(Donna) Hello, and thank you for joining us
for Check in With The Joint Commission for Behavioral Health Care
and Human Services Accreditation.
My name is Donna Rutkowski,
and we're happy to be able to spend some time with you.
Today, we're going to let you know what's new and what you need to know
regarding standards updates,
tips regarding the actual survey process,
and the most commonly asked questions
in RFIs.
You'll also hear some updates regarding legislative activities
in some of the states.
We'll send you both the webinar slides and a recording via email
a few days after the webinar,
so you can have them for reference and to share with your teams.
Who you'll hear from today
is Clinical Project Director Stacey Paul
from our Department of Standards and Survey Methods,
Field Director for the Behavioral Health Program, Peter Vance,
Associate Director Falguni Shah from our Standards Interpretation Group,
and Executive Director Mark Crafton from our Strategic Alliances area.
With that, I'm going to turn it over to Stacey,
who will help you learn what to expect
regarding standards updates for behavioral health care organizations.
Stacey?
(Stacey) Hello, everyone.
I am Stacey Paul, and I'm a Project Director
in the Department of Standards and Survey Methods.
I'll be doing a short update on standards updates
in the Behavioral Health and Human Services Manual.
Next slide.
First, I will do an overview
and then get a little more down into some specifics.
For July 2023, there have been some major changes.
I'll focus on those.
If you're unsure
on what changes are,
and you want to see every little change at the releases,
you can always go to the What's New section of the manual.
This is on E-dition, as well as in the print manuals.
The first thing I wanted to talk about was the Health Equity Standard,
which originally implemented in January of this year, I believe.
The standard reads,
"Improving healthcare equity of individuals served by the organization
is a health and safety priority."
This standard originally was put in the Leadership chapter,
but for July 2023,
it has been elevated to a National Patient Safety Goal.
So you'll now find it at National Patient Safety Goal 16.01.01.
The Elements of Performance, or EPs, are the same,
but it's been elevated to a National Patient Safety Goal now.
The other thing I wanted to highlight was
we've added 81 new requirements as part of our project
for Certified Community Behavioral Health Clinics, or CCBHCs,
becoming a new service option under accreditation.
Then, lastly, just remember,
if you do want to see the minor changes, editorial things,
standard renumberings, things like that,
that would be in the What's New section that I referred to earlier.
Next slide.
A Certified Community Behavioral Health Clinic, or CCBHC--
this is where the 81 new requirements came from.
It is a specially designated clinic that provides a comprehensive range
of mental health and substance use services.
CCBHCs serve anyone who walks through the door,
regardless of their diagnosis and their insurance status.
CCBHCs are required to provide
or contract with designated collaborating organizations
to provide a wide array of mental health care
and substance use disorder services,
as well as primary care screening and monitoring.
If you're not as familiar with CCBHCs,
the nine services they're required to provide
are crisis services,
treatment planning,
screening assessment,
diagnosis and risk assessment,
outpatient mental health and substance use services,
targeted case management,
outpatient primary care screening and monitoring,
community-based mental health care
for veterans,
peer, family support, and counselor services,
and the ninth is psychiatric rehabilitation services.
Our 81 new standards reflect the requirements
in SAMHSA's CCBHC criteria.
For CCBHC Accreditation through Joint Commission,
organizations will need to meet these 81 new Elements of Performance,
plus all the standards
that apply through their service profile
for accreditation.
You can view these standards in E-dition or the print manual.
Also, just another FYI,
SAMHSA, who created the CCBHC program,
updated their criteria,
and that updated criteria is going to go into effect July 1st of 2024.
We're in the process of updating our CCBHC Elements of Performance
to reflect SAMHSA's update as well.
We plan to release those around January,
but they will implement July 1st, 2024.
Next slide.
We also have been...
Joint Commission is putting a lot of efforts into standard simplification.
You may have heard we've made some efforts
to decrease the amount of requirements,
retiring or revising requirements
that are either redundant or maybe outdated,
like they've already been accepted in the field.
They're not as much of a quality and safety issue anymore,
or consolidating some that can be consolidated
without changing the requirement to lessen the burden on organizations.
For the August 27, 2023 release in the BHC manual,
there are 20 deleted or consolidated Elements of Performance,
and five revised Elements of Performance.
These changes-- since they haven't gone into effect yet--
you can go to the link here when you get these slides.
You can click on this link
or visit Joint Commission's main webpage, www.jointcommission.org
Go to the Standards tab, and then Prepublication Reports,
and you will see them as one of the reports you can view,
if you'd like to view those changes.
