Information
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Occupancy, Marketing, & Admissions
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What is the current census?
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Is occupancy within budget?
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Do staff behaviors reflect strong customer service standards?
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Weekend manager program in place?
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Marketing Plan Current & Implemented?
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How many hospital visits in the last 30 days?
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How many admissions in the next 7 days?
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How many discharges in the next 7 days?
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Does Admission Paperwork meet Standards (Focused Audit)?
Labor Management
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Labor Hours within budget?
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What is the budgeted labor hours for the facility?
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What are current labor hours?
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Is the stand-up tool in place and used?
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Is staffing plan posted and current?
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How much agency labor was used in the last 30 days? ($USD)
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How much agency was pro-staffing? ($USD)
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How many 1.5T Overtime Hours given in the last 30 days?
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How many 2T Overtime Hours given in the last 30 days?
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How many shifts were under the staffing ratio in the last 30 days?
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How many licensed nurse positions are open?
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How many CNA positions are open?
Human Resources
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Monthly Turnover report- is there evidence of positive trends?
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Is Orientation program in place and current?
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Employee recognition program in place?
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Education calendar in place (LMC)?
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Employee Incentive and referral program in place and promoted?
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Department evaluation schedule in place and current?
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Are Employee exit interviews being held and documented?
Safety Programs
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Can the administrator log into TELS and review the safety committee monthly minutes?
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Is the Safety Stars Program in place and promoted?
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Is there evidence of claims report follow up?
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How many claims YTD?
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How many Active claims?
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Are fire drills and inspections in TELS current?
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Has the administrator updated the disaster manual annually (phone list, evacuation letters updated, includes maps & directions)?
Business Office
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Accounting timeline routinely met (A/R, A/P/ P/R)?
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Evidence of Administrator involvement in A/R collections?
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Evidence of effective time clock management?
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Facility calendar in place with required meetings (Is it shared with operations)?
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Patient Trust Records current and reconciled?
Medicare
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Case management meetings held weekly with documented action plans?
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All members of Inter-disciplinary team present and engaged?
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Triple check system in place?
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Administrator has reviewed pharmacy bills, and actively screens for high cost medication?
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Therapy productivity is meeting facility benchmarks?
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ALOS-Trending?
Dietary
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Is the facility meeting the QI average for customer satisfaction for meals?
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How is customer satisfaction surveys for food trending ?
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Have the RD reports been reviewed and recommendations followed up on?
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Kitchen and dining areas meets accepted standards for sanitation and cleanness?
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Dish machine temperature log has been reviewed and is in compliance?
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Refrigerator temperature logs for all fridges (medication, snack, resident accessible) are being monitored and cleaned?
Physical Plant
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Administrator is conducting monthly walk-through of buildings and grounds and has a updated Maintenance work plan that shows progress?
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Maintenance Logs are accessible and are work is current?
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Preventive Maintenance Program (TELS) is being reviewed by Administrator and tasks are not over due?
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Patient equipment (beds, lifts, DME ect.) is being reviewed routinely by maintenance and is in good condition?
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Water Temps logs are updated and temperatures are in compliance?
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Laundry dryers are being maintained(lint cleaned every shift, fire box weekly, exhaust snaked once per quarter)?
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Laundry washers have water temps recorded at a minimum of 160 degrees F, or 75 F if bleach of 125 ppm is used?
Nursing
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Nursing consultant reports are reviewed and an action plan available?
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QAPI report current and action plan in place?
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Quality measures reviewed & action plan in place? (>5 star state average)
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Clinical documentation meets accepted standards (Focus audit)?
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Were there any substantiated complaint surveys since annual survey?
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Were there any falls with injury in the last 30 days?
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How many residents?
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Are care plans in place and being followed?
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How many In-house acquired decubitus ulcers in the last 30 days?
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What is the current status of those patients?
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Do you have appropriate clinical equipment in place to manage those injuries?
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Central supply system meets accepted standards?
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Are the ADL's reviewed and action plan in place?
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Does the current ADL scores meet the facilities benchmarks?
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What are the current ADL % scores?
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What is the ADL trend from the last 30 days?
Therapy
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Review of RUG's & Evidence of Accurate documentation?
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Productivity above 75%, less RPM?
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Overage is less than 10%?
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Rehab position openings?
Departmental Reviews & Comments
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Do any additional departmental review need to be completed?
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Activities?
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Action Plan:
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Admissions?
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Action Plan:
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Business Office
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Action Plan:
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Dietary?
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Action Plan:
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Housekeeping?
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Action Plan:
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Laundry?
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Action Plan:
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Medical Records?
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Action Plan:
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Nursing ?
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Action Plan:
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Physical Plant?
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Action Plan:
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Nursing Practitioner/ Medical Director
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Action Plan:
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Social Services?
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Action Plan: