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Compliance Services


    Compliance Services offer an array of programs to assist healthcare institutions to meet compliance standards from accrediting and regulatory organizations. Each engagement is carefully tailored to meet the needs of the client. Our efforts are focused to provide our clients the maximum benefit on every consulting engagement.  PECA professionals are prepared to assist you and your staff in a number of areas.


Accreditation Preparedness Services

Are you prepared for accreditation? We are able to facilitate your organization’s compliance of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), state licensing regulations, and Medicare “Conditions of Participation”.  We can conduct a comprehensive organization-wide survey prior to your JCAHO scheduled visit and report on all areas of deficiency.  Our staff can recommend courses of action that will bring your organization into compliance with JCAHO and/or NCAHO standards, state licensing regulations and Medicare “Conditions of Participation”.  We can conduct a follow-up survey to assure that your organization has achieved the highest possible level of compliance.  In addition, we can develop cost-effective organization-specific mechanisms for complying with the various regulatory standards.

Nursing Management Services

Are you managing patient care resources prudently?  With the increased acuity of the patient population, and the continued shortage of qualified RNs and LVNs, the prudent management of patient care resources is essential.  We can develop and implement effective nursing acuity systems to assure proper resource allocation based upon patient volume and service intensity.  Our staff can engineer nursing standards for patient care and develop action plans to evaluate your organization’s level of compliance with JCAHO standards, state licensing regulations, and Medicare requirements. Our staff can also supplement or enhance your staff development activities.

Licensure and Medicare Certification Services

Do you have effective programs for licensure and certification?  Acute care hospitals, long term facilities, psychiatric institutions, and home health agencies must meet specific criteria to establish and maintain licensure.  Our staff can prepare new facilities for licensure and accreditation surveys and provide detailed reviews and timely recommendations for licensure conversions.  We can also assist healthcare organizations in preparation for Medicare validation surveys and provide guidance in the event of a Medicare decertification action.

Human Resources Services

Are you maximizing the value of your human resource efforts?  The demands for human resource management have vastly expanded while the internal resources available have remained static.  This dynamic situation has created the need, in many organizations, to seek additional assistance in managing human resources.  Our staff can assist you in conducting area-wide salary surveys and establish salary benchmarks based on internal equity and external market competitiveness.   We can assist you in establishing personnel policies and procedures and help you in recruiting for middle and upper management personnel, as well as medical professionals in specific specialties (e.g., pharmacists, registered nurses, etc.).

Performance Improvement Services

Have you established an effective Performance Improvement Program? Our experts will assist you in developing organizational specific programs designed to meet JCAHO standards.  We can provide your organization with a smooth transition from Quality Assurance to Performance Improvement.  We can also develop education and training programs for the governing body, medical staff, leadership and employees in approaches to and methods for implementing continuous quality improvement.

Infection Control Services

Does your Infection Control Service meet accreditation and regulatory compliance?  Infection control is an essential part of JCAHO, state licensure, and Medicare surveys.Our skilled professionals will evaluate existing programs and recommend appropriate courses of action to bring your organization into substantial compliance. We can provide in-house training as well as implementation and maintenance assistance. We can also help you develop an organization-specific Bloodborne Pathogen Exposure Plan and develop an organization-specific Tuberculosis Control Plan. Our consultants can develop and evaluate AIDS protocols, provide AIDS-related in-service staff training, and facilitate the implementation of “Standard Precautions”.

Clinical Laboratory Services

Is your Laboratory in compliance with accreditation and regulatory organizations?  Our staff can help you prepare for accreditation, state licensure, and Medicare surveys and for obtaining certification from the College of American Pathologists.  We can review position descriptions, materials data safety sheets, and hazardous materials policies for compliance.  Our staff has extensive experience in reviewing and revising Laboratory policy and procedure manuals and can assist you in achieving the highest possible level of compliance with CLIA 88 requirements

Medical Staff Services

Are you receiving maximum value for your Medical Staff Services?  Our professionalstaff can provide both interim support and day-to-day operational support. We can provide consultants certified as Certified Medical Staff Coordinators and Credentialing Specialists. We can assist with the development and management of your credential procedures and licensure verification practices.  Our staff can assist with the preparation for accreditation surveys and provide on-site availability during the surveys. We can design and implement Medical Staff Office management systems, policies and procedures and train your staff in all areas of Medical Staff Office management.