The 10 Things I’d Check the Week Before Joint Commission Walks In

If Joint Commission were walking into your behavioral health organization next week, where would you start?

Most organizations immediately think about policies.

I wouldn’t.

After going through several Joint Commission surveys recently, I continue to see the same pattern: organizations often have the big things in place. It’s the smaller operational details—the things everyone assumes are fine—that create findings.

So, if I had one week before a survey, these are ten things I would be looking at.

1. I’d Open Personnel Files

Not just check that the employee has a license. I’d make sure primary source verification is there. I’d look for initial competency assessments. I’d make sure required training and credentials are current.

And most importantly, I’d make sure we can actually find everything.

“We did it, but we can’t find it” doesn't help much when a surveyor is sitting across the table waiting for the documentation.

2. I’d Read Treatment Plans Like a Surveyor

Not just confirm that a treatment plan exists.

Are the goals individualized? Do they reflect what the patient actually wants to accomplish? Are the objectives measurable? Are there identifiable steps to achieve them?

Then I’d compare the treatment plan to the assessment.

If the assessment identifies trauma, depression, grief, substance use, medical concerns or another problem, where is it addressed in the plan?

And if it isn't being addressed, is there documentation explaining why?

3. I’d Look at the Assessment Questions—Not Just the Completed Assessments

This one is easy to miss.

Sometimes staff are completing every field on an assessment perfectly, but the form itself doesn't ask everything it needs to ask.

Does your trauma screening address all required areas? Does your nutritional screening ask the questions the standard requires?

A 100% completed form can still be deficient if the form itself is incomplete.

4. I’d Walk Through the Building With Fresh Eyes

This is where leadership teams need to stop seeing the building they walk through every day.

Look up. Look down. Open things.

Are walls marked or damaged? Are vents and filters clean? Are electrical panels completely labeled? Is anything missing, broken or being temporarily “worked around”?

Walk through your facility as though you've never seen it before.

Because your surveyor hasn't.

5. I’d Open the Refrigerators—and the Cabinets

Yes, really.

Are food items dated? Labeled? Covered?

What about food stored in cabinets?

These aren't complicated compliance issues, which is exactly why they're frustrating findings to receive. They are also the kinds of things that can often be caught during a five-minute environmental round.

6. I’d Look at Every Testing Supply

If your organization performs waived testing, take a close look at your supplies and equipment.

Are containers dated when opened? Are products being used according to the manufacturer's instructions? Are the correct cleaning and disinfecting products being used?

Don't assume that because something has been done the same way for years that it is being done according to the manufacturer's current instructions.

7. I’d Check the Logs—and Ask What the Log Actually Proves

A checked box doesn't always prove compliance.

For example, documenting that emergency lighting was tested monthly doesn't necessarily establish that it was tested for the required duration.

Look at your logs and ask a different question:

If I knew nothing about our organization, would this documentation prove that we met the requirement?

If the answer is no, fix the process now.

8. I’d Ask Staff Questions

This is one of my favorites.

Don't only audit documents. Ask the person responsible for the process to explain it.

“How do you test this?”

“What do you do if this happens?”

“Show me where you document it.”

“Where would I find that?”

You can have a beautiful policy and a perfect log, but if the person responsible for the process can't explain what they're doing, you may have a problem.

9. I’d Look at the Data

Organizations collect an enormous amount of data.

But what are you doing with it?

If you're administering standardized outcome measures, are those results being used in treatment planning and to evaluate patient progress?

If you're collecting quality and safety data, are you analyzing it?

If you're collecting demographic information, have you determined how you're using it to evaluate potential disparities within the population you serve?

Collecting data and using data are two very different things.

10. Finally, I’d Ask One Question Over and Over: “Show Me.”

This may be the most important exercise of all.

Don't ask your team:

“Do we do this?”

Ask:

“Show me.”

Show me the competency.

Show me the primary source verification.

Show me where the assessment addresses it.

Show me where the treatment plan connects to the assessment.

Show me the log.

Show me the manufacturer's instructions.

Show me the data.

Show me what you did with the data.

Because during a survey, being confident that something happens isn't the same as being able to demonstrate that it happens.

The Week Before Survey Isn't the Time to Reinvent Your Organization

You shouldn't need to rebuild your compliance program seven days before Joint Commission arrives.

But it is absolutely the time to look at your organization differently.

Step away from the policy manuals for a minute. Walk the building. Open the files. Read the charts. Look inside the refrigerator. Check the logs. Talk to staff.

And keep asking:

“Can we prove that we're doing what we say we do?”

You may be surprised by what you find.

And it's much better for you to find it on Monday than for your surveyor to find it the following week.