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Week 9 Assignment 4: The Regulatory Environment – Survey Readiness
Course Objectives for Assignment:
· Apply management theory, concepts, and models to examine ethical best practices in long-term care administration and to foster performance excellence.
· Develop and refine students’ ethical problem solving and analytical skills when confronted with complex challenges, decision making, and strategic planning in long-term care administration.
Background: Preparing for a regulatory survey is essential in
long term care and complying with these regulations is critical for the success an organization. Over the past several weeks, we have learned a tremendous amount of information on different departments as well as various administrative areas. Now, we will apply your knowledge to creating a proactive plan that assists your team in being prepared should regulatory bodies arrive to conduct a survey or inspection. While we do not have the time to implement and discuss a full mock survey, we will have the time for you to work on a few of the processes for a survey readiness plan.
Your Scenario (Option A, B, or C)
: Your instructor will assign you one of the scenarios provided below. This communication for your assigned scenario will be provided from your instructor no later than Week 2 of the course.
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Option A: Florida Assisted Living Facilities
If Option A was Assigned to You, then You will be Provided with One of the Following ALFs:
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ALF Option 1: Colonial Assisted Living located in Tampa, FL
· ALF Website:
Colonial Assisted Living Tampa Florida Website - Main Page
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ALF Option 2: Brookdale Senior Living located in Cape Coral, FL
· ALF Website:
Brookdale Senior Living Cape Coral Florida Website - Main Page
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ALF Option 3: Addington Place Senior Living in Titusville, FL
· ALF Website:
Addington Place Senior Living Titusville Florida Website - Main Page
If the ALF Option was Assigned to You, then you will be Provided with One of the Following Florida ALF Regulatory Standards:
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Florida ALF Standard Option 1: A0007 – Admissions -Criteria
· Rule: 59A-36.006(1) FAC
· Regulatory Information: Pages 21 to 25 of the Florida AHCA State Regulations PDF.
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Florida ALF Standard Option 2: A0030 – Resident Care – Rights & Facility Procedures
· Rule: 59A-36.007(5) FAC; 429.28(1-2) FS 429.27
· Regulatory Information: Pages 40 to 45 of the Florida AHCA State Regulations PDF.
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Florida ALF Standard Option 3: A0123 Fiscal – Resident Trust Funds
· Rule: 429.27(3-5) FS; 59A-36.013(2) FAC
· Regulatory Information- Pages 103 -104 of the Florida AHCA State Regulations PDF.
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Florida ALF Standard Option 4: A0183 Emergency Management - Facility Evaluation
· Rule: 59A-36.019(4) FAC
· Regulatory Information: Pages 131 to 132 of the Florida AHCA State Regulations PDF.
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Florida ALF Standard Option 5: AE201 – ECC – Policies
· Rule: 59A-36.021(2) FAC 429.07(3)(b)5, FS
· Regulatory Information: Pages 149 to 151 of the Florida AHCA State Regulations PDF.
Resources for this Scenario
:
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How to locate the specific regulations for this scenario: You can you the Control F function on your PC or Command F function on your Mac to search for a specific regulatory standard/tag/rule. Type in the information that you want to search for in the specific document that you are reviewing, using this search function, to locate your information:
· Florida Agency for Health Care Administration (AHCA) ALF State Regulations:
Florida AHCA State Regulations PDF
· Website link to Florida ALF Statutes:
Florida ALF Statutes Website
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Option B: South Carolina Home Health Agencies and Services
If Option B was Assigned to You, then you will be Provided with One of the Following HHAs:
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HHA Option 1: Amedisys Home Health of Lexington located in Lexington South Carolina
· HHA Website:
Amedisys HHA in Lexington South Carolina
· Company Website – Main Page:
https://www.amedisys.com/
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HHA Option 2: Carolinas Home Health in Florence South Carolina
· HHA Website:
Carolinas Home Health Part of LHC Group in South Carolina
· Company Website – Main Page:
https://lhcgroup.com/locations/carolina-home-care/
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HHA Option 3: Primsa Health Home Health located in Greenville South Carolina
· HHA Website:
Prisma Health Home Health of Greenville SC
· Company Website- Main Page:
https://prismahealth.org/
If the HHA Option was Assigned to You, then you will be Provided with One of the Following HHA Regulations:
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HHA Regulation Option 1: Federal CMS HHA Regulatory Condition: 484.50 Patient Rights
· Regulatory Reference and Standard: Be free from abuse.
484.59(c)(2)
· Regulatory Tag: G430
· Regulatory Information: Page 1 of the CMS 2018 HHA G Tag Information and Page 11 of the CMS State Operations Manual Appendix B for HHAs.