Once August 27th hits, which is coming soon,
these changes will just be in the manual,
so you won't need to look at the Prepublication Reports after that.
Next slide.
The last thing I wanted to talk about is just give you a heads up
on how to sign up for e-alerts for our field reviews.
The Department of Standards and Survey Methods--
we're always updating, developing, or revising standards.
And whenever that includes a requirement change
that we could get feedback on,
we like to post field reviews.
This is a period of public comments
before we finalize any changes to the standards.
Comments from the public,
people like the listeners today, our customers,
and people with experience working in the organizations
that these standards would affect,
are so valuable to us.
If you'd like to sign up to get an e-alert
when we have a new field review up
that affects behavioral health care and human service organizations,
you can go to www.jointcommission.org/e-alerts/
or click the link when you get these slides
and enter the information in the E-Alert Form.
Next slide.
Under Content Type, just make sure to choose a type that you would like.
You could say you would just like the behavioral healthcare ones,
or you can pick all health care settings, etc.
And then, pick Standards Field Reviews
under the Content Type.
You'll get an email whenever there's a new field review
that might pertain to you and your organization.
That is all I had today.
So I will hand it over to Peter.
(Peter) Thank you, Stacey.
I'm Peter Vance as Field Director
for the Behavioral Health Care and Human Services Program.
I manage the surveyors, and survey process,
and other projects related to survey.
Next slide, please.
So, the public health emergency is over.
I wanted to add this slide.
The majority of our accredited organizations,
under the Behavioral Health Care and Human Services Program,
do not have to worry about this,
but I do know that some of you do,
related to CMS and some requirements.
This is something that's--
It'll be in the manual,
but it's no longer going to be surveyed to.
We're also no longer wearing masks,
unless that is part of your organization's protocol.
Whatever your protocol is going to be, we will follow that.
We may have surveyors who-- depending on whatever the situation is--
they may want to wear a mask,
and that's just okay with us.
That's their personal preference,
and we would just ask to respect that.
The other piece that I want to say
is that while the PHE is over,
we also know that organizations are still having some challenges
with a variety of things,
but that would include things like staffing, telehealth--
what to do with those services,
and even documentation, getting back into the documentation
that maybe they had missed or lapsed during the pandemic.
We will be scoring those things
if you have some challenges.
But the concept there, of course,
is to just identify that you, as an accredited organization,
are having challenges with that,
so that we know that you're working on it.
And we're also trying to get a good sense
of how many of our accredited organizations
are still having challenges, such as that.
Next slide, please.
Offsite surveys.
During the pandemic,
we were completing all surveys offsite,
and offsite is our term for virtual.
We did find some success with those surveys.
I'm mentioning this
because, even though we are back on site,
and that is our plan,
we will utilize some offsite techniques when needed.
We were using Zoom, but now we're using Microsoft Teams.
That's one important thing to note.
But, primarily, what we will do is remote into sites
that might be really distant.
We know that there are actually quite a few organizations
that have these distance survey sites
or distance sites from their organization.
It might be across an entire state or even in multiple states.
So there may be times when surveyors,
to make things more efficient for you and for us,
will remote there.
We'll use our offsite or virtual means to go to that site.
That usually will save some travel time,
resource, and cost on everyone's end.
That is something that you will likely see in the survey process,
just be aware of that.
Another place that you will, certainly, see this--
currently, we're using offsite processes
for single-day special surveys.
So something like an extension survey.
If you have a new building or a new service,
and we do an extension survey,
we might come out for one day.
That actually might be an offsite survey,
similar with some early survey options
and even some follow-up surveys.
Know that some of those single-day special surveys
may also be done virtually, or offsite, as we say.
The next thing I want to talk about here is treatment planning.
Of course, we always seem to talk about treatment planning quite a bit.
It's important, which is why we do.
I wanted to mention a particular thing here
is that I know many states are trying to do things
with treatment planning, as they always are,
to make it more efficient for the person served,
but also for the organization.
We know that some states even are moving toward
having a treatment plan that's not just a single document.
In fact, our standards are okay with that.
They can accommodate that.
I just want to point that out, that if a surveyor is onsite
and reviewing information about your treatment planning process,
please be sure to just show them all aspects of it.
We do not expect a treatment plan to be in a singular document
or a singular place even, in the treatment record.
It may be found in a variety of different areas.
I'll give a very simple example.
There may be a clinical assessment and a nursing assessment.
