Findings in the Provision of Care chapter typically account for a significant number of Requirements for Improvement (RFIs) on surveys for both psychiatric hospitals and behavioral health organizations/programs. These findings relate primarily to assessment, treatment planning and clinical documentation. Some of the frequently cited topics have been around for awhile and make the Top Ten each year. Sometimes, however, new issues crop up that are worth noting.  The following is a summary of highlights and trends in this chapter from our clients surveyed in 2014. Note: The relevant chapter for psychiatric hospitals is Provision of Care in the Hospital manual. For BH organizations/programs, it is Care, Treatment, and Services in the BH manual.

 

Assessment

For psychiatric hospitals, the most frequent findings in the Provision of Care chapter related to assessment and reassessment. Surveyor findings continued to focus on problems identified in assessments but not addressed on the treatment plan. These often included medical problems, pain issues, and nutritional issues. In 2014, the issue of incomplete neurological screenings cropped up again. The frequent finding was that the neurological screening did not address all of the cranial nerves II – XII (a CMS requirement.)

For BH organizations, the issues were similar but in 2014 the topic of trauma assessment was cited more frequently than in the past. Surveyors cited organizations for not including the full range of trauma issues in their assessment (beyond physical and sexual abuse.)  Take note that the scope of the trauma assessment should include all types of trauma. See our October 2013 newsletter article on trauma assessment.

 

Nutrition Screening and Assessment

For psychiatric hospitals, a common issues related was lack of follow-up on nutrition screenings and nutritional assessments. Diabetic patients were frequently selected for tracers. For BH organizations, the issues continued to relate to lack of clear criteria in the nutritional screening for when a nutritional assessment should be recommended. For compliance tips, see our September 2010 newsletter article on nutrition screening.

 

Treatment Planning

Treatment planning issues remained high on the radar for both psychiatric hospitals and BH organizations. The typical shortcomings were, as always, lack of measurability and lack of individualization. For psychiatric hospitals, we noted the trend of treatment plans not being updated to include medical problems that had been identified during the patient’s stay.

For BH organizations, the trend was more findings related to goals not stated in a way that captures the client’s words or ideas. There is a specific BH standard (CTS.03.01.03) that requires goals to be expressed in that manner.

On a different note, we saw a finding in 2014 for the first time related to lack of therapeutic groups and activities on inpatient units over the weekend. Although this issue has been frequently cited on CMS surveys, this was the first time we had seen it on a TJC survey.

 

Storage of Nutritional Products

Surveyors have been checking refrigerators for a long time. Typically, findings relate to problems with recording refrigerator/freezer temperatures. In 2014, however, we saw an uptick in findings related to improper food storage. For more info, see our November 2012 newsletter article on food storage.

 

Health screening for non-24 hour BH Programs

This one has been in the Top Ten for several years. However, many BH organizations have not yet mastered their health screening process. Common Issues cited in 2014 were:

•       No written procedure describing the health screening process.
•       Lack of triggers in the health screening to determine the need for a physical exam.
•       Triggers met but no evidence of follow-up

For compliance tips, see our April 2012 newsletter article on health screenings.

 

Physical Holding of Children/Youth

These standards apply only to BH programs that use physical holding with children/youth. Common issues cited were:

• No information in the assessment regarding techniques to help minimize need for physical holding (Remember: This information needs to be gathered at the initial assessment.)
• No observer present during the hold
• Lack of debriefing following the hold

 

General Trend: More Findings on Survey Reports

Since July 2014, survey reports include a new section titled Opportunities for Improvement (OFIs). As a result, there are typically more findings in the survey report than in the past. These OFIs are surveyor findings for C elements of performance where there was only one observation of non-compliance. See our July 2014 newsletter article on this change in TJC survey reports. So, you may want to give your leadership team a heads-up on this new report format and the likelihood of a higher number of survey findings.