Following an incident of non-compliance, HealthCap Risk Management will:

• Collaborate with the center including the QAPI committee and governing body to conduct a Root Cause Analysis to identify and address the reasons for non-compliance identified in the CMS 2567

• Take immediate action to implement an infection prevention plan consistent with the requirements at 42 CFR § 483.80 for the affected residents impacted by the non-compliance identified in the CMS 2567 to include identification of other residents that may have been impacted by the non-compliant practices. This plan will include the implementation of procedures to ensure:

  • Staff have the tools and abilities to ensure residents practice appropriate social distancing

  • Staff are provided with and use Personal Protective Equipment (PPE) in accordance with the Centers for Disease Control (CDC) guidelines

  • Shared medical equipment is properly disinfected after each use and

  • Residents impacted by the failure to maintain social distancing use PPE appropriately and clean shared medical equipment are identified for enhanced monitoring and/or precautions to minimize further spread of infection.

• Review all relevant facility infection control policies and procedures and make recommendations for revisions based on the RCA

• Work with the facility to ensure all staff that provide direct resident care as well as staff that enter into resident rooms to provide for dietary needs or to perform therapy, activities, cleaning, laundry, or maintenance services are fully trained on infection prevention and control including:

  • Standard Infection Control Practices

  • Transmission Based Precautions

  • Isolation

  • Hand Hygiene

  • Disinfecting Shared Medical Equipment

  • Appropriate use of PPE

  • Proper Storage of Clean Linens

• Based on the training provided, design a scheduled, objective format for the facility to implement for follow-up employee supervision and work performance appraisal. Facility supervisors will be scheduled to observe and appraise employee implementation of the knowledge, skills, and procedures.

The one-time on-site Risk Management Assessment contract includes the following:

• Review of both operational and clinical processes

• Review of the environment for liability risk exposures

• Identification of operational and clinical opportunities

• Making recommendations for improvement of operational and clinical processes

• Developing a strategy to implement the recommendations

Ongoing Risk Management Oversight

• QA Reader® tracks incidents that occur at your facility, automatically identifies potentially serious events, and immediately routes them to our team of long-term care risk management experts.

• Our risk managers review the incidents and assist your staff in reducing ongoing risk.

• Scope of Services for QA Reader

  • Full access to the QAR web-based platform

  • Web-based Quality Assurance and Improvement training sessions – 24/7 access

  • Bi-annual review of incident trends with formal recommendations

The HealthCap Pre-Survey is an intensive, onsite program intended to focus your team on doing the right things for the right reasons on a daily basis. Two HealthCap partners focus on a same team approach and review clinical and operational systems while providing a step-by-step plan of action to address areas of non-compliance.

2 full days visit to review clinical and operational areas including:

• Assessing current systems and practices,

• Evaluation and development of quality of care and quality of life programs,

• Assessing the overall quality of:

  • clinical services

  • documentation

  • quality assurance processes

• Environmental assessment

• Review of current policies and procedures related to direct care

• Medical record reviews and monitoring direct care to determine compliance with established protocols

• Social service, activities and admissions review

• Assessment of nutritional programs, dietary management, meal service, weight loss/gain and special needs diets

• Assist in achieving and maintaining regulatory compliance.

• Facility visit report and corrective action plan

In the event areas of deficient practice and/or non-compliance are identified, corrective recommendations and training will be provided while on-site. Development of a plan for past-non-compliance may be initiated pursuant to separate proposal

The HealthCap risk management assessment is an intensive, onsite, collaborative program to assist in focusing your team on doing the right things for the right reasons on a daily basis. Your HealthCap partners will provide an interdisciplinary team approach with a comprehensive review of clinical and operational systems while providing a step-by-step plan of action to address areas of non-compliance.

1 full-day visit to review clinical and operational areas including:

• Assessing current systems and practices,

• Evaluation and development of quality of care and quality of life programs,

• Assessing the overall quality of:

  • clinical services

  • documentation

  • quality assurance processes

• Environmental assessment

• Review of current policies and procedures related to direct care

• Medical record reviews and monitoring direct care to determine compliance with established protocols

• Social service, activities, and admissions review

• Assessment of nutritional programs, dietary management, meal service, weight loss/gain, and special needs diets

• Assist in achieving and maintaining regulatory compliance.

• Facility visit report and corrective action plan

In the event areas of deficient practice and/or non-compliance are identified, corrective recommendations and training will be provided while on-site.