Services

Accreditation Preparation

Preparing for and maintaining accreditation, licensure and certification.

Policy & Procedure Manuals

Updated policy & procedure templates tailored for accreditation requirements.

Medicare and Life Safety

Preparing for and maintaining Medicare certification / Deemed Status and Life Safety.

New Facility Development

Customized consulting for new facility development and compliance.

Mock Surveys

Mock surveys for accreditation, licensure and CMS / Medicare Certification.

Service Line Expansion

Customized consulting for adding surgical services to increase case volume.

Customized Consulting

Consulting and training customized to meet compliance requirements and staff education.

COVID Compliance

Strategy, tools and guidance addressing Pandemic / COVID-19 Compliance.

 “Thank you for helping us prepare for our re-accreditation survey. We would not have done as well without your assistance and support. I look forward to working with you again.”

— Quality Assurance Manager, Lac Courte Oreilles Community Health Center

 Accreditation Preparation

Accreditation Preparation services include:

• Dedicated consultant through completion of accreditation process

• Consultative visits, required policy & procedure templates, remote consulting, and mock surveys

• Education regarding quality management and improvement activities, credentialing/privileging, peer reviewing, benchmarking, infection prevention, medication management, risk management, etc.

• Direction on writing effective policies and procedures that are compliant with accreditation standards, or customization of your policies and procedures by your consultant

• CMS / Medicare guidelines or accreditation with Deemed status when appropriate

• Medical Home and Dental Home recognition included when appropriate

Policy & Procedure Templates/Manuals:

Updated for new 2020 Handbook v41!

• Templates in electronic format covering all chapters of the accreditation handbooks

• Customize them to reflect specific activities of your organization (they're already 95% complete)

• Compliant with accreditation standards and other regulatory requirements including Medicare and HIPAA

• Each policy includes the accreditation standard number(s) it complies with (and Medicare guideline number when appropriate)

• Infection Prevention, Quality Improvement, Governance, Emergency Preparedness, Peer Review, Credentialing, and Privileging

• Also includes new COVID-19 Policies and Procedures

Services related to the Policy & Procedure Templates/Manuals include:

• Consultants are available to provide direction on customizing the templates and writing effective policies and procedures

• Consultants can also customize the templates for you, per your facility-specific practices and state/local regulations

Medicare and Life Safety

CMS Certification/Deemed Status and Life Safety services include:

• CMS / Medicare guidelines

• Dedicated consultant through completion of certification process

• Consultative visits, required policy & procedure templates, remote consulting, and mock surveys

• Education regarding quality management and improvement activities, credentialing/privileging, peer reviewing, benchmarking, infection prevention, medication management, risk management, etc.

• Direction on writing effective policies and procedures that are compliant with certification standards, or customization of your policies and procedures by your consultant

• Compliance Review and Plan of Correction

• Fire Prevention and Life Safety Code (LSC)

  • Life Safety Mock Surveys

  • Required Risk Assessments

  • Fire/Smoke Door and Damper Inspections

  • Fire/Smoke Barrier Reviews

  • Fire Safety Evaluation Systems (FSES)

  • Policy and Procedure Development

New Facility Development

New Facility Development consulting services include:

• Customized project checklist and timeline

• Assistance with accreditation preparation, Medicare certification, and state licensure requirements

• Information and guidance on facility requirements for your setting

• Review of architectural and design plans -- with a focus on space, operational flow, and operational efficiency (excluding design services)

• Guidance on administrative, regulatory, and operational requirements, including staffing and medical equipment planning

• Templates for and liaison with administrator/attorney for preparation of Governance materials, Medical Staff Organization, and Bylaws

• Assistance with completing the multitude of required applications -- such as state license, CMS-855 Medicare Enrollment, CLIA, DEA, Pharmacy license, Hazardous Waste, and Local Business applications, etc.

• Accreditation Preparation services listed above

• Mock Surveys listed above

• Policy and Procedure Templates/Manuals listed above

Mock Surveys 

Mock Surveys include:

• Onsite accreditation and/or certification assessment

• Follow-up deficiency/gap analysis with recommendations in the form of a Work Plan summary report

• Mock Surveys are consultative and educational, and are performed by your peers who are also accreditation surveyors

• Available for ambulatory surgery centers (ASCs), office-based surgical centers (OBS), Endoscopy centers, medical practices, community health centers and FQHCs, Medical Home, Dental Home, health plans, etc.

• Medicare/CMS requirements included, when applicable

• Life Safety Code (LSC) mock surveys and consulting, when applicable

 Surgical Service Line Expansion

Surgical Service Line Expansion consulting to increase case load and revenue streams in a competitive ASC environment:

• Clinical need analysis – for adding specialty surgical services/lines

• Optimal coding and billing procedures – for existing and new specialty procedures

• Financial feasibility analysis – integrating with appropriate payer and/or Medicaid programs for reimbursement

• Gap analysis – review existing facilities and resources to determine gaps

• Business plan – for expanding surgical specialties/service lines

• Evaluation of key staffing models

• Onsite consultation and staff training

• Turnkey program development and implementation – of expanding surgical specialties/service lines

• Regulatory compliance – with state/national board and accreditation/certification requirements for add-on services

• Clinical and administrative policy and procedure manuals

• Customized project checklist and timeline

Customized Consulting and Training

Customized Consulting and Training includes, but is not limited to:

• Consultative visits

• Remote/virtual consulting (hourly)

• Medicare/CMS certification preparation

• Preparing Medicare/CMS plans of correction (POC)

• Deficiency resolution

• Onsite or remote staff and/or Director of Nursing training

• Quality management and improvement, including Quality Improvement Studies

• Infection control and prevention

• Physician and staff credentialing and privileging programs

• Medical/Dental Home Recognition

• Risk management strategies

• Regulatory and legislative compliance (OSHA, HIPAA)

• Locums for ASC Administrators and Clinical Directors

• Strategic planning