Compliance Made Simple: How Briason Associates Supports Accreditation Success
- Sonji Phillips
- Nov 18
- 10 min read
Working in the human-services and developmental-disability world often means walking a tightrope between “doing good work” and “making sure the regulators say we’re doing good work.” At Briason Associates, we believe you don’t need to sacrifice humanity for compliance—and you certainly don’t need compliance to feel like a never-ending burden. Let’s talk about how we help organizations meet the requirements of the Office for People With Developmental Disabilities (OPWDD), Council on Quality and Leadership (CQL) and other standards (including broadly applicable Department of Developmental Services (DDS)-type standards) in a way that’s strategic, practical—and yes, dare I say, a little fun.
Why Accreditation & Compliance Matter (but not just for the paperwork)
It can feel like the field is drowning in acronyms and regulatory references. But at its heart, these standards exist for a reason:
OPWDD sets out both principles of compliance and standards of certification for its programs and facilities. These include requirements for policies/procedures, ongoing quality assurance, rights of individuals served, safety, fiscal accountability, etc. (Legal Information Institute)
OPWDD emphasises that providers should view accreditation (for example via CQL) not just as a “stamp” but as a pathway to excellence: “Providers may want to consider … using the CQL 21 Personal Outcome Measure domains … An agency may also choose to pursue accreditation … Accreditation can be an effective quality improvement tool.” (opwdd.ny.gov)
For DDS-type standards (which vary by state), compliance often means you’re meeting your contract obligations, operating ethically and legally, demonstrating quality of support, and showing continuous improvement. (Massachusetts Government)
Accreditation such as through CQL signals externally validated quality. As one provider who achieved it stated: “They’re showing … they genuinely care about enhancing the quality of their services.” (PR Newswire)
So why does your organization want this?
It strengthens credibility with funders, families, stakeholders.
It reduces risk (compliance issues, citations, non-renewal of certification).
It drives better outcomes for the people you support (after all, that’s the heart of it).
It supports operational efficiencies: when policies & procedures are clear, staff are well trained, documentation is solid — fewer surprises.
It gives your leadership a framework to embed culture of continuous improvement (not just “get through the survey” but “let’s get better”).
And yes, the survey or accreditation review will happen. For instance, OPWDD’s “Prepare for Your Survey” guidance emphasises self-assessment, ongoing operations, and readiness. (opwdd.ny.gov)
The Three Key Frameworks: OPWDD + CQL + DDS
Here’s how we think of the three major “pillars” you’ll often navigate—each with its own flavour.
1. OPWDD Standards
These include New York’s regulations such as 14 NYCRR 635 (certification of facilities), 633 (rights & responsibilities), etc. (Legal Information Institute)
They stress that your policies & procedures must reflect the regulations and be implemented in practice. (Legal Information Institute)
OPWDD expects ongoing compliance; for certification or recertification they will monitor standards of certification and may monitor principles of compliance if issues arise. (Legal Information Institute)
There are provider performance expectations (governance, fiscal health, quality improvement) via the OPWDD toolkit. (opwdd.ny.gov)
2. CQL Accreditation Standards
CQL (formerly Council on Quality and Leadership) uses tools such as the Basic Assurances®, the 21 Personal Outcome Measures®, and emphasises person-centred practices, continuous improvement, outcome measurement. (The Arc)
Accreditation is more than passing a test; it’s a transformation journey. (buffaloriverservices)
Example: Organisations announce achieving Person-Centred Excellence Accreditation with pride that they are aligning support practices, stakeholder involvement, data systems. (RHA Health Services)
3. DDS Standards (and equivalent state developmental-services standards)
While “DDS” may refer to specific state agencies (e.g., Massachusetts, California) the general concept is: providers must follow licensing/certification regulations, service standards, health & wellness standards, outcome measures.
For example Massachusetts' 115 CMR covers standards for supports. (Massachusetts Government)
Washington DC’s DDS health & wellness standards emphasise ongoing assessment, preventive health, care coordination for persons with intellectual and developmental disabilities.
Non-compliance consequences: serious risks of suspension/revocation, monetary penalties, and corrective actions. (Arkansas Department of Human Services)
How Briason Associates Helps: Consulting Strategies That Work
Now let’s get practical. How does Briason Associates help you make it simple? We break it into phases—with pragmatic tools and some culture-shifting strategies.
Phase 1: Readiness Assessment & Gap Analysis
We start by bringing your leadership and key staff together for a collaborative kick-off: what is our current state, what are the applicable standards (OPWDD regs, CQL accreditation standards, internal policies), where are we strong, where do we have gaps?
We map your policies & procedures against the regulatory requirements and accreditation standards. For OPWDD, that might involve reviewing your policy manual, your implementation plan, your evidence of practice (staff training records, service delivery logs). (Legal Information Institute)
We identify documentation needs, risk areas, and create a dashboard of “what must be done before survey/accreditation visit” vs “what is longer-term improvement.”
Importantly we set realistic timelines—with owners and milestones—and build this into your operations, not as a side project.
