 1

APR.08.01.01 The organization accurately represents its accreditation status and the programs and

services to which Joint Commission accreditation applies.

The organization’s advertising accurately reflects the scope of programs and services that are accredited by The Joint Commission.

EP 1

Accreditation of Rehabilitation Facilities [CARF], the Council on Accreditation [COA], the Accreditation Association for Ambulatory Health Care [AAAHC]). Accreditation does not mean “deemed” status.



6.c.2


Joint Commission


The organization does not engage in any false or misleading advertising about its accreditation award.EP 2

APR.09.03.01 The organization is truthful and accurate when describing information in its Quality

Report to the public.

The organization adheres to The Joint Commission’s published guidelines for how it describes information found in its Quality Report.

EP 1

APR.09.04.01 The organization provides care, treatment, services, and an environment that pose no

risk of an “Immediate Threat to Health or Safety,” also known as “Immediate Threat to

Life” or ITL situation.

The organization provides care, treatment, services, and an environment that pose no risk of an “Immediate Threat to Health or Safety,” also known as “Immediate Threat to Life” or ITL situation.

EP 1



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