Cross-References:
- REGULATORY_COMPLIANCE_TRACKER.md — Master compliance tracker
docs/compliance/AUTHORITATIVE_REFERENCES.md— Authoritative External References — Accreditation and Quality Measures
Overview
This document tracks governance, accreditation, quality measurement, incident reporting, and nonprofit compliance obligations for Encore OS. The GR module serves as the organizational compliance backbone — spanning accreditation survey readiness, quality measure reporting, mandatory incident reporting, board governance, document retention, and risk management.1. Accreditation Standards
1.1 CARF Behavioral Health
| # | Requirement | Responsible Spec | Status | Notes |
|---|---|---|---|---|
| CARF-01 | CARF accreditation — Achieve and maintain CARF Behavioral Health accreditation (1-year or 3-year) | GR-08 | ⏳ Not Started | Survey preparation features in GR-08; survey cycle tracking |
| CARF-02 | Person-centered planning — Demonstrate individualized treatment/service planning across programs | CL-02, CL-04 | 🟡 Partial | Assessment and treatment planning in CL module; CARF alignment needed |
| CARF-03 | Performance measurement — Systematic outcome measurement and program evaluation | CL-10, CL-15 | 🟡 Partial | Quality measures in CL-10/CL-15; CARF-specific indicators needed |
| CARF-04 | Health and safety — Policies and procedures for client and staff safety | GR-08, GR-12 | ⏳ Not Started | Policy library; incident tracking; safety plans; GR-12 adds procedure templates to accelerate SOP readiness |
| CARF-05 | Rights of persons served — Grievance procedures, informed consent, confidentiality | CL-11, RH-02 | 🟡 Partial | Consent in CL-11; resident rights in RH-02; centralized rights management needed |
| CARF-06 | Workforce development — Staff qualifications, training, supervision documentation | HR-02, HR-04, GR-02, GR-18, GR-19 | 🟡 Partial | Credentialing in HR-02; training tracking in HR-04; GR-02 owns canonical training & CEU schema (✅ Complete); GR-18 (📋 Specification) ships the competency assessment engine (question banks, attempts, server-side grading, surveyor evidence) — turns “attendance” into surveyor-defensible competency validation per CARF 1.B.6 (see CARF-08 below); GR-19 adds focused mandatory in-service compliance matrix + surveyor PDF packet (one-click “last 12 months of HIPAA / BBP / mandated-reporter completions, by employee”) on top of the GR-02 substrate + GR-02-EN-05 seed catalog |
| CARF-08 | Competency validation (1.B.6) — Demonstrate ongoing staff competency via assessment, not just attendance | GR-18 | 📋 Specification | GR-18 question banks + attempts + server-side grading + answer-key isolation (safe view + SECURITY DEFINER grading) + immutable response audit + surveyor evidence PDF (counts/score/citations only — no question stems). Closes the GR-02 “self-attest” gap. |
| CARF-07a | Quality improvement plan (QIP) — QIP-aligned procedure templates and starters | GR-08, GR-12 | ⏳ Not Started | QIP creation and tracking; corrective action plans; GR-12 templates include QIP-aligned procedure starters |
| CARF-07b | Quality improvement plan (QIP) — CAP lifecycle tracking from survey findings | GR-08, GR-16 | ⏳ Not Started | GR-16 CAP lifecycle tracks corrective actions from survey findings (CARF QIP component); GR-08 handles broader QIP |
1.2 Joint Commission CAMBHC
| # | Requirement | Responsible Spec | Status | Notes |
|---|---|---|---|---|
| JC-01 | Joint Commission CAMBHC accreditation — Community-based and Ambulatory Behavioral Health Care | GR-08 | ⏳ Not Started | Survey readiness features in GR-08 |
| JC-02 | National Patient Safety Goals (NPSGs) — NPSG.15.01.01 (suicide risk identification) | CL-07 | 🟡 Partial | Safety assessment in CL-07; NPSG.15.01.01 compliance mapping needed |
| JC-03 | Tracer methodology readiness — Demonstrate care continuity through patient tracer reviews | CL-01, CL-02, CL-04, GR-16 | ⏳ Not Started | GR-16 adds tracer pack generation and mock survey capability; clinical tracer views in CL specs |
| JC-04 | Performance improvement — Sustained improvement in clinical and operational outcomes | CL-15, GR-08 | ⏳ Not Started | Dashboard support; trend analysis |
| JC-05 | Leadership standards — Board governance, strategic planning, resource management documentation | GR-03 | ⏳ Not Started | Policy and governance management in GR-03 |
| JC-06 | Environment of care — Safety management plans, hazardous materials, emergency management | GR-08 | ⏳ Not Started | Safety management features |
