Readiness Services

Our accreditation and compliance consultants are experienced surveyors who are chosen by Compass because of their survey skills and their consultative ability. They are not just mock surveyors. We share your goal of achieving compliance, so our focus is not just on conducting a survey, but on providing the consultative advice necessary to implement and monitor compliance on a continuous basis.

Compass Clinical Consulting assists organizations in building or strengthening internal resources to maintain a culture of continuous readiness for surveys by the Joint Commission or the Centers for Medicare and Medicaid Services.

Because TJC and CMS surveys are unannounced, preparation and ongoing readiness are critical. Our team works with organizations to craft ongoing readiness and survey preparation activities with a focus on:

  • Mitigating deficiencies prior to survey
  • Refocusing staff attention and arming managers with a response plan to launch when surveyors arrive
  • Coaching and mentoring staff and managers on survey activities
  • Educating boards and executives on the latest trends in accreditation and their implication

Accreditation and Clinical Compliance Survey Preparation and Ongoing Readiness

To keep your hospital continuously prepared, we provide high-leverage services and products to help your organization achieve survey success through proactive strategies: 

CMS and TJC Mock Surveys

Through our Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS) mock surveys, we help your organization prepare for an unannounced accreditation or regulatory survey and strengthen your internal resources to maintain a culture of continuous readiness.

We can survey to your accreditation body or concentrate solely on compliance with the CMS CoPs. Surveys are customized to the needs of the hospital, including surveys of acute care hospitals, home health, hospice, durable medical equipment, laboratory, ambulatory surgery centers, psychiatric hospitals, critical access hospitals, and physician practices.

At the conclusion of the mock survey, you will receive a verbal exit report, followed by a comprehensive written report organized to facilitate immediate and decisive action in preparing for your upcoming survey, as well as maintaining ongoing survey and regulatory readiness.

Learn more about our CMS and TJC mock surveys.

System-Wide Accreditation Support

A benefit of working with Compass for system accreditation services is the option of receiving an annual system-wide summary report.

This comprehensive report for all surveyed entities, available only from a system level view, provides system executives with the following…

  1. Summarizes frequently cited standards and CMS Conditions of Participation.
  2. Identifies common challenges, trends, and patterns across entities for system-level action.
  3. Provides a road map for accreditation and regulatory compliance improvement.
  4. Includes a system-wide heat map of vulnerabilities that acts as an accessible overview for multiple audiences.
  5. Eliminates surprises at the system level of accreditation and regulatory compliance.

Learn more about the advantages of system-wide accreditation support.

Ongoing Information and Education (Retainer Services) for Continuous Readiness

Control costs over time and combine preparation resources in a retainer services package customized to your organization. Through a retainer, we provide ongoing information and education on adaptation and implementation of new rules and regulations as promulgated by either CMS or TJC for regulatory readiness teams. These services are based on clients’ specific needs, and may include…

  • Interpretation of standards, policy review, and guidance on maintaining compliance with accreditation standards and CMS Conditions of Participation
  • Selected model policies, procedures, and other templates for adaptation from Compass’ extensive library of successfully implemented models on frequently occurring or challenging areas
  • On-demand support to have your questions answered
  • Additional resources such as newsletters featuring summaries of changes in the accreditation and regulatory survey processes along with tips for successful surveys.

Targeted Consultations and Focused Assessments

Through on-site personalized consultation, our team proactively examines processes and assesses compliance in areas such as: focused nursing assessment, environment of care, ambulatory care, critical care, home health, or surgery centers.

We also work with a variety of organizations to perform assessments focused on standards such as…

  • Disease Management Certification
  • Occupational Health and Safety Administration (OSHA). Focuses on compliance with safety and health legislation standards such as fall protection, exposure to infectious diseases, personal protective equipment, etc.
  • Emergency Medical Treatment and Labor Act (EMTALA). Any patient coming to an emergency department must be stabilized and treated, regardless of ability to pay. These assessments can focus on areas such as: emergency department, obstetrics, and behavioral services and ensures that hospitals offer these emergency services safely.
  • Life Safety Code and National Fire Protection Association (NFPA) in acute care hospitals, critical access hospitals, and ambulatory surgery centers.
  • College of American Pathology (CAP), includes laboratory services and waived testing.

Focused Standards Assessment

We provide expert resources to complete your Focused Standards Assessment (FSA) or validate one prepared internally through building tours, document reviews, and interviews with staff using CMS survey methodologies.

Assessments are conducted specific to areas such as: cleaning and high-level disinfection; sterilization processes; behavioral health patients in the ED assessments; and Environment of Care areas.

The Compass Difference

When you hire Compass to work with you, we bring a small team of consultants in to learn about your organization. We don’t invade your hospital – we become part of it. By keeping our team small, your people will get to know us and trust us and will see us as part of your team. We believe transparency is a critical success factor for any project, so you will always know about project progress and obstacles in real time.  

Learn More

Compass works with your organization to craft ongoing readiness and survey preparation activities. We focus on mitigating deficiencies prior to survey; refocusing staff attention and arming managers with a response plan to launch when surveyors arrive; coaching and mentoring staff and managers on survey activities; and educating boards and executives on the latest trends in accreditation and their implications.

To learn more and discuss your organization’s needs, ontact Victoria Fennel, PhD, RN-BC, CPHQ, Director of Accreditation and Regulatory Compliance, at (513) 241.0142, via email, or fill out the contact form below. All inquiries are confidential.