Parents: Beware of JCAHO accreditation and state licensing

[AuntieEm]

Parents, I urge you to always investigate further the licensing and accreditation claimed by a therapeutic boarding school (TBS), wilderness program, or boot camp for teens.

* "JCAHO accreditation" is often very misleading.  Look specifically at what a facility's accreditiation actually means.  Here is the site for the Joint Commission Accrediting Healthcare Organizations (JCAHO): http://http://www.jointcommission.org/. Look for the "Quality Check" at the right, and search for your school. Also, look at the organization's "Publicity Kit" for its Gold Seal of Approval--very heavy emphasis on branding the Joint Commission. http://http://www.jointcommission.org/AccreditationPrograms/PublicityKit/gold_seal.htm

Now take the example of VisionQuest, a program in PA that a parent recently asked about here on Fornits.

According to what I've read VisionQuest is JACHO approved, and has been studied by the Rand Corp and University of PA and found effective.

JCAHO "accreditation" (not "approval") means things like the staff checks 2 IDs before administering meds, that the staff agrees on acronyms and abbreviations in written records, and that they follow handwashing protocol.

Have a look. Here are the "Safety Goals" that JCAHO accredits for VisionQuest:
http://www.qualitycheck.org/QualityRepo ... lth%20Care

The report further says that the last time JCAHO completed a "full survey" of the VisionQuest facility was 9/23/05--over two years ago--and the last time they  
completed an "on-site survey" was 3/17/06, more than 18 months ago.  

JCAHO accreditation tells you nothing about the facility's ability to handle a teen with mental illness, past traumas or violence, emotional difficulties, or drug use. Yet VisionQuest, like other facilities, is more than happy to let parents think that.

* Licensing can be equally misleading. Dig deeper. I looked into licensing of a facility in Idaho. What "licensing" means there is that they meet the miniumums for a licensed boarding school--such as, they have a fire evacuation plan, their food service is sanitary, they have written educational plans on file for each student, staff in certain positions have a certain level of education, etc. Here are the Idaho regulations: http://http://adm.idaho.gov/adminrules/rules/idapa16/0602.pdf. I encourage you to look up the regs for other states with TBSs. I found this of little value in knowing the quality of care, therapy or education at the facility. If they are found to be in violation of the licensing code,  a "deficiency" is reported and the facility is asked to fix it (the facility remains open).

Accreditation by the Idaho Department of Education (IDOE) means only that they can issue a high school diploma. As a private school, the accreditation comes not through the ID DOE, but through a private non-profit accrediting body, the Northwest Association of Accredited Schools (NAAS). I have learned through news reports and posts by others here at fornits that the State of New York has refused to accept diplomas from other boarding schools accredited by NAAS (Ivy Ridge, if I'm not mistaken).

This information is public record. By all means verify any of it for yourself.

Please do not be falsely reassured by licensing and accreditation. You must investigate further.

AuntieEm

[Deborah]

Further....

July 1, 1996, Three Springs of Duck River (Tennessee), 615-729-5040, no longer provides contract services for children in State of Tennessee custody. This has been the result of a several year plan to reduce the number of State of Tennessee contracted beds. This was accomplished earlier than expected due to their successful effort to gain accreditation through the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). JCAHO accreditation enabled the program to access referrals and payment from sources previously not available. They report the current payer mix at the Duck River program involves approximately 65% private out of pocket pay, 30% managed care pay, and 5% publicly funded through adoption assistance or education funds.

(October 28, 2002) Jared Balmer, Ph.D., Director of Island View, and Oakley School, accepted this past summer, an appointment to the Advisory Committee for Behavioral Health Care Services, which was recently developed by the Joint Commission on Accreditation of Health care Organizations (JCAHO).

(August 13, 2003) Sarah Moir, Catherine Freer Wilderness Therapy Expeditions, announced they were recently selected to serve as a test site for a JCAHO pilot project. The Joint Commission on Accreditation of Healthcare Organization project, Shared Visions-New Pathways, is designed to sharpen the focus of the accreditation process, emphasizing safety and quality of patient care. It “provided CFWTE with valuable feedback… and allowed staff to work with JCAHO surveyors to improve the accreditation process and new standards which go into effect in January, 2004.â€

[Anonymous]

Straight was accredited by JCAHO also at some sites.

