SURVEYOR Volume 2024 | No. 2 Quality Review Edition
Volume 2024 | No. 2
SURVEYOR
TABLE OF CONTENTS
BOARD OF COMMISSIONERS Brock Slabach, MPH, FACHE I Chair CHIEF OPERATIONS OFFICER, NATIONAL RURAL HEALTH ASSOCIATION Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN Vice Chair OWNER AND CHIEF EXECUTIVE OFFICER, MSMP ANESTHESIA SERVICES, LLC Mark S. Defrancesco, MD, MBA, FACOG I Secretary PAST PRESIDENT, AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS Leonard S. Holman, Jr., RPh I Treasurer HEALTHCARE EXECUTIVE AND CONSULTANT Roy G. Chew, PhD I Immediate Past Chair PAST PRESIDENT, KETTERING HEALTH NETWORK John Barrett, MBA I Board Member-at-Large SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Gregory Bentley, Esq. PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM Jennifer Burch, PharmD PHARMACIST/OWNER, CENTRAL PHARMACY, CENTRAL COMPOUNDING CENTERS José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER, ACCREDITATION COMMISSION FOR HEALTH CARE Richard A. Feifer, MD, MPH, FACP CHIEF MEDICAL OFFICER, INNOVAGE Denise Leard, Esq. ATTORNEY, BROWN & FORTUNATO Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY
03 CORNER VIEW
04 FROM THE PROGRAM DIRECTOR
05 FREQUENT DEFICIENCIES IN BEHAVIORAL HEALTH AGENCIES
LEADERSHIP TEAM
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES Matt Hughes VICE PRESIDENT, CORPORATE STRATEGY Barbara Sylvester, RN, BBA, MSOLQ DIRECTOR, REGULATORY AFFAIRS AND QUALITY
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Welcome to the 2024 Surveyor Quality Review. Each year, program-focused editions of this CORNER VIEW publication analyze compliance with ACHC standards over 12 months of surveys. This year’s data span initial and renewal surveys conducted between June 1, 2023, and May 31, 2024. ACHC-accredited organizations use the data to benchmark their performance by comparing these frequently-cited standards against their own survey report. There is value for non-accredited organizations, too. Because ACHC standards are closely aligned with CMS requirements, the information is relevant regardless of how your organization achieves its Medicare certification. For programs outside the Medicare regulations, the value remains. ACHC standards represent an important risk management/quality improvement framework. Reviewing the kinds of issues that arise in your peer organizations is an opportunity to act preemptively to manage your own risks. This is a critical business function in all healthcare settings. We know that some standards consistently present more compliance challenges than others. Frankly, if we offered only a list of frequent deficiencies, this publication wouldn’t vary much from year to year. Instead, Surveyor Quality Review gives insight into trends by quoting findings and offering practical tips to avoid citations. Some standards appear almost annually because of a large number of required elements. Perhaps a policy needs clarification, or staff members were not fully trained on a revision that impacts their work. Perhaps new or contract employees were not adequately oriented to a requirement for documentation, or employees made a change in their workspace that compromises fire safety. For a complex standard, any of these examples represents a potential deficiency and a risk to the organization, its staff, or its patients.
By sharing the observations of ACHC Surveyors, we offer an expert’s perspective on the most current issues impacting organizations. Trends by Program Internally, we use these data to guide the development of educational resources. Organizations seeking to renew their ACHC accreditation in 2024 were also surveyed in 2021. This year, our leaders are including comparative comments as they introduce their program findings. When we experience a large uptick in the number of initial surveys, as we have for several programs in this period, those difficult standards are likely to be prominent as new organizations confront them for the first time. However, we hope to see at least incremental improvement in standards that appeared as frequent deficiencies for this cohort of organizations three years ago. If we don’t see triennial improvements for some of the most frequently cited standards, it means we need to give more educational focus to these in the resources (webinars, workshops, tools) we offer. It is never ACHC’s intention to leave clients wondering about what is expected. To the contrary, our goal is to provide a range of resources that engage and enrich the experience of continuous quality improvement in the healthcare markets we serve. In this year’s first issue of Surveyor , I wrote about team collaboration and handoffs. Remember that ACHC serves as an extension of your team, ready to confer and coach. With Surveyor Quality Review , we are passing an evidence-based guidance tool to you. I hope you grasp it firmly and run with it!
MISSION STATEMENT
Accreditation Commission for Health Care (ACHC) is dedicated to delivering the best possible experience and to partnering with organizations and healthcare professionals that seek accreditation and related services.
