CHS Aces DSS Review

Posted on July 23, 2021

CHS recently passed the South Dakota Department of Social Services (DSS) annual licensing review with flying colors—as usual.

It’s the job of Compliance Director Jody Carpenter to ensure that CHS meets a multitude of stringent quality and documentation requirements. Many revolve around residential care, but others are department-specific or agency-wide.

Jody reports that DSS reviewers noted that children’s records were in perfect order. “The reviewers commented on the quality of documentation and specifically mentioned the thoroughness and individualization of master treatment plans.

The DSS review includes visiting with children. “At Sioux Falls Children’s Home, kids said they trust staff and feel staff treat them fairly. They knew about restrictions and discipline measures, and some even knew the child-to-staff ratio. Each reported liking the food served here,” Jody says.

“In the Black Hills Children’s Home, children’s interviews were also very positive,” she says. “They had good things to say about staff and CHS, and they understood their Master Treatment Plan goals and objectives. Child surveys listed many positives, including awesome cooks, great food and lots of care and support from staff.”

The 2,000-item checklist

The primary organizations that review CHS are The Joint Commission, DSS and Medicaid, which includes HIPAA law compliance. There are also food service and fire safety inspections. Loving and Owen Schools have their own state review processes.

The Joint Commission, established in 1910 for the purpose of standardizing hospitals, is the mother of all regulators, with more than 2,000 standards to meet. The requirements are organized into chapters, which have standards, comprised of specific elements (a little like Russian nesting dolls).

They vary according to the type of organization seeking accreditation. For CHS, the chapters include:

  • Medication management
  • Infection prevention and control
  • Life safety
  • Emergency management
  • Environment of care
  • Rights and responsibilities
  • Record of care, treatment and services
  • Care, treatment and services
  • National patient safety goals
  • Human resources
  • Performance improvement
  • Information management
  • Leadership
  • Accreditation participation requirements

“Hospitals receive Joint Commission accreditation, but it’s less common among nonprofit, social service agencies,” says CEO Michelle Lavallee. “Earning this certification means that we are holding ourselves to the highest level of quality.”

Meeting Joint Commission regulations pretty much ensures that CHS will meet DSS and Medicaid requirements.

Black Hills Campus and Sioux Falls Campus working together to ensure the highest quality of care for our children.

“On our last Joint Commission inspection, CHS received no citations, which is really remarkable,” Jody says. “On our last Medicaid certification, we also had zero citations, which is almost unheard of.”

Leaving no stone unturned

Every three years the Joint Commission comes to CHS, in person, for a scheduled, three-to-four-day review—with just a one-week notice. During the off years, CHS does its own Joint Commission audit.

“The Joint Commission accredits and certifies more than 22,000 health care organizations and programs in the United States…An independent, not-for-profit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care.” (

The Joint Commission uses the tracer methodology, which means tracing individual children from pre-admission through discharge. Reviewers look both at the quality of care, using a variety of sources, and the quality of the documentation itself.

Survey-ready goal

The same meeting as above, from the Sioux Falls Campus

Jody’s philosophy is “to be survey-ready at all times,” she says. “We have good systems in place, and we have ways to monitor what we do.”

Jody’s approach means avoiding last-minute scrambling to prepare for a scheduled review—and panic when there’s an unscheduled survey. And it means that CHS performance on all reviews is outstanding.

CHS is moving toward having Compliance handle regulation and certification for all programs, which will improve efficiency and consistency.

Like a kid’s straight A’s report card, our excellent compliance record doesn’t always get much attention. If there were a problem, however, concerns would escalate and spread quickly. By staying “survey-ready,” we leave no doubt about the quality of care at CHS.