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HHA Regulation Option 2: Federal CMS HHA Regulatory Condition: Quality assessment/performance improvement (484.65)
· Regulatory Reference and Standard: 484.65 Participate in the HHA’s QAPI program
· Regulatory Tag: G640
· Regulatory Information: Page 3 of the CMS 2018 HHA G Tag Information and Page 40 of the CMS State Operations Manual Appendix B for HHAs.
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HHA Regulation Option 3: Federal CMS HHA Regulatory Condition: Home health aide services 484.80
· Regulatory Reference: 480.80(d) 12 hours in-service every 12 months
· Regulatory Tag: G774
· Regulatory Information: Page 4 of the CMS 2018 HHA G Tag Information and Page 56-57 of the CMS State Operations Manual Appendix B for HHAs.
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HHA Regulation Option 4: Federal CMS HHA Regulatory Condition: Emergency Preparedness 484.102
· Regulatory Reference: 484.102(a) Emergency Plan
· Regulatory Tag: E-0004
· Regulatory Information: Page 3 to 4 of the CMS 2018 HHA G Tag Information and Page 12 to 15 of the E-Tags Emergency Preparedness CMS State Operations Manual Appendix Z for All Certified Federal Level Providers.
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HHA Regulation Option 5: Federal CMS HHA Regulatory Condition: Personnel qualifications 484.115
· Regulatory Reference: 484.115(a) Administrator
· Regulatory Tag: G1052
· Regulatory Information: Page 6 of the CMS 2018 HHA G Tag Information and page 83 of the CMS State Operations Manual Appendix B for HHAs.
Resources for this Scenario
:
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How to locate the specific regulations for this scenario: You can you the Control F function on your PC or Command F function on your Mac to search for a specific regulatory reference/tag/rule. Type in the information that you want to search for in the specific document that you are reviewing, using this search function, to locate your information:
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CMS State Operations Manual Appendix B for HHAs PDF
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E-Tags Emergency Preparedness CMS State Operations Manual Appendix Z for All Certified Federal Level Providers PDF
· Website link to CMS Provider Compare– Main Page:
CMS Provider Compare Search Page
· Website link to CMS – Emergency Preparedness Rule Page:
CMS Emergency Preparedness Rule Landing Page
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Option C: Maryland Skilled Nursing Facilities
If Option C was Assigned to You, then you will be Provided with One of the Following SNFs:
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SNF Option 1: Autumn Lake Healthcare at Ballenger Creek located in Fredrick, Maryland
· SNF Website:
https://autumnlakeballengercreek.com/
· Company Website – Main Page:
https://autumnlakehealthcare.com/
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SNF Option 2: Chesapeake Shores located in Lexington Park Maryland
· SNF Website:
https://www.ltcrevolution.com/find-a-facility/chesapeake-shores/
· Company Website – Main Page:
https://www.ltcrevolution.com/
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SNF Option 3: Waldorf Center located in Waldorf, Maryland
· SNF Website:
https://www.genesishcc.com/waldorf
· Company Website – Main Page:
https://www.genesishcc.com/
If the SNF Option was Assigned to You, then you will be Provided with One of the Following SNF Regulations:
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SNF Regulation Option 1: Federal CMS SNF Regulation: Resident Rights 483.10
· Regulatory Reference: Safe/Clean/Comfortable/Homelike Environment 483.10(i)
· Regulatory Tag: F584
· Regulatory Information: Page 1 of the CMS SNF F Tags June 2021 PDF and Pages 62 to 66 of the CMS State Operations Manual Appendix PP for LTC Facilities.
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SNF Regulation Option 2: Federal CMS SNF Regulation: Freedom from Abuse, Neglect, and Exploitation 483.12
· Regulatory Reference: Reporting of Alleged Violations 483.12(b)
· Regulatory Tag: F608
· Regulatory Information: Page 1 of the CMS SNF F Tags June 2021 PDF and Pages 141 to 150 of the CMS State Operations Manual Appendix PP for LTC Facilities.
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SNF Regulation Option 3: Federal CMS SNF Regulation: Food and Nutrition Services 483.60
· Regulatory Reference: Provided Diet Meets Needs of Each Resident 483.60
· Regulatory Tag: F800
· Regulatory Information: Page 2 of the CMS SNF F Tags June 2021 PDF and Pages 564 to 565 of the CMS State Operations Manual Appendix PP for LTC Facilities.