We also engage staff across levels early—front-line, middle management, leadership—to gauge culture, readiness, engagement. One thing we see repeatedly: policy exists, but staff aren’t aware or trained, or the “how we do it” is inconsistent.
Phase 2: Policy-Procedure Enhancement & Practice Translation
Having identified gaps, we help you revise or create policy-procedure manuals that align with OPWDD and CQL (and any relevant DDS state standards). That means clear, accessible language; version control; staff roles/responsibilities; measurement & improvement loops.
But policy is nothing without practice. We provide training (in-person or virtual) to ensure staff understand not just what the policy says but how they apply it in day-to-day service delivery.
We support development of implementation tools: checklists, audit templates, self-assessment guides, performance dashboards. For instance, CQL accreditation emphasises externally-validated tools like the Personal Outcome Measures®, stakeholder data, etc. (The Arc)
We help embed practice-monitoring systems. For example: staff coach direct support professionals on how to document in a manner consistent with regulations, how to reflect person-centred outcomes, how to capture evidence of supports for individuals rather than just “we did it” check-boxes.
We help you align your governance/fiscal/quality improvement systems. For example OPWDD’s agency quality performance standards include requirements that mission & goals are communicated, knowledge-management is in place, fiscal systems provide meaningful data. (opwdd.ny.gov)
We assist in creating corrective‐action planning processes. For instance, OPWDD describes the “Plan of Corrective Action (POCA)” process when deficiencies are found. (opwdd.ny.gov)
Phase 3: Pre-Survey/Pre-Accreditation Coaching & Mock Reviews
We’ll conduct a mock survey/visit based on OPWDD or CQL criteria—think “what would the surveyor ask?” “What evidence would they want?”—and walk you through “findings” and corrective actions, so you’re not surprised.
We coach your leadership and front-line team on how to handle the actual visit: who speaks with surveyor, what documentation to have ready, how to showcase your best work and continuous-improvement mindset.
We help you develop a “survey readiness kit” that includes policy binders, evidence binders, staff sign-offs, training records, outcome reports, dashboards—all logically organised for quick access.
We also support your “when the survey is done” debrief: reviewing findings, drafting corrective action plan, assigning owners, integrating into your quality management system.
Phase 4: Post-Accreditation / Ongoing Improvement
Accreditation is not a one-and-done. We help you build a cycle of continuous improvement: review of outcomes (for example, using CQL’s outcome measurement tools), updates of policies, training refreshers, audit processes.
We support data-driven decision making: for example, tracking key performance indicators, aligning practice to outcome data, feeding results back into leadership and board dashboards.
We help you cultivate a culture of compliance + excellence: staff not just asking “How do we avoid a citation?” but “How do we provide the best for the people we support and how do we measure that?”
We support governance and accreditation maintenance: keeping the momentum so that accreditation renewal is not a crisis but a checkpoint.
Real-World Tips & Best Practices (straight from the field)
Here are some concrete strategies and lessons we’ve learned—with some fun analogies.
1. Think of compliance like performing a play—not just reading the script.You may have great policies (script) but if your staff don’t know their part or don’t rehearse (practice) you’ll flop. Regular training, role-play, mock scenarios matter.
2. Documentation isn’t just a “box to tick”—it’s your evidence of the show.Remember: when a surveyor from OPWDD or CQL walks in, they are looking for evidence that your system works. Policies + practice + documentation = credible. If your documentation trail is weak, you’ll have to explain more or will get findings. For example, OPWDD expects providers to have appropriate policies/procedures “which shall become part of the agency’s/facility’s policy and/or procedure manual(s). Upon development, such policies/procedures shall be implemented and the facility shall have responsibility for ensuring ongoing compliance.” (Legal Information Institute)So: implement, monitor, update.
3. Use “plain language” for staff and stakeholders.Too often we see manuals written in legalese. Instead: clarity, examples, “this is how we do this at our agency.” Staff need to understand why a requirement exists. For example: respecting rights, ensuring dignity, safety, etc. (opwdd.ny.gov)When staff understand the why, their practice aligns.
4. Build the bridge between “service delivery” and “accreditation readiness.”It’s not separate. When you help someone develop a personal outcome plan (CQL’s POMs) you can document how that links into your quality improvement system, which links into your accreditation validation. That alignment is gold. For example, OPWDD highlights use of CQL’s 21 POM domains as one method. (opwdd.ny.gov)So: service-delivery → documentation → outcome tracking → accreditation evidence.
5. Governance matters.Boards, leadership, fiscal oversight—they all matter to surveyors and accrediting bodies. For example, OPWDD’s Agency Quality Performance Standards emphasise that the mission and goals must be communicated to all stakeholders, and financial/fiscal systems must produce meaningful data. (opwdd.ny.gov)Make sure your board understands their role in compliance/accreditation, not just funding.
6. Make self-assessment routine.Rather than waiting for a survey, build internal audits. For example, monthly or quarterly internal check of key policies, staff training completions, incident reporting, person-centred plan reviews. This means when the external review comes, you’re already aligned.
