• Pre-survey assessments and mock surveys for JC accreditation

• CMS Consultants for compliance with Conditions of Participation

• Patient safety risk assessments including:

  • Ligature risk evaluations

  • Survey readiness

  • Evaluation of medical staff bylaws

  • Credentialing and privileging

  • Pharmacy compounding

  • Medication management evaluations

  • Sterile processing

  • Sterilization

  • High-level disinfection

  • Behavioral Health Readiness

  • Long-term Care Survey Readiness

  • Medical staff education

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• CMS Consultants for compliance with Conditions of Participation

• Roadmap of the CMS Conditions of Participation (CoPs)

• Mentorship & Feedback

• Post-mock survey reporting with SAFER Matrix

• On-Demand Answers to Ongoing Questions

• New Standards Review and Interpretation

• Facility Training & CMS Webinars

• One-on-one Subject Matter Expert Training

• Post on-site preparation for return surveyor visits

• Ongoing follow-on support

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• Delivering on-site assessments designed to identify and mitigate infection risks and provide feasible solutions.

• Conduct thorough examinations in sterile and instrument processing at the point of use in the following areas:

  • Operating Room

  • Labor and Delivery

  • Cath Lab

  • Other Procedural Areas

• Provide focused assessments designed to evaluate the hospital or healthcare facility’s infection control program

  • assess reported data

  • assess data outcomes

  • and apply interventions to improve undesirable trends.

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• Instrument and sterile tray inspections in critical procedural areas such as the operating room, labor and delivery, and the emergency department. 

• Evaluation of proper sterilization times and procedures based on the instrument manufacturer’s instructions.

• Staff competency assessment evaluations and recommendations for improvement.  Education is provided when deficiencies are identified. 

• Recommendations and implementation of improvements to prevent negative survey outcomes and address patient safety issues.

• A full report is provided after the initial assessment and when onsite implementation is required daily. 

• Compliance with AAMI ST79 and all applicable ISO requirements.

• Workflow optimization to improve productivity

• Equipment assessment to meet manufacturer guidelines

• Staff training and education tailored to sterile processing technicians and infection control

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• Privileging for physicians and other providers to include specialty-specific quality indicators, adequacy of oversight in granting initial privileges as well as the ongoing review of competence to maintain privileges (FPPE & OPPE)

• Structure and responsibilities of the various categories of membership

• Privileging low-volume physicians

• Requirements of telemedicine

• Dealing with disruptive behavior

• Involvement of the medical staff in accreditation preparation and surveys

• Opportunities to improve the quality of medical records documentation

• Medical staff’s leadership role in oversight of quality of care, infection control, and patient safety

• Medical staff’s involvement in emergency management

• Management of contracted clinical services

Delivering comprehensive webinar and onsite education programs

Regulatory and survey management

Topics Include:

Conditions of Participation (CMS)

The Joint Commission Standards

Education for all programs:

Hospital, Critical Access, Ambulatory Surgery, Dental Clinics, Laboratory, Hospice, Home Care, Long Term Care, Swing Bed, Environment of Care and Life Safety, Rehabilitation, Rural Health and Behavioral Health.

Specialty Areas: High Level Disinfection, Sterile Processing, Instrument Processing and Management, Water Management, AAMI guidelines, Dialysis, Medical Staff, Medication Compounding.