When seeking a behavioral health compliance consultant who can help us with ligature risk reduction and patient safety, we often hear:
“Is our inpatient psychiatric unit compliant with CMS rules?”
“We’ve had a sentinel event and need to improve patient safety.”
“How do we prepare for the Joint Commission survey?”
“Can you provide interim management of our inpatient psychiatric unit tfor full CMS compliance?”
“We need a behavioral health accreditation consultant to make sure we meet Joint Commission physical plant and operation standards.”
“We need to develop behavioral health policies and procedures.”
Behavioral Health Compliance Consultant
Our behavioral health compliance consultants have extensive experience assisting hospitals and treatment programs improve patient safety as well as meet federal, state, and Joint Commission regulations. We can also help with physical plant safety improvements and ligature risk mitigation.
Hospital behavioral health inpatient units and treatment centers must maintain compliance with federal and state regulations. The Centers for Medicaid and Medicare Services (CMS), The Joint Commission, COA, and CARF accreditations require compliance with risk management and risk reduction strategies. Patient or staff injuries associated with restraints, seclusion, falls, and medication errors expose organizations to lawsuits. Violations of patient rights compromise CMS and state licensing, Medicaid and Medicare reimbursements.
Our Behavioral Health Compliance consulting team is comprised of experienced behavioral health compliance consultants, certified quality management professionals, and senior partners with more than a combined 40+ years experience owning and operating behavioral health organizations.
Behavioral Health Compliance Area Options
- Behavioral Health Compliance Assistance and Monitoring
- Physical plant ligature risk assessment and mitigation
- Medicaid and Medicare CMS Compliance Review / Gap Analysis
- GAP Analysis & Corrective Action Plans
- Independent Compliance Review Audit
- Investigating and Preventing Sentinel Events
- Safety and Risk Reduction
1. Behavioral Health Compliance Assessment
We assist hospital inpatient psychiatric units, behavioral health clinics, mental health and substance abuse residential treatment centers and community based treatment providers meet and sustain compliance with federal, and state behavioral health and safety regulations. Areas of expertise include:
- CMS regulations and Conditions of Participation (COPs)
- State Medicaid requirements
- State mental health or substance abuse treatment laws
Our behavioral health compliance monitoring experience is trusted, knowledgeable, and informed by best practices in the field. Clients have included large urban safety net hospitals with multiple inpatient and outpatient psychiatric programs in immediate jeopardy of losing their CMS approval as well as residential treatment facilities at risk of losing their state licenses following sentinel events or “near misses”. We have proprietary checklists and tools to help behavioral health organizations monitor at risk operations, e.g. psychiatric patients in an emergency department, safety protocols for locked inpatient units, seclusion and restraint.
2. CMS Psychiatric Unit Conditions of Participation Compliance Review
Using proprietary assessment tools, we review the policies, procedures, sentinel events, staffing and operations relative to CMS regulations. The CMS Compliance review results in a comprehensive Gap Analysis with specific findings.
3. Corrective Action Plan
Functioning as an Independent Consultative Expert, our CMS compliance consulting team prepares a Corrective Action Plan that details the steps necessary for a hospital to bring it’s psychiatric service line into compliance with Medicaid/ Medicare Conditions of Participation (COPs).
Unique to Schafer Consulting, we relate recommendations to best practices in psychiatric and behavioral health services: inpatient psychiatric programs, psychiatric residential treatment centers, and residential rehabilitation facilities for drug and alcohol treatment. Based on our consulting and managing backgrounds, our Corrective Action Plan makes recommendations that can improve a hospital’s operations from efficiency, productivity and financial perspectives.
4. Independent Compliance Review
For organizations concerned with an upcoming CMS or state survey relative to Medicaid, Medicare or their state department of mental health or substance abuse treatment, we conduct independent compliance assessments and provide written recommendations. Our compliance attorney assists in these reviews and provides statute interpretation and guidelines.
5. Plan of Correction for Sentinel Critical Events
Sentinel and critical events are a serious concern to behavioral health agencies and service line providers. Our team reviews events on-site and in collaboration with senior management from multiple perspectives: legal, clinical, evidence based practice, and quality management.
Typically, following a sentinel event or a critical incident, a qualified, professional, and independent Root Cause Analysis will bring into clear focus contributing factors. In addition to a Root Cause Analysis (RCA) and preventive Failure Mode Effects Analysis (FMEA), we apply statistical techniques to identify or measure correlations such as time, place, and staffing to incident trends. The report and Plan of Correction specifies alternate practices and recommends monitoring tools/processes to measure compliance.
We stay involved with the process and sequence of developing or revising new policies and procedures, implementing operational changes, and measuring outcomes.
6. Safety and Risk Reduction Analysis Tools
Our written safety and risk reduction analysis is designed relative to the needs and concerns of each client and is a crucial part of preventing critical incidents
Through interviews and observation, we develop a picture of the organizational culture relative to safety and incidents. As state facilities have closed, increasingly complex and aggressive patient populations are served in less restrictive settings. Our assessment considers the impact on staff, programming, and the delivery of care.
Our safety and risk reduction assessment and analysis is system focused, not punitive. We review program operations, facilities, clinical and business documentation, staffing, qualifications and other elements pertinent to risk. We provide seasoned input, specific recommendations, and training for executives and staff so the organization can move forward.
Behavioral Health Accreditation Consultant
Every organization Schafer Consulting has helped prepare for accreditation has obtained it on their first survey.
The Accreditation consulting team of Schafer Consulting has provided CARF, The Joint Commission, and COA accreditation assistance to behavioral health service lines and behavioral health agencies for over 20 years. We assist psychiatric hospitals, inpatient psychiatric units, residential treatment centers, and behavioral health outpatient clinics meet their accreditation needs.
The accreditation consultant team provides a range of services from readiness site visits to complete, start to finish accreditation preparedness. We have successfully prepared psychiatric hospitals, psychiatric inpatient units and behavioral health agencies for accreditation.
Our approach is highly tailored to each client’s needs, capabilities, state licensing requirements and CMS regulations. We work collaboratively with all levels of the organization achieve cost effective and tested evidence-based accreditation policies and procedures.
Our team is experienced with Person Centered and Recovery Model treatment approaches, behavioral health integration, behavioral health medical homes, and residential treatment centers.
Tailored Accreditation Options
- New behavioral health program accreditation assistance and policy manual
- Full start-to-finish accreditation application, policy and procedure development, on-site implementation assistance and staff training, action plans following the survey
- Accreditation preparation plan and “as needed” guidance, policies, procedures, forms
Re-Accreditation Preparation Options
We have developed operating policies, procedures and forms for all psychiatric and substance abuse treatment programs that have helped them meet accreditation standards: hospitals, inpatient units, outpatient clinics, practices, children’s residential treatment centers, and behavioral health service lines. When it is time for re-accreditation, our team can:
- Review your existing policies and procedures
- Conduct a mock survey with report and recommendations on corrective preparation actions, or
- Conduct the mock survey with report and take your organization through the corrective preparation actions
Talk to Us
The results are clear – every organization Schafer Consulting has helped prepare for accreditation has obtained it on their first survey. Our behavioral health compliance experience is trusted, knowledgeable, and informed by best practices in the field.
Uniquely focused in the behavioral healthcare field since 1993, we look forward to speaking with you about your specific needs and tailoring a customized solution. Call (724) 213-0200, or contact us in confidence.