Accreditation and Compliance Response and Recovery Services

Respond Quickly and Effectively to Achieve Sustainable Change

Compass has a 100% successful record in leading hospitals to CMS recertification. 

Clinical Consulting’s team of compliance and accreditation experts is prepared to help you respond quickly and effectively to achieve sustainable changes toward a goal of safe, quality patient care.   

When surveyors leave, organizations may be faced with a perplexing and, at times, overwhelming list of deficiencies and findings. Receiving a TJC finding of Accreditation with Follow-up Survey, Preliminary Denial of Accreditation, Denial of Accreditation, or Immediate Threat to Life, or CMS Condition-level deficiencies or Immediate Jeopardy can derail even the best organizations – and no organization is immune.

Unresolved, these problems put healthcare organizations at risk of CMS decertification – the financial, reputational, and patient care consequences of which can be devastating. Negative survey results call for immediate action—there’s often only a short timeframe in which to turn things around before these potential consequences become a reality.

CMS & TJC Response and Recovery Services

Compass Clinical Consulting partners with the staff and leadership of our client organizations to…

  • Provide post-survey consultation that addresses deficiencies and redesign processes to be transparent, easily measured, and simply maintained
  • Develop solutions to cited deficiencies that conserve time and resources
  • Understand how noncompliance occurred and create strategies for sustainable improvements in quality and patient safety
  • Review and implement thorough and credible Plans of Correction (CMS) and Evidence of Standards Compliance Plans (TJC) within the designated timeframe
  • Provide direction on what to expect once the surveyors are gone, or after the survey once the action plans are submitted
  • Provide a sense of calm and turn anger or anxiety into action through an organized response

For hospitals, home health agencies, or ambulatory surgery centers responding to survey findings, Compass Clinical Consulting offers support through each step of the process.

Responding to TJC Survey Findings

  • Evidence of Standards Compliance (ESC) Development. 
  • Evidence of Standards Clarification Development. 
  • Sentinel Event and Root Cause Analysis Consultation.

Responding to CMS Survey Findings

  • Review and Assistance in Formulating the CMS Conditions of Participation Plan of Correction. Develop credible, achievable, thorough, measurable, and sustainable plans of correction aimed at addressing CMS deficiencies from Condition-level findings or Immediate Jeopardy situations in a short period of time before a potential resurvey
  • Plan of Correction Implementation.
  • Event Analysis Consultation.
  • Focused Surveys or Full Mock Surveys Prior to Validation Survey.

Compass also provides customized support for TJC and CMS response and recovery needs through…

  • Culture Transformation Consultation. Compass can help engage staff and improve policies, procedures, and processes toward a culture focused on establishing a standard of care rooted in evidence-based guidelines and nationally accepted standards.
  • Targeted Consultation and Solutions. Examples of areas of focus include high-level disinfection and sterilization, suicide risk assessments in the Emergency Department or other departments, and assessments specific to pharmacy, lab, or radiology.
  • On-Site Support or Interim Leadership. Compass can provide on-site support to work in the command center during accreditation or regulatory surveys, or interim leadership to support the post-survey process when staff vacancies may impede the successful resolution of serious survey findings.

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.

Contact Us

Compass Clinical Consulting has successfully guided an organization through successful resolution of a CMS Systems Improvement Agreement (SIA). To find out more about our Compliance and Accreditation services, send us an email or contact our office at (800) 241.0142.