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LHCSA Compliance Retainer · New York
Your re-licensure survey is unannounced. Readiness has to be standing.
Re-licensure surveys are unannounced and triennial. There is no preparation window, which means readiness is either a condition your agency maintains or a scramble it performs badly. This retainer keeps documentation current, samples your own records the way a surveyor would, and puts a named owner on every standing obligation, so the survey finds an operation that was already ready.
Book a readiness callThirty minutes. We will tell you where your exposure most likely is and whether a retainer is the right instrument or whether you need a one time cleanup first.
What actually goes wrong
Almost nobody fails a survey on the policies. They fail on the drift.
Agencies rarely get cited because a required policy does not exist. They get cited because the practice and the binder stopped matching, and nobody inside the building noticed. Surveyors do not only check that a policy exists. They check whether the agency implemented and follows it.
Drift has a shape and it repeats. A personnel file stops being maintained when the person who maintained it changes roles. A supervisory visit slips by a month, then a quarter, and the documentation quietly reflects the slip. An in-service is delivered but the attendance record is never closed out. A policy is revised to satisfy a funder and the floor never hears about it. Each of these is small. Together they are a Statement of Deficiencies.
The question we ask
If a surveyor asked who performs each step in your manual, could you name them? Not the department. The person.
What the retainer does
Four standing functions, on a calendar.
Documentation cadence and personnel file discipline
A schedule for what gets updated, by whom, and when, covering personnel files, supervisory records, in-service documentation, and service records. The output is boring on purpose: a recurring obligation with a named owner, so maintenance does not depend on anyone remembering.
Quarterly self-sampling against survey criteria
Each quarter we pull a sample of your records and read them against the criteria a surveyor applies, then hand you the findings and the remediation. You see your own weaknesses on your own schedule, while there is still time and no citation attached.
Statement of Deficiencies and Plan of Correction support
If a citation comes, the Plan of Correction is the document that determines what happens next. We help you write one that is specific, owned, achievable, and not a promise you will fail to keep in month four.
Regulatory change monitoring
Operating requirements for licensed home care services agencies change, and the change does not come with a notification addressed to you. We track what moves and tell you what it means for your operation, in plain terms, with the action item attached.
The engagement is built against the operating requirements for licensed home care services agencies at 10 NYCRR Part 766 and the documentation practices surveyors actually examine. If your manuals came from somewhere else and have never been reconciled with your practice, we will tell you that in the first quarter rather than the third year.
Scope and fee
A monthly retainer, a twelve month minimum, a named owner for everything.
Compliance Retainer
From $2,800 / month · 12 month minimum
Readiness as a standing condition, not a project you start when you hear a rumor.
- Documentation cadence and personnel file discipline
- Quarterly self-sampling against survey criteria
- Statement of Deficiencies and Plan of Correction support
- Regulatory change monitoring
- Named owner for each standing obligation
- Annual readiness review
Most clients add this at the close of an LHCSA Licensure Build. Available to agencies we did not license.
This is for you if
- You are operating and your last survey is more than a year behind you
- Your documentation depends on one person who has never taken a long vacation
- You inherited manuals you have never reconciled with your practice
- You have to prove compliance to a plan or a funder as well as the state
This is not for you if
- You want someone on call only when a surveyor is in the lobby
- You want the findings without doing the remediation
- You are pre-licensure. Finish that first
Prices are starting points for a single-site agency. Scope depends on census, staffing, and the condition of your current documentation. Agencies with significant backlog usually need a one time cleanup before a retainer makes sense, and we will say so.
Questions we get
Compliance questions.
The ones that come up when a survey is overdue.
How often is a LHCSA surveyed?
Re-licensure surveys are unannounced and run on a triennial cycle. Unannounced is the operative word. There is no window to prepare in, which is the entire argument for treating readiness as a standing condition rather than a project.
We passed our last survey. Why would we need this?
Because passing once tells you the agency was compliant on one day. Most citations we see are drift: a personnel file that stopped being updated when the person who updated it left, a supervisory visit cadence that slipped a month and then a quarter, a policy that was revised without the practice following. Drift is slow, invisible from the inside, and obvious to a surveyor.
What is self-sampling?
We pull a sample of your own records each quarter and read them the way a surveyor would, against the criteria a surveyor uses. You get the findings before the state does, with enough time to fix them. It is the least dramatic and most useful thing in the engagement.
What happens if we get a Statement of Deficiencies?
We help you write the Plan of Correction, which is a more consequential document than it looks. A weak Plan of Correction invites a return visit and commits you to remedies you may not be able to sustain. A good one is specific, owned by a named person, and achievable on the timeline it promises.
Is there a minimum term?
Twelve months. Compliance work produces nothing useful in a single month, and a retainer you can cancel the moment things look calm defeats the purpose of a standing condition.
We are still getting licensed. Should we start now?
Not yet. Finish the licensure build and the pre-opening survey first. Most clients add this at the close of that engagement, which is the natural handoff point.
Start here
Book a readiness call.
Thirty minutes. We will tell you where your exposure most likely sits and whether a retainer is the right instrument or whether you need a cleanup first.
Spence Consultants, LLC
275 East Sandford Boulevard
Suite 1040
Mount Vernon, NY 10550
Phone
Hours
Monday to Friday, 10:00 AM to 6:00 PM ET