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*TJCsvyrMD_BAUER_Anne C Bauer, MD


Anne C. Bauer, MD


Surveyor Program(s): Hospital

Surveyor Tenure: x 2007

Lives: Massachusetts

TJC Bio:

  • 2016: Dr. Bauer is a Psychiatrist Surveyor and a Field Director in the Hospital Accreditation Program. She started surveying for The Joint Commission in 2007 and has been a Field Director since September of 2013.  She has held a variety of roles within mental health care delivery systems throughout New York and New England. Previously she was the Medical Director for a state mental health system of care. She has held Medical Director roles at a Psychiatric Hospital,Community Mental Health Center and community hospital based Inpatient Psychiatric Units.
  • 2013: She has a small psychiatric practice in Northhampton and is on staff at Cooley Dickenson Hospital.  She has worked in a variety of mental health systems of care and held the role of Medical Director for a State system, a psychiatric hospital, and a community mental health center clinic.

Other Background:

  • Dr. Bauer completed her psychiatric residency training at Columbia College of Physicians and Surgeons in NYC and a Fellowship in Public Psychiatry.
  • She is board certified in General and Adolescent Psychiatry

Comments & Recommendations

  • Complimented on nice building, environment for patients
  • Something was off for us from the start, really was not easy to work with, seemed very negative, efforts to engage in consultative process unsuccessful.  None of our staff seemed able to connect with this surveyor.  Not receptive to looking at things differently, cited on lack of social assessment, we have our social assessment built into our treatment plan and call it a bio-psycho-social formulation, which was not acceptable.  Had to be a stand-alone assessment.


Relevant Surveying History:

• Metropolitan Regional Hospital ### • Alaska Psychiatric Institute 1301
• Downtown Psychiatric Health Center  ###  • Richmond State Hospital 1607


** Sample Survey Citations (Premier Level)**

[private Membership premier]


Sample Citations:


  • HR.01.02.05/EP 1/Observed in Personnel File Review: Review of the personnel file for a therapist (Social Worker) it was evident that primary source verification of current licensure had not been conducted at time of expiration of license..
  • LD.04.04.05/EP 8/Observed in Death Review: During a review of an unanticipated death at this facility, it was learned that a Root Cause Analysis had not been done because the Medical Director and others had determined it was not a Sentinel Event. However, the patient had not been diagnosed with a medical illness that was expected to lead to his death and he was being treated for psychiatric illness. Therefore it would seem that this met the definition of a Sentinel Event according to the facility’s
    definition. Moreover, the facility’s Sentinel Event policy indicates that a RCA should be done when it is not clear.
  • MM.02.01.01/EP 9/ Observed in Medication Management Tracer: It was learned in discussion with the Pharmacy Director and the Medical Director that the formulary had not been reviewed since 2011.
  • MS.06.01.05/EP 7/ Observed in Medical Credentials Review: It was observed in one file that the NPDB query had been done after the date that the Medical Staff member was reprivileged
  • MS.06.01.05/EP 8/Observed in Medical Credentials Review: Peer recommendations which are required for the privileging process were absent from one file and obtained after the Medical Staff member was re privileged in 2 other files.
  • MS.08.01.03/EP 3/Observed in Medical Credentials Review: In reviewing files of 2 medical practitioners, a PA and an Internist, it was learned that OPPE has not yet been developed and utilized for the reprivileging of these practitioners.
  • NPSG.02.03.01/EP 2/Observed in Pt Tracer: In the patient record it was observed that 3 separate high valproate levels had been reported and faxed to the facility. The facility considers these to be critical results and there was no documentation in the record that these had been called by the pharmacy within the expected time frame.
  • PC.01.02.01/EP 1/Observed in Pt Tracer: It was observed in the patient record that there was no comprehensive Social Services assessment. A review of policy revealed that there was no description of the content and scope of the Social Services assessment which is required in B108.
  • PC.01.02.13/EP 3/ Observed in Pt Tracer: It was observed that the patient record did not include a comprehensive Social Services Assessment as required
    by B108.



You may provide surveyor feedback by clicking on the ‘Comments’ link above (2nd line, top left) and/or via the New Post Survey Questionnaire (PSQ).

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