| JC-07 | HR.01.04.01 — Ongoing competency assessment — Competency must be assessed, not just attended (annual + role-triggered) | GR-18, GR-19 | 📋 Specification | GR-18 ships the assessment engine (question banks, attempts, server-side grading, immutable evidence). GR-19 surfaces compliance via the in-service matrix and surveyor PDF packet. Together they close the gap that GR-02 alone (attendance + self-attest) does not. |
| JC-08 | CMS Conditions of Participation §482.13 — Restraint training competency — Documented competency for restraint application post-training | GR-18 + GR-02-EN-05 | 📋 Specification | GR-18 supports linking an assessment to any gr_training_courses row (no schema special-casing). Restraint courses in the GR-02-EN-05 mandatory training seed catalog can be configured with an assessment template. |
2. Quality Measures and Outcome Reporting
2.1 NCQA HEDIS (Healthcare Effectiveness Data and Information Set)
| # | Requirement | Responsible Spec | Status | Notes |
|---|---|---|---|---|
| QM-01 | Follow-Up After Hospitalization (FUH) — 7-day and 30-day follow-up for mental illness | CL-15 | ⏳ Not Started | Requires encounter/discharge tracking integration |
| QM-02 | Follow-Up After Emergency Department Visit (FUM) — 7-day and 30-day follow-up for mental illness/SUD | CL-15 | ⏳ Not Started | Requires ED visit tracking |
| QM-03 | Initiation and Engagement of SUD Treatment (IET) — Initiation within 14 days; engagement within 34 days | CL-15, CL-10 | ⏳ Not Started | SUD treatment timeline tracking |
| QM-04 | Antidepressant Medication Management (AMM) — Effective acute and continuation phase treatment | CL-05, CL-15 | ⏳ Not Started | Medication tracking integration |
| QM-05 | Screening for Depression (SDD/CDF) — PHQ-9 screening and follow-up | CL-02, CL-07 | 🟡 Partial | PHQ-9 in assessment; reporting integration needed |
2.2 SAMHSA NOMs (National Outcome Measures)
| # | Requirement | Responsible Spec | Status | Notes |
|---|---|---|---|---|
| NOM-01 | Abstinence from drug/alcohol use — Track substance use outcomes | CL-10 | ⏳ Not Started | Outcome tracking in CL-10 |
| NOM-02 | Employment/education — Functional outcomes | CL-18 | ⏳ Not Started | SDOH tracking per CL-18 |
| NOM-03 | Criminal justice involvement — Reduced involvement | CL-10 | ⏳ Not Started | Outcome measure |
| NOM-04 | Stable housing — Housing stability outcomes | CL-18, RH-02 | 🟡 Partial | Housing data in RH; SDOH in CL-18 |
| NOM-05 | Social connectedness — Social support and community engagement | CL-18 | ⏳ Not Started | SDOH domain |
| NOM-06 | Access/capacity — Service utilization and retention metrics | PM-01, CL-15 | ⏳ Not Started | Scheduling and reporting data |
| NOM-07 | Client perception of care — Satisfaction surveys and outcome ratings | CL-10 | ⏳ Not Started | Survey data collection and reporting |
3. Mandatory Incident Reporting
| # | Requirement | Responsible Spec | Status | Notes |
|---|---|---|---|---|
| IR-01 | Arizona mandatory reporting — vulnerable adults (ARS 46-454) — Report suspected abuse, neglect, exploitation immediately | GR-09 (intake), GR-08, CL-13, GR-14 | 📋 Specification | GR-09 captures incident and emits gr_incident_created event; GR-14 automates APS obligation creation, deadline tracking, and report package generation |
| IR-02 | Arizona mandatory reporting — children (ARS 13-3620) — Report suspected child abuse/neglect immediately to DCS or law enforcement | GR-09 (intake), GR-08, GR-14 | 📋 Specification | GR-09 captures incident; GR-14 automates DCS obligation creation and deadline tracking |
| IR-03 | Restraint/seclusion reporting (42 CFR 482.13(e)) — Document and report per federal and state requirements | GR-09 (CL-GR bridge intake), CL-13, GR-14 | 📋 Specification | GR-09 CL-GR bridge creates draft incident with severity=critical; GR-14 implements CMS death_report obligation (1 calendar day deadline) |
| IR-04 | Critical incident tracking — Deaths, serious injuries, elopements, medication errors | GR-09 (intake), GR-08, GR-14 | 📋 Specification | GR-09 is the incident intake layer; GR-14 adds regulatory classification, deadlines, and report packages on top of GR-09 data |
| IR-05 | AHCCCS incident reporting (AMPM 1620-O) — Report critical incidents to AHCCCS per policy | GR-09 (intake), GR-08, GR-14 | 📋 Specification | GR-09 captures incident and emits event; GR-14 implements AHCCCS verbal (8 business hrs) + written (40 business hrs) packages with business-day deadline calculator |
