Readiness Services

Compass Clinical  Consulting assists organizations in building or strengthening internal resources to maintain a culture of continuous readiness for surveys by The Joint Commission (TJC) or the Centers for Medicare and Medicaid Services (CMS). Because TJC and CMS surveys are unannounced, preparation and ongoing readiness are critical. To keep your hospital continuously prepared, we provide high-leverage services and products to help your organization achieve survey success through proactive strategies.

The Need to Create a Culture of Continuous Readiness

TJC and CMS surveys are unannounced, preparation and ongoing readiness are critical. Compass assists organizations in building or strengthening internal resources to maintain a culture of continuous readiness for surveys by The Joint Commission (TJC) or the Centers for Medicare and Medicaid Services (CMS). 

Compass Can Help

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

Continuous Readiness Packages

Control costs over time and combines preparation resources in a convenient package customized to your organization. These include an on-demand question and clarification support, webinars, and other educational services on CMS and TJC changes and interpretation.

CMS & TJC Survey Preparation

Prepares the organization for an unannounced validation survey through the intense scrutiny of state surveyors in a safe setting. Surveyor team conducts mock survey to identify deviations from compliance to federal standards set forth by CMS or TJC, indicate high-level risks, and provide recommendations to address findings and manage compliance to achieve patient safety expectations

CMS Conditions of Participation (CoPs)

Requirements organizations must meet to begin and continue participating in Medicare and Medicaid programs.

Applies to: acute care hospitals, critical access hospitals, psychiatric hospitals, home health, hospice, and ambulatory surgery centers.

The Joint Commission (TJC)

Applies to: acute care hospitals, critical access hospitals, psychiatric hospitals, physician practices, home health, hospice, ambulatory surgery centers, and laboratory.

Disease Management Certification

OSHA

Focuses on compliance to safety and health legislation with standards such as fall protection, exposure to infectious diseases, personal protective equipment (PPE), etc. Goals of finding and correcting safety and health hazards.

Targeted Consultation

On-site personalized consultation proactively examines processes and and assesses compliance in areas such as: focused nursing assessment, ambulatory, critical care, home health, surgery center, etc.

Tracer Methodology Mock Surveys

Allows staff to respond in mock survey conditions while identifying opportunities for targeted improvement.

EMTALA

Focuses on areas such as: Emergency department, obstetrics, and behavioral services.

Any patient coming to an emergency department must be stabilized and treated, regardless of ability to pay.

Focused Standards Assessment

We provide expert resources to complete your Focused Standards Assessment (FSA) or to 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.

Life Safety Code and NFPA

Applies to: acute care hospitals, critical access hospitals, and ambulatory surgery centers.

College of American Pathology (CAP)

Includes laboratory services and waived testing. 

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.  

Contact Us

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.

Contact 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.