UPStandards aligns to The Joint Commission, CARF, and CMS Conditions of Participation — out of the box, for every level of behavioral health care. Chart audits, facility rounds, document builders, and a policy library with gap analysis, all referencing the specific standards your accreditor uses.
No generic checklists. Real standards. Real survey readiness.
The largest behavioral health accreditor in the U.S. Surveyors use a tracer methodology and SAFER Matrix scoring of findings during on-site visits.
UPStandards aligns to the Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC) and the National Patient Safety Goals — with audit templates, rounds, and document builders that reference specific TJC standards.
The other major behavioral health accreditor. Surveys are consultative in tone and evidence-driven, organized around the ASPIRE to Excellence framework.
UPStandards covers Section 1 (leadership, governance, performance measurement, performance improvement), Section 2 (general program standards), and program-specific Section 3 — including annual program evaluations, accessibility plans, and rights of persons served.
For Medicare-certified inpatient psychiatric facilities, CMS Conditions of Participation set the federal floor — and they sit alongside, not instead of, accreditation.
UPStandards generates CMS-aligned policies and documentation for 42 CFR 482.13 Patient Rights, restraint and seclusion (including the 1-hour face-to-face), search and contraband, and inpatient treatment plans.
Below is a selection of the specific standards UPStandards helps you address — and the part of the platform that does the work. The full mapping is broader; this is the high-frequency citation surface.
Standards mappings are guidance, not a substitute for an organization's own crosswalks or surveyor judgment. Specific codes and chapters reference the publicly identified standards used by each accrediting body.
Surveys don't reward effort; they reward evidence. UPStandards is organized around the artifacts and walkthroughs surveyors most commonly look at.
Generate the documents accreditors most often want to see — pre-populated with your organization's data and aligned to the relevant standards.
Configurable rounds that run on the cadence surveyors expect — and produce printable inspection reports with signatures.
Run audits across stay phases — admission, mid-stay, discharge — against standards-aligned audit templates. Findings can be scored on the SAFER Matrix (Likelihood × Scope) the way TJC surveyors score them.
The Safety Matrix view and By-Clinician view let quality and clinical leadership see patterns across the program rather than chart by chart.
Upload your existing manuals and run a gap analysis against the standards that apply to your program type, your accreditor, and your level of care. Track review cycles, store edits, and surface what's missing before a surveyor does.
Every annual plan — HVA, EOP, QI Plan, Annual Program Evaluation, ICRA, Staff Training Plan, HR Plan — lives in one approval-tracked binder with effective dates and signatures.
When a surveyor asks for "your most recent HVA," you open the binder and print.
Visitor sign-in, client belongings, staff training hours, emergency equipment inspections, fridge temperatures, patient safety observations — captured in logs that double as survey evidence.
The visitor kiosk records by initials only — privacy by default, the way TJC and CARF expect.
Standards apply differently across levels of care. UPStandards configures itself to your program type so you only track what's relevant.
No software can guarantee accreditation, and any vendor that claims otherwise should be treated with deep suspicion. The work, the people, and the patient care are what earn it.
What UPStandards does do is take the documentation, audit, and rounds burden off your team — so when a surveyor walks in, you have the records, evidence, and policies they expect to see, organized in one place. The decision still belongs to the accrediting body, and survey outcomes still depend on your clinical and operational reality.
Yes — programs holding both accreditations can configure UPStandards to track both standards sets simultaneously. The Document Builder's Quality Improvement Plan generator adapts its structure for TJC-only, CARF-only, or dual-accredited organizations. The Policy Library's gap analysis cross-references your manuals against the chapters and sections relevant to each accreditor.
You won't find yourself writing two QI Plans or maintaining two separate audit programs. The platform unifies the work and surfaces the differences only where they actually exist.
Yes. Every audit, round, and policy gap-analysis configuration is editable 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 — for example, state-specific hold codes (5150, Section 12, 302) for inpatient psychiatric units, or state DMHAS-specific items for outpatient programs.
Standards do shift, and the platform's templates are updated as accreditors publish changes. The 2024 TJC Workplace Violence Prevention Plan requirement is one example — it's a first-class document type in the Document Builder. Major NPSG changes and chapter revisions are folded in over time.
Because the policy gap analysis and document generators are configured against current standards, you generally don't need to do anything special when a small revision drops. Larger changes (new chapters, new mandatory documents) are communicated when they go live.
This is one of the strongest use cases. First-time accreditation typically takes 6 to 18 months of preparation, and the work is dominated by three things: writing policies that align to the standards, building out the audit and rounds program, and producing the annual plans the accreditor expects to see at survey.
UPStandards gives you a head start on all three. The Policy Library lets you upload what you already have and identifies gaps; the Document Builder produces the HVA, EOP, QI Plan, Annual Program Evaluation, and accessibility plans that surveyors will ask for; and the Facility Compliance Tracker establishes the round cadence and history that surveyors look for during the look-back period.
No, and this is important to be clear about. UPStandards is a compliance and accreditation platform — not an EHR, not a designated record set, not a billing system, and not a substitute for professional judgment. Treatment plans, progress notes, psychotherapy notes, SUD counseling notes, lab results, prescriptions, and full medical records belong in your EHR.
UPStandards lives alongside your EHR and handles the operational, audit, policy, and accreditation-readiness workflows that an EHR isn't built to handle.
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