Those would be in two different places.
But the surveyor will need to see both of those.
Just make sure that the surveyor is seeing all of those areas
where you might have parts of that treatment plan
that come together for that final planning process.
Clarification.
When we're on survey, we want you to ask questions.
We want to make sure we're very clear about what we're scoring.
We want you to understand what it is we're scoring.
That's why we want you to get clarity.
We want you to do that during the survey process.
Ask those questions.
The surveyor should be talking about the intent of the standard
and why it's being scored,
but please ask those questions.
They should be discussing that with you as well.
But if there is something
that perhaps the surveyor is missing,
and you think there's more information that you could provide,
please do.
We really want to resolve all of those kinds of questions
onsite during the survey.
Nothing has to happen post-survey.
Part of that could be, just as I said, talking to the surveyor.
It could also be asking the surveyor
to take a look at the standards.
You can both look at the standards
to see what the introduction to the chapter talks about,
the introduction to the standard,
it talks about the intent.
There could be a place to find some information.
You could also ask the surveyor
to contact our Standards Interpretation Group,
which is a common practice for us during the survey process
is to contact what we call SIG, our Standards Interpretation Group,
to check in and get their objective view
of what this intent of the standard is all about.
We really think that you can take the time to do that.
In fact, there is even a section called Special Issue Resolution
that isn't a typical part of the survey,
but it is time set aside just for cases like this.
If you have questions,
if there needs to be further discussion,
you have time for Special Issue Resolution
You can even ask the surveyor to say,
"Can we discuss this in Special Issue Resolution?"
That way we can get everything understood, wrapped up,
and move forward while we're on-site,
so that you can then move forward
with what you need to do for your organization.
Now, this next one: binders versus laptop.
I know that binders seem to have a sacred role in the survey process,
but they're really more of an archeological artifact.
If you use binders that's part of your process,
that's absolutely fine with us,
but there is no need to create binders for The Joint Commission.
If you use information electronically,
which we honestly hope you're doing--
it's a little more efficient, it saves trees, etc.--
then we will use that electronic means
to review any policies, procedures, plans, documentation, etc.
If you have that information,
there is no need to put it in a binder,
unless that is your process.
We really want to see your information and how you use it,
not just something presented for The Joint Commission.
If the surveyor asks for that,
maybe you can make that available just to have a separate laptop,
or tablet, or something, or a station that they could look at.
We tend to like someone to navigate us through that,
but something like that, so that we can see the documentation
if you have it electronically.
But again, no need for large three-ring binders.
Policies and procedures.
I've mentioned policies and procedures a couple of times,
they are obviously an important part of the survey process.
I'm going to say something very simple
but something that we actually run into quite often.
Organizations--
we very often will see
that organization's policies and procedures
don't match the actual process that's occurring.
Again, that sounds simple
and to an extent, that's one of the reasons
why you all bring us in as The Joint Commission,
so that we can be that new set of eyes,
that fresh set of eyes,
that objective observer to identify these areas.
And, of course, we're going to do that.
But something that you can do ongoing
is just to make sure that you're reviewing those policies and procedures
to ensure that they actually do match
what the process is at your organization.
I know sometimes organizations...
You acquire maybe another program,
and it's coming into your system,
into your corporate system,
and so it's new.
That new program has to get accustomed to those policies and procedures.
Just ensure that all of that is part of your transition
for that new organization,
so that those things do match.
We do see that fairly often.
So again...
as just kind of a warning,
just make sure you're reviewing those on an ongoing basis,
so that they match.
This next piece is related-- about tracer activity.
Tracer activity, very often individual tracer activity--
we're talking to staff,
we're talking to people you serve,
we're talking to anyone and everyone
who's involved in the treatment, or the care,
or the service that's being provided.
And that's part of the tracer activity.
Tracer is also sometimes a session.
We're tracing processes rather than just individual care.
But either way, we really do want to get to
the boots on the ground,
or where the rubber meets the road,
or whatever metaphor or analogy you want to add there,
in the sense that we truly are trying
to get a great comprehensive view of your organization,
so that we could provide even more help and information and education.
With the tracer, ideally,
if whoever that primary clinician, or caseworker,
or whomever for the particular individual served,
that's the person we really want to talk to.
That doesn't always happen.
That's not always possible.
Maybe they're busy,
and we certainly don't want to disrupt care.
That's not our goal.
Sometimes it may just be a clinical director
or a program person who's giving us the information.