[ZenAgent]

Peninsula Village claimed JCAHO accreditation even when it didn't have it - it's umbrella hospital Park West had it for two of their clinical labs.  Now when I check JCAHO, I see Peninsula Behavioral Health has accreditation - that includes much more than PV, and I'd be interested to know if the JCAHO even peeked into the Village or only checked out the hospital, the lighthouse,etc.  The qualifications met looked like the basic ground rules a Taco Bell employee should follow.

[AuntieEm]

Zen

The JCAHO qualifications looking like basic rules for Taco Bell...
Ouch, that's funny.

AuntieEm

[Deborah]

Same with Ridge Creek
http://www.qualitycheck.org/QualityRepo ... lth%20Care

Deals with meds and handwashing.
Ridge Creek has had record breaking violations of regulations on two seperate inspections.
http://fornits.com/wwf/viewtopic.php?p=227534#227534
http://fornits.com/wwf/viewtopic.php?p=285705#285705

[hanzomon4]

Bump

[AuntieEm]

Deborah,

How did you go about requesting those records of citations? From JCAHO itself? From the state? From whom did you request what, exactly?

Thanks,

AuntieEm

[Ursus]

Yes, I sure would like to know more about that as well.  Also, the academic accreditation.  Hyde posters have complained about Hyde credits being considered non-transferable or, at the very least, of significantly less value to public or other school systems than they had been led to believe.  Many of the faculty are, in fact, athletic coaches doing double duty.  Some of the coaches are actually teachers doing double duty as well.  Some people are teaching courses when they haven't even graduated from college yet.

Hyde claims it is a lot of school with "a little therapy on the side."  That is a complete bogus misnomer; one's whole life there revolves around being "therapeutized" 24/7.  Yet no one there is a qualified therapist or similar profession in that field.  In fact, they hold tremendous disdain for these professionals, since all that should be necessary is that "you care."

How does one go about forcing such an institution to "come clean?"  They don't measure up in either department, yet seem to pull the wool over our eyes so well.

[Deborah]

Deborah,
How did you go about requesting those records of citations? From JCAHO itself? From the state? From whom did you request what, exactly?
Thanks,
AuntieEm

The violations of regulations for Ridge Creek are posted on the Office of Regulatory Services website, the agency that licenses and monitors programs in Ga. To clarify, they weren't JCAHO violations.
From this page
http://ors.dhr.georgia.gov/portal/site/DHR-ORS/
Select "Facility Compliance Reports"

Unfortunately, all states don't make the results of inspections public on their websites, but you can request reports if the facility is licensed.

[Deborah]

This was JCAHOs response when I filed a complaint against Ridge Creek.
Note that there is a time limit regarding complaints.

Thursday, September 07, 2006
Regarding: Ridge Creek, Inc.
Incident #1708HMC-6831XCM

This is to inform you that we have completed our review of your complaint regarding the above organization.

Based on Joint Commission policy, we are unable to evaluate issues greater than three years old. Please be assured that although no action could be taken at this time, this does not mean that we do not view your issues as important.

Per our Public Information Policy, the following information is provided upon request as it becomes available:

-The number of standards-related written complaints filed against an accredited organization that have met criteria for review
-The applicable standards are as involved in a specific complaint review
-The standards areas in which requirements for improvement were issued as a result of complaint evaluation activities
-When an unannounced or unscheduled survey is based on information derived from a complaint or public sources, the standards areas related to the complaint
-Any determination that the complaint is not related to Joint Commission standards

In addition, you may also wish to refer to the organization's Quality Report, which is available at the Joint Commission's web site (www.jcaho.org, and click Quality Check), to obtain general information about the organization's performance on key quality measures. To obtain a hard copy of the report, please contact our Customer Service Center at (630) 792-5800 or write to the Customer Service Center at

Customer Service Center
Joint Commission on Accreditation of Healthcare Organizations
One Renaissance Blvd.
Oakbrook Terrace, IL 60181

The Joint Commission stands ready to receive and review issues of concern about accredited organizations at any time and will act in accordance with all the information that is provided to us.

