Behavioral Health Joint Commission Audit

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Joint Commission Audit

Gaining accreditation from the Joint Commission is a pivotal piece when opening a behavioral health center. The accreditation process can be arduous and complex, sometimes causing delays and other challenges when attempting to open your doors. Later, a surprise audit that seeks to confirm compliance with the standards may expose areas of weakness within your center. To learn some important tips about a Joint Commission audit, read on.

About the Joint Commission

The Joint Commission is a nonprofit agency that uses an accreditation process to improve patient safety. The benchmarks the Joint Commission established pertain to patients in all realms of healthcare, including behavioral health. It currently accredits over 20,000 healthcare programs and centers.

Since 1972, the goals of the Joint Commission are to improve the quality of healthcare, prevent harm, and enhance patient advocacy. Being accredited gives behavioral healthcare centers an added stamp of approval, demonstrating to patients a commitment to their well-being.

What is the Joint Commission Survey Process?

When a behavioral health entity applies for Joint Commission accreditation, it will participate in a survey. The survey looks at the treatment center’s compliance with the list of standards, allowing the center to fix any problem areas. These standards are spelled out in a document called CAMBHC, showing which standards are mandatory for each treatment setting. Prior to applying for accreditation, the behavioral health provider has time to research these standards. They can self-assess and make improvements where needed prior to the survey visit.

To initiate the survey process, the applicant submits an application and a deposit toward the fee. Once the application is on file, the center prepares for the on-site visit by the surveyors. The day of the survey involves a comprehensive dive into the center’s various protocols and the physical facility itself. The surveyor selects random patients and traces the patient experience within the treatment setting to assess compliance with the standards.

Once accreditation is granted, the behavioral health center does not need to renew it for three years.

What Do the Behavioral Health Standards Encompass?

The Joint Commission regulates an array of operational standards that are designed to address the behavioral health patient experience. These are tailored to the exact type of behavioral health service provider, but the basics include:

  • Leadership. The survey reviews the organization’s culture and organizational health. It is seen as intrinsic to safety, quality of care, treatment, and cultivating a healthy workplace.
  • Medication management. To safeguard the patients and employees, the center’s practices with regard to medications is checked closely. The Joint Commission seeks to ensure that medication is securely stored and dispensed. Having a safe medication management system in place helps reduce misuse, incorrect dosing, or harm.
  • Infection control. The facility will be inspected to assess whether best practices are in place that protect patients from viral or bacterial infection.
  • Qualified staff. The survey will assess and verify staff qualifications, and whether further training and/or education is needed.
  • Emergency preparedness. Managing an emergency within a behavioral health setting requires mitigation, preparedness, response, and recovery efforts. The center is expected to identify potential risks to the patients in its care. This leads to planning for continuing treatment and safety, and possible closure if needed.
  • Data recording. The facility should have policies that protect the security of any data generated by the delivery of care, treatment, and services.
  • Life safety. For residential treatment centers, there are fire safety codes in place that limit the occupancy rate. The Life Safety Code ensures the patients are in a fire-safe environment.

Navigating the Joint Commission Audit

The audit process is in place to further ensure compliance with industry standards. An auditor will arrive without advanced notice to see if the center is indeed adhering to the standards. This visit is akin to a quality control checkup.

The audit involves inspecting the facility, patient practices, and records to assess whether the center is meeting the accreditation standards. To be prepared for the audit, treatment centers should have devised a system that helps monitor policies and procedures. With ongoing self-evaluation systems in place, the behavioral healthcare center is ready to ace the audit.

How to Avoid Setbacks During the Joint Commission Audit

To be prepared for a possible audit, the treatment center should have someone on staff, or a contract consultant, that oversees compliance. This person or team helps the provider maintain a high level of compliance with the Joint Commission standards.

With someone in charge of compliance, your center is well prepared for a surprise audit. This employee or consultant sees that ongoing training sessions are conducted as needed. In addition, this person will put in place self-evaluation methods that identify problem areas. These measures help ensure that the audit will go smoothly.

Enlisting Help for Preparing for a Joint Commission Audit

Managing standards compliance is an important job that some behavioral health entities are not geared to managing. They may lack the knowledge, time, or resources to properly manage all the various requirements that would ensure ongoing compliance. This may put them at risk of losing Joint Commission accreditation should they not be prepared when a surprise audit occurs.

A behavioral health consultancy can provide the expert support a treatment center needs to ensure compliance. These professionals are trained to recognize any problem area within the organization or facility and facilitate any needed improvements. Meanwhile, leadership is freed up to spend more time perfecting the treatment program and providing a high-quality patient experience.

Circa Behavioral Healthcare Solutions Provides Consulting Services for Joint Commission Audit Prep

Circa Behavioral Healthcare Solutions is a leading consultancy specializing in the addiction and mental health recovery space. If you would like to have ongoing support during the Joint Commission survey and audit process, we can help. Our consultants can prepare your treatment center for a Joint Commission audit. Call our team today at (888) 458-6619.