Built for Behavioral Healthcare

Behavioral Health Compliance, Simplified

Operations and compliance for every level of care — inpatient, residential, partial hospitalization, intensive outpatient, and outpatient — whether you're maintaining accreditation, pursuing it for the first time, or simply committed to running a program that meets the highest standards of care.

Chart audits · Facility rounds · Policy libraries · Ready-to-submit documents — all in one place.

Accredited Programs
Cut the hours your team spends recreating documentation for annual renewals, mid-cycle reviews, and re-surveys.
Pursuing Accreditation
Build a full compliance infrastructure — policy library, risk assessments, chart auditing, facility rounds — in weeks, not years.
Raising the Bar
Hold your program to industry best practices whether or not you're under external review — because good care starts with documentation that matches it.
Built for every level of care
From psychiatric units to private practices.
InpatientNew
Q15 observation logs, ligature risk rounds, CMS-aligned policy wizards, and restraint-and-seclusion documentation.
Residential
Milieu safety rounds, chart audits across stay phases, annual program plans, and risk assessments.
Partial Hospitalization
Chart audits, treatment plan reviews, annual program binder, and CARF-aligned policy library.
Intensive Outpatient
Chart audits, treatment plan compliance, annual standards reviews, and policy library.
Outpatient
Chart audits, annual standards reviews, supervision documentation, and policy library.
Facility

Facility Compliance Tracker

  • Facility Inspection Rounds for inpatient and residential programs — the rounds Joint Commission surveyors ask about first, with severity-graded findings and remediation tracking
  • Structured walkthrough rounds across every dimension of facility safety — Environment of Care, Infection Control, Med Room, Fire Drills, Medical Records, and more
  • Same checks happen the same way every shift, every site — by whoever's on duty
  • Hazards get caught with your weekly and monthly rounds, not at next quarter's incident review
  • Fully configurable per program — toggle items on or off, adjust frequencies, reassign roles, add your own site-specific checks
  • Schedules surface what's due and what's overdue at a glance
  • Every completed round produces a signed inspection report, archived permanently

…You're looking for a ready-to-go facility inspection app for behavioral healthcare based on accreditation criteria. And—you can easily configure the app to meet your own facility's needs!

Facility Compliance Tracker Rounds & Inspections
Rounds & Inspections
Pick a round type to start. Each one produces a signed inspection report.
Environment of Care
Full facility safety inspection
Monthly 41 items EC.02.06.01
Last conducted: 5 days ago
Start Round
Infection Control
IC compliance checklist
Monthly 29 items IC.02.01.01
Not yet conducted
Start Round
Medication Room
Medication storage & compliance
Monthly 23 items MM.01.01.03
Last conducted: 5 days ago
Start Round
Fire Drill
Quarterly fire safety drill
Quarterly 14 items LS.03.01.35
Last: 3 weeks ago
Start Round
Medical Records
Sample chart review for completeness
Monthly 18 items RC.01.01.01
Last conducted: 8 days ago
Start Round
Ligature Risk
Environmental walk for self-harm risks
Quarterly 22 items EC.02.06.05
Last: 2 weeks ago
Start Round
Back to Rounds
Environment of Care Rounds
Full facility safety inspection · Monthly · EC.02.06.01
Reviewer
Joe Johnson
Date
May 1, 2026
Time
10:42 AM
Fire Prevention
Egress paths are clear of obstructions
Pass Fail N/A
Fire extinguishers are clear of obstructions
Pass Fail N/A
Fire alarm equipment is clear of obstructions
Pass Fail N/A
All fire extinguishers are inspected and initialed
Pass Fail N/A
Electrical Safety
Outlets and switch faceplates are covered
Pass Fail N/A
Electrical cords are intact (no fraying)
Pass Fail N/A
Electrical panels are clear of obstructions
Pass Fail N/A
Hazardous Materials & Waste
Chemicals inventoried, labeled, and locked
Pass Fail N/A
Sharps containers are less than 3/4 full
Pass Fail N/A
Biohazard wastes properly stored and labeled
Pass Fail N/A
Medical Equipment & Supplies
Medication is properly stored and locked
Pass Fail N/A
0 of 41 rated
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Environment of Care Rounds · May 1, 2026
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Inspection report saved · added to Reports archive
Environment of Care
Monthly Rounds Inspection
UPStandards Behavioral Health · Main Campus
Date
May 1, 2026
Time
10:42 AM
Reviewer
Joe Johnson
Standard
EC.02.06.01
11
Passed
0
Failed
0
N/A
Fire Prevention
Egress paths are clear of obstructions
Fire extinguishers are clear of obstructions
Fire alarm equipment is clear of obstructions
All fire extinguishers are inspected and initialed
Electrical Safety
Outlets and switch faceplates are covered
Electrical cords are intact (no fraying)
Electrical panels are clear of obstructions
Hazardous Materials & Waste
Chemicals inventoried, labeled, and locked
Sharps containers are less than 3/4 full
Biohazard wastes properly stored and labeled
Medical Equipment & Supplies
Medication is properly stored and locked
Joe Johnson
Signed May 1, 2026 · 10:43 AM
Inspection saved
Clinical