But in general, we know
that probably the clinical director knows all these things,
but maybe some of the other staff don't.
Again, that's that objective view that we bring to you,
so that we can identify areas that might need some improvement.
That is our goal.
If you are, which we hope,
the clinical director or whomever is around,
that you'll allow those people to answer those questions.
Again, our goal is to try to hear from everyone,
to ensure that policies, procedures
are being enacted by everyone,
and that's how we can find out.
That even includes consultants.
We think consultants are great and offer a real great opportunity
for new organizations or any organization
to use some help and education
to prepare for some of these standards and elements of performance.
But, also, the consultant during the survey is an observer.
We want to, again, hear from the organization
and really those direct staff,
I guess you could say,
who are providing those services, care, or treatment.
Next slide, please.
Stacey mentioned NPSG 16.
This used to be, as she mentioned, the Leadership Standard 438.
That has to do with health care equity and population health.
There are many EPs involved in this standard.
It is still relatively new for people,
but we are surveying to it.
Primarily, we are having some discussions.
We try to brainstorm a little bit for organizations.
In general, I'll say all of our standards are scalable
to the size of an organization.
Certainly, we have some very large organizations
who are accredited,
and some smaller ones.
All the standards are really developed
so that they can be scalable to those organizations.
And this is exactly what surveyors will be discussing with you
in regard to health equity.
The key component here is that first EP,
that first Element of Performance,
which is about identifying who's in charge of that.
We know that some organizations' leaders
wear many hats,
so that may happen, and that's totally fine.
We just want to know who's going to be leading that process,
because there is data and other things involved in how that's collected.
CCBHC.
Again, as Stacey mentioned this,
the Certified Community Behavioral Health Centers--
we are surveying for that right now.
We know that there is still a lot of variation.
There are going to be the amended standards
because of SAMHSA's updates and revisions coming out.
But many of our surveyors, all of them have been trained in CCBHC,
and actually many of them are working in CCBHCs.
We have a very good understanding of those processes,
but we also know that there are many differences across states.
So, we will absolutely work with you on this.
Again, our goal is to identify areas for improvement.
That's what we'll be looking for.
Measurement-based care.
This has been something we've been surveying to
for some years now,
and we have seen mostly organizations
really understand this.
The place where we have seen
some organizations not meet some of these standards
are if you're a new organization.
If you are new
or looking to become a newly accredited organization
with The Joint Commission,
I wanted to point this standard out.
This is in our Care Treatment and Services chapter.
It's 03.01.09.
It really has to do with measuring care throughout the treatment episode,
not just when someone enters treatment and then exits treatment.
It's throughout the treatment episode,
and then you're basing care upon that data, that information.
It's not only singularly with that particular individual,
but then it's also by population.
In the future, we may even see
this type of data and information combined
with some of our other DE&I type of activities,
which, of course, DE&I,
I don't know that I mentioned that,
but it stands for diversity, equity, and inclusion.
That's a key thing to keep in mind
is that measurement-based care.
There is required
a validated instrument for that.
Please check out that standard and element of performance.
Lastly, here, something that's not a scorable issue--
it's the SAFER Dashboard.
What you'll see when we have a survey
is that the surveyor will use what we call the SAFER Matrix,
which is pointing out risk and the scope of that risk.
When the surveyor is going through information,
they're going to point out what are higher-risk issues
compared to lower-risk issues,
what are more widespread at the organization
versus maybe something that's very limited found or seen.
What you, as an organization, can do
is look at the SAFER Dashboard,
and over time you have access to this
to see what some of the trends are for your own organization
through the SAFER Dashboard.
It's another opportunity
that The Joint Commission offers for organizations
to maintain some consistency over time,
to take a look at that
for your own performance improvement development needs
is to look at that SAFER Dashboard.
If you're not familiar with that,
I would certainly suggest you take a look.
You can find that on our website, how it tells you to get there,
or actually even on your own extranet site,
and your surveyors will likely be discussing it with you.
I believe that is the last slide,
and I will turn it over to my colleague, Falguni Shah.
(Falguni) Thank you, Peter.
I'm Falguni Shah,
and I'm the Associate Director in Standards Interpretation Group,
and I mainly work with the Behavioral Health Care and Human Services
and Psychiatric Hospital programs.
Next slide, please.
I would like to start by sharing some results
of the top non-compliant standards that are scored
under Behavioral Health Care and Human Services.
Next slide.
