Service Domain Description

II – Compliance (CMS Certification & Joint Commission Accreditation)

A.     Compliance Assessment

1.  Comprehensive Assessments: 

  • Descrip:  PPR-type assessment and Systems Analysis to determine level of compliance of all applicable standards for your facility or program conducted by former TJC or CMS surveyor associate(s)
  • Venue: On site (evaluation)

2.  Focused Assessments:  

  • Descrip:  Assessment of specific areas of standard compliance concern using process analysis, chart/document review, tracers or combinations thereof.
  • Venue: On site (evaluation) or Off site (TeleVideo interviews, redacted document review and E-tracers)

3.  Improvement Assessments:  

  • Descrip:  Facilitation assistance and guidance with Root Cause Analysis (RCA) or Failure Mode Effects and Criticality Analysis (FMCA)
  • Venue: On site (consultation/facilitation) or Off site (TeleVideo interviews, redacted document reviews)

B.     Compliance Achievement

1.  Standards Clarification and/or Training:

  • Descrip:  Explication and clarification of CMS and/or TJC standards as they apply to psychiatric hospitals and BHC programs.  For programs, teams, professional disciplines and individuals preparing for Joint Commission Certified Accreditation Professional (JCAP) exam preparation.
  • Venue: On site (training/presentation) or Off site (TeleVideo conference)

2.  Standards Updating:  

  • Descrip: Overview of new, revised and/or pre-publication standards for the year.  [Note: SPHCC members also receive a monthly updating newsletter]
  • Venue: On site (training/presentation) or Off site (TeleVideo conference)


3.  Standards Applicability & Implementation : 

  • Descrip:  Consultative advice on applicability and strategies for implementing standards in psychiatric hospitals and BHC programs.
  • Venue: On site (consultation) or Off site (TeleVideo conference)

C.     Compliance Demonstration (i.e., Survey Success)

1.  Survey Process Training: 

  • Descrip:  Overview training on CMS or TJC on-site survey process to include typical schedules, technologies (e.g., tracers), interviews, citation and scoring processes
  • Venue: On site (training/presentation) or Off site (TeleVideo conference)


2.  Survey Management Strategies: 

  • Descrip:  Presentation and discussion of strategies and tips for increasing the effectiveness of managing surveyors and the survey process to include mitigation of RFI vulnerability.   [Note: SPHCC members also have access to our surveyor profile data]
  • Venue: On site (consultation) or Off site (TeleVideo conference)


3.  Mock Survey and/or Mock Tracers: 

  • Descrip:  Survey process run by former CMS or TJC surveyors designed to closely simulate the experience of an actual survey process with the benefit of strategic ‘time outs’ for training purposes.
  • Venue: On site (mock survey/tracers) 


4.   Survey Real-Time Backup: 

  • Descrip:  Former CMS or TJC surveyor associate on special availability to provide survey management assistance and/or respond to standards questions during actual survey   [Note: TJC Standards Interpretation Group is not available to organizations during survey].
  • Venue: On site (by pre-arrangement) or Off site (24/7 E-Support)  [Note: on site consultant may not directly participate in survey process, but can observe and facilitate admin, communication and other survey support processes]

D.     Compliance Maintenance

1.  Ongoing Compliance Plans: 

  • Descrip:  Customized 1-3 year plan and schedule of compliance maintenance activities.   
  • Venue: On site (consultation/facilitation) or Off site (TeleVideo interviews, redacted document reviews)


2.  State & Psychiatric Hospital Compliance Collaborative (SPHCC): 

  • Descrip:  Unique resource for the support of ongoing compliance via participation in an online collaborative of psychiatric facilities committed to sharing compliance information and survey experience.  Includes:

♣     a monthly newsletter identifying and reviewing official CMS and TJC publications relevant to psychiatric hospitals and BHC programs
♣    A CMS reference library of compliance articles, references and resources
♣    A TJC reference library of compliance articles, references and resources
♣    A mental Links library to mental health resources most commonly referenced in TJC and CMS compliance literature
♣    Surveyor Profiles database of surveyors of psychiatric hospitals and BHC programs
♣    Top 10 compliance issue report specific to psychiatric and forensic hospitals
♣    MiniwebNRs with Q&A sessions on psych-relevant compliance topics with access to previously recorded sessions
♣    Custom Support Page for each member for easy access to the most relevant compliance topics for your organization

  • Venue: Off site (online website access and MiniwebNRs))