As we all know, issues with treatment plans are one of the most frequently cited areas of non-compliance on TJC surveys. This is true for both psychiatric hospitals and behavioral health organizations. The problems typically cited are lack of measurability, lack of individualization, and failure to update the treatment plan. Recently, however, we have seen an issue being cited on TJC surveys of psychiatric hospitals that is different from these common issues and relates directly to a CMS requirement for treatment plans. The issue being cited is failure to have the names of the treatment team members listed on the treatment plan. An example of such a surveyor finding is as follows:

“The treatment plan for three patients did not include the responsibilities for each member of the treatment team. Responsibilities must include treatment team members’ names and disciplines.”

The applicable TJC standard in the Hospital manual states:

[blockquote author=”PC.01.03.01 EP 43“]”For psychiatric hospitals that use accreditation for deemed status purposes: The plan of care includes the responsibilities of each member of the treatment team.”[/blockquote]

So, on first reading of this element of performance, it requires that the treatment plan include the responsibilities of the members of the treatment team (i.e. the interventions that they will be providing) but does not indicate that their names need to be included. However, when one reads the corresponding CMS standard and Interpretive Guideline, this requirement becomes explicit. The corresponding Condition of Participation (CoP) is 482.61: Special medical record requirements for psychiatric hospitals. The wording of the CMS standard is as follows:

[blockquote author=”482.61(c) (1) (IV); Tag B123“]”The written plan must include the responsibilities of each member of the treatment team.” [/blockquote]

This wording is almost identical to the wording of the TJC standard. However, the CMS Interpretive Guideline that accompanies this standard is much more explicit. It states that “identification of the staff should be recorded in a manner that includes the name and discipline of the individual.”

Clearly, the TJC hospital surveyors are basing their finding on the CMS requirement. However, as we monitor our clients’ survey findings, we have not seen this consistently cited by all TJC surveyors. It is, as we often see, surveyor dependent. So, if you are not currently including the names of treatment team members on treatment plans, be aware that this may be an issue on your next survey. Consider whether you want to make the change proactively or wait and see if the issue is identified on your survey and address it at that time.

It should be noted that we have not seen this particular issue regarding treatment planning cited on surveys of organizations/programs accredited under the Behavioral Health standards.

If you are interested in how we can help you prepare for the next TJC survey, learn more about our Joint Commission mock surveys.