What you're seeing here on this slide
is the data for all our full triennial surveys
that are conducted with current customers
who are already Joint Commission accredited,
who are accredited
under the Behavioral Health Care and Human Services program specifically,
and the time frame is from July 2022
to June 2023,
so a one-year time frame.
On the left,
or, I would say, on the left and the middle section,
you will see the top non-compliant standards that are scored.
To summarize it,
it includes deficiencies under nutritional screening,
environmental risk assessment,
suicide prevention policy,
outcome measurement,
and aggregating data on the outcome measurement results,
ongoing HR competency assessments for staff,
treatment planning,
and screening for trauma, abuse, neglect, and exploitation.
These are some of the top deficiencies that we have seen being scored.
We have talked at length about some of these,
and we publish this or release this every year in our Perspectives,
usually around August of each year for the prior year.
We've also addressed some of these in our Heads Up Report,
which you can find when you log into your Joint Commission Connect site.
Next slide.
For today's presentation,
I'm really going to focus on those observations
out of these that are scored under high-risk zone or the red zone
on the SAFER Matrix that Peter just explained.
This includes those observations that are scored high
on likelihood of harm,
and they're either limited pattern or widespread in scope.
My goal is to share the reasons for non-compliance,
and share some tips and tricks for compliance.
Next slide, please.
When I filtered the previous data that I shared by those observations
that were scored under high risk,
here is what I found.
As you can see here,
the top five of these are in suicide prevention,
which is National Patient Safety Goal 15,
followed by a couple of leadership standards.
One of them is policies and procedures,
which Peter alluded to in his presentation,
and then some medication management requirements.
Let's dive into some of these.
I would like to share some reasons for non-compliance
and some tips and tricks.
Next slide, please.
What are some of the common non-compliance reasons for deficiencies
under Suicide Prevention requirements for National Patient Safety Goal 15.
We've seen that...
the requirement for screening
is to use a validated tool.
But oftentimes, organizations will ask
some sort of homegrown question,
whether the individuals they are serving have suicidal ideation,
and then subsequently administer the validated screening tool
only to those who verbalize suicidal ideation.
But the requirement is that a validated tool be administered
to all the individuals at the time of admission.
The second issue we're seeing
is once the screening is positive for ideation
and the assessment is being administered,
The Joint Commission requires evidence-based assessment,
which oftentimes is missing risk and protective factors,
or there's no synthesis or determination of risk
at the end of the assessment.
We also see that, based on the level of risk,
the mitigation is not either implemented or not documented,
and they're both the requirements, again.
Recently, we've also seen--
and this is
very prevalent in terms of policy requirements--
we have very specific requirements of what we want organizations to address
in the suicide prevention policy,
and the policy does not include all of those requirements,
as we have seen frequently.
In the future slides,
I will go deep-dive into each of the standards
and what we can do to comply.
The next deficiency that we often see is
that the organizations do not have a quality review program
to ensure that the staff is implementing
their suicide prevention activities,
such as screening, assessing, and mitigating,
and identifying needs for improvement.
Organizations need to have a comprehensive evaluation
of their suicide prevention program.
Next slide, please.
Here are some tips and tricks on how to comply for EP2,
which is a suicide screening requirement.
The Joint Commission requires organizations to use a validated tool,
which means that it is research-based,
it has reliability, sensitivity,
it is studied on a normative population.
Some of the validated tools that are acceptable by Joint Commission
are Columbia-Suicide Risk Assessments,
the ones that are recommended by National Institute of Mental Health,
such as ASQ, PHQ-9,
SBQ-R, and PSS-3.
These are not--
You don't have to use one of these.
There can be other tools,
because there are a number of tools,
but these are some that we recommend.
You can also find these in our Suicide Prevention Portal.
We see that organizations oftentimes will modify these tools,
which is one of the common reasons for non-compliance.
These tools need to be implemented
as they're intended for use by the developer.
Do not change any of the questions.
If you're working with the EMRs,
make sure that the tools are scored and interpreted
as intended by the developer as well.
Another important thing to note in terms of what is expected
in terms of mitigation
is that if the patients are assessed at high or imminent risk
using a screening tool,
we would expect a one-on-one observation
until you're able to complete a full assessment.
Next slide, please.
To talk about the assessment requirements,
again, our assessment, like I said earlier,
does not require a validated tool.
The assessment requires an evidence-based process,
and the assessment is required
when individuals are screened
using a validated tool with suicidal ideation.
So assessments,
how can we tell if it's an evidence-based assessment?