Clinical Chart Auditor

  • Full chart-by-chart audits across your entire caseload — phase by phase, contact through discharge, with separate phase sets for outpatient and inpatient programs
  • Flags missing documentation and late completions against nationally-recognized behavioral healthcare standards
  • Surfaces safety-critical gaps — suicide screening, safety plans, crisis assessments — before they become survey findings
  • Q15 Patient Safety Observation Logs for inpatient units — every-fifteen-minute safety check tracking with shift-end review, gap reporting, and signed close-out
  • Aggregate risk scored by severity-by-scope, so a single high-severity gap never gets buried under administrative completions
  • Fully configurable per program — toggle tasks on or off, adjust risk weights, reassign roles, or add your own audit items alongside the defaults

…You want to audit client charts so that you can stay on top of any potential safety risks before they happen! Client chart auditing that meets accreditation standards—and you can easily configure the app to meet your regular auditing needs!

CLIENT
Jane Doe
Jane Doe — Clinical Tasks MED Risk (40%)
31/33 tasks (94%)
Overall Progress 94%
All Phases:
Initial Contact & Screening In Progress 0/4
::
Medium Risk
Document initial contact/referral source and reason for referral
Responsible: Intake Coordinator
⏱ Late
::
High Risk
Screen for immediate safety concerns (danger to self or others)
Responsible: Intake Coordinator / Clinician
⏱ Late
::
Medium Risk
Screen for substance use / intoxication and withdrawal management needs
Responsible: Clinician / Nurse
⏱ Late
::
Low Risk
Document insurance / financial verification and authorization
Responsible: Clinical Director
⏱ Late
Suicide & Risk Screening In Progress 0/4
::
High Risk
Administer validated suicide screening tool (C-SSRS, PHQ-9 Item 9, ASQ)
Responsible: Clinician
⏱ Late
::
High Risk
Assess for access to lethal means (firearms, medications, etc.)
Responsible: Clinician
⏱ Late
::
High Risk
Develop initial safety plan (Stanley-Brown or equivalent) if indicated
Responsible: Clinician
⏱ Late
::
Medium Risk
Identify protective factors (reasons for living, social supports)
Responsible: Clinician
⏱ Late
Treatment / Care Planning In Progress 0/4
::
Medium Risk
Develop individualized, measurable treatment goals with client
Responsible: Clinician
⏱ Late
::
Medium Risk
Document client/family input in treatment plan development
Responsible: Clinician
⏱ Late
::
Medium Risk
Obtain signed informed consent to proposed treatment plan
Responsible: Clinician
⏱ Late
::
Low Risk
Set treatment plan review date and responsible clinician
Responsible: Clinical Director
⏱ Late
Discharge Planning In Progress 0/4
::
High Risk
Complete comprehensive discharge summary within required timeframe
Responsible: Clinician
⏱ Late
::
Medium Risk
Provide written aftercare plan to client and family/caregivers
Responsible: Clinician
⏱ Late
::
High Risk
Schedule follow-up appointment within 7 days of discharge
Responsible: Clinician
⏱ Late
::
Low Risk
Document medication list and prescribed dosages at discharge
Responsible: Nurse
⏱ Late
Generating summary report… Summary complete
Documents

