Most of the time, behavioral health organizations appear to be adhering to quality standards when it comes to meeting operations and management benchmarks. But a significant number overall are still not hitting the target, according to a recently released report by a leading health care accrediting body.
The nonprofit Accreditation Commission for Health Care (ACHC), which provides accrediting standards for community-based organizations and education programs, disclosed its findings in a quality review publication called The Surveyor, which the organization puts out regularly.
A legacy publication of ACHC, The Surveyor also incorporates quality standards used by another accrediting body, the Healthcare Facilities Accreditation Program (HFAP).
ACHC and HFAP, which both have deeming authority from the Centers for Medicare and Medicaid Services, merged operations last year.
For its analysis, ACHC looked at deficiencies in operations and management at organizations from June 1, 2020 to May 31, 2021.
Categories evaluated in the study were for provision of care and record management, program/service operations and human resource management. Those categories altogether contained nine benchmarks that measured the prevalence of deficiencies, with all nine recording double digit incidence rates of organizations failing to adhere to standards.
The report acknowledged that over the last year, behavioral health organizations might have experienced deficiencies as a result of the pandemic, which subsequently shifted overall priorities among some away from compliance matters.
“Many organizations made significant adjustments to continue to meet the needs of their patient/client populations: adopting new technology for remote visits, and patient monitoring; sourcing against PPE shortages; reassigning staff to manage furloughs and quarantines,” the report stated. “These are all examples of unanticipated change that required quick action that may have shifted focus away from some areas of required compliance.”
Of the nine benchmarks, ACHC found that organizations were particularly lacking when it came to proper policies for securing and releasing health information that was confidential and protected.
In all, organizations 31% of the time did not have proper protocols regarding confidential and protected health information.
ACHC specifically cited that in these instances, organizations came up short when it came to clients getting and understanding information related to confidentiality upon receiving services. Additionally, in the instances of deficiency, organizations did not have evidence of a signed release of information when either billing a third-party vendor, or sharing information with individuals outside of the organization.
To rectify issues with patient health records, the report recommended that organizations conduct periodic audits of personnel and client records to maintain compliance. The report also stated that human resource managers should be assigned duties to periodically audit all personnel records for signed confidentiality statements.
Additionally, it was recommended that clinical directors and administrators be assigned duties to review client documents pertaining to confidentiality policies.
“As a requirement for Program/Service Operations because of its dependence on organizational policy, the standard nonetheless points directly to the client-centered focus of the therapeutic relationship,” the report noted.
Among the nine benchmarks, organizations 26% of the time also did not provide a process for orientating personnel, which was the second highest deficiency incidence. The plan recommended that organizations develop plans for proper employee orientation, with human resource managers taking a lead role in doing so.
Organizations also had trouble 15% of the time when it came to creating a plan for adequately training their personnel. Compared to the deficiency rates of other benchmarks, problems were less so in this area, as it fell in the bottom half of all nine benchmarks measured.
The report recommended that human resource managers, likewise, manage personnel educational plans and that personnel record reviews be conducted to document employee training and knowledge of educational requirements.
Maintaining an adequately trained and staffed workforce might especially seem pertinent to behavioral health organizations, given the issue of employee shortages that have been affecting the industry for some time.
“Generally speaking, we find that those providers that embrace the concept of accreditation as a framework for continuous quality improvement are more data- and outcome-driven and subsequently develop more sustainable business practice,” according the report.
Companies featured in this article:
Accreditation Commission for Health Care, Healthcare Facilities Accreditation Program