7. Continuous improvement, not “compliance audit panic.”Some organisations treat accreditation like “let’s cram for the test.” That works short-term, but long-term you’ll struggle. Accreditation bodies like CQL emphasise a journey of improvement. (buffaloriverservices)You want to build momentum: celebrate successes, share outcomes, engage staff, embed improvements.
8. Engage the people supported and their families.Surveys and accreditation reviews increasingly focus on whether the people you support are experiencing meaningful outcomes, engaging in planning, participating in decision-making—not just that you “have supports.” CQL emphasises stakeholder involvement. (The Arc)Make sure you can show case studies, testimonies, data of “what matters to the person” and how you helped deliver.
Navigating Common Challenges (and how we help you overcome them)
Challenge 1: Documentation backlog or inconsistencies.Solution: We work with you to prioritise key policies and trainings, create a remediation plan, assign owners. We help develop documentation templates so consistency improves.
Challenge 2: Policy exists but staff don’t know or follow it.Solution: Staff engagement, training sessions, focus groups; we help you develop practical “how to” job aids.
Challenge 3: Data is collected but not analysed or reported.Solution: We help you develop KPIs aligned with person-centred outcomes and accreditation requirements, set up dashboards/scorecards, support report generation and management review.
Challenge 4: Survey/visit anxiety among staff.Solution: Mock-visits, role-plays, coaching. We demystify “what will the surveyor ask?” and make sure your team is confident.
Challenge 5: Sustainability post-accreditation.Solution: We support you in embedding the accreditation maintenance process into your quality improvement system so it doesn’t feel like a one-time surge.
Challenge 6: Aligning multiple regulatory frameworks (OPWDD, CQL, state-DDS).Solution: We map them together so you have a unified compliance framework—not three separate silos. You save duplication, reduce confusion, create synergy.
Case Example Snapshot (Hypothetical but Based on Real-Life Patterns)
Let’s say Agency X is a community-based provider in New York serving individuals with developmental disabilities who wants to pursue CQL accreditation and ensure OPWDD compliance.
Kick-off & Gap Analysis: We meet with leadership; review current OPWDD certification status, prior surveys, policies; map current practices against CQL Basic Assurances® and POMs.
Policy Revision: We update the agency’s policy manual to reflect person-centred planning, rights protections (as required under 14 NYCRR 633.4), documentation standards, outcome measurement. (opwdd.ny.gov)
Staff Training: We provide training sessions across frontline, supervisory, leadership levels on person-centred language, outcome measurement, documentation practices.
Implementation Tools: We create job aids, audit templates, training calendars, self-assessment checklists.
Mock Visit & Readiness Kit: We simulate a CQL accreditation visit and an OPWDD survey, provide findings, support plan of corrective action, ensure materials are ready.
Accreditation Review & Survey: Agency X passes the CQL review, receives Person-Centred Excellence Accreditation. Now they promote that externally and embed into their quality improvement cycle.
Post-Accreditation: The agency now uses quarterly outcome-data reviews, staff training refreshers, annual policy review, board dashboards, ensuring compliance and excellence continue.
Why Briason Associates?
We specialise in both regulatory compliance and culture/practice transformation.
We bring both “check-the-boxes” know-how (policy, audit, survey readiness) and “how do we actually deliver person-centred supports” experience.
We believe you can enjoy the process: with clarity, with tools, with staff engaged. Compliance doesn’t have to feel like dread.
We see accreditation not as a burden but as an opportunity: to raise the bar, to engage staff, to strengthen outcomes, to improve operations.
We stay current: regulation updates, accreditation standards evolutions (for example OPWDD’s shift toward emphasizing person-centred outcomes).
We provide scalable support: whether you are a small agency or a multi-site provider, we tailor our consulting to your size, resources, and culture.
Final Thoughts: Turning Compliance into a Competitive Advantage
Let’s close with a bold statement: compliance + accreditation is not just a line in the budget—it’s a strategic differentiator. Agencies that embrace compliance and accreditation can…
Demonstrate higher credibility to funders, referral sources, families.
Attract/refine a workforce that values quality, training, person-centred practice.
Use accreditation as a marketing tool: “we meet CQL standards”, “we align with OPWDD top practices”, “we show measurable personal outcomes”.
Use compliance data to inform business decisions: staffing, service design, resource allocation.
Build culture: where staff see that there’s integrity behind what we do, that documentation reflects real supports, that we are accountable—and that supports the people we serve.
For example, one accredited provider said: “Through this accreditation… we’re showing people supported, families, employees, and others, that we’re committed to quality services that help people’s dreams come true.” (PR Newswire)
So if you’re leading an agency and you’ve been thinking: “We have a survey coming. We want accreditation. We know we have gaps but how do we get it done without panic mode?”—that’s exactly where Briason Associates comes in. We help turn the ambiguity into a roadmap, the compliance burden into a structured process, the accreditation goal into tangible steps—and we do so with your team, not just to your team
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