Surveys can be stressful, but they offer healthcare providers the chance to look under the hood and figure out exactly where the engine of the organization needs a tune-up.
A little inspection to prepare for a behavioral health survey can make certain all systems are performing well before surveyors arrive. But that’s only the first part of the full systems review. It’s equally important to ensure things continue to run smoothly.
The compliance experts at SimiTree work with behavioral healthcare organizations of all types and sizes for full survey readiness. Our goal is to help the client set up internal audits and self-monitoring processes that make ongoing compliance easy. We show clients what to look for and how to create alerts for issues, so that prompt action can be taken to correct any missteps.
Beginning this week and in my next two weekly compliance reports, I’ll share some “before and after” tips for the survey process. We’ll look at commonly cited areas your organization may want to review before the survey, and how to address any deficiencies after the survey.
What will a behavioral health survey look at?
Behavioral health providers span a wide variety of treatments and services. No matter the type of organization, however, surveyors will likely focus on four areas:
- Policies and procedures
- Administrative
- Clinical care, treatment, and services
- Client/Patient/Family Satisfaction
Your organization’s survey readiness efforts should scrutinize each of these areas from a surveyor’s perspective. Look for where you may have forgotten to adequately update records or overlooked evidence of follow-through on information obtained.
The behavioral healthcare surveyor’s perspective
Surveyors want to see how well your behavioral health organization designs its processes, monitors and measures its own performance, and, ultimately, improves its own performance.
In many ways, it would be fair to say surveyors are less interested in the mistakes your organization makes than in how well it proactively addresses the potential for mistakes, designs processes to catch and correct them, and keeps them from happening again.
It's hard to give strong enough emphasis to the importance of consistent monitoring and follow-up for all aspects of behavioral health operation, from personnel matters to care and services delivered.
Surveyors will review your organization’s screening/assessment processes as well as care planning and delivery. If you assess a client for Social Determinants of Health (SDoH), for example, it’s likely that surveyors will check to make certain the findings were documented and follow-up occurred. Were referrals made to community resources? Did the treatment plan reflect the findings?
This is true for personnel matters as well as care and services. Let’s say, for example, that your organization has a written policy setting timelines for baseline TB tests and individual TB risk assessments. This means surveyors are likely to check records for all direct care personnel to determine whether and when they received the baseline TB test, risk assessment, and symptom evaluation.
Missing evidence of these things will garner a citation.
Two top behavioral health survey deficiencies
The Accreditation Commission for Health Care (ACHC) reports that lack of adequate personnel training is the single most common deficiency noted in its behavioral health accreditation surveys.
Providers should make certain their employees have written plans for education in government regulations, organization-specific policies, and position-specific skills. The employee’s written plan should define the content, and frequency of evaluations, and show when training was provided.
The ACHC’s second most frequently cited standard on behavioral health surveys is the security and release of protected health information, or PHI. In its most recent survey report, ACHC says PHI citations were often issued because:
- Personnel records lacked signed confidentiality statements
- Client information release forms did not meet HIPAA standards
- Policies missed the mark on the definition of PHI
- Policies did not identify persons/positions authorized to release PHI.
NEXT WEEK: A checklist of omissions that lead to behavioral health survey citations
How SimiTree can help
SimiTree’s certified healthcare experts help organizations set in place the policies, procedures, training, and processes needed to ensure full compliance, safety, and quality for optimal performance.
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.