Be Ready for Anything: Commonly Cited Survey Items

Policies and procedures function as the blueprint for a behavioral healthcare organization, but providers often struggle to keep them updated and to provide evidence that they are adhering to their own policies. Accrediting organizations say policy omissions and inadequacies, as well as problems

with supporting documentation, lead to many of the most common deficiencies during behavioral health surveys. No matter the type of survey, from accreditation to complaint investigation, a review of policies and procedures is the survey foundation. (In last week’s Compliance Report I talked at length about what behavioral health surveyors typically review. If you missed that report, you’ll find it here.)

It can be challenging to maintain policies that not only align with all federal, state, and local laws and regulations, but also are fully supported by personnel and client records, notices, and consent forms.

SimiTree’s compliance experts work with clients to audit records and make certain the organization meets privacy requirements under HIPAA, 42 CFR Part 2, and any other applicable regulations.

We also look carefully for omissions in the records – because when it comes to survey citations, the devil is definitely in the details.

Behavioral health survey readiness targets details

Missing signatures, missing minutes, and other missing documentation are among the top reasons for behavioral health survey citations, according to the most recent report from the Accreditation Commission for Health Care (ACHC). Other common reasons for citations included inadequate definitions and missing explanations of who is responsible for what.

A strong survey readiness program targets omissions with a thorough review and cross-reference of policies and all supporting documentation.

We recommend working with SimiTree compliance experts for full survey preparedness. We can help you develop a readiness plan that takes into account the total scope of documentation requirements for the types of behavioral health services your organization delivers, as there are many variances in policy and record requirements.

Here is a brief general checklist, compiled from recent AO survey reports, to

illustrate some of the types of omissions that get many behavioral health organizations cited on the survey.

Behavioral Health Survey: Common Omissions Checklist

Personnel Records

_Check for signed confidentiality statements in personnel files.

_Is there evidence of initial and annual competency testing for all direct care personnel? Records should indicate qualified personnel observed. Examples of assessments include clinical observation, skills lab review, supervisory visits, knowledge-based tests, and situational analysis/case studies.

_Does documentation reflect ongoing staff training, appropriate for each job classification, with a written education plan that addresses content, performance evaluation, and date of last in-service training? Note this will be needed for both direct care and non-direct care personnel.

Client/Patient Records

_ Were patient rights addressed? Is there Informed Consent documentation? Did the patient participate in decision-making and were services provided to respect the rights of the individual?

_Was emergency preparedness information/education provided?

Forms and Releases

_ Make sure information release forms align with HIPAA regulations, and specifies with whom the information may be shared.

_Note that for Substance Use Disorder (SUD) providers, new consent forms will be required under new 42 CFR Part 2 regulations pertaining to patient/client confidentiality.

Common Policy Omissions

_Check your organization’s PHI policy to make certain it adequately defines protected health and confidential information. Does it reference electronic information, phone communications, and faxed information? Does it identify who at your organization is authorized to release PHI? Does it address the storage, removal, and retention of records?

_Are there policies accurately reflecting client/patient rights and responsibilities? Has your organization outlined the process by which a patient, client, or responsible party may contest the accuracy, completeness, or relevancy of information and request an alteration of the record?

_Do performance improvement policies describe expected performance thresholds, including plans for corrective action, reporting timeframes, and measurement when thresholds are not met? Many citations occur because there is a lack of corrective plans specifying the frequency of data collection, and acceptable limits for findings/thresholds.

_Make sure to have all applicable infection risk management policies to address the prevention and control of infectious diseases. Note that types of behavioral healthcare providers vary and different policies may be applicable. However, all organizations are expected to meet OSHA standards, have in place infection prevention policies, and conduct an annual TB risk assessment

_ Emergency management policies need to address an organization’s plans and readiness for emergency situations. Policies should outline how a safe, functional, and effective environment is being maintained for both individuals served and staff in the organization’s facilities, if applicable. _Note that Substance Use Disorder (SUD) providers will need to update policies to conform to new 42 CFR Part 2 regulations on client confidentiality.

NEXT WEEK: What happens after the behavioral health survey?

How SimiTree can help

SimiTree’s certified healthcare experts help organizations review policies and procedures for full compliance, safety, and quality.

Our team is made up of former surveyors and auditors who help behavioral healthcare providers of all types and sizes prepare for accreditation surveys and maintain dynamic compliance programs. Our HIPAA Privacy Assessments identify PHI risks and other vulnerabilities that need corrective action.

Reach out to us today and let’s work together to shore up your organization’s survey readiness.

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Have a compliance question?

SimiTree’s healthcare experts can help! Our team is made up of former auditors and surveyors from across healthcare settings who help behavioral health organizations achieve accreditation from AOs, understand regulatory and compliance demands, and meet quality goals. We have the know-how and the experience to help your organization mitigate risk. Contact us today with all your compliance needs. 

J’non Griffin serves as Senior Vice President/Principal for the Compliance as well as Coding divisions at SimiTree. Her healthcare career spans three decades of clinical and leadership experience, and she has a track record of helping many provider types implement effective compliance programs. She is a certified ACHC and CHAP consultant and holds additional certifications in diagnosis coding and other healthcare specialties. As an AHIMA ambassador, she was instrumental in the implementation of ICD-10.