Document Builder

  • Comprehensive risk assessments, annual program evaluations, QI plans, and emergency management documents — generated in minutes, not weeks
  • Hazard Vulnerability Analysis (HVA), Infection Control Risk Assessment, Environment of Care Risk Assessment
  • Workplace Violence, Fall Risk, and Ligature Risk Assessments
  • Inpatient documentation — Restraint and Seclusion summaries, Patient Rights notifications, and Search and Contraband reports for hospital-based programs
  • Fire Drill Documentation, Emergency Operations Plan, Annual QI Plan, Person-Centered Plan Policy — and more
  • Each backed by current industry standards and pre-populated with your organization's data

Your compliance officer has ever had to write a full HVA or QI plan from scratch, or if your program is preparing for first-time accreditation and needs a complete document library built in weeks instead of months.

Document Builder Choose a document type
Environment of Care & Safety
Hazard Vulnerability Analysis (HVA)
Identify and score natural, technological, human-caused, and hazardous material threats sp…
Environment of Care
EC.04.01.01
Workplace Violence Prevention Plan
2024 TJC requirement. Annual risk assessment, prevention strategies, incident response, an…
Environment of Care
EC.02.01.01
EC Risk Assessment
Assess risks in the physical environment including safety, security, fire, utilities, medical equi…
Environment of Care
EC.02.01.01
Health & Safety Plan
Annual health and safety plan addressing environmental risks, emergency preparedness, inci…
CARF Standard 2.A
2.A CARF
Emergency Management
Emergency Operations Plan (EOP)
Comprehensive plan for responding to emergencies with the 6 Critical Functions: communic…
Emergency Management
EM.02.01.01
Generating Hazard Vulnerability Analysis streaming…
Emergency Management Program
Hazard Vulnerability Analysis
UPStandards Behavioral Health — Main Campus
Document Date
Apr 21, 2026
Prepared By
Clinical Director
Facility Type
Residential
Annual Review
Apr 2027
Executive Summary
Hazard Analysis Matrix
Event Prob Impact Prep Relative Threat
Plans

Annual Plans Tracker

  • A digital binder for the plans accreditors actually ask about — HVA, EOP, QI Plan, Infection Control, Safety, Security, Hazardous Materials, and more
  • For inpatient programs: Annual Patient Rights Review (CMS 482.13), Restraint and Seclusion review, and Inpatient Treatment Plan audits — built into the binder out of the box
  • Each plan tracks its own review cycle — see at a glance what's current, what's due soon, and what's overdue
  • Log who approved each plan and when, with optional signature image, so you can answer the "show me the current one" question in seconds
  • Direct hand-off to the Document Builder when a plan is due — refresh, approve, done
  • Dashboard card surfaces what's coming due well before it becomes a survey finding

…You want a single place to track the specific plans surveyors will ask about — with annual reviews, signatures, and live status all in one binder!

