Most behavioral health organizations generally appear to meet quality standards in operations and management. However, a recent report from the nonprofit Accreditation Commission for Health Care (ACHC) reveals that a significant number are still falling short in crucial areas that affect both compliance and the quality of care. These ongoing behavioral health compliance challenges present risks to both patient safety and organizational sustainability.
The findings were published in The Surveyor, a quality review publication by ACHC that incorporates standards from both ACHC and the Healthcare Facilities Accreditation Program (HFAP). ACHC and HFAP both have deeming authority from the Centers for Medicare and Medicaid Services (CMS) and merged their operations last year. This merger combined their expertise and regulatory oversight, strengthening the standards applied to community-based health organizations and education programs.
For its analysis, ACHC reviewed deficiencies reported by behavioral health organizations from June 1, 2020, to May 31, 2021. The report focused on three major categories: provision of care and record management, program and service operations, and human resource management. Within these categories, nine specific benchmarks were assessed for compliance. Alarmingly, all nine benchmarks recorded double-digit rates of non-compliance, indicating widespread gaps that behavioral health providers need to urgently address. These findings highlight persistent behavioral health compliance challenges that require focused attention.
Impact of the Pandemic on Behavioral Health Compliance Challenges
The report recognizes that the COVID-19 pandemic had a significant impact on the operations of behavioral health organizations. Many providers had to make rapid, unplanned changes to continue serving their patients and clients. These adaptations included adopting new technologies to enable remote visits and patient monitoring, dealing with personal protective equipment (PPE) shortages, and reallocating staff to manage furloughs and quarantine requirements.
These emergency responses, while necessary, shifted organizational priorities. The report notes that such changes likely diverted attention from routine compliance activities, contributing to the higher rates of deficiencies seen during this time. This context is important to understand, but it also highlights the need for organizations to strengthen their internal processes to overcome ongoing behavioral health compliance challenges.
Confidential Health Information Policies Among Top Behavioral Health Compliance Challenges
The most significant area of non-compliance involved policies and procedures for securing and releasing confidential and protected health information. The report found that 31% of organizations lacked proper protocols in this area. This is concerning given the critical importance of protecting patient privacy in behavioral health care.
Specifically, organizations were often deficient in ensuring that clients received clear information about confidentiality policies at the start of services. There were also frequent instances where organizations failed to obtain or maintain signed releases of information before sharing patient records with third-party vendors or individuals outside the organization. This lack of proper documentation can lead to serious breaches of privacy and legal risks.
To address these issues, the report recommends that behavioral health organizations conduct regular audits of personnel and client records. Human resource managers should be tasked with periodically reviewing personnel files to confirm the presence of signed confidentiality statements. Clinical directors and administrators should also review client documentation related to confidentiality policies to ensure compliance. These steps will help reinforce the client-centered nature of therapeutic relationships by safeguarding sensitive information, a critical step toward resolving major behavioral health compliance challenges.
Gaps in Staff Orientation and Training as Behavioral Health Compliance Challenges
The second most prevalent deficiency, reported in 26% of organizations, was the lack of a standardized process for orienting new personnel. A formal orientation is essential to ensure that employees understand the organization’s policies, procedures, and expectations from day one.
The report urges organizations to develop detailed orientation plans and assigns human resource managers the lead role in implementing these. Proper orientation supports consistent service delivery and regulatory compliance, which in turn protects both clients and staff. Lack of orientation processes remains a persistent behavioral health compliance challenge that impacts organizational effectiveness.
Training also emerged as an area with notable deficiencies, although at a lower rate compared to orientation. About 15% of organizations failed to have adequate plans for ongoing personnel training. Given the complex nature of behavioral health care, continuous education and skill development are critical to maintaining high-quality services.
The ACHC recommends that human resource managers manage educational plans and conduct regular personnel record reviews to document training activities and verify that staff meet educational requirements. Investing in staff development is especially important in the behavioral health sector, which faces ongoing workforce shortages and burnout issues—both major underlying factors contributing to behavioral health compliance challenges.
The Bigger Picture: Why Overcoming Behavioral Health Compliance Challenges Matters
Maintaining compliance with operational and management benchmarks is not simply about meeting regulatory requirements—it directly impacts the quality and safety of patient care. Organizations that struggle with these standards risk compromising client confidentiality, service consistency, and overall treatment effectiveness.
The report highlights a key insight: providers that fully embrace accreditation as a framework for continuous quality improvement tend to be more data-driven and outcomes-focused. These organizations often develop more sustainable business practices and build stronger reputations in their communities.
In an environment where behavioral health needs are growing and evolving rapidly, having robust policies and procedures is essential. Providers who strengthen their internal compliance programs not only enhance client trust but also position themselves better for long-term success. This is particularly important as the industry continues to navigate pandemic recovery, workforce challenges, and increasing regulatory scrutiny.
Moving Forward: Strategies to Address Behavioral Health Compliance Challenges
To close the gaps identified by ACHC, behavioral health organizations should consider the following actions:
- Implement regular audits of personnel and client records focused on confidentiality agreements and data security.
- Develop and enforce comprehensive policies for managing protected health information, ensuring that clients fully understand their rights.
- Establish formal orientation programs for all new employees to promote consistency and regulatory compliance from the start.
- Create detailed and ongoing training plans overseen by human resource departments, documenting all educational activities.
- Assign accountability at leadership levels, including clinical directors and administrators, for reviewing compliance related to client confidentiality and staff training.
- Use accreditation as a continuous improvement tool, adopting data-driven approaches to monitor compliance and outcomes over time.
By focusing on these areas, behavioral health organizations can reduce risk, improve client outcomes, and build a resilient operational foundation to support their mission of care while overcoming persistent behavioral health compliance challenges.
The ACHC report serves as a valuable reminder that even in times of crisis, behavioral health organizations must prioritize adherence to quality standards. Doing so ensures that the vulnerable populations they serve continue to receive safe, respectful, and effective care. Addressing behavioral health compliance challenges head-on will strengthen the entire field for the future.