Psychiatric hospitals that use TJC accreditation for CMS deemed status were the first organizations to experience the SAFER (Survey Analysis for Evaluating Risk) methodology starting in June 2016. TJC recently published six months of compliance data for these hospitals. Many of the Top Ten issues remain the same but it’s interesting to see how they play out on the SAFER matrix. Here’s some highlights from the TJC data and our own database.

Treatment planning (PC.01.03.01) remains the most frequently cited standard and will continue to be a heavy hitter for the foreseeable future. With the increased emphasis on the B Tags, treatment planning has taken on even greater prominence. On the SAFER matrix, the vast majority of findings in this area (approximately 85%) are scored as Moderate Risk and either Limited or Pattern in Scope. However, it’s important to keep  in mind that even when scored at the Moderate Risk level, treatment planning RFIs can result in non-compliance at the Condition level with the CMS CoP for treatment planning and thus result in a 45 day unannounced Medicare follow-up survey.

Assessment (PC.01.02.13) is the second most frequently cited standard. The most common RFIs in this area are for missing components on the psychiatric evaluation, psychosocial assessment and neurological screenings. Similar to treatment planning, the majority of RFIs fall in the category of Moderate Risk and either Limited or Pattern in Scope.

A safe, functional environment is the # 3 finding. RFIs in this area frequently relate to environmental features with potential for self-harm such as ligature points. Although only about 3% of psych hospitals scored in the High Risk range, this may increase with TJC’s more robust scoring of this issue announced on 3/1/17. (See our March 2017 newsletter article on this topic.)

There are three Life Safety standards in the Top Ten related to fire safety and building features (LS.02.01.35, LS.02.01.30, and LS.02.01.10) and this is similar to med/surg hospitals. More than 50% of findings are in the Low Risk and Limited Scope range. Once again, be aware that even this scoring can result in a Condition level finding for Physical Environment.

Noncompliance related to fire drills (EC.02.03.03) is new to the Top Ten. The majority of findings fall in the Moderate Risk and Limited Scope category. The issue we see occurring recently is that hospitals do not vary the times of their drills and this is required so heads up on that one.

The governing body’s responsibility for safe patient care (LD.01.03.01) makes the list because this standard is typically cited when there is a Condition level finding (previously an automatic RFI but now up to surveyor judgement.)

There are three Record of Care standards in the Top Ten: RC.02.04.01, RC.02.02.01, and RC.01.01.01. This is predictable since this chapter is the repository for findings related to poor clinical documentation. Our database shows the usual culprits (medical issues not on treatment plans, late authentication of orders, legibility, etc.) but we are also seeing many more RFIs related to lack of active treatment (a B Tag issue) and discharge summaries (# 7 on the Top Ten list.) The issue frequently cited for discharge summaries is that the discharge summary does not include a description of the patient’s physical and functional status at time of discharge. Make note that the CMS requirement (B135) is for a summary of the patient’s psychiatric, physical, and functional condition at discharge.

So, make use of this data to manage standards compliance within your organization. Keep in mind that the important drivers for compliance are not only the Top Ten issues but also the patterns of non-compliance that can roll up to a Condition level finding. Avoid those follow-up surveys that are no fun for anyone!


Environment of Care Updates: Exit Signs and Fire Drills Welcome Valley Hospital