View all articles | Read the next article
SM: Your path into compliance is not the typical one we see in healthcare. How did your clinical background shape the way you eventually found your way into compliance work?
TL: It became clear early on that my clinical background could be best channeled and that more people could be helped by focusing on staff development. It’s easy to overfocus on product elements, whereas the process can enlist greater, more meaningful staff participation and execution, especially outside formal meeting times. This led me to the creation of the Partnership of Change Paradigm (see image below). Staff (vested active stakeholders) who are involved, especially in the
beginning where strong fortified roots form, are invested in their collective decisions (goals and objectives), take ownership of these decisions plus responsibilities (goals and objectives) along with their accomplishment, and are ultimately accountable to operationalizing of all that they agreed to. I’ve developed voluminous models and papers over the years, some of which are published. It’s a good strategy for professionals to consider: as you develop, document. Your original work can be repurposed for training, edification, and publication. To keep your team motivated, take time to smell the roses. I often have an ambitious agenda. Point out the successes (even small ones), especially the small ones that team members might not see .It demonstrates their effectiveness, shows they are making a difference,
gives hope, and builds them up. Be enthusiastic. Be inspirational. It’s easy to do when you are sorting for success. Use lots of meaningful eye contact. Emotional intelligence is important. As Maya Angelou said, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
SM: Human services and community mental health often operate with fewer resources and less established infrastructure than other sectors. How does this reality influence the way compliance programs are built?
TL: This depends on the organization, its financial resources, and whether a compliance program was in place. For me, I was the first compliance officer and did not have a program. You don’t know what you don’t know. It takes research. Don’t stop at the first voice or the first tool. You need to be creative and quick-thinking as
you’re running a business at the same time. The Association for Behavioral Healthcare (ABH) corporate compliance committee was a huge benefit. I work with Don
Siddell whom I see is like the Dean of Compliance. Through Don the committee has provided clear, concise guidance, sources, camaraderie, and
unwavering support.
SM: You often mention that many roles you’ve stepped into — including your compliance position — didn’t exist before you arrived. How do you approach building something from scratch?
TL: You must be comfortable operating on your own, relish creating things, and understand the new operation enough to see where you want to end up. There is also a predictive element of where the technology that you have access to is going. For me, it has been Microsoft suite. Each successive version continues to create
more overlap between program functionality.
SM: Let’s go back to your early career at Hayden School. What did that environment teach you about leadership, team-building, and culture?
TL: Hayden was a great challenge. Trust had to be earned. Early on, when I built my first team, it cemented in me that the greatest difference could be made by developing staff while concomitantly developing mission and culture. Sewn in a neighborhood in Boston, congregate care staf shaped by the neighborhoods that they grew up in, moving through the haze of post-desegregation Boston, taking the collective chance to grasp the promise of what we could only attain together.
When building a solid operation, you need an excellent lieutenant. Sheila Spence was that exceptional person. It’s imperative to have someone carry the message and vision when you are not there.
It’s essential to create time for supervision, which is also part of staff-focused training. Many human services — especially congregate care operations — don’t genuinely value true in-depth supervision either consistently or in how it is designed. Program scheduling must be set realistically so that it does happen. One of the models I created, Trickle Down Supervision, gave it focus. Mini teams helped to operationalize it clinically. Goals and objectives were regularly reviewed. Regular supervision gives the message that staff and their development are important, valued, and creates a learning culture that permeates the environment. The values garnered here influence the future.
SM: You soon transitioned from team culture to operational systems. How did creating the electronic policy manual and improving intake processes change the organization?
TL: The intake system showed agency staff that interagency cooperation could occur and that the system/workbook made a direct impact right away while promoting accuracy.
The digital policy manual provided all staff with computer access to an up-to-date manual. Updating was easy with all agency emails sent when updates occurred. Text identifying other policies or documents was linked to those instruments.
Thinking systemically, you seek to ensure an efficient, compliant, auditable structure where all other parts fit together as a cohesive whole.
SM: You led the agency through repeated licensing studies and successful Council on Accreditation re-accreditation. What practices were key to achieving that level of consistency and performance?
