Does The Joint Commission survey your organization under the Behavioral Health Care Accreditation Program (now formally known as Behavioral Health Care & Human Services Accreditation?)

If so, we have important feedback about current high focus areas we’re seeing in 2021 surveys.

Notably, the Behavioral Health Care Accreditation Program has been very active throughout the COVID-19 pandemic. They’ve conducted the highest number of virtual surveys of any Joint Commission accreditation program. They’re now conducting both onsite and virtual surveys.

Behavioral Health Care Accreditation: When Does it Apply?

TJC applies the Behavioral Health Care Accreditation standards in a variety of settings. These include freestanding behavioral health organizations providing mental health services, addiction treatment, eating disorder treatment, child welfare, and a range of other types of human services.

TJC also applies the Behavioral Health Care Accreditation standards to some behavioral health programs within organizations surveyed primarily under a different accreditation program. For example, if a hospital runs a behavioral health partial hospitalization program with an average daily census of 11 or more, TJC will survey that program under the Behavioral Health Care Accreditation standards. Another example would be an outpatient opioid treatment program operated by a hospital.

Interestingly, over the last few years, many psychiatric hospitals (as well as some acute care hospitals) have expanded their services into community based behavioral health programs such as these.

2021 TJC Surveys: Continued High Focus Areas

Some of the 2021 high focus areas are a continuation of trends from the past two years:

National Patient Safety Goal 15: Suicide Prevention

Predictability, the heightened attention to NPSG 15 continues. That includes your suicide risk assessments and care plans for patients at risk. Surveyors are also closely evaluating compliance with the other NPSG 15 requirements for policies, staff training, and PI data to monitor the implementation of your suicide risk assessment process.

So, we strongly encourage you to review our articles on this topic and refresh yourself on all the requirements:

• NPSG 15 Suicide Risk Reduction: Feedback from the Field
• NPSG.15.01.01 Suicide Risk Reduction: Monitoring High Risk Patients
• NPSG.15.01.01 Suicide Risk Reduction: Safety Planning at Discharge

Nutritional Screening

Surprisingly, we see many behavioral health organizations receiving survey findings for noncompliance with the 2018 requirements for nutritional screening.

That should be an easy one to fix. Review your nutritional screening tool and make sure it includes the five required criteria. Moreover, make sure you have a process in place to conduct (or refer out) those clients whose screening indicates they need a full nutritional assessment.

Trauma Screening and Assessment

On a similar note, many behavioral health organizations continue to receive survey findings for incomplete trauma screening. Specifically, for not including exploitation in their trauma screening. That should be another easy one to fix. For details, see our 2018 article on trauma assessment.

Outcomes Measurement

At this point, most behavioral health organizations are using an outcomes measurement tool. Thus, they’re in compliance with the 2018 requirements.

However, many aren’t yet using the outcomes data for treatment planning purposes as TJC requires. For tips on that, see our coverage on how one organization is meeting those outcomes measurement requirements.

2021 TJC Surveys: New High Focus Areas

So, what are the new trends in  survey findings? There are two areas we want to alert you to where we’re seeing an uptick: Environment of Care and Medication Management. In order to provide the full detail of what’s being cited, we’re sharing the actual survey findings (with identifying information redacted.)

Environment of Care

We’re seeing a high focus on the environment of care in all types of behavioral health settings. That includes how you maintain your environment and how you keep it safe. Here’s a sample of survey findings:

“The organization was unable to demonstrate that all portable fire extinguishers were checked monthly.”

“It was observed that the organization had not labeled the gas and water shut-off valves so that staff were able to partially or completely shut down systems in emergencies.” (This issue was cited frequently on 2021 surveys.)

“In the electrical utility room located in the ___office area of the second floor, the electrical panels labeled P3, P4, H3, and L3 did not have complete legends that identified what each circuit breaker served.”

“The organization was unable to demonstrate that monthly generator tests were completed under load for thirty (30) minutes.” (This issue was cited frequently on 2021 surveys.)

“It was noted that some of the sound proofing mats by the tables in the area used by the partial hospital program had torn covers exposing the interior padding which cannot be effectively sanitized.”

“During tracer activities, the surveyor observed the program’s food refrigerator that had significant dust buildup on the top.  The surveyor used a paper towel to check the top of the refrigerator, and the dust was significant.  The staff immediately began to clean the refrigerator subsequent to the observation.”

“The surveyor observed soiled ceiling tiles in the PHP Program.  The program reported that there had been torrential rain in the recent past, but the tiles appeared to be brown and dry.  Subsequent to the observation, the program changed the tiles and began the process of finding out the cause.”

“The surveyor observed uneven concrete flooring in the stairwell upon exiting an emergency door which was a potential trip hazard.  The program reported they will be relocating in 2022 and had not planned to improve the unit.  They did not discuss any mitigating  plans.  Subsequent to the observation, the program cemented the stairwell to decrease the risk of tripping.”

“During the building tour of the Outpatient site, a stained ceiling tile was observed in the hallway across from the bathrooms.  This was corrected on site.” (This issue was cited frequently on 2021 surveys.)

“The organization was not able to show the toilet in the women’s bathroom was maintained as evidenced by an absence of full water level in the bowl, damp tissue paper stuck to the bowl interior, and discolored matter in the bottom.” 

