Upon completion of a psychiatric hospital or behavioral health and human services Joint Commission survey, organizations receive a final report of findings approximately 10 business days after the survey’s conclusion. This report outlines areas requiring improvement to meet compliance standards. Organizations are then tasked with submitting Evidence of Standards Compliance (ESC) for each identified finding within 60 days of the report’s publication. This process ensures that corrective actions are implemented promptly and effectively, addressing any deficiencies while maintaining the organization’s commitment to patient safety and quality care.

Highlighting Patient Impact in Evidence of Standards Compliance

When addressing findings from a Joint Commission survey, it is critical to provide a clear and comprehensive description of the corrective actions taken. The Correcting the Non- Compliance section of the ESC requirement includes detailing staff training initiatives, as well as the development, revision, and approval of relevant policies and procedures. Additionally, the ESC must specify the final date by which all corrective actions were completed, demonstrating that the issue has been fully resolved. 

In May of 2024, the Joint Commission introduced an important update to the Evidence of Standards Compliance – Correcting the Non-Compliance section of the (ESC) template. Organizations are now required to address an additional element: If further analysis reveals additional factors impacting patient care, these should be thoroughly described, including the actions taken to address them, and whether follow-up with affected patients was needed. Where applicable, any follow-up with affected patients should be described, ensuring transparency and accountability in mitigating the issue and preventing recurrence.

Examples of Acceptable Corrective Action

Below are examples of corrective action statements for findings involving both scenarios where patients were impacted and where they were not.

Example Observation – 1:

Acceptable Corrective Action – Without patient impact

• It was determined that although a suicide risk assessment was not documented, the psychiatrist had completed one as part of their psychiatric evaluation. The two patients had been determined to be at low risk of suicide necessitating standard 15-minute observation, which were implemented. The psychiatric evaluation template in the EHR has been updated to include specific prompts for the elements of the suicide risk assessment as well as level of risk and plan to mitigate the suicide risk. The providers have all been trained on the EHR updates and expectations for the completion of a suicide risk assessment on all patients who screened positive for suicide risk. 

Acceptable Corrective Action – With patient impact

• It was determined that the psychiatrist did not complete the suicide risk assessments for the two patients identified as expected. Both records were current inpatients and full suicide risk assessments were completed immediately by another provider. All current inpatient records were audited to ensure that suicide risk assessments were completed when required. Three additional deficient records were identified and corrected immediately. Mitigation was amended to match level of risk and organizational policy expectations. FPPE was initiated for the deficient provider. Additional training was provided to all providers regarding the expectations for the completion of a suicide risk assessment on all patients who screen positive for suicide risk.  

Example Observation – 2:

Observed in two of four records reviewed, there was no plan of care established for the patient based on individualized assessed needs. For example, it was identified the patients were diabetic, however this problem with subsequent interventions was not included in the treatment plans. 

Acceptable Corrective Action – Without patient impact

• It was determined that in the two records identified the nurse did not add the problem of diabetes to the plan of care as required, however, both patients had appropriate interventions ordered and implemented – for example,  glucose monitoring and oral medications. The plan of care form did have a section for active medical issues to be added, however, this was left blank. The nurses have all been retrained on the expectations for completion of the active medical issues section of the plan of care. 

Acceptable Corrective Action – With patient impact

• It was determined that in the two records identified the nurse did not add the problem of diabetes to the plan of care as required and neither patient had glucose monitoring or medications ordered. The providers were contacted immediately for orders regarding the diabetes and the problem was added to the plan of care with the ordered interventions. All current patient records were audited to ensure active medical problems were identified on the plan of care with subsequent interventions. The plan of care form did have a section for active medical issues to be added, however, it was not completed as required. The nurses have all been retrained on the expectations for completion of the active medical issues section of the plan of care. 

Resources

• Your TJC Connect Site – Important Updates:  Update to the Evidence of Standards Compliance

• Your TJC Connect Site – Survey Process Tab:  Resource Center – Evidence of Standards Compliance Instructions
• Contact your Account Executive for assistance

Barrins & Associates

Barrins & Associates has successfully guided hundreds of organizations in crafting and submitting their ESCs. Contact us today to learn more about how our expert services can support your compliance needs.

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