TL: You have to be hyper-organized, and then staff are more likely to follow. If you drop the ball, it’s almost subtle permission for others to not try as hard.
One of the downfalls of some organizational (and treatment) plans is not following up on tasks and objectives. If there are problems, address them with immediacy. Break it down, amend, but don’t stop. You’re on a timeline.
Goals and objectives need to have ways to be accomplished from the outset; otherwise, they are doomed to failure. Feedback loops prior to quarterly reporting are a way to check whether preplanning was accurate at the start: focused planning comes prior to onset and execution, just as discharge planning starts as close to intake as possible. There are identified needs (goals) that are currently identified to be addressed/executed (measurable objectives with who is doing what by when).
Always take into account compliance, contractual, and organizational requirements. If there is a difference in level of expectation, use the highest standard.
SM: The transition to the Community Counseling of Bristol County (CCBC) placed you again in a brand-new program born out of Rosie D. v. Romney. What were the biggest challenges in building the Community Service Agency (CSA) structure without existing tools?
TL: As a result of the Rosie D. v. Romney class action lawsuit, Massachusetts was ordered to overhaul its mental health system for children with serious emotional disturbances (SED) leading to the formation of the Children’s Behavioral Health Initiative (CBHI). Some of the key services implemented under the CBHI included intensive in-home therapy, in-home behavioral services, 24/7 mobile crisis intervention, and therapeutic mentoring. CSAs were also established as high fidelity (evidence-based) programs specialized to provide intensive care coordination, comprehensive home-based assessments, and wraparound services for Medicaid-eligible children with SED. Family partners that were part of the program were required to have lived experience. I was the first program director for our CSA.
At the onset, there were 32 CSAs. It is a fidelity-based program, which required very detailed training provided through Vroon VanDenBerg. Their team was top notch and made a huge difference toward our success. Our service performance was graded on this execution with national and statewide norms. Our program often met or exceeded both. Senior staff went through a rigorous fidelity-based training program to become eligible to train and certify staff. Our senior intensive care coordinators were certified second and third in the Commonwealth. Our senior family partner was certified second in the Commonwealth. There were a number of other firsts and events of distinguishing ourselves.
A huge challenge was getting staff trained at the same time they were providing services. We could only hire enough staff to cover the number of clients we had. Training to provide services at high fidelity took weeks to months. You could only have someone being trained for a week or two without providing services. The goal was to maximize the initial time so that they could execute the initial aspects of wraparound when they went out and provide the additional training as they progressed with their clients. When to hire posed a lot of stress.
SM: Your Excel-based billing and reporting system dramatically cut processing time. What did that experience teach you about designing practical, sustainable systems under resource constraints?
TL: This actually started at Saint Vincent’s Home (now Saint Vincent’s Services), a primarily congregate care agency, at the time. I was new to the rotation for the afterhours new student admissions. It was a paper-and-pencil system that took over an hour just to complete the initial paperwork before the referral arrived. I was baptized at 2 a.m. for my first intake. This was when I first learned about Excel and how you could have data go from one cell to another. It was the first time we were able to get three agencies to work together. I worked with my administrative assistant, Karen Roy, to develop an admissions workbook. For the clinician conducting the admission, the preparation time, including printing, was about 10–15 minutes. This was much easier than the over an hour that it took before.
For the CSA, I modified and seriously upgraded another agency program’s billing workbook in Excel, as there was no electronic health record (EHR) for this brand new program. My electronic system included an encounter form element that captured billable and non-billable units, was able to pull data into a delivered billing report, and provided regular, up-to-date reporting to the CEO. Those elements were automatically built into the system, so there was no need to run additional reports.
I insisted on including certain non-billable tasks to demonstrate all the time that our staff was truly expending effort to provide quality service. It provided an eye-opening picture. This initial robust system took two-and-a-half days to execute. I was eventually able to improve upon it, to be executed in two-and-a-half hours.
My Excel-based risk management database captures over 10-years of data from when it was built in July 2014. Formulas guide the data by fiscal year (FY) quarter into a FY total, with key running totals and averages.
