Facts about Opioid Treatment Program (OTP) accreditation | Joint Commission
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Facts about Opioid Treatment Program (OTP) accreditation

December 8, 2017

The Substance Abuse and Mental Health Services Administration (SAMHSA) established an accreditation requirement in federal regulations in 2001 to help opioid treatment programs (OTPs) improve the quality of patient care, treatment and services delivered in the OTP setting. The requirement emphasizes person-focused care, integrated and individualized approaches to OTP services and outcomes, increased patient-satisfaction, improved recruitment of staff, and enhanced community confidence and outcomes. SAMHSA also developed the Federal Guidelines for Opioid Treatment Programs to further support OTPs in their adoption and implementation of the federal regulations. SAMHSA periodically reviews and revises these guidelines.

Federal regulations define opioid treatment as “the dispensing of an opioid agonist treatment medication, along with a comprehensive range of medical and rehabilitative services, when clinically necessary, to an individual to alleviate the adverse medical, psychological or physical effects incident to opiate addiction.” An Opioid Treatment Program (OTP) is defined as “a program or practitioner engaged in opioid treatment of individuals with an opioid agonist medication.”

Requirements

  • OTPs must be accredited by a federally deemed accrediting body. The Joint Commission has held deemed status for OTP accreditation since 2001. OTP’s that choose Joint Commission accreditation must be accredited under the Joint Commission’s Behavioral Health Care (BHC) Accreditation program, and each OTP program must be accredited separately. 

  • If an OTP is part of an organization accredited under a different program by The Joint Commission, the OTP(s) must be accredited under the BHC accreditation program.

  • OTPs must have one active patient to be eligible for survey.

Application and on-site survey 
Each OTP completes and submits a separate and unique application for accreditation to The Joint Commission (even if the OTP is a component of an already accredited organization or multiple OTPs). This allows The Joint Commission to provide CSAT a copy of the survey report for each OTP. An OTP that is a component of another organization may request to have its survey done at the same time as the survey conducted for the rest of the organization. Unique characteristics of an OTP survey are:  

  • Medication: Surveyors observe medication storage, preparation and security; procedures used to dose and dispense medication, including how patient confidentiality is protected, especially in the dosing line; procedures used to assure ingestion of medication and proper disposal of medication; and if there is adequate staffing. 

  • Business hours: The surveyor will observe opening procedures at least one day of the on-site survey to assess how well the OTP maintains business hours conducive to patient schedules. 

  • Treatment planning: Because OTP patients are often in treatment over an extended time (sometimes the rest of their lives), treatment planning and goals may focus on: sustained abstinence from drug use; shift from seeking employment or shelter to navigating retirement and moving into assisted living facilities; and address chronic health issues and issues related to aging. 

  • Diversion Control Plan: Each OTP should have a plan that lists the steps taken to reduce the risk of medication diversion by patients, staff and others who have access to the program (e.g., delivery agents, patient families and friends, and others in the building). The plan should be reviewed by leadership and staff at least annually.

After the survey
After the initial survey, OTP surveys must be conducted at least every three years. OTPs have access to The Joint Commission Connect® extranet site and all its resources. The Joint Commission posts all OTP survey results and related correspondence to a SAMHSA-only extranet site to confirm that The Joint Commission 

and accredited OTPs are in compliance with federal accreditation requirements. In addition, all complaints received by The Joint Commission regarding OTPs are posted to this site in conformance with federal accrediting body reporting requirements. 

For an accredited or applicant OTP acting as a health home for one or more individuals treated, The Joint Commission offers an optional behavioral health home certification.

To see if an OTP is Joint Commission accredited, go to Quality Check®

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