Response & Recovery Survey Services

When surveyors leave, you may be faced with a perplexing list of deficiencies and findings. Receiving a TJC finding of Accreditation with Follow-Up Survey, Contingent Accreditation, Preliminary Denial of Accreditation, Denial of Accreditation or CMS Condition-Level Deficiencies, Immediate Jeopardy, or Medicare Decertification can weaken community support, decrease staff morale, and derail even the best organizations.

Additionally, the financial impact of decertification is potentially devastating. Compass helps you gain needed insight and assistance to respond to TJC, HFAP, or CMS survey findings; prevent revenue loss and disruption of care if your hospital must address poor TJC or CMS survey results. Contact us: Learn More

 We work with your organization to:

Validate: Validate the accuracy of cited deficiencies and address survey report inaccuracies

Recognize: Recognize evidence of compliance not identified by surveyors

Deploy Resources: Deploy internal resources effectively to offer the best outcome possible in the public and private arenas to identify solutions to cited deficiencies that conserve time and resources

Detect Vulnerabilities: Detect areas of vulnerability not identified during survey

Organized Response: Provide a sense of calm and turn anger into action through an organized response


For hospitals responding to CMS or TJC survey findings, Compass Clinical Consulting offers:

  • Evidence of Standards Clarification Development. Challenge TJC survey findings through the clarification process.
  • Evidence of Standard Compliance (ESC) Development. Develop action plans aimed at addressing the TJC requirements for improvement without consuming unnecessary resources.
  • Revision of Medical Staff Bylaws, Rules, and Regulations. Address cited TJC or CMS deficiencies and potential problems associated with the ongoing standard changes and the focus on medical staff quality.
  • Targeted Consultation. Initiate redesign in response to TJC or CMS deficiencies based on expert input from across the country.
  • Sentinel Event and Root Cause Analysis Consultation. Consult with experts on the root cause analysis process to analyze near misses and sentinel events for possible review by TJC or CMS.
  • Review and Assistance in Formulating the CMS Plan of Correction.  Develop action plans aimed at addressing the CMS deficiencies from Condition-Level findings or Immediate Jeopardy that are achievable, measurable, and sustainable in a short period of time before a potential resurvey.

Additionally, if you have received a Medicare termination notice and have been offered the opportunity to enter into a Systems Improvement Agreement, we can help.

Compass Clinical Consulting has already been approved by CMS to serve as at the outside monitor for organizations undergoing Systems Improvement Agreements (SIA).

To find out more about our Compliance and Accreditation services, send us an email or contact our office at (800) 241.0142.