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Enhancing the Assisted Living Enforcement Process: A Comprehensive Improvement Framework

This project outlines a streamlined enforcement process for Assisted Living Centers, focusing on optimization of responsibilities, reduction of delays, and improvement of overall efficiency. Through a swimlane approach, it identifies key personnel such as Survey Staff, Enforcement Staff, LTC Leadership, and General Counsel to ensure effective handling of compliance issues. The goal is to minimize mistakes and create an opportunity for correction while maintaining high standards of care and legal compliance. This structured method aims for a seamless interaction between facilities and regulatory bodies.

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Enhancing the Assisted Living Enforcement Process: A Comprehensive Improvement Framework

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  1. Assisted Living Enforcement Process Improvement ProjectSwimlane StepsUnderstanding complexity & consequencesMike Cook, Assistant ChiefLong Term Care ServiceProtective Health Services

  2. Swimlane Process Map Responsibilities Processes Delays Mistakes Inefficiency

  3. Responsibilities • Swimlane Assignments • Survey Staff • Enforcement Staff • LTC Leadership • General Counsel • Assisted Living Center • Admin Law Judge

  4. Optimum Example • No Delays • No Mistakes • Efficient • Swimlane Assignments • Survey Staff • Enforcement Staff • LTC Leadership • General Counsel • Assisted Living Center • Admin Law Judge

  5. Survey Staff • conduct & review survey • complete state forms  Enforcement Staff • Enforcement Staff • review the state forms for Harm, SIC or CNC. • if no conditions then Opportunity to Correct (OTC), prepare state forms & letters  Facility

  6. Assisted Living Center • review state forms • complete the Plan of Correction (POC) •  Enforcement Staff

  7. Enforcement Staff • receives the POC from the Facility  Survey Staff • Survey Staff • reviews the POC • if POC meets all 6 conditions, the POC is accepted • Enforcement is notified of acceptance • Enforcement Staff • notifies Facility of POC acceptance

  8. Survey Staff • schedules the revisit • conduct the revisit & review the survey • complete state forms  Enforcement Staff • Enforcement Staff • review state forms • cycle 1 survey closed, no penalty, send notice to Facility

  9. Delays Mistakes Inefficiency

  10. No Opportunity to Correct • Harm • Serious and Immediate Concern • Continuing Non-compliance Penalties, Legal Counsel, IDRs, Extended Time Delays

  11. Deficiencies – Not Corrected Continuing Non-compliance, Penalties, Legal Counsel, IDRs, Extended Time Delays

  12. Swimlane Assignments • Survey Staff • Enforcement Staff • LTC Leadership • General Counsel • Assisted Living Center • Admin Law Judge

  13. Plan of Correction – Not Accepted Survey Staff  Notify Enforcement Staff  Notify Facility  Facility prepares a new POC  Submits POC to Enforcement Staff  Survey Staff for review

  14. Areas of Delays, Mistakes & Inefficiency • No Opportunity to Correct • Deficiencies – Not Corrected • Plan of Correction – Not Accepted • Areas of Opportunity • Reduction in Enforcement Actions • Reduction in Penalties • Reduction in Legal Counsel • Reduction in Time Delays • Optional Plan of Correction Tool • designed to walk Assisted Living Center • through all the required elements

  15. Thank You ! Mike Cook, Assistant ChiefLong Term Care ServiceProtective Health Servicesmikec@health.ok.gov

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