Accreditation prep

The Joint Commission expects compliance in multiple areas of behavioral health, and distinguishes between the populations of the organization. PowderHorn Consulting offers a comprehensive review of your organization, classified according to setting, program, services and populations. Some of the requirements found in the Joint Commission accreditation manual include compliance with emergency, human resources management, information management, medication management, infection prevention and control, performance improvement and record of care, treatment and service standards. Populations addressed under TJC behavioral health expectations include adults with serious mental illness, individuals with addictions, primary care behavioral health, eating disorders, and children and youth.

After an assessment of the organization, PowderHorn Consulting will conduct the following exercises:

  • Review of the TJC survey process.
  • Survey preparation for staff.
  • Mock Survey conducted.
  • Standards Training established.
  • Review of Environment of Care and Life Safety Codes.

We want to help your organization use existing tools to meet the standards of care without re-inventing the tool. Sometimes, realignment is all that it takes to improve results.


Behavioral Health

The “Gold Seal of Approval” from The Joint Commission upon accreditation is a valuable tool in demonstrating to potential clients and insurers that your organization is prepared to provide the best care to your clients. Behavioral Health is PowderHorn Consulting’s area of expertise, and we will work with you from the beginning of your accreditation process through the actual survey.

TJC uses a Tracer Methodology to trace a client through the care, treatment and services of your organization. This method reduces paper submissions while demonstrating a real-time analysis of your strengths and potential challenges. PowderHorn Consulting works alongside you with the goal of accreditation to become a state-of-the art provider with the most efficient and effective treatment services.


Mock Surveys

PowderHorn Consulting asks the vital questions during a mock survey to help your organization be prepared for what The Joint Commission wants to see. We use tracers, as TJC does, from leadership to data management, to analyze your current systems. Process evaluation occurs first, with record assessment, staff meetings, environment and clinical documentation addressed. During our survey, we will walk through the system with a patient record to observe client explanation and assessments, individual and group meetings, treatment plan, measurement, and end with an interview with that patient. This exercise will discover any risks and gaps that must be covered prior to the actual TJC survey.

Our consultants are up to date on the most current TJC Survey techniques and can coach managers and staff on how to handle challenging survey issues. After the mock survey, PowderHorn Consulting will give the organization a detailed report outlining strengths and areas of improvement. The mock survey provides a critical opportunity for staff to experience the TJC survey process and gain confidence in their survey presentation skills.


Accreditation AfterCare

PowderHorn Consulting is prepared to assist your organization with aftercare to continue with accreditation in the future. Our team will assist with regular upkeep, as well as a mock survey prior to the TJC survey. We offer:

  • Ongoing training with mock tracers.
  • Implementation plans to use with quarterly basis tracer findings.
  • Impromptu survey readiness with examination of patient care and safety risks.
  • Sentinel event response preparedness.
  • Critical incidents and ongoing compliance for survey readiness.
  • Proactive FEMA response readiness.
  • Scheduled reaccreditation survey preparation.

Our goal is yours – to offer the best services possible to your client base, with the most efficiency and effectiveness.