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