You can’t be satisfied with not having a sustainable system. It requires the ability to experiment, research, and be willing to make mistakes. I’ve found YouTube videos helpful, but don’t stop at the first one. There are many resources out there. Asking yourself focused, short-term, long-term questions, and how your current project will influence (assistive and unserviceable) areas of the operation, is essential.
A tremendous resource for me is the ABH. It is the leading advocacy organization representing community-based mental health and addiction treatment organizations for over 80 agencies in Massachusetts. Of the many committees, I was a contributing member and now the chair of the corporate compliance committee. We are member-driven.
SM: You eventually became CCBC’s first compliance officer. How did you go about developing tools and frameworks when none were in place?
TL: As nothing existed, I searched for and modified four tools before combining them. ABH was essential here. These tools were described in my co-presentation with Jenn DeVoe, LCMHC, on Community Mental Health: The Broad Horizon & Application of Compliance at the HCAA Boston Regional Healthcare Compliance Conference. You can’t be satisfied with not having a sustainable system. It requires the ability to experiment, research, and be willing to make mistakes.
SM: The work you did with Carl Russell’s Seven Elements workbook evolved into a collaborative effort with the ABH. What impact did that work have across member agencies?
TL: I began to create a brand-new tool. As I labored forward, I decided to search the internet when I discovered the fantastic work of Carl Russell. Carl created an interactive Excel workbook version of the HCCA–OIG guide “Measuring Compliance Program Effectiveness: A Resource Guide” known as Measuring Compliance Program Effectiveness. He took the seven elements and made a dynamic workbook out of them. His only requirement is that it not be sold, even if modified. I took this work and led a roughly 18-month-long regular agenda item at monthly meetings of the ABH corporate compliance committee. The focus was to review the system, one element at a time, and to inscribe member-generated content plus modifications that would help the member agencies. It should be noted that I eventually rose to become chair of the committee, which I continue to operate in that capacity.
I held a compliance tool boot camp after development, which was well attended with full participation. There were a number of emails and/or Zoom chat messages providing positive feedback. There are still occasional requests for the tool. I’d like to condense it some more but haven’t been able to carve out the time. Though AI could be employed, this is a labor of love.
SM: AI in human services is still emerging. From your vantage point, how are agencies approaching AI, and what led you to develop the AI review checklist?
TL: I see three main paths human service and community mental health agencies tend to take with AI. Those who are bolder are looking for AI to become an integral part of the operation. In human services, we are looking at the Golden Thread (connections between the following: assessment, treatment plan, and progress notes). These agencies are also looking for auditing, possible connections to billing, and much more. The second group is trying AI for discrete tasks like policy development, training creation, and so on, but with no real integrated commitment. The third is less a path and more of just waiting.
I created the AI Review Checklist, which has been evolving with the ABH corporate compliance committee member agencies. It should be noted that this tool started at CCBC. It includes, but is not limited to, governance, selecting a vendor, technology needs, stakeholder involvement, user aptitude and attitude, etc. This is an evolving document. AI is now a regular agenda item with the intent of following logical progression for member agencies adopting AI.
Our monthly AI agenda follows logical progression, including a few major areas, but not limited to, an AI overview, governance, vendor questions and considerations, security access to client files, and the interplay of AI, soliciting staff input, policies and procedures, training, pilot/ sandbox considerations prior to full adoption, and so on. This is evolving.
SM: You’ve emphasized the importance of thoughtful, structured adoption of AI. What risks or misconceptions do you see most often in early AI conversations?
TL: I would look at some prohibitions on staff using AI until the agency makes some hard decisions on which camp they are in. This includes governance elements. Under no circumstances can protected health information or personally identifiable information be at risk. 42 CFR Part 2 is also sacrosanct. AI is not a technology for staff to learn on their own with agency resources using agency data (confidential or not).
Ambient listening is also something that should be taken into consideration if that is part of an AI product that an agency is considering. What happens with the data afterwards? Some products have features that reportedly automatically delete the material after the notes are composed. Tied to this is the data used as part of a large language model that the vendor uses to improve their product (potential exposure of agency data), used to improve the agency’s experience (is the data housed with the vendor?), or be deleted.
Another concern would be new clinicians who may become fatigued, not having the experience to fully scrutinize AI-generated notes, and relying on them.
