Quality & Regulatory Specialist - Long Term Care
- Supports planning and execution of the association’s education initiatives
- Member resource for quality and regulatory strategies
- Staff liaison to Professional Development Committee
Director of Professional Development & HH/Hospice Regulatory Relations
- Reviews state and federal policies and regulations and determines impact on the delivery of Ohio health care services
- Staff liaison to Clinical Executive Action Council and Assisted Living special interest group
- Works with state and federal agencies and regulatory bodies
In early June 2017, CMS released the S&C 17-30-Hospitals/CAHs/NHs REVISED 06.09.2017 Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease.
The surveyor software has already been updated to ask for this upon entrance for the annual survey. This toolkit contains valuable resources to help members meet survey requirements.
- Legionnaires draft policy. The first 4 pages follow the CDC guideline for a water management program. The last 4 pages also follow the CDC guidelines but should be used as a guide by organizations to develop a robust water management program.
- Legionella Risk Assessment (pdf)
- CDC Guidelines to Reduce Legionella (pdf)
Home Health Conditions of Participation: Regulatory Checklists
LeadingAge developed for members a set of checklists that delineate the requirements of the new home health Conditions of Participation (HHCoPs) published in the final rule and the actions needed to be in compliance. Members can access the checklists HERE.
Immediate Jeopardy (IJ) Citations: What You Need to Know
Side Rail Toolkit
In the 1st quarter of 2017, use of side rails without an assessment, monitoring or orders was cited as an Immediate Jeopardy. The purpose of this toolkit is to provide facilities with guidance about the use and monitoring of side rails.
Side Rail Checklist
- Discuss the list of alternative measures that will be used prior to installing a side/bed rail.
- Update the side/bed rail protocol to include how the facility ensures correct installation, use, and maintenance.
- Discuss the protocol for documenting resident assessment, review of risks, and bed and resident dimensions.
Members can access additional resources including the Accidents QIS tool, Side Rail Usage Assesment, Bed Inspection Policy, Bed Rail Use and Bed Inspection Training PowerPoint and more HERE.
Pressure Ulcer Toolkit
Immediate Jeopardy related to pressure ulcers continues to be a trend in the 1st quarter of 2017. LeadingAge Ohio has developed a toolkit to provide facilities with guidance about pressure ulcer care and prevention.
The toolkit includes a Pressure Ulcer checklist, language from the federal register, referenced websites, link to the CMS critical element pathway, staff interview questions and an audit tool for members to use in their improvement efforts.
To access the toolkit, click here.
Infection Control Toolkit
There are many resources available to providers on implementing effective infection control protocols. These resources are available from The Centers for Medicare and Medicaid Services (CMS) and The Centers for Disease Control and Prevention (CDC).
Since the implementation of Phase 1 of the new Requirements of Participation, infection control (F 441) has ranked as the most cited F tag in Ohio. To access the toolkit for more information, click here.