Healthcare Equity Compliance Evaluation Tool
A survey-ready assessment tool that supports compliance with 2026 Health Care Equity requirements by integrating leadership accountability, data stratification, and equity action planning.
read moreInterview Questions for Staff Tool – Tech
Tele‑behavioral specific interview questions to evaluate staff competencies, privacy/security practices, and workflow compliance readiness in virtual care.
read moreTransplant Tracer Tool
System tracer for transplant services within psychiatric hospitals (rare use cases), ensuring coordination and documentation where applicable.
read moreClosed MR Review Tool: Psych Hospitals
Closed‑record review tool tailored to psychiatric hospital documentation requirements.
read moreRestraint Seclusion MR Review Form
Medical record review form to evaluate restraint/seclusion documentation, orders, monitoring, and debriefs.
read moreA Crosswalk of HAP PC to BHC CTS
Crosswalk mapping TJC HAP Provision of Care standards to BHC Care, Treatment & Services standards.
read moreTJC Medical Staff Credentialing and Privilege Tracer Checklist
Tracer checklist for MS credentialing and privileging files, OPPE/FPPE, and app monitoring.
read moreTJC Medical Staff Bylaws Review Tool
Tool to review bylaws and rules/regulations for required elements and alignment with practice.
read moreRequired Board Review and Approval Checklist
Checklist of policies, plans, and reports that require board review/approval with suggested cadence.
read moreManagement Rounds 101
How‑to guide for effective leadership rounds, including scripts, observation points, and follow‑up tracking.
read moreLeadership Session Tracer Tool
Tracer to evaluate leadership communication, PI, resource allocation, and management of contracted services.
read moreGoverning Body Duties
Summary of required governing body duties with evidence examples the surveyor may request.
read moreGoverning Body Checklist
Checklist of governing body responsibilities, bylaws elements, board education, and minutes documentation.
read moreContract Review
One‑page tool to rapidly screen contracts for risk, value, and regulatory compliance.
read moreContract Review Checklist
Checklist to ensure contracts include scope, performance metrics, credentialing/insurance, and compliance clauses.
read moreCompetency Session Checklist
Checklist to prepare and conduct a competency fair or focused competency validation session.
read moreCompetency File Request List
List of competency records to pull for survey, by role and department.
read moreQuick Reference ILSM & Pressure Relationships
Pocket reference for required ILSMs and room pressure relationships during construction or outages.
read morePart 1: Eye Wash Risk Assessment Instructions
Step‑by‑step instructions for completing the eyewash risk assessment, including frequency and thresholds.
read moreEye Wash Basics
Quick guide on eyewash station placement, testing, documentation, and training.
read moreEnvironmental Risk Checklist: Inpatient
Inpatient psychiatric environmental risk checklist focusing on ligature and self‑harm prevention controls.
read moreTJC Survey Checklist
Global checklist of pre‑survey tasks, documents, tracers, and leadership sessions.
read moreRehab/PT/OT Tracer Tool
Tracer for rehabilitation services covering assessments, goals, care coordination, and progress reporting.
read moreModerate Sedation Audit Tool
Audit form to verify consent, monitoring, reversal agents, recovery, and post‑sedation handoff documentation.
read moreEmergency Department Tracer Tool
ED tracer focusing on triage, suicide screening, EMTALA processes, and boarding management.
read moreHealth Care Equity Survey
Survey tool to assess health care equity policies, data collection, stratification, and improvement actions.
read moreEHR Documentation Scavenger Hunt
Gamified checklist to locate required data elements across the EHR and standardize documentation locations.
read moreECT Tracer Tool
End‑to‑end tracer for electroconvulsive therapy: consent, equipment checks, credentialing, and recovery documentation.
read moreEarly Survey Option Required Resurvey Document
Template for documenting requirements and timelines when selecting the Early Survey Option.
read moreDischarge Summary
Model discharge summary elements for psychiatric inpatients, including meds, follow‑up, and safety plan.
read moreDepartment Walkthrough Checklist
Departmental readiness checklist focused on policies, competencies, logs, and performance boards.
read moreClinical Walkthrough Checklist
Unit‑level walkthrough checklist addressing environment, equipment, medications, and patient safety practices.
read moreCentral Sterile Processing
Job aid outlining CSP workflows, sterility assurance, logs, and survey‑ready documentation.
read moreBusiness Occupancy Checklist
Compliance checklist for hospital‑owned business occupancy sites (life safety, signage, emergency plans).
read moreTJC Closed Records Request Form
Form to track closed medical records pulled for survey review and their chain of custody.
read moreStaff Competency Checklist
Master checklist to verify required competencies by role, including initial, annual, and high‑risk procedures.
read moreRole of Survey Ambassador Scribe
Defines responsibilities for the ambassador/scribe to capture requests, route documents, and maintain surveyor satisfaction.
read moreHospital Risk Assessment Form
Blank risk assessment form to identify hazards, rate likelihood/impact, and assign mitigation actions.
read moreExpanded Review Business Occupancy Sites
Guide to extend survey readiness to business occupancy sites affiliated with the hospital (clinics, admin offices).
read moreDay 1 Instruction Sheet
Operational instructions for Day 1 of survey—who, where, what to have ready, and hour‑by‑hour cadence.
read moreAnnual Summary Report Checklist
Checklist for compiling the annual performance summary (PI, sentinel events, grievances, R&S, etc.) for psychiatric hospitals.
read moreA-Tag Review Sheet
Worksheet to log applicable CMS A‑Tags, evidence, gaps, and status tracking for psychiatric hospitals.
