Regulatory Affairs

The Office of Accreditation & Standards is responsible for receiving and facilitating the response to inquiries from regulatory bodies. Regulatory bodies making inquiries can include:

  • Federal and state agencies;
  • Accrediting bodies such as the TJC; and
  • Insurance quality agencies

These requests can relate to a variety of issues; for example:

  • Notice of survey activity;
  • Request for information regarding a complaint;
  • Request for assistance with an investigation of an outside agency (such as patient medical information for an outside abuse investigation);
  • State licensing board request for employee information; and
  • An insurance agency concern about the quality of care for its member.

Receiving Requests: Regulatory Affairs Inbox:

Accreditation & Standards maintains an inbox that is monitored daily by a member of our team.  When an inquiry is received, Accreditation & Standards determines the type of action that is needed and contacts the leadership of the affected departments (for example, nursing leadership, Quality staff, the Office of Legal Affairs, Medical Records etc.).  A response is then developed with this team and submitted by Accreditation & Standards.

Have you received a communication from a regulatory body or lawyer’s office?

  • Send an email to
  • Label the email as “Private” or, if it contains patient information, as “Restricted”
  • Attach any emails, forms, and/or letters you received.
  • If you received the inquiry as a phone call, include all of the caller’s contact information.
  • A&S will notify you if any further assistance is needed.

If you are unsure if the inquiry is from a regulatory body, follow the steps above and A&S will help to navigate the inquiry for you.