Annual Plans Binder
8 current 2 due soon 1 overdue
Hazard Vulnerability Analysis
Last approved Apr 12, 2026 by L. Chen, MD
CURRENT
Emergency Operations Plan
Last approved Mar 03, 2026 by L. Chen, MD
CURRENT
Performance Improvement Plan
Last approved May 14, 2025 — due in 18 days
DUE SOON
Infection Prevention & Control Plan
Last approved Feb 28, 2025 — 65 days overdue
OVERDUE
Safety Management Plan
Last approved Jan 18, 2026 by R. Patel
CURRENT
Security Management Plan
Last approved Apr 02, 2026 by R. Patel
CURRENT
Reports

Reports & Saved Documents

  • Every chart audit, risk assessment, QI plan, drill critique, facility round, Q15 observation log, and ligature inspectionautomatically saved
  • Searchable by type, site, and date
  • Print for leadership binders
  • Export for regulatory submissions
  • Pull historical versions when a reviewer asks how your program has improved year-over-year
  • Always formatted to match the document conventions reviewers expect to see

…You want a super-easy and organized way to store your facility rounds inspections, chart audits, annual policy plans and reports—and print or export them at any time!

Saved Documents
All your generated compliance documents and audit reports in one place.
All Sites
NewestOldestBy DateBy Type
8 docs
DOCUMENT BUILDER 7 documents
QUALITY IMPROVEMENT PLANS 1
Quality Improvement Plan
Lakeport Clinic · Apr 20, 2026
ViewPrint
EMERGENCY OPERATIONS PLANS 1
Emergency Operations Plan
Lakeport Clinic · Apr 18, 2026
ViewPrint
ACCESSIBILITY PLANS 1
Accessibility Plan
Hull House · Apr 16, 2026
ViewPrint
CLINICAL CHART AUDITOR 1 document
AUDIT REPORTS 1
Q1 Adolescent Chart Audit
Hull House · Apr 14, 2026
ViewPrint
Document
Print Preview · 1 of 4
Policies

Policy & Procedure Library

  • Central library — upload your P&P manuals as PDFs, tagged by accreditation standard (TJC, CARF, both, or internal) and by site
  • Log review history per policy — date, reviewer, and notes — so you have a clean audit trail when surveyors ask "when was this last reviewed?"
  • AI Gap Analysis cross-references your manuals against applicable standards for your program type — outpatient, residential, PHP, IOP, or inpatient
  • CMS-aligned policy wizards for inpatient and hospital-based programs: Patient Rights (482.13), Restraint and Seclusion, Search and Contraband, Treatment Planning, and Admission
  • Get a prioritized list of missing policies, and draft any of them on the spot

…You'd like to do your own instant gap analysis of your policy and procedure and easily correct any gaps or add any missing policies!

