Psychiatric hospitals that use TJC accreditation for deemed status and have been surveyed in the last few months have experienced a shift in focus. Many report that their recent TJC survey felt more like a CMS survey. That’s because TJC surveyors now have a mandate to survey for close adherence to the “B Tags” (CMS Special Conditions of Participation for Psychiatric Hospitals). As part of that focus on the B Tags, we are seeing an increasing emphasis on the requirement for active treatment in psychiatric hospitals. This is an issue that has long been a key focus area for CMS and TJC is now beginning to follow suit. So, as surveyors conduct tracers on the inpatient units, they are observing the milieu and the implementation of the program schedule to determine if active treatment is being delivered. In light of this, we encourage you to conduct your own tracers and take a look at the programming being delivered on your inpatient units. As a resource, the following are key elements we review during tracers to evaluate the provision of active treatment:

Does the unit have a program schedule that is suited to the needs of the patients?

• Are there tracks for different groups of patients or are all patients expected to attend the same groups? (We’ve seen substance abuse groups for patients who did not have a substance abuse diagnosis.)
• Do the groups take into account the cognitive level of the patients?
• Is there too much “down time” on the schedule?
• Is medication education included on the schedule?
• Is there programming on evenings and weekends?
• For children/adolescents, is there adequate time on the schedule for physical activity?
• Has there been input from patients regarding the program schedule and whether it meets their needs?

Is the program schedule consistently implemented?

• Do groups and activities take place each day as indicated on the program schedule?
• If a staff member is absent, is another individual assigned to conduct the group/activity?
• Are nurses assigned to run groups but frequently unavailable due to other nursing tasks?

Do staff running groups and therapeutic activities have appropriate competencies?

• If mental health workers run groups, how have they been trained for this function?
• How is their competency assessed on an ongoing basis?
• Are groups observed periodically by a clinical supervisor?

Are staff effectively engaging patients in programming?

• Do staff actively encourage patients to attend groups/activities?
• If patients are reluctant, do staff reach out and attempt to engage them?
• Do all treatment team members (including the psychiatrist) reinforce with the patient the importance of group attendance?
• If patients consistently refuse groups, is this addressed with them in treatment team meetings?

For patients who do not attend groups, are alternative therapeutic activities provided?

• Are specific staff assigned to engage patients who have not attended the group/activity?
• Are there materials and resources for staff to use as alternatives to the group/activity?
• How are these alternative therapeutic activities documented in the patient’s record?

As we track the surveys of our clients, we have begun to see some of these issues related to active treatment cropping up on survey reports. TJC surveyors have cited issues such as lack of alternative treatment for patients who did not attend groups, lack of programming on weekends, and progress notes for groups not addressing the patient’s goals and objectives on their treatment plan.

As you review your active treatment model and program schedules, it might also be useful to take a look at the Surveyor Worksheet used by CMS and now TJC surveyors as they conduct tracers on the inpatient units. It includes patient observations and a medical record review as well as staff and patient interviews. Completing the worksheet for a sample of patients at your hospital will provide a good insight to how active treatment will be evaluated during your next survey and where you may need to make some improvements.