The LTC On-site assessment initiative includes a review of the following areas:

Organizational Leadership Objectives:

• Focus interviews with key stakeholders and medical director

• Review of strategic plans, policies and procedures

• Regulatory compliance, state survey readiness, and survey outcomes

• Medical staff credentialing, peer review, and performance evaluation

• Leadership and medical director resident safety education session

Regulatory/Administrative Compliance:

• Abuse/neglect/exploitation response management

• Quality data collection, management, and analysis

• Resident rights/confidentiality

• Professional credentialing/licensing procedure

• Physician orders/assessment standards

• Restraint policy and monitoring

• End-of-life care/ethics

• Advanced directives/no-code status

• Admission assessment and selection criteria

Incident/Event Response Management:

• Resident occurrence/injury management process

• Managerial training in incident response

  • Investigation, reporting (internal/external)

  • Documentation, communication, and follow-up

• Professional liability claims review

Clinical Quality Outcomes and Staff Performance

• Respiratory, physical therapy, and special services

• Clinical documentation and medical records handling (EMR)

• Staff competency, performance evaluations

• Staff recruitment and retention/staffing ratios

• Resident/family satisfaction

• Performance improvement/quality and resident safety program integration

• Education and training- orientation and annual

• Staffing ratios/contract labor

Proactive Prevention Initiatives:

• Resident fall prevention and response management

• Reducing pressure ulcers- wound/skin program

• Medication error prevention

• Elopement procedure and prevention strategies

• Security measures/emergency response

• Theft prevention/property handling

• Structured communication hand off process