When the assessment directly asks about suicidal ideation,
plan, intent,
suicidal or self-harm behaviors,
risk factors, and protective factors,
then it is considered to be evidence-based.
So you may be assessing each of these components
in your biopsychosocial assessment,
which is acceptable.
As long as you're able to demonstrate that it's an evidence-based process,
it meets The Joint Commission requirements.
One thing to remember is
the assessment process needs to ultimately help
with synthesizing the level of risk,
which also needs to be documented.
There are times when, let's say, an intake staff or a clinician,
mental health clinician
completes an assessment and identifies a level of risk.
And the provider,
who may see the individual a few weeks later,
may determine a different level of risk,
but it's important to document
how they arrived at this level of risk
for the surveyors to evaluate compliance.
And it's also important to document
the plan for mitigating that risk for suicide,
based on the level of risk.
The organization determines the mitigation strategies
for moderate and low level of risk.
It can be based on the setting,
it can be based on the population you're serving,
whether they are able to restore functioning on their own.
You may be treating individuals that are lower functioning,
and the mitigation would depend on that as well.
Again, it is up to the organization
to determine the mitigation strategies for moderate and low.
But if the patients are at high risk for suicide in an environment,
especially with ligatures,
we expect that they are monitored on a continuous basis,
so that somebody is able to immediately intervene
if something were to happen.
In the environments that are ligature resistant,
it is up to the organization to determine that mitigation.
We don't require continuous observation,
but I would still make sure,
that if there are any ligature points,
that you are able to remove those from the environment,
like sharps, et cetera,
that the individual may use to self-harm.
Next slide, please.
Next, I want to talk a little bit about the policies and procedures,
especially as it relates to suicide prevention
and The Joint Commission requirements
under EP5
for National Patient Safety Goal 15.
The standards require that the policy, at the least,
addresses training and competencies of staff
who care for patients at risk for suicide.
It must also include guidelines for reassessment of patients,
and how the patients will be monitored depending on the level of risk.
You may outline your entire process within your policies and procedures,
but these are just the minimum requirements.
Also, one thing to keep in mind
is that the surveyors will want to look at documented evidence of completion
of such training and competency assessments of staff.
It is up to the organization to really determine
the frequency of reassessments,
and this would depend on changes
in their suicide ideation status,
changes in their condition,
stressors in their daily lives,
things like that,
that can be used to determine if a reassessment is needed or not.
And, obviously, if they are verbally expressing ideation
or there are any signs of self-harm or gestures,
then it's pretty obvious
that we would expect you to do a reassessment.
But, really, the time frame and the frequency
can be determined by the organization,
if nothing were to change or if they don't express ideation.
It is required, although, that you include this
in your policy for suicide prevention.
Next slide.
As I mentioned earlier,
there needs to be a process
for how you're evaluating your suicide risk reduction program.
This entails monitoring of all aspects of suicide prevention,
starting with screening,
assessment,
determining the level of risk,
implementing the mitigation.
We want to make sure that the organization,
and the leadership,
and their quality improvement teams
are doing audits,
looking at implementation of their suicide prevention program,
and identifying any needs for opportunities for improvement,
re-education, etc.
Next slide, please.
Next, I'm going to focus on
another high-risk issue that we have seen scored,
which is under Leadership 04.01.07, EP 1,
and Peter gave a really good overview of this requirement.
We expect that leaders are engaged in all aspects
of policy development and implementation.
It's advisable to have some sort of timetable for review of these policies,
either annual or every three years.
Make updates to these policies as appropriate.
Involve key stakeholders within your organization
in the review process.
Educate the staff any time the policy changes.
And then lastly,
do audits to ensure implementation of these policies and procedures.
One thing I do want to emphasize
that ensure that your policies and procedures
also include compliance
with any federal or state law and regulation.
This would just save time during survey activity.
If you already have modeled your policy after the law and regulation,
it will just make it really easy
to evaluate compliance at the time of survey.
Next slide, please.
LD.04.01.01, EP 1 really requires organization
to have an active license, certification, or registration
and comply with law and regulation
to provide care, treatment, and services.
Very frequently we see the observation,
as it relates to organization not having a CLIA certificate,
which is a certificate for performing point-of-care waved testing.
It is required that your CLIA certificate is active at all times,
that if you have applied for a CLIA certificate,
that you make the proof of payment
available to the surveyor,
and not perform any waved testing,
unless you have permission from the state,
while you're waiting for the CLIA certificate to arrive.
