Background:Preparing for a regulatory survey is essential in long term care and complying with these regulations is critical for the success an organization. Over the past several weeks, we have learned a tremendous amount of information on different departments as well as various administrative areas. Now, we will apply your knowledge to creating a proactive plan that assists your team in being prepared should regulatory bodies arrive to conduct a survey or inspection. While we do not have the time to implement and discuss a full mock survey, we will have the time for you to work on a few of the processes for a survey readiness plan.
Your Scenario (Option A, B, or C): Your instructor will assign you one of the scenarios provided below. This communication for your assigned scenario will be provided from your instructor no later than Week 2 of the course.Option B: South Carolina Home Health Agencies and ServiceI be HHA Option 3: Primsa Health Home Health located in Greenville South Carolina HHA Regulation Option 2: Federal CMS HHA Regulatory Condition: Quality assessment/performance improvement (484.65) o Regulatory Reference and Standard: 484.65 Participate in the HHA’sQAPI program o Regulatory Tag: G640 o Regulatory Information: Page 3 of the CMS 2018 HHA G TagInformation and Page 40 of the CMS State Operations Manual Appendix B for HHAs.Resources for this Scenario:How to locate the specific regulations for this scenario: You can you the Control F function on your PC or Command F function on your Mac to search for a specific regulatory reference/tag/rule. Type in the information that you want to search for in the specific document that you are reviewing, using this search function, to locate your information:CMS State Operations Manual Appendix B for HHAs PDFE-Tags Emergency Preparedness CMS State Operations Manual Appendix Z for All Certified Federal Level Providers PDFWebsite link to CMS Provider Compare– Main Page: CMS Provider Compare Search PageWebsite link to CMS – Emergency Preparedness Rule Page: CMS Emergency Preparedness Rule Landing PageResources for this Scenario:How to locate the specific regulations for this scenario: You can you the Control F function on your PC or Command F function on your Mac to search for a specific regulatory reference/tag/rule. Type in the information that you want to search for in the specific document that you are reviewing, using this search function, to locate your information:CMS SNF F Tags June 2021 PDFCMS State Operations Manual Appendix PP for LTC Facilities PDFE-Tags Emergency Preparedness CMS State Operations Manual Appendix Z for All Certified Federal Level Providers PDFWebsite link to CMS Provider Compare– Main Page: CMS Provider Compare Search PageWebsite link to CMS – Emergency Preparedness Rule Page: CMS Emergency Preparedness Rule Landing Page
Creating the PowerPoint Presentation:
- Survey Readiness PowerPoint:Must be 10-12 slides, excluding the introduction slide(s) and reference page slide(s).
- Presenter Notes:Every slide must have presenter notes except for the reference page(s).Your presenter notes will be the information that you will be sharing with your team.Your notes should be detailed and contain APA in-text citations.
- References:Minimum of five scholarly references, professional publications, and/or academic journals from the last five years.Include any references from your assigned LTC facility or setting such as the website, company information, facility website, service-level website, etc.Every reference must have a correlating in-text citation(s).
- APA 7th Edition Style:PowerPoint slides, cover page, and reference page.
The PowerPoint Must Contain the Following Content Aspects for Your Assigned Scenario:
Aspect A: Introduction Slide(s)
- APA Cover Page – Include the title of the presentation, your name, your instructor’s name, course name, your assigned LTC facility or setting, your assigned regulation, and date submitted.
- Provide bulleted points to identify each Content Aspect that will be presented in the presentation.
Aspect B: Regulatory Survey Readiness Analysis Slide(s)
- Provide an analysis of the regulatory survey process that includes the importance of survey readiness; a mock survey overview; and an assessment of being survey ready, as a means for creating successful survey outcomes.
Aspect C: Stakeholders Evaluation and Leadership Selection Analyses Slide(s)
- Include an evaluation of at least three stakeholders for the regulatory survey process.You must include the internal stakeholders of the patients and/or residents.The other stakeholders that you present, as part of your evaluation, may be internal or external.Include at least two of the applicable items from this list in your evaluation of the stakeholders: (a.) survey awareness; (b.) survey process understanding; (c.) survey engagement; (d.) stakeholder contribution; (e.) stakeholder justification; and/or (f.) importance of the stakeholder.
- Identify at least three specific leadership roles that will be involved in the mock survey process and provide an analysis of the assigned facility-level or service-level leaders involved in the mock survey.You must include the Administrator, Executive Director, or a top leader of the LTC facility or service in your analysis.The other two leadership roles may be any manager or director-level position at your assigned LTC facility or service for your analysis.
Aspect D: Regulation Assessment Slide(s)
- State the regulation that you assigned from your scenario and provide an assessment of this regulation to your assigned LTC facility or setting.You must include the regulatory standard, condition, rule, and/or tag in the assessment.Include an evaluation of the mock survey process for the assigned regulation, applying this information to your assigned LTC facility or setting.Apply your assigned specific regulation for one mock survey step, as this will act as an introduction for your LTC employees to understand the entire mock survey process. (Note - Remember you are only introducing the mock survey process to your staff, so this should be an overview of the potential regulatory mock survey steps.)
Aspect E: Conclusion Slide(s)
- Highlight the key takeaways of your presentation and include an explanation to why the information presented in the PowerPoint is essential for the staff to know.
- Include one call to action and share with your team any next steps for the upcoming mock survey.
Aspect F: APA Reference Page Slide(s)
- Provide the list of all references presented in the PowerPoint, formatted in APA 7th Edition.
Resources for Creating PowerPoints:
Resources for Mock Surveys:
Mock Survey Process Example PDF
Home Health Mock Survey Example Guide PDF