Were you cited during a behavioral health survey?

Which do you think is the most stressful for behavioral health providers: preparing for an upcoming survey or dealing with deficiencies afterward?

Both the before and after of a behavioral health survey can seem daunting to providers tasked with reviewing, evaluating, and making any necessary corrections. However, surveys can be helpful tools for pinpointing exactly where providers need to shore up privacy and security, address competency issues, improve care coordination, strengthen overall company performance, and deliver better care and services.  

If your organization is cited during a survey, know that you’re far from alone. Few providers escape surveys with perfect policies, procedures, and processes.

SimiTree’s compliance experts help behavioral health providers address survey deficiencies and strengthen vulnerabilities with sustainable plans of correction that are based on best practices and tailored to the individual organization.  

Developing the plan of correction after the survey

Specificity is the foundation for a solid plan of correction for deficiencies found in a behavioral health survey. Your plan will need to include specific actions your organization will take, such as re-educating staff or revising an organizational policy.

Your plan will also need to establish a date of compliance – the timeframe for making any corrections.

Generally speaking, organizations can expect accrediting organizations or other surveying agencies to allow 30 days in which corrective steps to be taken. Your organization will need to decide who will be in charge of ensuring corrective action occurs within the specified timeframe. This is important because failure to comply with the necessary timeframe could result in a change in accreditation status, including accreditation denial.

Preventing recurrences after the survey

There are two parts to every plan of correction. In addition to corrective steps, your organization’s plan will need to include action plans to prevent recurrences of the issues that led to the citations.  

This means self-auditing, monitoring, and tracking processes are essential components of a sound plan of correction.

Will charts need to be audited? If so, specificity is once again the bedrock of the corrective plan. The plan should include the percentage of charts to be audited, the frequency of the audit, and the target thresholds. It should also specify what happens once thresholds are met. What will the new frequency become?

SimiTree compliance experts work with our clients to build self-evaluation and regular monitoring into the organizational workflow for efficiency, productivity, and ongoing compliance.  

The after portion of a behavioral healthcare survey is much like the before portion in that it is about making certain the organization has in place written blueprints for effective, safe, and compliant operation and is carefully following its own blueprints.

It's a matter of making certain all the details are in place to bridge any gaps that were identified during the survey.

How SimiTree can help

If your behavioral healthcare organization needs help developing and implementing a plan of correction, SimiTree’s certified healthcare experts are available to help. 

We guide behavioral healthcare providers of all types and sizes in developing corrective action plans that are sustainable and scalable. In addition, we work with providers to develop self-checks and auditing procedures that integrate seamlessly into workflow and operations to prevent recurrences.

Our compliance experts are former surveyors and auditors who fully understand the policies, procedures, training, and processes needed to ensure full compliance, safety, and quality for optimal performance.  We’re ready to help your organization prepare for the survey, take corrective action afterward, and maintain a dynamic compliance program going forward.  

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

(Did you miss my previous two articles in this Before & After series on behavioral health surveys? Be sure to check out my list of common behavioral health survey citations here) and my article on what surveyors will focus on here.

NEXT WEEK: Are we really hearing what the OIG is telling us?

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.