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Wondering what types of behavioral health tracers The Joint Commission is conducting as they resume surveys? By “behavioral health tracers” we mean the tracers done in psychiatric hospitals, behavioral health organizations, and psychiatric units of med/surg hospitals.

Current TJC Survey Activity

As we know, The Joint Commission resumed regular onsite survey activity in June.

TJC is targeting geographic areas that are low risk for COVID-19. They’re also conducting virtual surveys for initial deemed status for hospitals and opioid treatment programs.

2020 Behavioral Health Tracer Topics

So, what types of tracers are surveyors conducting in behavioral health settings? Many of the topics are familiar themes. Others have somewhat of a new twist. Let’s take a look so you can be prepared for the current tracer focus during your next survey.

High Risk for Suicide

In this tracer, the focus is on the suicide risk assessment process and interventions to address the suicide risk. Specifically, does the organization use an evidence based suicide risk assessment process? Further, are the treatment plan and interventions congruent with the patient’s level of suicide risk?

Deficiencies in the suicide risk assessment process are a frequent finding in behavioral health settings. For more insight on this topic, see our recent posts:

Patient Treated for Infection

This is a somewhat newer tracer topic for behavioral health. It’s in keeping with TJC’s heightened focus on infection control in recent years.  Moreover, with the COVID-19 outbreak, we can expect this IC Focus to continue.

Transfer to Emergency Room

Surveyors often do a tracer on a patient sent to the ER or admitted to a med/surg hospital. For more insight on how this tracer unfolds, see our post TJC Tracer: Patient Transferred to Emergency Room.

Patient on Detox Protocol

If you provide detoxification for patients with substance use disorders, you can expect a tracer in that area. The focus is typically on how nursing staff implemented the detox protocol. And how they monitored the patient’s clinical status during the detox phase.

Frequently, we see survey findings related to nursing staff not administering the CIWA (Clinical Institute Withdrawal Assessment for Alcohol) according to the detox protocol. Another frequent finding is  no reference to the detox protocol in the patient’s treatment plan.

On a related note, if you’re looking for best practices for detoxification services, check out the SAMHSA Treatment Improvement Protocol on Detoxification and Substance Abuse Treatment.

Patient on High Risk Meds – Clozaril, Anticoagulants, Insulin

This tracer evaluates how well the organization follows its own policies on prescribing and administering high risk medications. For example, if your policy on insulin administration requires a second nurse to observe, surveyors would expect documentation of that process.

Re anticoagulants: National Patient Safety Goal NPSG.03.05.01 requires that hospitals use approved protocols and evidence based practice guidelines for anticoagulant therapy. Surveyors will review your written protocols. Next, they will review a patient’s chart to see that staff followed all the steps in the protocol.

In addition, be sure you’re up to speed on the National Patient Safety Goals Effective July 2020 for the Hospital Program and the Behavioral Health Care Program.

Kitchen Tracer

Joint Commission surveyors are now routinely conducting a kitchen tracer during all hospital surveys. Similarly, behavioral health surveyors routinely inspect kitchens and food storage areas in non-hospital behavioral health settings. For details on this tracer, see our post TJC Tracer Update: Focus on Dietary Services.


Tracers on patients who’ve had a restraint or seclusion are longstanding in behavioral health.  Accordingly, the emphasis on this high risk intervention continues.

The focus is on staff training – not just in the use of restraint or seclusion but also in how to prevent its use through de-escalation techniques. Surveyors also closely scrutinize how staff monitor patients during a restraint or seclusion and how they document this in the medical record.

Barrins & Associates Mock Surveys

When we conduct our Mock Surveys, we routinely include these types of tracers. As a result, staff get firsthand experience in talking with the “surveyors” and walking them through the medical record to answer questions.

Our clients consistently report this experience makes staff feel much more prepared for when the actual Joint Commission survey occurs. That’s always a good thing!