{"id":445,"date":"2012-08-08T19:56:31","date_gmt":"2012-08-08T19:56:31","guid":{"rendered":"http:\/\/www.fieldsinc.com\/?page_id=445"},"modified":"2013-07-31T17:39:14","modified_gmt":"2013-07-31T17:39:14","slug":"serv-domain_compliance","status":"publish","type":"page","link":"https:\/\/www.fieldsinc.com\/services\/serv-domain_compliance","title":{"rendered":"Serv Domain_Compliance"},"content":{"rendered":"

Service Domain Description<\/h1>\n

II \u2013 Compliance (CMS Certification & Joint Commission Accreditation)<\/h1>\n

\"\"<\/a><\/p>\n

A.\u00a0\u00a0 \u00a0 Compliance Assessment<\/strong><\/span><\/p>\n

1.\u00a0 Comprehensive Assessments:\u00a0<\/span><\/p>\n

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    \n
  • Descrip:\u00a0 PPR-type assessment and Systems Analysis to determine level of compliance of all applicable standards for your facility or program conducted by former TJC or CMS surveyor associate(s)<\/span><\/li>\n
  • Venue: On site (evaluation)<\/span><\/li>\n<\/ul>\n<\/blockquote>\n

    2.\u00a0 Focused Assessments:\u00a0\u00a0<\/span><\/p>\n

    \n
      \n
    • Descrip:\u00a0 Assessment of specific areas of standard compliance concern using process analysis, chart\/document review, tracers or combinations thereof.<\/span><\/li>\n
    • Venue: On site (evaluation) or Off site (TeleVideo interviews, redacted document review and E-tracers)<\/span><\/li>\n<\/ul>\n<\/blockquote>\n

      3.\u00a0 Improvement Assessments:\u00a0\u00a0<\/span><\/p>\n

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        \n
      • Descrip:\u00a0 Facilitation assistance and guidance with Root Cause Analysis (RCA) or Failure Mode Effects and Criticality Analysis (FMCA)<\/span><\/li>\n
      • Venue: On site (consultation\/facilitation) or Off site (TeleVideo interviews, redacted document reviews)<\/span><\/li>\n<\/ul>\n<\/blockquote>\n

        B.\u00a0\u00a0 \u00a0 Compliance Achievement<\/strong><\/span><\/p>\n

        1.\u00a0 Standards Clarification and\/or Training:<\/span><\/p>\n

        \n
          \n
        • Descrip:\u00a0 Explication and clarification of CMS and\/or TJC standards as they apply to psychiatric hospitals and BHC programs.\u00a0 For programs, teams, professional disciplines and individuals preparing for Joint Commission Certified Accreditation Professional (JCAP) exam preparation.<\/span><\/li>\n
        • Venue: On site (training\/presentation) or Off site (TeleVideo conference)<\/span><\/li>\n<\/ul>\n<\/blockquote>\n

          2.\u00a0 Standards Updating:\u00a0\u00a0<\/span><\/p>\n

          \n
            \n
          • Descrip: Overview of new, revised and\/or pre-publication standards for the year.\u00a0 [Note: SPHCC members also receive a monthly updating newsletter]<\/span><\/li>\n
          • Venue: On site (training\/presentation) or Off site (TeleVideo conference)\u2028<\/span><\/li>\n<\/ul>\n<\/blockquote>\n

            3.\u00a0 Standards Applicability & Implementation :\u00a0<\/span><\/p>\n

            \n
              \n
            • Descrip:\u00a0 Consultative advice on applicability and strategies for implementing standards in psychiatric hospitals and BHC programs.<\/span><\/li>\n
            • Venue: On site (consultation) or Off site (TeleVideo conference)<\/span><\/li>\n<\/ul>\n<\/blockquote>\n

              C.\u00a0\u00a0 \u00a0 Compliance Demonstration (i.e., Survey Success)<\/strong><\/span><\/p>\n

              1.\u00a0 Survey Process Training:\u00a0<\/span><\/p>\n

                \n
              • Descrip:\u00a0 Overview training on CMS or TJC on-site survey process to include typical schedules, technologies (e.g., tracers), interviews, citation and scoring processes<\/span><\/li>\n
              • Venue: On site (training\/presentation) or Off site (TeleVideo conference)\u2028<\/span><\/li>\n<\/ul>\n

                2.\u00a0 Survey Management Strategies:\u00a0<\/span><\/p>\n

                  \n
                • Descrip:\u00a0 Presentation and discussion of strategies and tips for increasing the effectiveness of managing surveyors and the survey process to include mitigation of RFI vulnerability.\u00a0\u00a0 [Note: SPHCC members also have access to our surveyor profile data]<\/span><\/li>\n
                • Venue: On site (consultation) or Off site (TeleVideo conference)\u2028<\/span><\/li>\n<\/ul>\n

