Accreditation Preparation

Preparing for and maintaining accreditation, licensure and certification.

Mock Surveys

Mock surveys for accreditation, licensure and Medicare certification.

Policy & Procedure Manuals

Policy & procedure templates and manuals tailored for accreditation requirements.

New Facility Development

Consulting services for new facilities.

Customized Consulting & Training

Consulting services and training customized for your individual needs.


 “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 and Life Safety Code (LSC) requirements included when appropriate

  • Medical Home and Dental Home recognition included when appropriate

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

Policy & Procedure Templates/Manuals:

Policy & Procedure Templates/Manuals:

  • 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

  • Infection Prevention, Quality Management and Improvement, and Governance policies and procedures, such as peer review, credentialing, and privileging

  • NEW -- Emergency Preparedness Plan 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

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

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 Home Recognition

  • Risk management strategies

  • Regulatory and legislative compliance (OSHA, HIPAA)

  • Locums for ASC Administrators and Clinical Directors

  • Strategic planning