We do not need a CLIA certificate
for collecting samples and sending to the lab,
but if you are performing the test at your organization
and interpreting the results for care, treatment, and services,
you wouldn't need a CLIA.
Again, CLIA regulations are determined
by FDA and your respective state,
and so Joint Commission will really survey
to the requirements
that are derived by the state and FDA.
You would know if you need a CLIA certificate
also by looking at the manufacturer's instructions
for use for the test that you are using at your sites.
One common mistake that we also see happen is
if the name of the individual on the CLIA certificate,
if this individual has left the organization,
you do need to apply with the state to change that name.
Sometimes, in our busy schedules,
we forget to do that.
But that is another common reason for non-compliance
that we've seen cited.
Next slide, please.
Under the requirement LD.04.01.01, EP 2,
this really requires organizations to follow their state law and regulation,
while providing care, treatment, and services.
A number of things fall under this, really,
starting with the credentials of your staff,
starting with the number of staffing requirements
based on the number of licensed beds
or the number of individuals you're serving,
whether the organization requires a medical director or not.
We highly recommend that you look at your state law and regulation
in terms of the staffing requirements,
and have that ready and available at the time of survey.
It's important also to ensure
that all of the care, treatment, and services
or the activities that you're performing,
you're also complying with state law and regulation.
For example, if you have individuals
that have just graduated from a master's program,
are they really allowed to diagnose?
If you have case managers,
are they allowed to diagnose?
Who can sign off on the biopsychosocial assessments?
Who can administer or even self-administer medications?
You want to make sure that both
your policies and procedures and your practices
are compliant with state law and regulation
for all of the activities that you're performing.
To go even further--
every state has supervision requirements:
whether the supervision needs to be documented;
do we need some kind of agreement
that needs to be completed and filed with the state;
are there contracts that they're interns or students,
that can be made available to the surveyor at the time of survey?
All of these things really need to be kept in mind
while really developing your policies and procedures
and providing care, treatment, and services.
And lastly,
I want to talk a little bit about telehealth,
and I know Peter talked about it as well.
Telehealth has its own regulations for every state.
You want to make sure
that the licensure requirements
of the providers performing telehealth services
is compliant with their state
and with their respective licensure boards.
You want to also consider whether you have the technology
that is HIPAA compliant to provide telehealth services.
Do you have the technology to perform,
for example, physical exams?
If you are doing telehealth physical exams,
can you do heart and lung sound checks,
or can you perform these via technology?
So it's important
that you consider all of these while providing telehealth services.
We do have a really good FAQ
on our Joint Commission website for telehealth,
which has great resources where you can access state requirements.
Next slide, please.
In terms of medication management,
I wanted to focus a little on--
again, ensuring that you have experts
that you're consulting with
while developing your medication management processes,
such as a pharmacist, or prescriber, or a medical director.
The reason being
a pharmacist will be able to tell you
how you can comply with law and regulation
in terms of all the labeling requirements.
What are the minimum requirements of a complete medication order?
Are there temperature requirements
for storing specific controlled and non-controlled medications?
You can have such exports available on-site or through contract,
or even through consultation basis,
but it's important to ensure
that you're able to comply with these requirements.
Also, in terms of wasting or handling medications,
every state has specific requirements
in terms of the method of destruction of medications,
whether a two-nurse count is required or not by your state.
I would look at all of those laws and regulations.
Last but not least, the diversion control practices.
If you are storing controlled substances,
you'll need to have diversion control plan in place.
These are just some examples
of how you can implement a diversion control plan,
but these are not prescriptive.
Counting medications between storage and administration.
Counting medications
when the medications are brought within the organization
by individuals that are being served.
Securing medications.
It's important to know
that Joint Commission does not prescriptively require medication
to be double-locked.
Joint Commission does require that they are secure
and that you follow any state law and regulation
as it pertains to locking medications.
If the medications are kept in a secure area,
where staff is present,
staff ensures that this area is restricted
only to authorized persons or authorized individuals.
Then you are compliant with that requirement.
If there is adequate supervision in these areas,
and unauthorized individuals
are not getting a hand on these medications,
then you are really securing medications.
But again,
follow all the state laws and regulations for any kind of diversion control,
and storing, labeling of medications.
This also includes sample medications.
Next slide.
Those were really the standards that I wanted to highlight
that have caused high-risk requirements
for improvements.
Lastly, I do want to share
how you can submit questions to Standard Interpretation Group.
This can be done through our Joint Commission website.
It does not require you to log in.