                  3.\u00a0 Mock Survey and\/or Mock Tracers:\u00a0<\/span><\/p>\n

                    \n
                  • Descrip:\u00a0 Survey process run by former CMS or TJC surveyors designed to closely simulate the experience of an actual survey process with the benefit of strategic \u2018time outs\u2019 for training purposes.<\/span><\/li>\n
                  • Venue: On site (mock survey\/tracers) \u2028<\/span><\/li>\n<\/ul>\n

                    4. \u00a0 Survey Real-Time Backup:\u00a0<\/span><\/p>\n

                      \n
                    • Descrip:\u00a0 Former CMS or TJC surveyor associate on special availability to provide survey management assistance and\/or respond to standards questions during actual survey\u00a0\u00a0 [Note: TJC Standards Interpretation Group is not available to organizations during survey].<\/span><\/li>\n
                    • Venue: On site (by pre-arrangement) or Off site (24\/7 E-Support)\u00a0 [Note: on site consultant may not directly participate in survey process, but can observe and facilitate admin, communication and other survey support processes]<\/span><\/li>\n<\/ul>\n

                      D.\u00a0\u00a0 \u00a0 Compliance Maintenance<\/strong><\/span><\/p>\n

                      1.\u00a0 Ongoing Compliance Plans:\u00a0<\/span><\/p>\n

                      \n
                        \n
                      • Descrip:\u00a0 Customized 1-3 year plan and schedule of compliance maintenance activities.\u00a0 \u00a0<\/span><\/li>\n
                      • Venue: On site (consultation\/facilitation) or Off site (TeleVideo interviews, redacted document reviews)\u2028<\/span><\/li>\n<\/ul>\n<\/blockquote>\n

                        2.\u00a0 State & Psychiatric Hospital Compliance Collaborative (SPHCC):\u00a0<\/span><\/p>\n

                        \n
                          \n
                        • Descrip:\u00a0 Unique resource for the support of ongoing compliance via participation in an online collaborative of psychiatric facilities committed to sharing compliance information and survey experience.\u00a0 Includes:<\/span><\/li>\n<\/ul>\n<\/blockquote>\n

                          \u2663\u00a0\u00a0 \u00a0 a monthly newsletter identifying and reviewing official CMS and TJC publications relevant to psychiatric hospitals and BHC programs<\/span>
                          \u2663\u00a0\u00a0 \u00a0A CMS reference library of compliance articles, references and resources<\/span>
                          \u2663\u00a0\u00a0 \u00a0A TJC reference library of compliance articles, references and resources<\/span>
                          \u2663\u00a0\u00a0 \u00a0A mental Links library to mental health resources most commonly referenced in TJC and CMS compliance literature<\/span>
                          \u2663\u00a0\u00a0 \u00a0Surveyor Profiles database of surveyors of psychiatric hospitals and BHC programs<\/span>
                          \u2663\u00a0\u00a0 \u00a0Top 10 compliance issue report specific to psychiatric and forensic hospitals<\/span>
                          \u2663\u00a0\u00a0 \u00a0MiniwebNRs with Q&A sessions on psych-relevant compliance topics with access to previously recorded sessions<\/span>
                          \u2663\u00a0\u00a0 \u00a0Custom Support Page for each member for easy access to the most relevant compliance topics for your organization<\/span><\/p>\n

                          \n
                            \n
                          • Venue: Off site (online website access and MiniwebNRs))\u2028<\/span><\/li>\n<\/ul>\n<\/blockquote>\n

                            \u00a0<\/p>\n","protected":false},"excerpt":{"rendered":"

                            Service Domain Description II \u2013 Compliance (CMS Certification & Joint Commission Accreditation) A.\u00a0\u00a0 \u00a0 Compliance Assessment 1.\u00a0 Comprehensive Assessments:\u00a0 Descrip:\u00a0 PPR-type assessment and Systems Analysis to determine level of compliance of all applicable standards for your facility or program conducted by former TJC or CMS surveyor associate(s) Venue: On site (evaluation) 2.\u00a0 Focused Assessments:\u00a0\u00a0 Descrip:\u00a0 […]<\/p>\n","protected":false},"author":60,"featured_media":0,"parent":30,"menu_order":4,"comment_status":"open","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-445","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/pages\/445","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/users\/60"}],"replies":[{"embeddable":true,"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/comments?post=445"}],"version-history":[{"count":16,"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/pages\/445\/revisions"}],"predecessor-version":[{"id":454,"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/pages\/445\/revisions\/454"}],"up":[{"embeddable":true,"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/pages\/30"}],"wp:attachment":[{"href":"https:\/\/www.fieldsinc.com\/wp-json\/wp\/v2\/media?parent=445"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}