José Domingos President & CEO
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BEHAVIORAL HEALTH FROM THE PROGRAM DIRECTOR
repeating standards ( BH4-4A, BH5-1A, BH5-3A ) were all more frequently cited than they were three years ago. Each of these is foundational to the section in which it appears. Section 4 is comprised of standards related to personnel and BH4-4A focuses on establishing and confirming competencies related to job description. Standards BH5-1A and BH5-3A represent the elements of a complete client record and of an individualized plan of care. Each of these includes a list of expected components. If any of the required elements is omitted, it represents a deficiency. Checklists and documentation are great strategies to avoid error with these topics. I hope the content of this report offers actionable ideas for meeting the standards. As always, ACHC’s behavioral health team is ready to offer guidance and troubleshooting assistance. Contact us at any time. We look forward to continuing our partnership to deliver excellence in behavioral health services.
When it comes to behavioral health, clients and families are often searching for services at a time of crisis. Accreditation represents an independent, third-party validation of quality that serves as a differentiator for organizations. Achieving ACHC’s accreditation seal is a visible sign that an organization has gone above and beyond to ensure that its services meet the needs of its client population. Our program offers flexibility. Standards are not one-size-fits all. An organization providing medically monitored inpatient services differs from one that focuses on assessment and referral services. ACHC standards are designed to ensure sustainable business practices and requirements for care that align with the nature and intensity of treatment. We individualize your business just as you individualize your clients. Surveyor findings This year’s evaluation of the most frequent deficiencies identifies those that were noted as out of compliance on at least 20% of the surveys conducted. While all the standards that met the 20% threshold apply to all behavioral health services, what they look like in practice may vary. For example, standards from Section 7: Risk Management: Infection and Safety Control play out differently in a residential vs. a community setting. In 2021, the last time this cohort of organizations was surveyed, four standards rose to the 20% deficiency rate. Of those, the most frequent ( BH2- 6A at 31%) improved in compliance so much that it does not appear in this year’s report. The other three and five “new” standards comprise the eight that we are focusing on this year. The three
BEHAVIORAL HEALTH SERVICES AND DISTINCTIONS
Services Assertive Community Treatment Team Assessment and Referral Case Management Community Support Day Treatment Integrated Care Services Intensive In-Home Intensive Outpatient Treatment
Outpatient Treatment Partial Hospitalization Services Personal support Services Prevention Services Psychosocial Rehabilitation Psychosocial Rehabilitation for Minors Residential Treatment Residential Treatment III.7
Supervised Group Living Supported Employment Services Withdrawal Management Services Withdrawal Management with Extended on-Site Monitoring Services
Distinctions Telehealth
FREQUENT DEFICIENCIES FROM BEHAVIORAL HEALTH SURVEYS
Teresa Hoosier Associate Program Director
60% 50% 40% 30% 20% 10% 0%
BH1-8A BH4-4A BH5-1A BH5-3A BH5-3F
BH7-1A BH7-3B BH7-7B
Organization and Administration
Human Resource Management
Provision of Care and Record Management
Risk Management: Infection and Safety Control
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BEHAVIORAL HEALTH
SECTION 1: ADMINISTRATION BH1-8A Overview of the requirement:
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT
BH5-1A
The standard reiterates requirements of the U.S. Department of Labor and state- level equivalents regarding notices to be posted in the workplace. It also covers professional licensure/certification and compliance with ACHC Accreditation Process and the organization’s own policies and procedures. Compliance is assessed by direct observation, review of policies and procedures, and review of personnel files. Despite the breadth of the standards, deficiencies were cited exclusively for the absence of current, required posters.
Overview of the requirement:
The organization has policies and procedures defining the elements of records for individual service recipients. The standard identifies the minimum contents of the record and requires that it be maintained on the premises where service is provided, or at the organization’s office if services are provided in community settings. Compliance with the standard is assessed through review of policies and procedures and service recipient records. Most deficiencies noted missing documentation of one or more required element.
Comment on deficiencies:
Comment on deficiencies:
Frequency of citation:
26%
Frequency of citation:
24%
Examples of surveyor findings:
n State and federal posters were out of date (expired). n State and federal posters were not present in the building.
Examples of surveyor findings:
n Client record review lacked evidence that critical incident reports were documented on the day of the incident. n Documentation of allergies was missing from client records. n Service recipient records did not include a signed notice confirming receipt of the clients rights document. n Date of admission was incorrectly entered as the date from a prior episode of care. n Create a checklist to ensure all required elements are included in each client record. Standards with multiple required elements are often noted as non- compliant for individual missing items. Audit records to identify whether missing documentation varies or is consistent from file to file. Train staff to enter all required data.
Tips for compliance:
n Ensure that posters are placed in high-visibility areas and updated as needed to reflect current requirements.
SECTION 4: HUMAN RESOURCE MANAGEMENT BH4-4A Overview of the requirement:
Tips for compliance:
The organization has an established orientation process for all personnel that covers at least the standard’s list of 21 required topics. Compliance is evaluated through review of policies and procedures, personnel files, and response to interview.
