Behavioral Health Regulatory Compliance Consultants

Our behavioral health compliance consultants work with psychiatric inpatient programs to obtain full CMS certification. We can also help you make the necessary preparations to meet state licensing regulations and Joint Commission standards. Additionally, we evaluate CMS or state findings and then collaborate with hospitals to develop, monitor, and implement corrective action plans following patient safety incidents.

Behavioral Health Regulatory Compliance Consultants

Our behavioral health  compliance consultants work with psychiatric inpatient programs to obtain full CMS certification. We can also help you make the necessary preparations to meet state licensing regulations and Joint Commission standards. Additionally, we evaluate CMS or state findings and then collaborate with hospitals to develop, monitor, and implement corrective action plans following patient safety incidents.

Backed by our experience in providing behavioral health compliance consulting services, we can assist hospitals and treatment programs in ensuring patient safety. We can also help with physical plant safety improvements and ligature risk mitigation. If you wish to learn more, feel free to read the Joint Commission’s article on Suicide Prevention in Health Care Settings.

Behavioral health care facilities, hospital-based inpatient units, and treatment centers must maintain compliance with federal and state regulations. The CMS and The Joint Commission require compliance with risk management and risk reduction strategies.

Restraints and falls as well as seclusion and medication errors that result in patient or staff injuries expose organizations to lawsuits. These are tantamount to violations of patient rights, which compromise CMS and state licensing as well as Medicaid and Medicare reimbursements.

Backed by our experience in providing behavioral health compliance consulting services, we can assist hospitals and treatment programs in ensuring patient safety. We can also help with physical plant safety improvements and ligature risk mitigation. If you wish to learn more, feel free to read the Joint Commission’s article on Suicide Prevention in Health Care Settings.

Behavioral health care facilities, hospital-based inpatient units, and treatment centers must maintain compliance with federal and state regulations. The CMS and The Joint Commission require compliance with risk management and risk reduction strategies.

Restraints and falls as well as seclusion and medication errors that result in patient or staff injuries expose organizations to lawsuits. These are tantamount to violations of patient rights, which compromise CMS and state licensing as well as Medicaid and Medicare reimbursements.

Meet Our Accreditation and Compliance Consulting Team

Our team is composed of behavioral health compliance consultants, certified quality management professionals, and senior partners. We have more than 40 years of experience in owning and operating behavioral health organizations.

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Our Scope of Support

  • Behavioral Health Compliance Assessment and Monitoring
  • Overall Behavioral Health Operations Assessment Including Compliance and Accreditation
  • Physical Plant Ligature Risk Assessment and Mitigation
  • Medicaid and Medicare CMS Compliance Review/Gap Analysis
  • Corrective Action Planning
  • Independent Compliance Review Audit
  • Sentinel Event Investigation and Prevention
  • Safety and Risk Reduction
  • Interim Management and Implementation Assistance With Corrective Action Plans for CMS and State Behavioral Health Licensing
  • Oversight of the Behavioral Health Services as Part of an Agreement With the State and CMS
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Recent Compliance and Accreditation Projects

We specialize in CMS compliance, Joint Commission, and Commission on Accreditation of Rehabilitation Facilities (CARF) accreditation for psychiatric inpatient programs and service lines. Our team has handled a broad range of compliance and accreditation projects including:

  • Full CMS compliance for one of the nation’s largest safety net hospitals previously under a federal systems improvement agreement
  • Full CARF accreditation for large children and youth behavioral health residential treatment, foster care, and adoption agency
  • Full Joint Commission accreditation for major academic teaching hospital with a large-scale behavioral health service line

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. Our areas of expertise include:

  • CMS Regulations and Conditions of Participation (COPs)
  • State Medicaid/Medicare Requirements
  • State Mental Health or Substance Abuse Treatment Laws

Our team of trusted and knowledgeable professionals has the experience needed to guide you in complying with behavioral health standards and regulations. We share our best practices in the field to help you achieve your goals.

Over the years, we have had the pleasure of serving various clients including large urban safety net hospitals with multiple inpatient and outpatient psychiatric programs as well as residential treatment facilities. We pride ourselves on our ability to assist clients who are facing immediate jeopardy of losing their CMS approval as well as those who are at risk of losing their state licenses following sentinel events or “near misses.”

We employ proprietary checklists and tools to help behavioral health organizations monitor at-risk operations such as treating psychiatric patients in an emergency department. Our team strives to assist you in upholding safety protocols for locked inpatient units, implementing seclusion measures, and using restraints.

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.

Corrective Action Plan

Our CMS compliance consulting team is composed of independent consultative experts who can help you prepare a corrective action plan. In doing so, we hope to assist you in understanding the steps necessary to bring your hospital’s psychiatric service line into compliance with Medicaid/Medicare COPs.

Leveraging our consulting and management backgrounds, we can create a corrective action plan that includes recommendations for improving a hospital’s operations from efficiency, productivity, and financial perspectives. We tailor our recommendations to the best practices in psychiatric and behavioral health services as provided by the following:

  • Inpatient Psychiatric Programs
  • Psychiatric Residential Treatment Centers
  • Residential Rehabilitation Facilities for Drug and Alcohol Treatment

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:

  • Legal
  • Clinical
  • Evidence-Based Practice
  • Quality Management

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:

  • Developing or Revising New Policies and Procedures
  • Implementing Operational Changes
  • Measuring Outcomes

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:

  • Program Operations
  • Facilities
  • Clinical and Business Documentations
  • Staffing
  • Qualifications

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.