Accreditation & Regulatory Compliance

Accreditation & Regulatory Compliance


In healthcare, adhering to CMS Conditions of Participation and accreditation standards while also creating a culture that is always prepared for surveys is paramount. Whether you’re responding to a survey by the Centers for Medicare and Medicaid (CMS) or educating your staff and practitioners about accreditation standards and CMS Conditions of Participation, our consultants are ready to guide you every step of the way. With extensive experience with CMS, TJC, HFAP, and other accrediting bodies, our focus is on helping you build a culture that drives continuous readiness and values patient safety above all else.

customized support for your journey

CMS and TJC Readiness and Mock Surveys

We assist organizations in building or strengthening internal resources to maintain a culture of continuous readiness for surveys by CMS or accrediting organizations such as TJC, HFAP, and others. Because these surveys are unannounced, preparation and ongoing readiness are critical.

Here are some of the ways our experienced clinicians and life safety experts can help you identify deficiencies, immediately mitigate risk, implement solutions, and sustain compliance while providing safe, quality patient care:

  • Identify the trouble spots. Our mock surveys spotlight potential issues that can threaten certification and accreditation.
  • Equip your staff. We provide your staff and practitioners with the right skills and tools to keep pace with changes and better understand accreditation standards and regulatory compliance to ensure patient safety.
  • Address risks. When we find a deficiency in the mock survey, we immediately correct and mitigate the risk to patient safety.
  • Serve as your champion. In addition to conducting mock surveys, our team can support you before, during, and after your regulatory and accreditation surveys. We’re just a phone call or email away.

In addition to deep expertise in CMS Conditions of Participation and TJC accreditation, we have experienced clinicians who can provide ongoing and timely support in responding to HFAP, DNVHC, CIHQ, and AAHHS.

CMS and TJC Response and Recovery • Immediate Jeopardy

When surveyors leave, organizations may be faced with a perplexing list of deficiencies and findings. Our team of regulatory and accreditation experts will help you respond quickly and effectively to achieve sustainable changes toward a goal of safe, quality patient care through assistance in development of Clarifications, Evidence of Standards Compliance (ESC), Plan of Correction, and more.

In the event that you find yourself faced with Immediate Jeopardy or Immediate Threat, we’re well equipped to guide you in responding. We help you mitigate threats to clinical operations and life safety to protect patient safety. Our clinical experts work with your staff to resolve deficiencies and protect the organization’s accreditation and regulatory status. In addition, our team brings a breadth of expertise that allows us to scale to the scope of the issue you are faced with.

Systems Improvement Agreement (SIA)

CMS has a powerful quality improvement tool to gain compliance from hospitals with repeat or multiple Immediate Jeopardy findings on compliance or validation surveys: Systems Improvement Agreement (SIA). We are approved by CMS to serve as the outside monitor for healthcare organizations with a SIA.

Patient Safety Assessment

Are you confident that your organization truly has a culture of safety? Our Patient Safety Assessment analyzes your current patient safety practices and processes. From there, we determine how effectively they prevent human errors, detect system vulnerabilities and weaknesses, and course-correct to prevent events of harm or adverse outcomes.

Clinical Regulatory Compliance Due Diligence Assessment

We perform clinical regulatory compliance due diligence assessments to provide health systems with knowledge of compliance risks that may accompany an acquisition, including careful attention to triggers for additional scrutiny from CMS.

Consulting and Program Development for a Safe, Harassment-free Environment for Staff and Patients

As media reports continue to emerge on harassment in healthcare settings, hospitals and health systems can anticipate increased reporting related to sexual harassment and hostile work environments, along with increased attention from regulators and surveyors. Our team of consultants is equipped to address concerns of harassment and help organizations deliver safe, quality care while maintaining full compliance with applicable standards and regulations, including assurance of a safe work environment for all.

Retainer Services for Continuous Readiness

Regulations and standards frequently change. Ensure you’re ready when they do by taking advantage of our retainer services. You’ll receive ongoing information on adapting to and implementing regulations and standards issued by TJC or CMS.

Services are tailored to your specific needs so you can control costs, combine resources, and prevent risks to patient safety.

Failures with accreditation and regulatory compliance are serious issues. But they don’t have to be overwhelming. We have the tools and expertise to support you before, during, and after accreditation and regulatory surveys. And we have results to show how rigorous we are:

  • 100% of Medicare revocation clients successfully reinstated
  • 100% successful record in leading hospitals to CMS recertification
  • 100% success rate in remediating Immediate Jeopardy findings and achieving successful Systems Improvement Agreement (SIA) resolution