| IR-06 | Sentinel event reporting — Joint Commission sentinel events require root cause analysis | GR-09 (intake, RCA via investigations), GR-08, GR-14 | 📋 Specification | GR-09 investigation + root cause analysis workflow; GR-14 implements sentinel event report tracking with 45-day RCA deadline monitoring |
| IR-07 | Reporter protection — Good-faith reporters protected from civil/criminal liability (ARS 46-454) | GR-08 | 📋 Policy | Organizational policy; system documents reporter identity confidentially |
4. Nonprofit Governance
| # | Requirement | Responsible Spec | Status | Notes |
|---|---|---|---|---|
| NG-01 | Whistleblower policy — Required under Sarbanes-Oxley §1107; no retaliation for reporting financial impropriety | GR-03, GR-15 | 📋 Specification | GR-15 Phase 2: anonymous-capable whistleblower intake with non-retaliation tracking; see specs/gr/reviews/GR-15-COMPLIANCE-SIGNOFF.md W-1 through W-5 |
| NG-02 | Document retention policy — SOX §802 prohibits destruction of records to impede investigation; establish retention schedule | GR-03, GR-15 | 📋 Specification | GR-15 Phase 4: PF-46 retention schedule configuration (7yr COI/WB; permanent board records); legal hold enforcement |
| NG-03 | Conflict of interest policy — Board member/officer disclosure; IRS requires for Form 990 | GR-03, GR-15 | 📋 Specification | GR-15 Phase 1: annual COI attestation + Form 990 Schedule L prep report; see specs/gr/reviews/GR-15-COMPLIANCE-SIGNOFF.md C-1 through C-4 |
| NG-04 | Board composition and independence — Independent directors; audit committee (best practice) | GR-03, GR-15 | 📋 Partial | GR-15 Phase 3 adds board roster via minutes attendees; full independence scoring deferred |
| NG-05 | Board minutes and records — Maintain meeting records per state law and accreditation requirements | GR-03, GR-15 | 📋 Specification | GR-15 Phase 3: board minutes + resolutions with approval workflow and PDF export |
| NG-06 | Executive compensation review — Reasonableness and documentation per IRS intermediate sanctions (IRC 4958) | GR-03, HR-07 | 📋 Policy | Board reviews compensation; documented in minutes |
| NG-07 | Arizona nonprofit compliance — Annual report to ACC; maintain registered agent; charitable solicitation (if applicable) | GR-03 | 📋 External | ACC filing managed externally; see FA compliance for financial aspects |
5. Risk Management
| # | Requirement | Responsible Spec | Status | Notes |
|---|---|---|---|---|
| RM-01 | Risk assessment — Periodic organizational risk assessment covering clinical, operational, financial, compliance | GR-08 | ⏳ Not Started | Risk register and assessment workflow |
| RM-02 | Insurance management — Professional liability, general liability, D&O, workers comp | GR-08, HR-11 | 📋 External | Insurance managed externally; track policy dates and coverage |
| RM-03 | Corrective action plans — Track and resolve deficiencies from surveys, audits, incidents | GR-08 | ⏳ Not Started | CAP workflow; evidence of correction tracking |
| RM-04 | Compliance program — Designated compliance officer, training, hotline, audit schedule | GR-03, GR-08, GR-19 | ⏳ Not Started | Compliance program management features. GR-19 contributes the training element (mandatory in-service completion matrix, automated reminders 90/60/30/7 days before due date, surveyor PDF packet); designated-officer / hotline / audit schedule remain pending. |
6. Authoritative External References
7. Periodic Review Schedule
| Review | Frequency | Next Due | Owner |
|---|---|---|---|
| CARF survey preparation | Per survey cycle (annual/triennial) | //____ | Quality Director |
| Joint Commission survey prep | Per survey cycle | //____ | Quality Director |
| HEDIS measure calculation | Annually | //____ | Quality Director |
| SAMHSA NOMs reporting | Per grant requirements | //____ | Program Director |
| Incident reporting audit | Quarterly | //____ | Compliance Officer |
| Board governance review | Annually | //____ | Board Secretary |
| Conflict of interest disclosures | Annually | //____ | Board Secretary |
| Risk assessment | Annually | //____ | Risk Manager |
| Document retention audit | Annually | //____ | Compliance Officer |
Version History
1.0.0 (2026-02-27)
- Initial comprehensive GR governance and risk compliance document
- Covers CARF, Joint Commission, NCQA HEDIS, SAMHSA NOMs, mandatory incident reporting, nonprofit governance, risk management
- 45+ compliance requirements tracked across 5 categories
Last Updated: 2026-02-27 Next Review: 2026-05-27