Survey Readiness and Writing Plans of Correction MTRA

Survey Readiness and Writing Plans of Correction MTRA 2019 Annual Conference Friday November 8, 2019 Speaker Pamela Hayle, BA, ACC, SFPT Assistant Administrator – Augustana Health Care Center MPLS Corporate TR Consultant Cassia Care

Survey Readiness and Writing Plans of Correction MTRA 2019 Annual Conference Compliance Update MDH Surveyor Training State Approved Course for Activity Professionals Phase 3 Final Implementation

Survey Readiness and Writing Plans of Correction MTRA 2019 Annual Conference Session Objectives: 1. Understand how to prepare for and manage the survey experience in your facilities 2. Understand the different tags that can be associated with Therapeutic Activities and current status of F 679 and F 680 tags 3. Describe how to write an effective plan of correction 4. . Participate in creating a specific plan of correction 5. . Understand how to implement and monitor your plan of corrections.

Survey Readiness and Writing Plans of Correction MTRA 2019 Annual Conference q Survey Ready All the Time – It’s a 24/7 process! q Internal Audits q External Monitoring q Systematic Process Review and Change – QAPI Integration / Are you ROP Phase 3 Ready

Survey Readiness and Writing Plans of Correction MTRA 2019 Annual Conference Facility Specific Readiness q It is about MORE than bingo q Be a Clinician q Key vulnerabilities and Therapeutic Activities

Survey Readiness and Writing Plans of Correction MTRA 2019 Annual Conference The Surveyors are HERE! q Know your Plan q Own your Building q Evidenced Based Discussion

Survey Readiness and Writing Plans of Correction MTRA 2019 Annual Conference Writing a Successful Plan of Correction q Always on the defensive q Meaningful Can-Do Actions q Methods and Documentation of Monitoring and Evaluation

Survey Readiness and Writing Plans of Correction MTRA 2019 Annual Conference Following the CMS Format q q q Immediate Corrective Action Identification of Other Residents Measures Put in Place Monitoring Mechanisms Responsible Person Implementation/Action Dates / Substantial Compliance Date

Survey Readiness and Writing Plans of Correction MTRA 2019 Annual Conference Practice Exercise

Survey Readiness and Writing Plans of Correction MTRA 2019 Annual Conference Lessons Learned… 1. Are you survey ready 24/7? 2. Can you increase your knowledge base and external monitoring- understand the LTC system 3. Can you demonstrate a competency based / individualized program of activities? 4. Do your understand the Rules for Writing Plans of Correction? 5. Is the corrective action sustainable/practical for the identified resident/s? 6. If the Measures Put in Place included education is it competency based and provided to all employees involved in the practice? 7. Do your Monitoring Mechanisms reflect the QAPI process?

Survey Readiness and Writing Plans of Correction MTRA 2019 Annual Conference In Summary… Survey Readiness Plans of Correction Questions & Comments

Survey Readiness and Writing Plans of Correction MTRA 2019 Annual Conference Contact Information: Pam. Hayle@cassialife. org