Comment on deficiencies:
Frequency of citation:
28%
Examples of surveyor findings:
n Personnel records did not include evidence of an orientation that covered all required elements. n Personnel records showed inconsistency in topics covered by orientation. n Job descriptions and duties performed were missing from personnel files. n Create an orientation checklist to ensure all required topics are covered for all personnel.
Tips for compliance:
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SECTION 7: RISK MANAGEMENT: INFECTION AND SAFETY CONTROL BH7-1A Overview of the requirement: Written policies and procedures meet accepted standards of practice to prevent transmission of infections and communicable diseases. Comment on deficiencies: Evidence of compliance includes review of policies and procedures, direct observation, and response to interviews. Most deficiencies noted missing policies related to mitigating infection risks or the adoption of OSHA and CDC standards within policies without subsequent education for personnel.
BH5-3A
Overview of the requirement:
An individualized, written plan of care is developed for each service recipient based on initial assessment/screening or comprehensive assessment. Compliance with the standard is assessed through review of client records. Surveyors noted plans of care that appeared templatized and did not refer to and align with assessments. The goal is to link client needs with goals, planned interventions/services, and timelines whenever possible.
Comment on deficiencies:
Frequency of citation:
33%
Examples of surveyor findings:
n Required elements of the initial plan of care were missing. n Treatment goal and interventions were not identified.
Frequency of citation:
23%
Examples of surveyor findings:
n There was no evidence of an annual TB risk assessment for direct care personnel. n The organization has adopted OSHA and CDC standards within its policies and procedures, but personnel were unable to address these expectations for infection prevention. n The organization’s health and safety policy did not adequately address the required elements of the standard.
n There was no evidence connecting the plan of care to the assessments. n The state requires an individualized treatment plan to be completed and signed by the drug and alcohol counselor and the patient within seven days of the comprehensive assessment. There was no evidence that this timeframe was met. n Create a checklist to ensure all required elements are included in the initial plan of care. n Include documentation that notes findings of the initial or comprehensive assessment. n Ensure that the organization’s policies address state specific requirements that may be more stringent. The plan of care must be reviewed for appropriateness and effectiveness at least quarterly. Compliance with the standard is assessed through review of client records and response to interviews. Most findings cited a failure to review and update treatment plans within timelines imposed by the standard or state requirements; whichever is more stringent.
Tips for compliance:
Tips for compliance:
Checklists are useful tools for compliance when standards include multiple required elements. Ensure policies address, at least, the 13 elements noted in the standard.
n Conduct an annual TB risk assessment to determine the need, type, and frequency of testing for direct care personnel.
BH5-3F Overview of the requirement:
BH7-3B Overview of the requirement:
Comment on deficiencies:
The organization educates clients with regard to emergency preparedness.
Comment on deficiencies:
Evidence of compliance includes review of service recipient education materials and records. Surveyors noted the lack of client education for both in-center and home-based dialysis patients regarding what to do in an emergency.
Frequency of citation:
24%
Frequency of citation:
17%
Examples of surveyor findings:
n State rules require review at a specific frequency based on the level of care. There was no evidence that plan of care reviews met these requirements (90 days for outpatient treatment; more frequent for supervised group living and residential treatment). n There was no evidence that plans of care were reviewed at least every 90 days. n There were no treatment plans or evidence of modifications after the initial plan. n At the time the initial plan of care is developed, schedule review based on state requirements or within 90 days, whichever is sooner. n Document all changes to client plans of care.
Examples of surveyor findings:
n The organization’s educational materials did not include information guiding service recipients in planning for emergencies including: an evacuation plan, medications, food/water, important documents, care for pets, if applicable. n Update client education materials, ensuring that emergency planning is relevant to the services provided.
Tips for compliance:
Tips for compliance:
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NOTES
BH7-3B Overview of the requirement:
Hazardous chemicals must be labeled and safety data sheets (SDS) accessible for proper use, storage, and disposal. Compliance is assessed through review of policy and procedure and direct observation. Surveyors noted the lack of SDS.
Comment on deficiencies:
Frequency of citation:
17%
Examples of surveyor findings:
n Current Safety Data Sheets were not accessible to personnel for cleaning chemicals observed onsite. n The organization did not have evidence that it follows OSHA’s Hazard Communication Standard for the use, storage, and disposal of hazardous chemicals and materials. n Inventory any hazardous chemical kept on site and ensure that they are labeled and SDS maintained nearby.
Tips for compliance:
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ACHC Redefining the Culture of Accreditation
We’re here to help. To learn more, visit our website at achc.org , call us at (855) 937-2242 , or email customerservice@achc.org .
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SURVEYOR 2024, NO. 2
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