Policy & Procedure Library
Upload, manage, and track your organization's P&P manual. Monitor review dates and TJC compliance status.
P&P Manuals
1
Manual in library
Due for Review
0
Past or within 30 days
Critical Gaps
Last run: Apr 20, 2026
Policies Drafted
0
From gap findings
All Standards
All Statuses
All Sites
+ Add P&P Manual
Gap Analysis
Policy / Plan / Assessment Accreditation Sites Review Status Last Review
Policy & Procedure 2026 TJC All Sites Never Reviewed
Policy & Procedure 2026 1 / 444
Sierra Pathways Counseling & Wellness
FAX 707.900.5026
WWW.SIERRAPATHWAYS.ORG
55 FIRST STREET
LAKEPORT, CA 95453
Policy & Procedure
and
Employee Guidebook
Updated February 2026
1
Sierra Pathways Policy & Procedure · Page 2
TABLE OF CONTENTS
Mission, Vision & Values3
Code of Ethical Conduct7
Client Rights and Responsibilities15
Confidentiality and HIPAA Compliance28
Admission, Intake and Screening42
Treatment Planning58
Medication Management74
Crisis Intervention Procedures91
Discharge Planning and Aftercare108
Staff Training and Orientation129
Employee Conduct & Expectations156
Infection Control201
Environment of Care & Safety234
Emergency Management268
Performance Improvement310
2
Sierra Pathways Policy & Procedure · Page 15
Client Rights and Responsibilities
Purpose
Sierra Pathways is committed to providing services that honor the dignity, autonomy, and rights of every individual served. This policy establishes the framework for ensuring client rights are protected throughout all phases of treatment.
Policy Statement
Every client admitted to Sierra Pathways shall be informed of their rights and responsibilities at the time of intake. A written copy of the Client Rights Statement shall be provided to each client and acknowledged with signature.
Procedures
1. Intake staff shall review the Client Rights Statement with each client upon admission.
2. Clients shall sign the Rights Acknowledgment form, which becomes part of the permanent clinical record.
3. Posted copies of the Rights Statement shall be visible in all waiting and treatment areas.
15
P&P Gap Analysis
Analysis complete
Run Again
Save to Documents
Print
Gap Analysis — Behavioral Health 21 Critical39 Important
TJC · All Sites · 1 policies analyzed · April 21, 2026
Executive Summary
21
Critical
39
Important
0
Covered
21 critical gaps require immediate attention before survey, including: Initial Safety Assessment, Suicide Risk Screening Implementation, Sentinel Event Root Cause Analysis Timeline.
Filter: All (60) 21 Critical 39 Important
1TJC CTS.02.01.01
Feedback-Informed Treatment MeasuresMissing policyCTS.03.01.09
Required: Organizations must implement routine feedback-informed treatment measures using standardized tools to monitor progress from the client's perspective.
Current status: The requirement is described in the standards section but no actual policy or procedures for implementation are provided.
Recommended action: Create a policy specifying the feedback-informed treatment tools to be used, administration frequency, and how results will inform treatment planning.
Draft This Policy
Life Transition Services AssessmentMissing policyCTS.06.03.01
Required: Organizations serving young adults must assess and address life transition needs including financial literacy, employment readiness, educational planning, housing stability, healthcare management, and social support development.
Current status: The standards describe the requirement for life transition services but no actual assessment tools or service delivery policies are provided.
Recommended action: Develop comprehensive life transition assessment tools and service delivery policies addressing all required domains for transitional age youth.
Draft This Policy
Initial Safety AssessmentMissing policyCTS.02.01.01
Required: Organizations must conduct an early assessment for risk of harm to self or others upon admission with validated screening tools and clinical interviews.
Current status: The document mentions the requirement but does not provide the actual policy, procedures, or specify which validated tools will be used.
Recommended action: Develop a comprehensive initial safety assessment policy with specific validated screening tools, procedures, and staff training requirements.
Draft This Policy
Suicide Risk Screening ImplementationNeeds revisionNPSG.15.01.01
Required: Perform standardized suicide risk screening on individuals aged 12 or older presenting with behavioral health concerns using validated tools.
Current status: The NPSG section mentions validated suicide screening tools but does not specify which tools will be used or provide detailed procedures.
Recommended action: Specify the exact validated suicide screening tools to be used and develop detailed procedures for administration, documentation, and follow-up actions.
Draft This Policy
7TJC
Fire Drill Documentation RequirementsNeeds revisionEC.02.05.07
Required: Fire drill critiques must document specific performance elements including staff response times, problems encountered, and corrective actions needed.
Current status: Policy mentions drill evaluation and critique but lacks detail on specific documentation requirements for drill performance assessment.
Recommended action: Expand fire drill documentation requirements to include specific performance metrics, timing, problems encountered, and corrective action planning.
Draft This Policy
Sentinel Event Root Cause Analysis TimelineMissing elementSE.01.01.01
Required: Root cause analysis must be completed within 45 days of sentinel event identification or becoming aware that a reviewable sentinel event has occurred.
Current status: Policy states root cause analysis is required but does not specify the 45-day timeline requirement.
Recommended action: Add specific language requiring completion of root cause analysis within 45 days of sentinel event identification.
Draft This Policy
Generating Initial Safety Assessment policy… Policy draft complete
✨ Fun Feature

