As the year winds down, we thought it would be useful to review the top compliance issues encountered by psychiatric hospitals and behavioral healthcare organizations in 2015. However, truth is that the Top Ten list hasn’t changed much and the topics are quite familiar (treatment planning, competencies, pain screening, etc.) So, we decided to take a look at recent survey findings from the other side of the coin; i.e. findings that we have never seen cited before (or at least not often cited.) Here’s a list of these from our clients’ surveys in 2015.  Consider them a “Heads Up” for your next survey!

 

HUMAN RESOURCES CHAPTER

Psychiatric Hospitals

• Spanish speaking staff member acting as translator without documented competency
• No orientation for law enforcement personnel coming to hospital
• No training re identifying early warning signs of change in patient’s condition
• No documented competency for nurses to do AIMS testing
• Nurse could not correctly demonstrate how to use emergency suction

BH Organizations

• Cultural diversity not included in orientation

 

INFECTION CONTROL CHAPTER

Psychiatric Hospitals

• No documentation of temperature testing, sanitizer usage, or test strip results for dishwashers
• No description of methodology used to determine flu vaccination rates
• Flu vaccination goals not consistent with achieving 90% by 2020

BH Organizations

• No incremental flu vaccination goals
• No goal for improving hand hygiene compliance (commonly seen in hospital surveys; not often  in BH settings)

 

LEADERSHIP CHAPTER

Psychiatric Hospitals

• No evaluation of hospital’s culture of safety and quality
• No PI Director
• No PI Plan
• Inadequate implementation of recommendations from the FMEA

 

MEDICATION MANAGEMENT CHAPTER

Psychiatric Hospitals

• No process for communicating outage or shortage of a medication (Hospital had a shortage of emergency, short acting intramuscular antipsychotics.)
• Hospital storing vaccines in dormitory-type refrigerator; against CDC recommendations
• Suspected adverse drug reaction not reported as ADR; patient transferred to local hospital “due to over sedation and changes in mental status possibly due to an increased sensitivity to psychotropic medication and dehydration” (per discharge summary.)

BH Organizations

• Poor hand hygiene during med administration
• Preprinted med order sheet with no check-offs but meds being administered

 

NATIONAL PATIENT SAFETY GOALS CHAPTER

Psychiatric Hospitals

• Critical test results identified for lab but not for radiology or EKG
• No hand hygiene data collected for physicians, dietary, or housekeeping
• No risk assessment for MDROs and no training for staff and MDs re MDROs
• No variation in 15 minute checks for patient who was high suicide risk
• Suicide/Homicide risk assessment combined into one tool

BH Organizations

• No hand hygiene data in setting where meds administered; meals served; ADL assistance provided (commonly seen in hospital surveys; not often cited in BH settings)

 

PROVISION OF CARE CHAPTER

Psychiatric Hospitals

• H&P did not include information from referring Emergency Dept. re medical conditions
• No non-verbal assessment tool for pain (for cognitively impaired population)
• Discipline of “Nursing” identified on tx plan but no specific name (CMS requirement)
• Focus and purpose of groups not identified on tx plan (CMS requirement)
• No therapeutic groups/activities offered on weekend for Adolescent Unit
• AED did not have defibrillator pads for children
• No language interpreter until next day for Spanish speaking patient admitted with psychosis
• No patient teaching re glucometers being sent home with them

 

CARE, TREATMENT, SERVICES CHAPTER

BH Organizations

• Waiting list not managed appropriately: no severity ranking or referral to other services
• Staff not educated about trauma, abuse, neglect, exploitation
• No assessment of clinical outcomes
• Poor coordination of care; client not asked about primary care provider
• No annual assessment of foster parents

 

RIGHTS AND RESPONSIBILITIES CHAPTER

Psychiatric Hospitals

• Patients not informed of hospital not having MD in-house 24/7 (CMS requirement)

BH Organizations

• Blank consent forms signed

 

WAIVED TESTING CHAPTER

BH Organizations

• No competency assessment (using two methods to assess competency) for staff doing urine drug screens (commonly seen in hospital surveys; first time cited in BH setting)

 

MEDICAL STAFF CHAPTER

Psychiatric Hospitals

• Nurse practitioner covering all units as a “float”; no privileges for substance abuse or geriatrics
• No evidence of medical staff monitoring quality of H&Ps

 

We recommend that you keep your eye on these issues in your own settings. Often, what starts as a seemingly random observation by a surveyor soon becomes a trend in survey findings!