CLINICAL PROGRAM QUALITY, ACCREDITATION, INTEGRITY, AND TRAINING
SAM's clinical, quality improvement, accreditation, and training processes provide Clinical Quality Control to ensure that all services are utilizing clinically sound practices and are delivered in accord with the company's standardsof high clinical quality. As a result, SAM can provide consultative services toward the establishment or enhancement of:
QUALITY AND ACCREDITATION
CARF Accreditation
- Assist in the development of a CARF-readiness action plan.
- Assist in the development of an organizational review process related to business and program practices as it relates to the CARF standards.
- Support the development of internal communication and training associated with the CARF survey standards and process for staff and key stakeholders.
- Assist in the development of a documentation and reporting process and formats related to business practices and CARF standards conformance.
Risk Management Planning
- Assist in the development of a risk management plan and review process.
- Assist in the development of building safety and accessibility audits to identify potential health and safety issues for review and response.
- Assist in the development of emergency procedures testing process.
HIPAA and HITECH Compliance Activities
- Assist in the development of internal use and disclosure tracking processes.
- Assist in the development of breach analysis and notification processes.
- Assist in the development of key policies and procedures related to HIPAA Privacy compliance, including internal audits.
- Assist in the development of internal disclosure and breach reporting, as well as development of procedures for external breach reporting (to Health and Human Services).
Program Integrity
- Assist in the development of mechanisms to ensure that programming functions in accordance with all accreditation, licensing, regulatory, and other relevant quality standards.
- Assist in the development and implementation of methodology for systematic on-site clinical program reviews, including, but not limited to, record audit reviews and mock licensing visits. Provide consultation to program management staff in utilizing the information obtained through these mock visits in order to assist in planning and preparing for actual licensing visits.
- Provide consultative services to assist managers in identifying, developing, and implementing plans to ensure the efficient utilization of human and financial services.
Training
- Assist in identifying and assessing training needs by meeting with managers and facilitating the preparing and collecting of surveys and completing training reports.
- Assist in developing trainings and improvement activities in response to training data, accreditation standards, and organizational needs.
- Assist and consult in obtaining resources for training activities.
- Conduct trainings.
- Assist in identifying and evaluating available Learning Management Systems, and/or in developing a system for the entry and tracking of external/internal employee training.
- Assist in exploring, identifying, and evaluating new technologies and resources for future training options.
- Assist in the development of New Staff Orientation and Annual Training schedules.
