Does TJC survey your organization under the Behavioral Health & Human Services  standards? If so, it’s important to be aware of the training requirements for the Joint Commission BH pain management standards.

We notice organizations sometimes overlook these requirements. As a result, they risk a citation for this on their Joint Commission survey.

Background on Joint Commission BH Pain Management Standards

The BH requirement for pain screening has been around for several years. Specifically, standard CTS.02.01.09 Element of Performance (EP) # 1 requires the organization to “screen all individuals served to identify those for whom a physical pain assessment is indicated.”

Furthermore, EP # 2 states “Individuals for whom a physical pain assessment is indicated are either assessed and treated by the organization or referred for assessment or treatment.”

By now, most BH organizations have incorporated a pain screening into their initial assessment process. Ideally, they’ve also developed a process to refer clients who need further pain assessment. (Although some organizations still lack this component.)

Joint Commission BH Pain Management Standards: Training Requirements

In 2019, TJC introduced new training requirements into the pain management standards. They’re in the Human Resources Management chapter.

HRM.01.05.01 EP # 11 requires that “Staff performing pain screening participate in education and training on screening individuals for pain.” Essentially, this new requirement made it explicit that staff who conduct the pain screening must receive training on that process.

In addition, HRM.01.05.01 EP # 12 has a specific requirement for acute 24-hour settings. It states that “Practitioners providing direct care, treatment, or services participate in education and training on pain assessment and pain management consistent with the scope of their license.”

It’s important to note that “acute 24-hour settings” include inpatient crisis stabilization and medical detoxification.

Although these training requirements have been in place since 2019, we find many BH organizations overlook them. They simply don’t train their staff on pain screening and assessment.

Pain Management Training in Behavioral Health Settings

Pain Screening

In many BH settings, non-medical staff conduct the pain screening as part of the initial assessment. In this scenario, it’s important for these staff to understand the key aspects of this process:

• How to appropriately ask the pain screening questions
• If the client completes the pain screening: How to review the results
• How to make a determination re whether the client needs a full pain assessment
• How to refer the client for further pain assessment if that’s indicated

Additionally, there should be a written procedure describing the pain screening and assessment process. It should include criteria for determining the need for a full pain assessment. This written procedure would form the basis for training the staff who conduct the pain screening.

Pain Assessment & Pain Management

In acute 24-hour settings, the training should cover not just pain screening but also pain assessment and pain management. The content and extent of this training would depend on the role practitioners play in pain assessment and pain management in that particular setting.

Resources on Pain Management in Behavioral Health

If you’re looking for additional information on the Joint Commission BH Pain Management Standards, check out the following resources:

• TJC R3 Report Issue # 20 Pain Assessment and Management Standards for Behavioral Health Care
• Barrins & Associates March 2019 post: Pain Management: New Requirements in TJC Behavioral Health Standards
• TJC FAQ: Pain Assessment and Management – Understanding the Requirements (BHC)

Barrins & Associates

TJC is getting 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 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.