Other
Auditing
Calming Waters Consulting, LLC will prepare the facility for DCF audits by reviewing charts, Human Resource Records, and Physical space. This includes providing reports to owners, managers, and directors, as well as outlining findings and best-care practice recommendations. We will be on-site for DCF audits and utilize our established relationships with the DCF auditors to assist obtaining a quick and positive outcome.
Client Chart Auditing
Preparing the facility for DCF audits by reviewing charts, Human Resource Records, and Physical space. Providing reports to owners, managers, directors outlining findings and best-care practice recommendations. Being on-site for DCF audit, utilizing our established relationships with the DCF auditors to assist obtaining a quick and positive outcome.
We can provide on-going quarterly chart and HR record auditing to address any ongoing patterns and keep record-keeping and documentation compliant, as well as meeting with staff to direct them on licensing or accreditation body’s compliance needs. Utilizing a third-person, outside source for reviewing charts, is paramount to catching trends in documentation that have become common to the internal staff so is not caught and therefore continues inaccurately. We can provide that clinical oversight of documentation review that allows your staff to improve clinically and therefore providing continuous growth in client care.
Each chart audit is followed by a report sent to leadership regarding the individual chart findings as well as ongoing patterns of non-compliance. Furthermore, suggestions will be provided for addressing continuous improvement based on the findings in the chart audits.
Human Resources File Auditing
Full auditing of all HR records or using a sample percentage, we will give a complete report of the status of each file, what is missing/required, and provide sample forms for use. Calming Waters Consulting, LLC will work closely with the Human Resources staff at the facility to address concerns, and to assure complete understanding of the processes.
Following best practices and licensure/accreditation compliance represent two main areas of the human resources audit. The audit can be utilized to assist in identifying strengths, weaknesses and any need for changes in processes and procedures.
Although the primary focus of the session will be conducted based on licensure/accreditation compliance, the company’s Client Handbooks and HR Policies and Procedures will be reviewed to ascertain if the stated areas are being completed as well as whether they are in compliance.
To assist in preventing lawsuits regarding discrimination and wrongful termination, facilities must have clearly defined policies and procedures as well as employee handbooks. At hire, all employees must participate in a new employee orientation so that full disclosure of all policies and benefits are explained and clarified. New employees must also be given the time to raise any questions at this time. Facilities should then require the new employee to sign acknowledgement indicating they have received the information in writing. The orientation processes and documentation will also be part of the auditing process to assure the company has been fully upfront and compliant in all areas to assist in protecting the facility from issues arising from non-compliance.
A final report of findings, corrective action requirements, and best practice suggestions will be provided at the conclusion of the audit.
Compliance
Small to medium size facilities often have employees and leaders wear many hats. With this in mind, we have found that one of the areas we can take additional stress off of the staff is to follow all DCF and Joint Commission changes for your organization. Both the DCF regulations and The Joint Commission Standards are cumbersome to read and to correlate back to your daily activities, Policies and Procedures Manuals, and documentation to assure compliance in all areas. Allow Calming Waters Consulting, LLC to take this additional requirement for you.
We provide updated compliance to all new Department of Children and Families regulations and/or Joint Commission standards. Both organizations are continuously adding new or revised requirements. We will follow those changes and update your facility as those changes become effective. We will make changes to your manuals and handbooks, meet with staff regarding how to follow the changes, and audit those changes for compliance.
Policies and Procedures Manuals and Updates
When visiting Behavioral Health organizations, we have found that most have outdated or inaccurate Policies and Procedures Manuals that do not reflect the services the organization actually provides. We will revise outdated manuals to better represent the actual processes the organization utilizes. We can provide complete new Policies and Procedures Manuals, written to your specifications and to the DCF and/or Joint Commission requirements. Or we can review your existing Policies and Procedures Manuals and update them to the newest revised DCF regulations and/or Joint Commission standards. We take pride in providing manuals that address your unique philosophies, services, and practice.
Corrective Action Plans
Upon completion of DCF audit or TJC/CARF/AHCA site survey, the facility will receive a written report detailing auditor/surveyor’s findings. This report highlights State or Federal Regulations or Accreditation Standards that may be in noncompliance. The facility is required to respond with a Corrective Action Plan within a certain timeframe. There are also varying levels of the deficiencies that may require different time frames of response.
Developing the plan, in the format that is required and in the mandated timeframe, can be a daunting task for a staff that is already busy with client care and running the daily activities of the facility. Completing the plan correctly requires knowledge and experience. Calming Waters Consulting, LLC is proficient at Corrective Action Plans and will work with each department sited to develop a Corrective Action Plan that follows what the facility is specifically doing in order to bring a resolution the sited area of need.
Some of the areas that are addressed by Calming Waters Consulting, LLC are as follows:
• Opportunity for improvement
• Opportunity for improvement
• Intervention
• Expected outcome or goal
• Responsible parties
• Method of evaluation
• Expected date of completion
Calming Waters Consulting, LLC will work with your leadership team to prepare your post survey Evidence of Standards Compliance (ESC). We keep a focus on achieving a successful outcome in any follow up survey, such as Accreditation with Follow-up Survey (AFS) and Condition Level Follow-up Survey (CON).
Client and Employee Handbooks
We can provide comprehensive, individualized handbooks for Employees as well as Clients that meet all Joint Commission standards and Department of Children and Families’ regulations. These manuals would address each area of your unique agency and would encompass your rules and regulations, benefits, and documentation while meeting, or exceeding DCF/TJC requirements. We work closely with your Human Resource officer to assure each area of the employee handbook is addressed accurately and clearly and likewise work with the Clinical Director to address the same areas in the client handbook. Both are provided to you as Word documents so that your leadership can make changes as needed in the future.
