Behavioral Health Regulatory Compliance Consulting Firm CMS, Joint Commission, DNV Accreditation
Our Behavioral Health compliance consultants assist mental health and addiction treatment programs obtain and maintain full CMS certification.
We also help organizations meet state mental health and addiction treatment program licensing regulations as well as Joint Commission and DNV accreditation.
Additionally, we frequently review CMS or state findings and then develop, monitor, and implement Corrective Action Plans following surveys and patient safety incidents.
Improving Behavioral Health Patient Safety With Tested Risk Reduction Strategies
Restraints, patient self-harm, falls as well as medication errors that result in patient or staff injuries expose hospitals and other organizations to the potential loss of CMS certification and lawsuits.
Backed by our experience in providing behavioral health compliance consulting services for hospitals and academic medical centers, we assist psychiatric programs help ensure patient safety. We understand physical plant safety requirements and ligature risk mitigation. We have collaboratively developed a culture of safety and communication that works.
We have helped many healthcare organizations comply with the CMS Conditions of Participation for psychiatric units as well as The Joint Commission and DNV accreditation standards.
To do this, we have developed risk management and risk reduction tools and strategies that are now successfully being used by academic medical center Clients and healthcare systems.
Recent Compliance and Accreditation Projects
We specialize in CMS compliance, Joint Commission, and DNV accreditation for hospital psychiatric inpatient programs, residential treatment facilities, rural hospitals, Critical Access Hospitals, and ambulatory services. Our team has handled a broad range of compliance and accreditation projects including:
Conditions of Participation (CoP) Compliance Review
Using proprietary assessment tools, we review the policies, procedures, sentinel events, staffing, and operations in relation to CMS regulations. Our CMS compliance review results in a comprehensive gap analysis with specific findings.
Independent Compliance Review
We conduct independent compliance assessments and provide written recommendations for organizations concerned with an upcoming CMS or state survey related to Medicaid, Medicare, or their state department of mental health or substance abuse treatment. Our compliance attorney assists in these reviews and provides statute interpretation and guidelines.
Plan of Correction for Critical Incidents and Sentinel Events
To behavioral health agencies and service line providers, sentinel and critical events can lead to grave consequences. For this reason, our team, in collaboration with senior management, meticulously reviews events on-site from multiple perspectives:
A qualified, professional-level, and independent root cause analysis (RCA) may be necessary after a sentinel event or critical incident in order to bring contributing factors into clear focus. Aside from conducting RCA and preventive failure mode effects analysis (FMEA), we employ statistical techniques to identify or measure correlations such as time, place, and staffing to incident trends.
Our team uses the report and plan of correction to specify alternate practices and recommend the monitoring tools/processes needed to measure compliance. We stay involved with the process and sequence of:
Patient Safety and Risk Reduction Analysis Tools
Utilizing a written safety and risk reduction analysis is a crucial part of preventing critical incidents for clients. As such, we customize our analysis to fulfill the needs and address the concerns of each client. By considering interviews and observations, we can get a clear picture of your organizational culture in relation to safety measures and incidents.
As state facilities have closed, increasingly complex and aggressive patient populations are served in less restrictive settings. This situation—its impact on staff, programming, and the delivery of care—is one of the things that we consider during our assessment.
We focus our safety and risk reduction assessment and analysis on creating system improvements instead of developing punitive action plans. Additionally, we provide seasoned input, specific recommendations, and training initiatives for executives and staff. In doing so, we can help the organization in securing a position at the forefront of the industry. We review other elements pertinent to risk including:
Allow Us to Assist You
Schafer Consulting has helped various organizations prepare for accreditation. We take pride in the fact that every client we assisted has been accredited on their first survey. By leveraging our behavioral health compliance experience and upholding the best practices in the field, we have become one of the most trusted, knowledgeable, and informed accreditation consultants in the industry.