Regulatory & Compliance Supports
H&W is the premier provider of Regulatory and Compliance supports. H&W principal, Catherine Hayes, served as the ICF/IID (formerly ICF/MR) team leader for CMS immediately prior to forming H&W. We are the only national firm that maintains a team of consultants with either federal or state ICF/IID survey experience, and were trained and certified by CMS in the current ICF/IID survey process. All of our trained surveyors also have experience as an ICF/IID provider, which provides them with a unique perspective to better serve the needs of our customers.
Mock Surveys/Training Surveys:
We developed this process to provide ICF/IID organizations with a proactive approach in providing services for individuals with intellectual/developmental disabilities (I/DD) in ICFs/IID and to assist in preparations for certification visits. H&W offers a collaborative effort that results in a comprehensive mock survey to assist in meeting the Centers for Medicare and Medicaid Services (CMS) ICF/IID (formerly ICF/MR) regulations. The H&W process is a flexible approach to reviewing the supports and services at the facility in accordance with ICF/IID regulations. It is not just another assessment of those services, but may be customized to meet the specific needs of the organization, including recommendations for corrections, action plan development and compliance training during the mock survey process. H&W will work with management prior to performance of the mock survey to address issues such as:
- Specific areas that have been cited in previous surveys
- Specific incidents that have been identified by the risk management process
- Problematic residential units or programs
- Other areas of concern identified by facility management
H&W offers five levels of mock surveys to meet your needs:
- Independent Survey producing citations and recommended actions.
- Interactive Survey incorporating facility staff as “shadows” with discussion of observations and findings. Produces a list of citations and recommended actions.
- An Independent or Interactive Survey plus technical assistance to develop a full Action Plan to address each of the deficiencies.
- Training Survey incorporating facility personnel into the survey process, train these personnel on the survey process and compare the survey results with a facility self-assessment tool [This is the option most often selected by residential agencies].
- The Training survey plus additional training on the development and implementation of Plans of Correction.
Please download the document Mock Survey Process for Certification Maintenance and Survey Preparation for more details.
Accelerated Corrective Action Team (ACAT):
The ACAT model is designed to provide rapid change in response to Immediate Jeopardy findings, or where sustained, high intensity change management is necessary to achieve and maintain compliance. The specific implementation elements of the ACAT model make it creative and successful.
The results can be remarkable and, if implemented correctly, this model is effective in producing sustainable change. The model works best if the key elements are put place early in the process. Intensity is key and separates the ACAT concept from the traditional corrective approach of training staff and completing follow-up monitoring/feedback on a periodic basis. The concept uses a team approach with several team members onsite on a constant basis.
This hands-on approach focuses on very quick improvement/change and is especially useful for new projects or situations where staff is resistive or supervisors are weak. By constantly being onsite, the team not only provides ongoing training but observes results and gives immediate feedback. Please download our document Accelerated Corrective Action Team (ACAT) Model for more details.
H&W offers a wide range of training opportunities. Both principals and several of our consultants are skilled trainers. Sessions are always tailored to the needs of the specific customer. They range from a few hours to two or three day sessions. Below is a partial list of our offerings:
• How to Think Like a Surveyor
• Demystifying or Understanding The Conditions Of Participation – “The Regs”
• Preparing for Survey and Surveyor Expectations
• Active Treatment Symposium
• Abuse and Neglect Prevention
• Transition Planning for Interdisciplinary Teams – Addressing Challenges to Community Placement
• Person Centered Planning – Making It Work Within The ICF/IID Program
• Aging and People With I/DD – What The Provider Needs To Know
• ICFs/IID and Behavior Management: The Who, What, How and Whys
• Quality Enhancement – Creating Services that Make a Difference
• Creating Some Quality Time – Using your Time More Effectively
• Managing Yourself to Manage Others – Developing Management Adaptability
• QDDP Training – What Every QDDP/QMRP Needs To Know
ICF/IID-based Quality Systems:
ICF/IID Quality Assurance systems usually look at compliance with the regulations only when the state’s licensing/survey agency performs the annual certification survey or investigates a complaint. H&W believes regulatory quality assurance should be reviewed periodically throughout the year. By adding this component to an already existing QA system, an agency will avoid the “surprises” that often occur during surveys with a facility being cited for unanticipated violations, non-compliance with Conditions of Participation or even Immediate Jeopardy situations. The agency will also assure that it does not lose its focus on the ICF/IID requirements, which provides significant funding for the agency.
Knowledge of the values that underlie the regulations will focus the staff on the outcomes desired for the individuals that reside at the agency. Implementation of a highly effective QA system needs to move the staff from thinking about processes and data to concentrating on the individuals being supported and their needs and desires, and to breaking down the barriers to maximizing the individual’s potential.
H&W can provide guidance based on narrowing the gap between the facility staff’s perception of compliance and what may be determined as compliance by the ICF/IID surveyors. Training the facility to recognize when a non-compliant situation exists and thereby enabling them to correct that situation before the surveyors arrive, is the surest way to decrease or avoid citations and raise the overall quality of the supports provided to the residents.
Contact H&W to discuss how we can customize a QA solution for your organization that will improve supports and services and increase regulatory compliance.