Scope of Services

Accreditation and Regulatory Compliance

An initial on-site assessment provides the content for detailed recommendations and a written action plan that is presented to the Executive Leadership Team. After discussion and consultation, a final plan and terms of a corrective action will be agreed upon between the Client and MLC.

The Joint Commission survey preparation for interval surveys. Should your organization experience an event that creates a crisis situation, MLC can help you effectively manage the event and address compliance issues at hand. Perhaps your organization has experienced leadership turnover or key roles have been vacant for a period of time and survey is just around the corner; you are in accelerated preparation mode. MLC can lead your organization through an accelerated process for the accreditation survey.

Centers for Medicare and Medicaid Services (CMS) survey in response to a clinical event or as an interval validation survey for quality. MLC can assist your organization in demonstrating compliance with the Conditions of Participation (CoPs) presented in the Code of Federal Regulations (CFR).

Quality / Performance Improvement / Culture of Safety

Key Performance Process and Outcome Measures (KPM) can be translated to a dashboard accessible on a specific drive on a secured server. This allows the leaders of the organization access to view the status of department quality at any time. Formatting of the dashboards can easily generate graphs and charts to display data to enhance discussion to improve quality.



Evaluation of the organization Risk Management program to include review of how sentinel events and reportable events are managed and communicated to the appropriate authorities. The Culture of Safety is evaluated by review of documents, talking with staff, and observation of interactions. The TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) approach is supported and strongly recommended for organizations striving to improve team performance and foster a culture of safety. Application of HIPAA to communication and healthcare records.