Barrins & Associates’ Continuous Survey Readiness Program for Behavioral Healthcare organizations incorporates a proven strategy for ongoing compliance with Joint Commission and CMS standards and continuous readiness for your next survey. The focus of the Continuous Survey Readiness Program is to develop the internal capacity of your organization to operationalize TJC and CMS standards and maintain ongoing compliance for a continuous state of readiness.
Our Continuous Survey Readiness Program includes the following:
Organizational Assessment
The comprehensive baseline Organizational Assessment evaluates your current level of compliance with the specific TJC and CMS standards applicable to your programs and settings. The assessment is tailored to your Behavioral Healthcare organization’s specific scope of service, client population, and settings. This baseline Organizational Assessment provides the foundation for developing a Customized Survey Preparation Plan for TJC and CMS survey readiness.
Focused Medical Record Review Process
Developing a Focused Medical Record Review Process is critical to a successful TJC and CMS Continuous Survey Readiness program. Our consultants work with your team to design a Focused Medical Record Review Process that monitors compliance with all of the key TJC and CMS documentation requirements. We also provide “best practice” examples of TJC and CMS compliant medical records documentation.
Internal Tracer Process
Developing an Internal Tracer Process is another key element of a successful TJC and CMS Continuous Survey Readiness program. Our consultants provide training on how to conduct tracers and incorporate the results of these tracers into your Behavioral Healthcare organization’s Performance Improvement program. We provide user friendly tracer tools that address all of the key TJC and CMS standards.
Annual Standards Training
We provide annual Joint Commission Update Training for your managers and staff. This annual training ensures that they have the latest information on new TJC standards and requirements issued each year as well as strategies for compliance.
Joint Commission and CMS Mock Surveys
The Mock Survey provides a critical opportunity for your staff to experience the TJC or CMS survey process and gain confidence in their survey presentation skills. The Mock Survey simulates the actual agenda for your TJC or CMS survey and includes numerous tracers and all of the standard TJC and CMS survey interviews. Our consultants are experienced in the most current TJC and CMS survey techniques. We coach your managers and staff on how to handle challenging survey issues.
Off-Site Continuous Readiness Support
In addition to on-site visits scheduled throughout the year, we provide TJC and CMS Continuous Survey Readiness Support off-site via phone and e-mail consultation. We schedule periodic conference calls to help you stay abreast of new TJC and CMS standards and requirements. Through our Off-Site Continuous Survey Readiness Support, we troubleshoot for you throughout the year and keep your Behavioral Healthcare organization TJC and CMS ready on an ongoing basis.
New in 2013: Focused Standards Assessment (FSA) Technical Assistance
In February 2013, The Joint Commission’s new annual Focused Standards Assessment (FSA) replaced the previous TJC requirement for Periodic Performance Review. We provide technical assistance on completion of the new FSA. This includes tracers, medical record reviews and policy review to assess your compliance with TJC’s new RISK standards contained in the FSA.