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The five ‘most challenging' standards in 2011

March 27, 2012
by Nick Zubko, Associate Editor
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Every year, the Joint Commission collects data on how well organizations are complying with standards to identify key trends and focus education on those requirements that pose the biggest challenges.

In the “Most Challenging Requirements” for 2011, five Joint Commission standards were cited as most frequently “non-compliant” by accredited behavioral health organizations and certified programs.

The top five offenders are listed by code below, along with a brief explanation and the reported rate of non-compliance.

1. CTS.03.01.03: The organization has a plan for care, treatment, or services that reflects the assessed needs, strengths, preferences, and goals of the individual served.

Non-compliance rate: 32%.

2. HR.02.01.03: The organization assigns initial, renewed, or revised clinical responsibilities to staff who are permitted by law and the organization to practice independently.

Non-compliance rate: 21%

3. CTS.02.01.11: The organization screens all individuals served for their nutritional status.

Non-compliance rate: 16%

4. NPSG.15.01.01: Identify individuals at risk for suicide.

Non-compliance rate: 14%

5. CTS.04.03.33: For organizations providing food services: The organization has a process for preparing and/or distributing food and nutrition products.

Non-compliance rate: 13%

Two standards (HR.02.01.11 and NPSG.15.01.01) were repeated from last year's list; non-compliance for the former increased by 1%, while the latter's went down that much. The biggest change was seen in the CTS.03.01.03 standard (known as PC.4.40 until last year), which decreased 6%. 

For a full look at the 2010 results, click here.


Nick Zubko

Associate Editor

Nick Zubko


Nick Zubko is associate editor of Behavioral Healthcare.

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