“During the _____tour, a yoga mat was observed rolled and stored with what appeared to be kinetic sand stuck randomly to it.  This was corrected on site.”

“It was observed that the organization had not sufficiently established and maintained a safe, functional environment in the following aspects:  in _____, the air vents were partially covered with dirt, and floors and walls had many stains and marks;  in _____, there was a leaking shower head staining shower tiles below it and missing grout.”

“The organization was not able to show evidence of furnishings and equipment in good repair as evidenced by  1) The water dispensing machine in the lobby showed a corrosive buildup in the drain tray, and 2) The cabinet beneath the coffee station showed signs of dried spillage and discoloration along the interior back wall and bottom.  These were corrected on site before close of survey.”

“The organization was unable to demonstrate how it was cleaning and monitoring for buildup in dryer lint traps.”

“There was a cabinet in the kitchen that had a broken lock where supplies are stored making furnishings and equipment not in good repair.”

“There was a piece of baseboard or molding that was loose between the dishwasher and the cabinet in the dining room making furnishings in need of repair.”

“During the Main location outpatient facility tour, one (1) of two (2) bathroom toilets was observed filled with urine and feces and was unable to be flushed.  This was corrected on site.”

Medication Management

In 2021, we’re noticing an increased focus on medication management issues in behavioral health settings. Specifically, the medication ordering, storage, and administration processes. Here’s a sample of actual survey findings:

“It was reported by the nurse on ____ that the organization had not identified in writing its hazardous medications that it stores, dispenses, or administers.”

“As observed by myself and the nurse, there was an expired Epinephrine dated 6/30/21 that was mixed in with the medications that were available for administration.  These were medications kept in the emergency box.”

“The organization did not have a policy or process to count non-controlled medications (e.g. at delivery by the local pharmacy, after administrations, after refills) such as keeping a written log or documenting medication counts on the organization’s Record of Supervised Self-Administration form.  Consequently, inaccurate medication counts, or diversion are possible.  For example, the organization received from a local pharmacy 60 Depakote pills (500mg each) for an individual served.  The Record of Supervised Self-Administration form showed that staff gave the individual 38 pills over time to self-administer (19 administrations).  The physician order required a 1000 mg daily dose.  However, there were 37 pills left in the bottle.  The remaining pill count was more than the total pill count at delivery by the pharmacy.  Staff onsite expressed that the inaccurate count was related to refills received.” 

“There was evidence in the March 2021 Controlled Substances Count sheet that a count of controlled medications was not consistently being done as per policy.  Shift counts were missing for March 21 and 23, and there were no documented counts for 2 consecutive shifts on March 28.”

“The organization’s Medication Confirmation of Drop-Off form showed that there were four medications dropped off between 2/24/21 and 2/25/21 and four medications on 2/27/21.  However, there were no initials of the staff member (or members) who received the medications, which was required.” 

“Medication refrigerator temperatures in the medication room (Cottage _) had not been consistently monitored.  For example, the February 2021 temperature log was noted to have 10+ missing days of data.  Within the refrigerator was Victoza injectable which requires storage between 36 and 46 degrees.  Without consistent temperature monitoring, there is no way to assure that medications are being kept within the temperature guidelines established by the manufacturer.” (This issue was cited frequently on 2021 surveys.)

“On 3/01/21, a student was ordered Benadryl 50 mg for insomnia.  The nurse who accepted the telephone order did not write in her transcription of the orders a “Time of Administration.”  A record review suggested the medication was intended as a “now” order but was not recorded as such.”

“On 3/15/21, a student was ordered Ibuprofen 800 mg for mild pain secondary to a recent dental procedure.  The nurse who accepted the telephone order did not write in her transcription of the order a “Route of Administration.”

“According to the nurse at the Women’s Outpatient Program, over the counter medications such as Ibuprofen and Acetaminophen were being administered to their patients without a prescriber’s order; therefore, the organization was not viewing an order prior to administering medications.  According to the nurse, she confirmed after this discussion they immediately got orders for the patients for these medications.”

“Organization policy 15.15 (page 3, paragraph 4) required monitoring of “first dose” effect.  In one of three records reviewed, a client newly prescribed Lexapro was not evaluated for first dose effect.”

Survey Strategies

These trends in survey findings are a heads-up for any behavioral health organization preparing for survey. We recommend you share this information with your key stakeholders and see if you’re at risk for similar findings. If so, take corrective action now and avoid these common pitfalls.

Also, you’ll notice that several times the surveyor states that the organization corrected the issue on site. However, that does not mean that the finding isn’t included in your report.

The finding (although corrected) is included in your report. You must then submit Evidence of Standards Compliance to TJC within 60 days. When you do that, you’ll essentially describe how you fixed the issue during your survey and how you’re monitoring for sustained compliance.

Barrins & Associates

For behavioral health organizations, TJC is pretty much back to “business as usual” in terms of conducting surveys. Likewise, we’re busy conducting Mock Surveys and Continuous Readiness Consultations  across the country.

We’ve incorporated all the new standards that go into effect in 2022. As always, we’re prepared to support your ongoing survey readiness and best practices for regulatory compliance.