read moreA-Tag Review and Recommendations
Review of CMS A‑Tags applicable to psychiatric hospitals with corrective recommendations and owner/action dates.
read moreSurvey Checklist of Common Findings
List of frequent survey findings in psychiatric units with prevention tips and references.
read moreSuicide Risk Patient Checklist
At‑a‑glance checklist to ensure required actions for patients at suicide risk are completed and documented.
read moreRestraint and Seclusion Standards
Quick‑reference of R&S standards with documentation requirements, monitoring, and de‑escalation expectations.
read moreOpioid Treatment Program Survey Checklist
Comprehensive readiness checklist for OTP programs covering regulatory, clinical, pharmacy, and safety elements.
read moreClosed MR Review Tool: BHC
Closed‑record review tool for behavioral health charts focused on, assessment, care, treatment and services, treatment planning, and discharge elements.
read moreMedication Room Tracer Checklist
Medication room tracer checklist for security, labeling, dating, temperature logs, and storage compliance.
read moreLD.04.03.05: Community Relations Plan Sample for OTP 2
Completed sample community relations plan for OTPs that can be adapted locally.
read moreLD.04.03.05: Community Relations Plan Sample for OTP 1
Guidance to develop a community relations plan for opioid treatment programs addressing neighbors, law enforcement, and local stakeholders.
read moreA Culture of Safety Checklist
Checklist to assess leadership commitment, event reporting, just culture, and learning systems.
read moreA Contract Review Checklist
Checklist to evaluate service contracts for regulatory, scope, performance monitoring, and risk provisions.
read moreSample BH Infection Control Plan
Example infection control plan tailored to behavioral health program risks and mitigation strategies.
read moreSample Spiritual Assessment
Structured spiritual needs assessment to inform person‑centered care planning.
read moreSample Recreational Therapist Competency Review
Competency checklist for recreational therapists addressing assessment, planning, interventions, and safety.
read moreSample Pharmacist Clinical Competency Review
Competency review form for pharmacists covering medication management, order verification, and patient education.
read moreSample Observer Checklist Skills Group Instructions
Instruction sheet and checklist for observers to reliably rate skills‑based group sessions.
read moreSample Nutritional Services Clinical Document Audit Tool
Audit tool to review nutritional service documentation for completeness, timeliness, and compliance.
read moreSample Group Progress Note
Template for documenting group therapy objectives, interventions, participant response, and next steps.
read moreSample BH Guidelines and Health Pain Nutrition Screening Tool
Example screening tool to document guidelines adherence and assess pain and nutrition needs in behavioral health settings.
read moreHuman Resource Checklist for HR Files & Competency
Comprehensive HR file checklist (licenses, certifications, competency validation, training, health screens) for non‑telebehavioral providers.
read moreHuman Resources Checklist for Outpatient Telehealth
HR compliance checklist for tele‑behavioral programs—competency, orientation, training, background checks, and other.
read moreCompetence, Credentialing, & Privileging Interview Tool – Tech
Criteria to assess Competency/Credentialing/Privileging for tele‑behavioral practitioners, including licensure-by‑location and tele‑specific OPPE/FPPE.
read moreCompetence, Credentialing, & Privileging Interview Tool – General
Guide to evaluate Competency/Credentialing/Privileging processes, primary source verification, and ongoing practice evaluation for non‑telebehavioral providers.
read moreEmergency Management Tool – Tech
Tool for Tele-behavioral health only providers to comply with the emergency management standards.
read moreEnvironmental Risk Checklist: Outpatient, Psych, IOP, PHP, Office-Based
Setting‑specific environmental risk checklist to identify ligature, security, and safety hazards across outpatient behavioral health sites such as office based, IOP, PHP services.
read moreSample Trauma History Questionnaire
Patient questionnaire to capture trauma history sensitively and consistently for treatment planning.
read moreSample BH Outline Discharge Summary
Discharge summary template aligned to behavioral health standards.
read moreFocus Areas: Comparison of HAP PC and BHC CTS
Side‑by‑side comparison of TJC Hospital Accreditation Program (Provision of Care) and Behavioral Health Care & Human Services Care, Treatment & Services standards with key EPs highlighted.
read moreOpening Conference, Safety Briefing, & Orientation Tool – Tech
Opening conference and safety briefing script optimized for tele‑behavioral programs, including technology and virtual‑care considerations.
read moreOpening Conference, Safety Briefing, & Orientation Tool – General
Outline of talking points, and documentation prompts to conduct the opening conference, safety briefing, and survey orientation for non‑telebehavioral providers.
read moreLeadership and Data Management Session Tool – Tech
Guide for evaluating leadership accountability and data management practices specific to tele‑behavioral operations.
read moreLeadership and Data Management Session Tool – General
Framework and question set to review leadership oversight, governance, and data/PI management for non‑telebehavioral providers.
read moreInterview Questions for Staff Tool – General
Standardized survey‑style interview questions to assess staff knowledge, competency, and readiness across departments for non‑telebehavioral settings.
read moreIC/EC/EM Tool – General
Management session for non‑telebehavioral providers.
read moreDaily Briefing, Special Issue Resolution, and Exit Conference – Tech
Step‑by‑step guide to conduct daily briefings, issue resolution, and exit conferences tailored to tele‑behavioral providers.
read moreDaily Briefing, Special Issue Resolution, and Exit Conference – General
Facilitator guide and templates to run the daily briefing, resolve special issues, and conduct the exit conference for non‑telebehavioral providers.
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