We're happy to answer any standards-related question,
either via email or a phone call.
When you complete the form,
you can request a response via either of those methods.
Asking a question to SIG
doesn't really impact your survey outcome or your survey activity.
The questions you ask
are not really communicated with the surveyors.
During survey, as Peter mentioned,
you want to make sure
you clarify all your doubts at the time of survey.
You can request a special resolution call
if everything that Peter mentioned earlier
does not work in collaborating with the surveyor
and understanding the standard requirement.
You can ask the surveyor to schedule a call with SIG.
But like Peter mentioned,
first, try to review the requirement,
look at the introduction and the rationale of the standard,
which more likely than not
will give you the intent of the requirement,
and try to get clarification from the surveyor.
But again,
SIG can always schedule a collaborative call
with you and the surveyor
to resolve any of those standard interpretation kind of questions.
In this last slide,
next slide,
I have just provided a screenshot of where you can find the FAQs
and how you can submit a standard-related question
to Standard Interpretation Group.
I will now hand it over to my colleague, Mark Crafton,
for state relations update.
(Mark) Thank you, Falguni.
Before I get to my first slide, I just did want to follow up
on what Stacey and Peter mentioned about CCBHCs.
We are seeing more and more states
adopting and getting on that CCBHC bandwagon
and designating it as its own separate provider type.
Most of the states that we're hearing from
are certainly following SAMHSA's guidance
and looking for accreditation to serve as the way
to certify and designate those particular organizations.
Next slide, please.
These are just three topics that I wanted to address briefly today,
that we see as trends throughout the country.
The first is workplace violence.
Since COVID,
there's been at least a dozen states
that have passed bills that have increased
the penalties for individuals
who have threats of intimidation
or actual physical harm upon staff of healthcare facilities,
both patients, family members, and visitors.
Certainly, as you all know,
behavioral health care providers are not immune
to those threats of violence and intimidation.
Today, we see a whole range of legislation,
some that are pretty mild with misdemeanors,
like a 30-day anger management course
for individuals convicted of threatening health care providers,
all the way up to third-degree felonies,
if the act occurs intentionally, annoyingly,
and causes substantial bodily injury.
We want to see more states become active in this area.
Secondly, I want to talk about overdose prevention.
More Americans under the age of 50
die from drug overdose
than any other cause.
Think about that.
More than die of a homicide, of suicide,
of a car accident, of cancer, or heart disease,
they die of drug overdose.
And two-thirds of those drug overdose deaths
occur through the use of fentanyl
or some other synthetic opioid.
States are starting to address this
by, number one, decriminalizing fentanyl test strips.
Back in the '80s and '90s, during our war on drugs,
every state, except Alaska, made it illegal
to have a fentanyl test strip
because they didn't want to enable drug dealers.
But now states are seeing that these test strips,
that cost about $10 on Amazon,
are a great way for those who are going to use
street-type cocaine and heroin,
to test it to see if there's a potentially fatal amount
of fentanyl in their drug.
We're also seeing increased access to naloxone.
States are finally figuring out
to put naloxone where overdoses are occurring.
Unfortunately, that's in middle schools,
and high schools, and in colleges.
That's where states are forwarding those resources.
Finally, just wanted to mention suicide prevention.
COVID was not good for anyone's mental health,
especially for our youth.
Social isolation with no school or activities,
worrying about becoming ill
or worried that a parent is going to become ill
really took a toll.
One study that I saw
showed that about 50% of middle and high-school-age students
experienced hopelessness and prolonged sadness
during the COVID epidemic.
20% considered harming themselves,
and almost 9% actually did attempt self-harm.
These numbers were certainly higher for LGBTQ youth.
What we're seeing states do is increase crisis services
through their Medicaid programs,
including mobile crisis services,
and also expanding access to mental health professionals,
primarily through the use of telehealth.
The early studies, I think,
show that telehealth for certain behavioral health services
can be done without any reduction in level or quality of care,
compared to in-person services.
With that, I am going to turn it back over
to our moderator, Donna.
(Donna) Thank you, Mark, and thank you, Stacey, Peter, and Felguni,
and thank you to all of you who are listening in today.
What we're going to do is
we're going to lock up this presentation.
We'll send you a PDF of it,
but we'll also send you the recording today.
A lot of great information, I'm sure you'll agree, that you heard.
We will send both of them together to you via email.
This is Monday.
You'll probably get it either late today or tomorrow.
We thank you for tuning in.
Thank you for all you do.
Have a great rest of the day.