Instructions
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 facing 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 of an organization. Over the past several weeks, we have learned a tremendous amount of information on different departments and various administrative areas. Now, we will apply your knowledge to create 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 complete mock study, we will have the time for you to work on a few of the processes for a survey readiness plan.
Your Scenario (Option A) Your instructor will assign you one of the scenarios provided below.
Option A: Florida Assisted Living Facilities
ALF Option 1: Colonial Assisted Living located in Tampa, FL
Florida ALF Standard Option 2: A0030 – Resident Care – Rights & Facility
Procedures o Rule: 59A-36.007(5) FAC; 429.28(1-2) FS 429.27 o Regulatory Information: Pages 40 to 45 of the Florida AHCA State Regulations PDF.
Resources for this Scenario:
How to locate the specific regulations for this scenario: You can you the Control F function on your PC or the Command F function on your Mac to search for a particular 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
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:
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/
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/
HHA Option 3: Prisma Health Home Health is 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:
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 11 of the CMS State Operations Manual Appendix B for HHAs.
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.
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.
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.
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 83 of the CMS State Operations Manual Appendix B for HHAs.
Resources for this Scenario:
How to locate the specific regulations for this scenario: You can you the Control F function on your PC or the Command F function on your Mac to search for a particular 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 State Operations Manual Appendix B for HHAs PDF
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
Option C: Maryland Skilled Nursing Facilities
If Option C was Assigned to You, then you will be provided with One of the Following SNFs:
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/
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/
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:
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.
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.
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.
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.
SNF Regulation Option 5: Federal CMS SNF Regulation: Emergency Plan for LTC Facility 483.73(a)
Regulatory Reference: 483.73(a) Emergency Plan. Develop and maintain an emergency preparedness plan that must be reviewed and updated 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:
How to locate the specific regulations for this scenario: You can you the Control F function on your PC or the Command F function on your Mac to search for a particular 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
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
Creating the PowerPoint Presentation:
Survey Readiness PowerPoint:
It must be 10-12 slides, excluding the introduction slide(s) and reference page slide(s).
Presenter Notes:
Every slide must have presenter notes except for the reference page(s).
Your presenter notes will be the information you will share with your team.
Your notes should be detailed and contain APA in-text citations.
References:
Minimum of five scholarly references, professional publications, and academic journals from the last five years.
Include 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).
APA 7th Edition Style:
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 presentation’s title, your instructor’s name, course name, your assigned LTC facility or setting, your assigned regulation, and the 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 to create 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 residents.
The other stakeholders you present as part of your evaluation may be internal or external.
Include at least two of the valuable 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 (f.) importance of the stakeholder.
Identify at least three specific leadership roles involved in the mock survey process and provide an analysis of the assigned facility-level or service-level leaders involved in the 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 you assigned from your scenario and provide an assessment of this regulation to your designated LTC facility or setting.
You must include the regulatory standard, condition, rule, and tag in the assessment.
Include an evaluation of the mock survey process for the assigned regulation, applying this information to your designated 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 fake 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 bogus survey steps.)
Aspect E: Conclusion Slide(s)
Highlight your presentation’s key takeaways and explain why the information presented in the PowerPoint is essential for the staff to know.
Include one call to action and share any next steps for the upcoming mock survey with your team.
Aspect F: APA Reference Page Slide(s)
Provide the list of all references presented in the PowerPoint, formatted in APA 7th Edition.
Resources for Creating PowerPoints:
https://writingcenter.uagc.edu/how-make-powerpoint-presentation
https://alum.mit.edu/best-practices-powerpoint-presentations
