Volume 2024 | No. 2
SURVEYOR
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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