Recent survey activity and subsequent findings indicate a renewed interest by the Centers for Medicare and Medicaid (CMS) and the Joint Commission (TJC) in inpatient behavioral health and psychiatric hospitals.

Along these same lines, Immediate Jeopardy (IJ) findings and even implementation of Systems Improvement Agreements (SIA) are becoming more and more common. Across the country, healthcare facilities are receiving extraordinary penalties for noncompliance, ranging from the implementation of SIAs to the revocation of participation to institutional closure. 

These extreme sanctions are clearly the result of assessments of compliance with the CMS Conditions of Participation (CoPs) for psychiatric services.


What is prompting this focus? Will the attention wane or increase in the coming months, or even years? How can hospital leaders proactively respond?

Expect Increased Scrutiny

Indications from the Inspector General of CMS point to increased attention as the focus on ensuring safe care in return for federal reimbursements intensifies.

The increased focus on psychiatric services may be in response to complaints and public information about incidents and potential injuries in inpatient facilities. Advocacy groups, families of patients, and even hospital staff have turned to state departments and health compliance hotlines to report allegations of mistreatment. News and media organizations then draw the public’s attention to these allegations of poor care or even abuse. With the eyes of the public cued in on happenings in behavioral health, increased regulatory scrutiny must follow.

What makes psychiatric care and behavioral health so vulnerable to noncompliance with the CoPs?

We know that’s a complex question, but here are four possible answers:

1. Standardization:

Unlike acute care hospitals, psychiatric facilities are less likely to impose standard care algorithms, checklists, and protocols as minima for treatment planning. Acute care hospitals offer care pathways; surgical staff implements universal protocols; ventilator patients are treated with regimented care plans to prevent infections. There are few such treatment guidelines available or implemented in behavioral health, as each patient follows a unique trajectory of care. Acute care has a long history of converging standards;  in behavioral health, this practice is just beginning.

2. Resources:

Psychiatry and behavioral health have experienced extreme pressure to constrain resources dedicated to treatment. Reimbursement rates are, to say the least, limiting. Providing sufficient facilities, technology, and professional staff becomes a complex challenge when faced with a scarcity of funds.

3. Staffing:

Educated and licensed staff have limited frontline care roles in behavioral healthcare. Behavioral health patients receive most of their direct contact with minimally trained—though often well-intentioned—behavioral aides or nursing assistants, while registered nurses, psychologists, and psychiatrists primarily contribute to care direction and supervision. As a result, daily contact and care are predominantly provided by nonprofessional staff.

4. Population:

Behavioral health patients are frequently the most vulnerable in terms of ability to advocate for personal rights. The very issues that necessitate inpatient care also expose these patients to jeopardy.

Preparation is the Best Prevention

Behavioral health leaders need to be cognizant of the increased regulatory scrutiny directed toward their institutions. Preparation is the best prevention—familiarity and compliance with TJC behavioral health standards is a start.

Most important, however, is that hospital leaders and staff pay rigorous attention to the CoPs for psychiatric facilities as articulated by CMS in the “B-tags.” A baseline assessment of compliance provides a working tool to address identified limitations. Additionally, leaders must respond diligently to any and all clinical compliance complaints and concerns.

A proactive plan for compliance reduces the risk of surprises and unhappy outcomes.

To learn more about Compass Clinical Consulting‘s Preparation Services, visit our website or contact Kate Fenner, PhD, RN, at (800) 241.0142.

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