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Are you a behavioral healthcare organization or a behavioral healthcare program within a hospital that is surveyed under TJC’s Behavioral Healthcare standards? If so, you should have updated your nutrition screening tool by now to comply with the new 2018 requirements.

We’ve recently seen several behavioral healthcare organizations and programs cited on their Joint Commission surveys because their nutrition screening criteria had not been updated to meet the new 2018 requirements. This is being closely scrutinized by surveyors, and it’s an easy fix. So, make sure you’ve updated your tool to meet all the requirements of Joint Commission standard — CTS.02.01.11 in the Care, Treatment, and Services chapter of the Behavioral Health manual, which reads:

CTS.02.01.11 The organization screens all individuals served to identify those for whom a nutritional assessment is indicated. At a minimum, the screening includes questions about the following:

  • Food allergies
  • Weight loss or gain of 10 pounds or more in the last three months
  • Decrease in food intake and/or appetite
  • Dental problems
  • Eating habits or behaviors that may be indicators of an eating disorder, such as bingeing or induced vomiting

Keep in mind, if the screening indicates a need for a full nutritional assessment, the organization must either conduct that nutritional assessment itself or refer the individual to another provider for that nutritional assessment. This is also a common area for findings on Joint Commission surveys. Many organizations have the screening component in place but fail to refer the individual for further assessment when the screening indicates this need.

As reported by one Quality Director after their recent Joint Commission survey: “Our surveyor looked for the nutrition screening in all the records he reviewed. Fortunately, we had updated our tool to have all the new 2018 triggers. Unfortunately, we didn’t have a good process in place for following up on clients who scored high risk on the screening. Sometimes, the clinician referred the client to their Primary Care Provider, but in most cases, this didn’t happen. We now have a procedure in place for reviewing the results of the nutrition screening at the first treatment team meeting to see if there is any follow-up needed. That has really helped plug the holes in our process.”

So, take the time to review your nutrition screening tool and process to make sure they’re fully compliant with Joint Commission standards. You’ll avoid a Requirement for Improvement on your next survey report!