Preparing for a Joint Commission survey can feel overwhelming, especially for behavioral health organizations balancing compliance, staffing challenges, documentation demands, and day-to-day client care. One of the biggest questions we hear at Curry Coaching and Consulting™ is: “What are surveyors actually looking for?”

While every organization is different, there are certain deficiencies that consistently appear during Joint Commission surveys. The good news? Most of these findings are preventable with the right systems, staff education, and ongoing preparation.

In this post, we’re going to break down 10 of the most commonly cited survey deficiencies and offer practical strategies to help your organization proactively address them before survey day arrives.

1. Incomplete or Inconsistent Documentation

Documentation remains one of the most frequently cited areas during Joint Commission surveys. Surveyors often identify missing signatures, incomplete assessments, unsigned treatment plans, or inconsistencies between clinical documentation and the services being provided.

The Fix:

• Conduct regular chart audits throughout the year—not just before survey time.
• Use standardized templates and documentation checklists.
• Train staff on documentation expectations and timelines.
• Create internal quality review processes to identify trends early.

One of the biggest issues we see is organizations waiting until survey season to review charts. Survey readiness should be part of your everyday operations, not a last-minute scramble.

2. Policies and Procedures That Don’t Match Practice

Having policies is not enough. Surveyors frequently compare written policies against what staff are actually doing in practice. When workflows don’t align with policies, deficiencies can quickly follow.

The Fix:

• Review policies annually and anytime regulations change.
• Ensure operational workflows reflect your written procedures.
• Include leadership and frontline staff in policy reviews.
• Train employees whenever policies are updated.

Your policies should reflect real-world operations—not an ideal process that no one is actually following.

3. Staff Training and Competency Gaps

Surveyors commonly review training records and staff competency documentation. Missing training, expired certifications, or inconsistent onboarding processes are major red flags.

The Fix:

• Maintain centralized training records.
• Create annual training calendars.
• Track due dates for certifications and required education.
• Conduct competency assessments routinely—not only during onboarding.

Staff should feel confident explaining safety procedures, client rights, emergency protocols, and their role in compliance efforts during interviews.

4. Environment of Care and Safety Concerns

Behavioral health organizations are frequently cited for environmental and safety issues, including blocked exits, unsecured hazardous items, improper storage, or incomplete safety checks.

The Fix:

• Conduct routine environmental rounds.
• Create monthly safety inspection checklists.
• Ensure fire extinguishers, alarms, and emergency equipment are inspected regularly.
• Document all safety drills and corrective actions.

Small environmental issues can create larger concerns during a survey because they may signal a lack of ongoing monitoring.

5. Infection Control Deficiencies

Infection prevention remains a major focus area across healthcare settings. Surveyors often look for gaps in hand hygiene practices, cleaning protocols, PPE usage, and documentation of infection control activities.

The Fix:

• Implement consistent infection control training.
• Monitor hand hygiene compliance.
• Maintain cleaning logs and sanitation schedules.
• Assign clear oversight responsibilities for infection prevention efforts.

Organizations should be able to demonstrate not only policies, but active monitoring and follow-through.

6. Medication Management Issues

Medication-related deficiencies are especially common in organizations providing psychiatric or substance use services. Common findings include incomplete medication logs, storage concerns, or lack of medication reconciliation processes.

The Fix:

• Conduct regular medication storage audits.
• Ensure expired medications are removed promptly.
• Review medication administration records routinely.
• Train staff thoroughly on medication documentation expectations.

Consistency and accountability are key when it comes to medication management processes.

7. Lack of Performance Improvement Data

The Joint Commission places strong emphasis on continuous quality improvement. Organizations sometimes struggle to demonstrate meaningful use of performance data or documented improvement activities.

The Fix:

• Develop measurable quality indicators.
• Collect and analyze data consistently.
• Document improvement initiatives and follow-up actions.
• Share performance improvement efforts with staff regularly.

Surveyors want to see that organizations are identifying problems, taking action, and monitoring outcomes over time.

8. Emergency Preparedness Weaknesses

Emergency management plans are another commonly cited area. Surveyors may identify outdated plans, missing drill documentation, or staff unfamiliarity with emergency procedures.

The Fix:

• Review emergency preparedness plans annually.
• Conduct and document drills consistently.
• Include behavioral health-specific emergency scenarios.
• Train staff on evacuation procedures, communication plans, and emergency roles.

Preparedness goes beyond having a binder on a shelf. Staff should know what to do if an emergency happens today.

9. Client Rights and Grievance Process Deficiencies

Organizations are often cited when clients are not properly informed of their rights or when grievance procedures are inconsistently documented.

The Fix:

• Ensure client rights are reviewed during intake.
• Post grievance information visibly within the facility.
• Maintain documentation of complaints and resolutions.
• Train staff on client rights protections regularly.

Behavioral health organizations must demonstrate that clients are informed, respected, and protected throughout the treatment process.

10. Staff Not Prepared for Survey Interviews

One of the most overlooked areas of survey readiness is staff confidence during interviews. Even strong organizations can struggle if employees are unsure how to answer questions about policies, safety procedures, or workflows.

The Fix:

• Conduct mock surveys regularly.
• Practice tracer scenarios with staff.
• Review common survey questions during team meetings.
• Focus on helping staff understand the “why” behind processes, not just memorizing answers.

Surveyors are not expecting perfection, but they do expect staff to understand the systems and processes within the organization.

Joint Commission surveys can absolutely feel stressful, but preparation makes all the difference. The organizations that perform best during surveys are not necessarily the ones with the most resources, they’re the ones that build compliance into their daily operations.

Survey readiness should be viewed as an ongoing process rather than a one-time event. When organizations focus on consistent documentation, staff education, quality improvement, and operational alignment, survey outcomes become significantly less intimidating.

At Curry Coaching and Consulting™, we help behavioral health organizations simplify the accreditation process, strengthen compliance systems, and prepare confidently for surveys. Whether you’re preparing for your first Joint Commission survey or working to improve after previous findings, having the right support can make the process far more manageable. What areas does your organization find most challenging during survey preparation? We’d love to hear your experiences and help support your team through the process.