> ## Documentation Index > Fetch the complete documentation index at: https://docs.encoreos.io/llms.txt > Use this file to discover all available pages before exploring further. # GR Governance & Risk Compliance Tracking > Version: 1.0.0 Last Updated: 2026-02-27 Status: Active Module: GR (Governance & Risk) **Version:** 1.0.0 **Last Updated:** 2026-02-27 **Status:** Active **Module:** GR (Governance & Risk) > **Cross-References:** > > * [REGULATORY\_COMPLIANCE\_TRACKER.md](REGULATORY_COMPLIANCE_TRACKER.md) — Master compliance tracker > * [AGENTS.md](../../AGENTS.md) § Authoritative External References — Accreditation and Quality Measures *** ## Overview This document tracks governance, accreditation, quality measurement, incident reporting, and nonprofit compliance obligations for Encore Health 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 | Source | URL | Used By | | ------------------------------------------------------------ | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | ------------------- | | CARF Behavioral Health | [https://carf.org/accreditation/programs/behavioral-health/](https://carf.org/accreditation/programs/behavioral-health/) | GR-08, CL-10, CL-15 | | Joint Commission CAMBHC | [https://www.jointcommission.org/en-us/accreditation/behavioral-health-care-and-human-services](https://www.jointcommission.org/en-us/accreditation/behavioral-health-care-and-human-services) | GR-08, CL-15 | | NCQA HEDIS Measures | [https://www.ncqa.org/hedis/measures/](https://www.ncqa.org/hedis/measures/) | CL-10, CL-15 | | SAMHSA NOMs | [https://www.samhsa.gov/data/faq/samhsas-national-outcomes-measures-noms-collected-mh-cld/](https://www.samhsa.gov/data/faq/samhsas-national-outcomes-measures-noms-collected-mh-cld/) | CL-10 | | SAMHSA Quality Measurement | [https://www.samhsa.gov/substance-use/treatment/advancing-quality-measurement-behavioral-health](https://www.samhsa.gov/substance-use/treatment/advancing-quality-measurement-behavioral-health) | CL-10 | | Arizona ARS 46-454 (Mandatory reporting — vulnerable adults) | [https://www.azleg.gov/ars/46/00454.htm](https://www.azleg.gov/ars/46/00454.htm) | GR-08 | | Arizona ARS 13-3620 (Mandatory reporting — children) | [https://www.azleg.gov/ars/13/03620.htm](https://www.azleg.gov/ars/13/03620.htm) | GR-08 | | AHCCCS AMPM Policy 1620-O (Critical incident reporting) | [https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/1600/1620O.pdf](https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/1600/1620O.pdf) | GR-08 | | IRS: Governance and Related Topics — 501(c)(3) Organizations | [https://www.irs.gov/charities-non-profits/governance-and-related-topics-501c3-organizations](https://www.irs.gov/charities-non-profits/governance-and-related-topics-501c3-organizations) | GR-03 | | Sarbanes-Oxley Act (Whistleblower/Document Retention) | [https://www.congress.gov/bill/107th-congress/house-bill/3763](https://www.congress.gov/bill/107th-congress/house-bill/3763) | GR-03 | *** ## 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