Joint Commission Behavioral Health Update

Barrins & Associates welcomes two new clients this month:

Michael's House is located in Palm Springs, California and provides specialized treatment services for individuals dealing with chemical dependency and mental health issues. Services are provided at four campuses that include a Men's Center, a Women's Center, a Stabilization Center, and an Outpatient Program. Michael's House is part of Foundations Recovery Network and is accredited by the Council on Accreditation of Rehabilitation Facilities (CARF).

  Congratulations Corner

Psychiatric Advance Directives

Heads up for organizations and programs surveyed under TJC's Behavioral Health standards: We have noted that the topic of psychiatric advance directives is receiving increased scrutiny during Behavioral Health surveys.

Background

The standard regarding psychiatric advance directives is in the Care, Treatment, and Services chapter of the 2013 BH manual and was added in 2011:

CTS.01.04.01 The organization supports the adult's decisions (psychiatric advance directives) about how care, treatment, or services are to be delivered during times when he or she is unable to make such decisions.

This standard applies only to organizations that serve adults with serious mental illness. The elements of performance require the following:

1. The organization documents whether the adult has a psychiatric advance directive.
2. Upon request, the organization shares with the adult sources of help in formulating psychiatric advance directives.
3. If the adult has a psychiatric advance directive, clinical staff who are involved in the care, treatment, or services provided to that adult are aware that the psychiatric advance directive exists and how to access it.

Survey Scrutiny

Recently, surveyors have been asking BH organizations that serve the SMI population what their process is for determining if a client has a psychiatric advance directive (PAD) and what resources they provide to clients who are interested in developing one. Surveyors have also reviewed records to find documentation of this process. Organizations have been cited for the following issues:

• Not having a policy/procedure on psychiatric advance directives
• No documentation in the chart that the client had been asked about psychiatric advance directives
• Staff unaware of any process for discussing psychiatric advance directives with clients

Interestingly, there is not a standard specific to PADs in the TJC Hospital Manual under which psychiatric hospitals are surveyed. There is, of course, a Hospital standard on advance directives (RI.01.05.01) as they relate to care received at the end of life. Thus, all psychiatric hospitals are required to have a policy on advance directives related to medical care. Some psychiatric hospitals broaden this policy to address PADs as well.

One complicating issue is that although TJC specifies that this standard applies only to "organizations that serve adults with serious mental illness", they do not provide a definition of "serious mental illness" (SMI). While definitions vary, the National Institute for Mental Health (NIMH) has used the following definition of SMI:

• A mental, behavioral, or emotional disorder (excluding developmental and substance use disorders)
• Diagnosable currently or within the past year
• Of sufficient duration to meet diagnostic criteria specified within the DSM-IV.
• Resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.
• Note: Serious functional impairment has been further defined as impairment equivalent to a Global Assessment of Functioning (GAF) score of less than 60 (Endicott, Spitzer, Fleiss, & Cohen, 1976).

Most BH organizations serve both adults who would qualify as SMI and adults who would not. Thus, a key decision when developing a PADs policy is whether to apply the process to all clients or just those who qualify as SMI. Understandably, it's often easier to implement the policy for all adults served.

State-by-State Variability

One of the challenges in formulating a policy on psychiatric advance directives is that laws governing these directives vary from state to state. There are 25 states that have specific PAD statutes. All states provide health care power of attorney which clients can use to plan for their psychiatric as well as medical treatment. Thus, it's critical to research and determine your state laws re PADs in order to develop a policy that is compliant with state statute. The National Resource Center on Psychiatric Advance Directives provides state by state information on the different state laws pertaining to PADs and is an excellent resource on this subject.

Compliance Tips

So, in order to be fully compliant with the BH standard on PADs, we recommend the following steps:

• Research your state law on PADs.
• Research the resources that you can provide to your clients about PADs.
• Develop a written policy/procedure. Be sure to address:
• The specific process for having a discussion with the client about PADs (who, when, etc)
• How this should be documented in the record.
• The specific resources to be shared with clients who want more information about PADs.
• Educate staff about your PADs policy and their role in the process.
• Monitor your records for compliance with documentation of the PADs process.

Resources

In addition to the National Resource Center on Psychiatric Advance Directives, another good resource is the presentation Integrating Psychiatric Advance Directives into Clinical Practice by Dr. Eric Elbogen of University of North Carolina-Chapel Hill School of Medicine.

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