Sign-In Kiosk

  • Lock a tablet at the front desk to a clean, visitor-facing screen — big Welcome, big Sign In button, nothing else for guests to fumble with
  • Visitors enter name, purpose, and signature on the spot — the kiosk auto-tags them with its site, so multi-site programs never have to ask "which one?"
  • Privacy by default: the visitor log shown on the kiosk is initials only, never full names — the next person in line can't see who else is in the building
  • One-tap Sign Out when a visitor leaves; no staff intervention needed
  • Hidden corner unlock with an admin PIN — staff can pop back to the full app, the screen stays kiosk for everyone else
  • Registered devices show up in Admin → Kiosks so you can name them, swap sites, or revoke a device that walked off

…You want a polished, professional way to handle visitor sign-in at the front desk — visitor logging made effortless, privacy-safe, and zero work for your staff!

Welcome to Lakeport Residential!
Please sign in.
Today's Visitors
Initials only — privacy by default
Time InInitialsStatus
9:47 AM JJ In Facility Sign Out
8:15 AM SK Signed Out 10:30 AM
8:01 AM MT Signed Out 9:55 AM
Sign in
Lakeport Residential · Main Entrance
Name
Joe Johnson
Visiting
Dr. J. Chen · Clinical Director
Signature
Sign here →
Thanks, Joe!
You're signed in.

Common questions

Quick answers to what behavioral health leaders ask before signing up.

What is UPStandards?

UPStandards is compliance and accreditation software built specifically for behavioral healthcare programs. It covers operations and compliance across every level of care — inpatient, residential, partial hospitalization, intensive outpatient, and outpatient — with chart audits, facility rounds, an AI document builder, an annual plans binder, a policy library with gap analysis, and a sign-in kiosk in one place.

What accreditation standards does UPStandards support?

UPStandards aligns to The Joint Commission (TJC), CARF, and CMS Conditions of Participation. Standard codes appear throughout the app — for example, EC.02.06.01 for Environment of Care rounds, IC.02.01.01 for infection control, NPSG.15.01.01 for suicide risk screening, EM.02.01.01 for emergency management, and CMS 482.13 for inpatient Patient Rights. Policy gap analysis cross-references your manuals against the standards that apply to your program type.

What levels of care does UPStandards support?

All five levels of behavioral health care: inpatient (Q15 observation logs, ligature risk rounds, CMS-aligned policy wizards, restraint and seclusion documentation); residential (milieu safety rounds, chart audits across stay phases, annual program plans, risk assessments); partial hospitalization (chart audits, treatment plan reviews, annual program binder, CARF-aligned policy library); intensive outpatient (chart audits, treatment plan compliance, annual standards reviews, policy library); and outpatient (chart audits, annual standards reviews, supervision documentation, policy library).

Is there a free trial?

Yes. UPStandards offers a 14-day free trial with full access to every feature. A credit card is required at signup so your account is ready to continue uninterrupted when the trial ends — but you can cancel anytime, during the trial or after.

Can the audits, rounds, and policies be customized to my program?

Yes — every audit, round, and policy library view is configurable per program. You can toggle individual tasks or checks on and off, adjust risk weights and frequencies, reassign responsible roles, and add your own site-specific items alongside the built-in defaults. Multi-site organizations can enable different items for different sites so each program tracks only what's relevant to it.

What kinds of compliance documents can UPStandards generate?

The Document Builder generates the documents accreditors most often ask for: Hazard Vulnerability Analyses (HVAs), Workplace Violence Prevention Plans, Environment of Care Risk Assessments, Health & Safety Plans, Emergency Operations Plans, Fall Risk Assessments, Infection Control Risk Assessments, and Ligature Risk Assessments. For inpatient and hospital-based programs, it also produces Restraint and Seclusion summaries, Patient Rights notifications (CMS 482.13), and Search & Contraband reports. Each document is generated in minutes and pre-populated with your organization's data.

Ready to Simplify Compliance?

Join behavioral healthcare organizations that rely on UPStandards to stay accreditation-ready, elevate clinical care, and take the manual work out of compliance.

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