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SNF Regulation Option 4: Federal CMS SNF Regulation: Infection Control 483.80
· Regulatory Reference: Influenza and Pneumococcal Immunizations 483.80(d)
· Regulatory Tag: F883
· Regulatory Information: Page 2 of the CMS SNF F Tags June 2021 PDF and Pages 708 to 749 of the CMS State Operations Manual Appendix PP for LTC Facilities.
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SNF Regulation Option 5: Federal CMS SNF Regulation: Emergency Plan for LTC Facility 483.73(a)
· Regulatory Reference: 483.73(a) Emergency Plan. Must develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually.
· Regulatory Tag: E-0004
· Regulatory Information: Page 12 to 15 of the E-Tags Emergency Preparedness CMS State Operations Manual Appendix Z for All Certified Federal Level Providers.
Resources for this Scenario
:
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How to locate the specific regulations for this scenario: You can you the Control F function on your PC or Command F function on your Mac to search for a specific regulatory reference/tag/rule. Type in the information that you want to search for in the specific document that you are reviewing, using this search function, to locate your information:
·
CMS SNF F Tags June 2021 PDF
·
CMS State Operations Manual Appendix PP for LTC Facilities PDF
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E-Tags Emergency Preparedness CMS State Operations Manual Appendix Z for All Certified Federal Level Providers PDF
· Website link to CMS Provider Compare– Main Page:
CMS Provider Compare Search Page
· Website link to CMS – Emergency Preparedness Rule Page:
CMS Emergency Preparedness Rule Landing Page
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Creating the PowerPoint Presentation
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Survey Readiness PowerPoint
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· Must be 10-12 slides, excluding the introduction slide(s) and reference page slide(s).
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Presenter Notes
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· Every slide must have presenter notes except for the reference page(s).
· Your presenter notes will be the information that you will be sharing with your team.
· Your notes should be detailed and contain APA in-text citations.
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References
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· Minimum of five scholarly references, professional publications, and/or academic journals from the last five years.
· Include any references from your assigned LTC facility or setting such as the website, company information, facility website, service-level website, etc.
· Every reference must have a correlating in-text citation(s).
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APA 7th Edition Style
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· PowerPoint slides, cover page, and reference page.
The PowerPoint Must Contain the Following Content Aspects for Your Assigned Scenario:
Aspect A: Introduction Slide(s)
· APA Cover Page – Include the title of the presentation, your name, your instructor’s name, course name, your assigned LTC facility or setting, your assigned regulation, and date submitted.
· Provide bulleted points to identify each Content Aspect that will be presented in the presentation.
Aspect B: Regulatory Survey Readiness Analysis Slide(s)
· Provide an analysis of the regulatory survey process that includes the importance of survey readiness; a mock survey overview; and an assessment of being survey ready, as a means for creating successful survey outcomes.
Aspect C: Stakeholders Evaluation and Leadership Selection Analyses Slide(s)
· Include an evaluation of at least three stakeholders for the regulatory survey process.
· You must include the internal stakeholders of the patients and/or residents.
· The other stakeholders that you present, as part of your evaluation, may be internal or external.
· Include at least two of the applicable items from this list in your evaluation of the stakeholders: (a.) survey awareness; (b.) survey process understanding; (c.) survey engagement; (d.) stakeholder contribution; (e.) stakeholder justification; and/or (f.) importance of the stakeholder.
· Identify at least three specific leadership roles that will be involved in the mock survey process and provide an analysis of the assigned facility-level or service-level leaders involved in the mock survey.
· You must include the Administrator, Executive Director, or a top leader of the LTC facility or service in your analysis.
· The other two leadership roles may be any manager or director-level position at your assigned LTC facility or service for your analysis.
Aspect D: Regulation Assessment Slide(s)
· State the regulation that you assigned from your scenario and provide an assessment of this regulation to your assigned LTC facility or setting.
· You must include the regulatory standard, condition, rule, and/or tag in the assessment.
· Include an evaluation of the mock survey process for the assigned regulation, applying this information to your assigned LTC facility or setting.
· Apply your assigned specific regulation for one mock survey step, as this will act as an introduction for your LTC employees to understand the entire mock survey process.
(Note - Remember you are only introducing the mock survey process to your staff, so this should be an overview of the potential regulatory mock survey steps.)
Aspect E: Conclusion Slide(s)
· Highlight the key takeaways of your presentation and include an explanation to why the information presented in the PowerPoint is essential for the staff to know.
· Include one call to action and share with your team any next steps for the upcoming mock survey.
Aspect F: APA Reference Page Slide(s)
· Provide the list of all references presented in the PowerPoint, formatted in APA 7th Edition.
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BYSTANDER
longtermcareWeek9Assignment4instructions.docx
