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Compliance and Accreditation Support

Achieving and maintaining compliance involves knowledge of standards, and the ability to implement them, in a way that both fits the organization and is maintainable. The YBHCS team is especially skilled at assisting organizations in operationalizing standards in ways that are practical and efficient. We assist clients in developing internal controls through ongoing data collection and auditing to support sustainability.

YBHCS has experience working with the following regulatory and accrediting bodies:

  • State licensing agencies
  • Centers for Medicare and Medicaid Services (CMS)
  • The Department of Justice (DOJ)
  • The Joint Commission (TJC)
  • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • National Council for Quality Assurance (NCQA)
  • Utilization Review Accreditation Commission (URAC)
  • Council on Accreditation (COA)

After our consultants conduct an assessment, we will provide a comprehensive and timely report. It will include recommendations for addressing all areas that were found to be out of compliance. During the assessment process, staff at multiple levels of the organization will be provided with education and coaching. This helps to ensure that compliance can be achieved and that they will be prepared for future surveys from accreditation and regulatory bodies.

Yale Behavioral Health can respond rapidly should an organization receive an adverse decision such as Preliminary Denial of Accreditation, Condition Level Deficiencies, or Immediate Jeopardy from regulators or accreditors. Our team will work alongside you and your staff to prepare a response, develop, implement, and monitor a well-designed plan of correction, and prepare for follow up surveys.

If your organization needs urgent assistance with an issue, please contact us at or 203-927-4767. If you are looking for clinical care please call “211” or “911” in an emergency.

Program Development Support

The Yale Behavioral Health Consulting Services staff tracks major trends in behavioral health services. We identify emerging opportunities for new program development and follow best practices in the management and quality improvement of existing services.

Opportunities include:

  • Integrated Care
  • Crisis Services
  • Certified Community Behavioral Health Clinics (CCBHC)
  • Value-based performance and contracting

YBHCS acknowledges the difficulties that healthcare organizations encounter in maintaining and expanding access, integrating care, implementing evidence-based practices, and managing value-based contracting. Our understanding and experience in managing complex projects of all sizes allows us to provide your organization with practical solutions. YBHCS does this by offering tools and strategies that help behavioral health providers remain flexible and responsive to ever-changing demands including the development and expansion of behavioral health services.

Expert Clinical Consultation

Our psychiatry and behavioral health teams have experience in providing clinical oversight from organizational protocols to challenging individual cases. They have assisted organizations with bringing improved standards to clinical care. Areas for clinical consultation include the following:

  • Moving individuals to less restrictive levels of care with ongoing assessments of risk to the person and the community.
  • Providing additional clinical support from Psychiatry and behavioral services for individuals who have significant behavioral disruptions including self-injurious behaviors, aggression to others or the environment.
  • Assuring psychiatric and behavioral treatment plans meet best practices in community and hospital-based settings.
  • Assessing clinical care to reveal areas of existing clinical practice that need improvement to militate against potential malpractice claims.
  • Training for clinical staff in understanding positive behavioral support plans and implementing best practices in the evaluation and treatment of individuals at high risk for violence.

Provider Assessment and Monitoring

Our assessment and monitoring services are available to organizations such as psychiatric hospitals, residential care facilities, mental health and substance use treatment centers, and juvenile justice systems.

YBHCS has a comprehensive approach to assessment and monitoring that involves three phases: (1) Assessment, (2) Improvement, and (3) Maintenance of Change. Using a team of skilled experts, these three phases help to build clear and concise action plans designed to improve quality; meet applicable regulatory, accreditation, and safety standards; and avoid or exit a consent order.

Assessment Phase 1: The YBHCS team begins by conducting a full assessment of the organization. This includes an on-site visit and thorough examination of policies, staffing, documentation, and operational workflow. The output is a developed action plan to address gaps and/or deficiencies.

Improvement Phase 2: The YBHCS team consults on the implementation of a corrective action plan, while simultaneously monitoring and validating that implementation.

Maintenance Phase 3: This final phase is designed to document the progress that was accomplished, and to promote sustainability and long-term success regarding quality of care and compliance.

Workforce Development

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Recruitment and Retention

Staff turnover and vacancy rates in behavioral health organizations are at unprecedented levels. Over 95% of provider agencies report significant difficulties finding and keeping workers. The YBHCS team has decades of experience managing these issues in hospitals, ambulatory clinics, and community programs. They can educate your staff and clinical leaders about effective recruitment and retention practices, and assist your organization in building and implementing a comprehensive recruitment and retention plan. These plans typically address the following:

  • Compensation and benefits
  • Advertising and outreach
  • Selection processes
  • Workforce diversity
  • Onboarding
  • Supervision and Coaching
  • Employee support and recognition
  • Efficiency in the recruitment and retention process

The Yale Program on Supervision

The Yale Program on Supervision is part of the Yale School of Medicine and its Department of Psychiatry operates under the direction of Yale Faculty members who are national and international leaders on workforce development in healthcare. The Program provides a diverse range of services including skills training with supervisors and middle managers; staff coaching; strategic planning and consultation with agency leaders on organizational change strategies to foster effective supervision; supervision policy and standards development; and specialized training and consultation addressing secondary trauma in the health and social service workforce.

Training and Education

YBHCS consultants are experienced educators who have worked in hospitals, clinics, for profit and not for profit organizations, and in academic settings. They know that staff who receive ongoing training and professional development will in turn provide high quality care, better services to customers, and low attrition rates. Trainings are available on-site and virtually.

Examples of our training topics include:

  • Treatment Planning and Documentation
  • Reducing the Use of Restraint and Seclusion
  • Understanding and use of positive behavioral support plans
  • Best practices for evaluation and treatment of individuals at high risk for violence
  • Suicide Risk Assessment
  • Preparing for Your Survey
  • Medical Necessity