Just like when EHRs were rolled out, there was a lot of anxiety. There will be here, however, AI will require higher guardrails, built-in compliance requirements, as well as robust auditing systems.
The federal government is relying on states to regulate AI. This will create a variety of rules, which will challenge multistate entities. With potential regulatory upheaval, business associate agreements should be reviewed with more regularity.
SM: Beyond compliance, you’re heavily involved in crisis prevention, martial arts, kettlebells, and debriefing practices. How do these disciplines influence your approach to leadership and staff support?
TL: Martial arts are as much about training the body as the mind, which is why I continue my studies, including my fourth (Tai Chi Chuan) and fifth (Kali) styles under Sifu Jaime McGuire. Sifu Jaime has the uncanny ability to blend both principles into a meaningful whole that translates into everyday life.
Sifu Jaime introduced us to kettlebells. Kettlebells, often described as the martial arts of weightlifting, build full-body strength, endurance, and power by engaging multiple muscle groups at once. I became certified Level 1 under the International Kettlebell and Fitness Federation. Kettlebells are another way to train the body and the mind.
It helps to be competitive. Ultimately, you are in competition with yourself. Martial arts and kettlebells are invaluable towards this end.
I have participated on a national level through blog articles, been selected for a podcast interview,1 a Crisis Prevention Institute (CPI) mental health virtual focus group, as well as reviewing content for a new CPI training program entitled Introduction to Mental Health. Learn more about my various CPI contributions: https://www. crisisprevention.com/search page/?q=Loftus&category=all
CCBC has refined a CPI technology. Debriefing is a form of post-vention processing which we have modified for staff losses, serious client crises of impact, and other possible traumatic events. Often, other traumatic experiences that staff have experienced surface and are related. It is a way to process the incident, help them not carry unnecessary baggage, and build staff up for positive things they might not realize they did. I find these experiences to be uplifting.
Lastly, it is important to have an agency that is heavily invested in safety. Our CEO, Andrew Dawley, and Chief Operating Officer, Kevin Medeiros, with the full support of CCBC’s board, have brought our agency’s safety committee and its surveys to life. CPI came from one of them. Personal safety devices are another. You have probably seen these in commercials with John Walsh for seniors. Staff complete profiles. When staff deploy the device, personnel at the other end know who and where they are, cutting valuable time. Both initiatives are huge financial investments. The board sees that as the cost of doing business. How amazing is that?
SM: Looking back across your career of building programs, tools, and systems that didn’t exist before, what advice would you give to compliance officers entering environments with limited resources or limited precedent?
TL: As stated earlier, I moved from one first to another throughout my career, now the agency’s first compliance officer. This is not unusual in human services. As stated earlier, I’m a trained clinician who escalated into this position. Just like any other of the many brand-new positions, it was an opportunity to create and invent.
My history catalogs the resource challenges that I faced at different stops along the way, working for nonprofits. Each was negotiated, though some not on the first try. Some of the feedback I received at the HCCA Boston Regional Healthcare Conference was that I spent more time on past work. Here is my chance to explain: the professional gains, whether it be creating a database, creating electronic policies and procedures, staff evaluation packages, training, etc., are a journey of invention and creation that I had to make, some building off others, all pointing towards compliance. I used and still use the Microsoft suite of programs. Though technically not “free” as we pay for licenses, “free” here means that it was not a specific vendor-purchased software system or an EHR program.
Be willing to take chances. As long as your head and heart are in the right place, you are unlikely to make catastrophic mistakes. Think like an entrepreneur. Relish the opportunities to create. You don’t have the time to be a burden on your supervisor. You were hired to build. Do it!
It’s truly satisfying to build something sustainable, develop staff to reach heights they didn’t think were possible, and create operations that will make a difference in our clients’ lives.
SM: Thank you, Thomas.CT
1. Tom Loftus, “Podcast: Acting With Intention Promotes Culture Change Within a Caring Work Environment,” Crisis Prevention Institute, Unrestrained: A CPI Podcast, episode 61, accessed February 5, 2026, https://www.crisisprevention. com/library/behavioral-health/podcast-acting-with-intention/ .
March 2026 | Compliance Today
View all articles Read the next article