Volume 2024 | No. 2
SURVEYOR
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n State and federal posters were out of date (expired).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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