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Leaders of TJC’s Behavioral Healthcare Accreditation Program recently conducted a webinar for the Consultants Forum. They provided an informative update on survey scheduling and other Behavioral Healthcare Accreditation activities. We’re sharing the highlights with you to support your ongoing readiness efforts.

Behavioral Healthcare Accreditation Surveys

TJC is now caught up on overdue surveys for the Behavioral Healthcare Accreditation Program. That includes both initial surveys and resurveys.

During the pandemic, the Behavioral Healthcare Program made wide use of virtual surveys. That will now become a thing of the past. However, TJC reserves the right to utilize virtual surveys in areas where there are COVID spikes.

So, the takeaway here is you now need to be ready for the rigor on the onsite survey process. Thus, continuous readiness is more important than ever.

Also, TJC plans to use Zoom during onsite surveys to review residential programs that are distant from the main site. This process worked well during the pandemic and makes efficient use of surveyor time and travel. So, be prepared for that option as well.

Opioid Treatment Programs (OTPs)

TJC has deemed status with the Substance Abuse and Mental Health Services Administration (SAMHSA) to provide accreditation for OTPs.

The news here is SAMHSA is now requiring that OTP surveys include two surveyors onsite at each survey. Previously, TJC had one surveyor onsite and one available in Central Office.

Usually, when there are multiple surveyors, that means more survey findings since each surveyor typically has findings of their own. We see this pattern on the TJC survey reports for our clients.

So, if you provide opioid treatment, be sure to brush up on both the OTP-specific standards and the generic BH standards applicable to OTPs. We find OTPs get just as many findings under the generic BH standards as they do under the OTP-specific standards.

Top Five Findings on Behavioral Healthcare Accreditation Surveys for 2021

The Top Five requirements found noncompliant on Behavioral Healthcare Accreditation surveys for January through December 2021 were all under National Patient Safety Goal 15 for Suicide Prevention. No surprise there as this has been a major focus area for almost three years now.

Here are the Top Five Elements of Performance cited along with links to some of our earlier posts on these topics.

EP 2: “Screen all individuals served for suicidal ideation using a validated screening tool.”

The issue surveyors typically cite is the organization is not using a validated screening tool. Or they’ve altered the screening tool and, thus, it’s not a validated tool.

EP 1: “The organization conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide and takes necessary action to minimize the risk(s).”

A common issue here is organizations think because they’re not an inpatient psychiatric setting, they don’t need to do a risk assessment. It’s true that TJC doesn’t require non-inpatient settings to be ligature resistant. However, these programs must still conduct an environmental risk assessment and take actions as needed to keep clients safe.

For more info on this requirement, see our post Environmental Risk Assessment: Non-inpatient Behavioral Health Settings

EP 5: “Follow written policies and procedures addressing the care of individuals served identified as at risk for suicide. At a minimum, these should include the following:

  • Training and competence assessment of staff who care for individuals served at risk for suicide.
  • Guidelines for reassessment.
  • Monitoring individuals served who are at high risk for suicide.”

Frequently, the problem here is organizations have trained their staff and have processes for assessment and monitoring but they haven’t developed written policies and procedures.

For compliance tips on this one, see our post NPSG 15 Suicide Prevention: Training and Competency Requirements

EP 3: “Use an evidence-based process to conduct a suicide assessment of individuals served who have screened positive for suicidal ideation. The assessment directly asks about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors.”

When surveyors cite this one, the issue is typically that the organization is using a home-grown tool for suicide risk assessment. Thus, it’s not an evidence based process. We see fewer citations on this one as time goes by as most organizations are now using an evidence based tool.

EP 4: “Document individuals’ overall risk for suicide and the plan to mitigate the risk for suicide.”

This is a very common finding. Usually, the issue is that the client is assessed as a medium or high suicide risk but there’s no clear plan to mitigate the risk. Often, despite the rating of medium or high risk, the client’s level of observation is routine checks with no rationale to explain why this is a safe level of observation.

To learn more about this one, see our post NPSG 15 Suicide Risk Reduction: Feedback from the Field.

Barrins & Associates Consultation

Our Mock Surveys and Customized Survey Preparation address all these challenging areas along with strategies for compliance. As always, we’re prepared to support your ongoing survey readiness and best practices for regulatory compliance.