Volume 2024 | No. 2
SURVEYOR
BEHAVIORAL HEALTH
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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