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Joint Commission Behavioral Health Update

July 2009     
In This Issue
Modifying the Treatment Plan following Restraint or Seclusion
Heads Up: Be Sure to Align your Emergency Management Drills with your Hazard Vulnerability Analysis
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 
This month we are providing a follow-up to our June article regarding the changes to The Joint Commission's restraint and seclusion standards. Specifically, we are responding to some frequently asked questions about the new requirement to modify the treatment plan following an episode of restraint or seclusion.
In addition, we are sharing some tips on a common survey challenge in the Environment of Care related to hazard vulnerability analysis and emergency management drills. 
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Treatment Team PNGModifying the Treatment Plan following Restraint or Seclusion

In last month's newsletter, we covered The Joint Commission's new restraint and seclusion standards. These new standards apply to hospitals that use TJC accreditation for CMS deemed status. Questions arose from several readers regarding the new requirement for modifying the treatment plan when restraint or seclusion is used.
Specifically, the new standard (PC.03.05.03 EP 2) states: "For hospitals that use Joint Commission accreditation for deemed status purposes: The use of restraint and seclusion is in accordance with a written modification to the patient's plan of care."
In TJC's previous restraint/seclusion standards, there was no specific requirement for modifying the treatment plan following restraint or seclusion. The only reference to this point was in the previous standard that addressed debriefing. This standard indicated that one of the elements to be included in the debriefing was "modification of the patient's plan for care, is such modification is indicated." Clearly, the language of the new standard is more stringent and requires a modification to the treatment plan whenever restraint or seclusion is used, not just "as indicated."
This focus on modifying the treatment plan following restraint or seclusion has long been an emphasis during CMS surveys. The rationale, as stated by CMS surveyors, is that the use of restraint or seclusion represents a "treatment failure." It indicates that the treatment plan is not working and needs to be revised.
Now that this requirement has become a TJC standard, here are some of the questions that have been raised:
Does the entire treatment plan need to be re-done?
The entire treatment plan does not need to be re-done. The modification to the plan may be the addition of a new intervention or a change to an existing intervention. For example, there may be a change to the patient's medication or a decision to refer to the psychologist for development of a behavior management plan. Both of these would constitute modifications to the treatment plan.
Whatever the modification is to be, its focus should be on identifying strategies that will help minimize the need to use restraint or seclusion again.
Does the change need to be documented on the treatment plan itself?
Yes, the change(s) to the treatment plan should be documented on the treatment plan itself or on a form used to document treatment plan updates/reviews.
What mechanisms do hospitals use to accomplish this updating of the treatment plan?
Many hospitals use the approach of conducting what they call a "focused treatment plan review." This is distinct from the routine treatment plan reviews typically required every three to six months. During the focused review, the treatment team analyzes the events leading up to the restraint or seclusion and tries to identify where the current treatment plan is breaking down and how it should be changed.
Another approach is to use the information gained from the debriefing following the restraint or seclusion. If done well, the debriefing with the patient and staff can provide valuable input to what changes might be useful for avoiding the use of restraint or seclusion in the future.
Many hospitals use their Morning Report meeting to efficiently accomplish this task. During discussion of the patient and the episode of restraint or seclusion, the team identifies what should be modified (medications, groups, time with therapist, etc.) and one team member is responsible for writing this on the treatment plan.
How will compliance with this requirement be reviewed during TJC surveys?
Cases of restraint or seclusion are still frequently selected as tracers during surveys of all types of behavioral health organizations. Surveyors routinely focus on cases where there have been multiple episodes of restraint or seclusion. When they see this type of scenario, they often pursue the issue of what is being done differently with this patient and what types of alternatives to restraint or seclusion have been considered.
It's anticipated that the stronger requirement in the new standards will reinforce this scrutiny. We're keeping our eye on this issue during our clients' surveys and will be sure to keep you posted in future editions of our newsletter.
Click below to view TJC's new restraint and seclusion requirements and read the transcript from their teleconference:

Hazard Vulnerabilbity PNGHeads Up: Be Sure to Align your Emergency Management Drills with your Hazard Vulnerability Analysis

Some behavioral health organizations got a surprise during their surveys this past year in the Environment of Care review. They received Requirements for Improvement related to their hazard vulnerability analysis and their emergency management drills. The issue was not that they had overlooked doing the emergency management drills. They had actually done the required number and type of drills they had always done in the past. The issue was that the drills they conducted were not related to the priorities they had identified on their HVA.
For example, one organization had identified a hostage situation as one of their potential emergencies in their HVA. Their program was located in a high crime area and a neighboring organization had recently gone through a hostage stand-off. The organization carried out two emergency management drills during the year: one for a severe snowstorm and one for a utility failure (same ones they had conducted the previous year.) The surveyor reviewed their EOC Committee minutes and asked if they had drilled on the hostage situation. Since they had not, he cited them as out of compliance with the following standard:
EC.4.20 EP 6: "The organization regularly tests its emergency management plan. Planned exercises are realistic and related to the priority emergencies identified in the organization's hazard vulnerability analysis." (In the Hospital Manual, it's standard EM.03.01.03 EP 5.)
So, the take-away is to make sure that your drills relate back to the priorities that you identified in your HVA. Once you've identified a disaster scenario as a potential for your organization, you must develop a response plan and then conduct a drill on that response plan.
It's also important to remember that all emergency management drills must be critiqued. This is another area where organizations sometimes get caught short during surveys. What we're seeing on our clients' surveys is that surveyors are not just looking for a description of the drill in the EOC minutes. What they want to see is a documented critique of the drill which identifies:
  • What worked well during this drill?
  • What didn't work so well?
  • What are the opportunities for improvement?
These results then need to be reviewed by the EOC Committee and adjustments made as needed to the Emergency Management plan.
It should be noted that Joint Commission standards do allow for an actual emergency to take the place of an emergency management drill. However, the response to that actual emergency must be critiqued in the same manner as a real drill. Too often, organizations overlook this part when counting their real emergency as a drill.
Finally, keep in mind that the HVA must be reviewed and updated annually. If needed, it should be modified based on any new emergency management issues that have been identified over the past year. 
If you subscribe toTJC's Environment of Care News, see the September 2008 issue for the article "How to Perform a Hazard Vulnerability Analysis."
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Barrins & Associates provides Joint Commission consulting services for the Behavioral Healthcare industry. Our clients include both psychiatric hospitals and freestanding Behavioral Healthcare organizations. We specialize in providing Survey Preparation and Continuous Survey Readiness services exclusively for the Behavioral Healthcare industry.  Barrins & Associates was founded by Anne Barrins who was a Joint Commission surveyor for 13 years.