Sincerely,

Ms. Carol L Ally, RN, BSN
Office of Quality Monitoring

[Ursus]

...This is to inform you that we have completed our review of your complaint regarding the above organization.

Based on Joint Commission policy, we are unable to evaluate issues greater than three years old. Please be assured that although no action could be taken at this time, this does not mean that we do not view your issues as important.

Per our Public Information Policy, the following information is provided upon request as it becomes available:

-The number of standards-related written complaints filed against an accredited organization that have met criteria for review
-Any determination that the complaint is not related to Joint Commission standards

The Joint Commission stands ready to receive and review issues of concern about accredited organizations at any time and will act in accordance with all the information that is provided to us.

Sincerely,

Ms. Carol L Ally, RN, BSN
Office of Quality Monitoring

Basically taken straight off the "kiss-off" template.  Was your complaint kept?  Or filed in the nearest trash receptacle?  I can understand where logistically they might need to put a time limit on complaints (although three years does seem rather short), but keeping said complaints on file, despite being outside the time limit, would seem prudent from their perspective...

[AuntieEm]

I assume, too, that one can only file complaints about the handwashing, meds dispensing, use of acronyms and abbreviations etc. the JCAHO covers.

Per our Public Information Policy, the following information is provided upon request as it becomes available:

-The number of standards-related written complaints filed against an accredited organization that have met criteria for review
-Any determination that the complaint is not related to Joint Commission standards

Deborah, you may not wish to discuss further, but do I assume correctly that your complaint was related to the JCAHO standards? The kiss-off about 3 year time limit conveniently eliminates any meaningful response. I got the records for past 3 years on BCA, NWA, and Ascent in ID (from ID HHS and Dept of Ed) and there was nothing. No complaints? None? Just doesn't seem logical.  

AuntieEm

[TheWho]

I think this further shows that parents cant rely on accreditation, licenses or government regulation of any of these schools to keep their kids safe.  We all know it doesn’t help kids in the public school system, so why rely on this in the private sector.

Parents need to treat this as they would if they were looking for a doctor by getting referrals from other patients or a doctor you have come to trust.
Don’t assume a TBS is a good fit for your child because of its affiliations or number of organizations it belongs to!

 Parents need to:

1.   Visit the schools and get a feel for the staff and grounds where your child will be staying.

2.   Ask to speak with other parents who have had children attend the school.

3.   Ask to see the schools policies on discipline, academics etc. to see if this is a good match for your family values.

4.   Look at what types of children they accept (i.e. juvenile offenders, court ordered minors etc.).  It is important that your children be with others who are on a similar path in life.

5.   Ask if your child can see a therapist who is independent from the school (who you pay separately)

6.   Ask about your financial obligations in the event the school isn’t a good match and you need to pull the child out early.

There are more, but this should serve as a good start.



...

[Deborah]

I assume, too, that one can only file complaints about the handwashing, meds dispensing, use of acronyms and abbreviations etc. the JCAHO covers.

I have never seen the JCAHO requirements or rules. One must purchase that information. http://fornits.com/wwf/viewtopic.php?p=288722#288722

Deborah, you may not wish to discuss further, but do I assume correctly that your complaint was related to the JCAHO standards?

No. I've never seen the requirments for wilderness programs or RTCs. The information I sent would be considered a violation of any agency's standards.

The kiss-off about 3 year time limit conveniently eliminates any meaningful response. I got the records for past 3 years on BCA, NWA, and Ascent in ID (from ID HHS and Dept of Ed) and there was nothing. No complaints? None? Just doesn't seem logical.  AuntieEm

No it doesn't seem right. But plausible. Parents may not know where/how to file complaints.
Look at VisionQuest. 14 deaths and they're still JCAHO accredited. Catherine Freer, 3 deaths, still accredited.
What, if any, violations would result in a program loosing their accreditation?