Week 9 Assignment 4: The Regulatory Environment – Survey Readiness
Course Objectives for Assignment:
Apply management theory, concepts, and models to examine ethical best practices in long-term care administration and to foster performance excellence.
Develop and refine students’ ethical problem-solving and analytical skills when facing complex challenges, decision-making, and strategic planning in long-term care administration.
Background: Preparing for a regulatory survey is essential in long-term care and complying with these regulations is critical for the success of an organization. Over the past several weeks, we have learned a tremendous amount of information on different departments and various administrative areas. Now, we will apply your knowledge to create 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 complete mock study, we will have the time for you to work on a few of the processes for a survey readiness plan.
Your Scenario (Option A) Your instructor will assign you one of the scenarios provided below.
Option A: Florida Assisted Living Facilities
ALF Option 1: Colonial Assisted Living located in Tampa, FL
Florida ALF Standard Option 2: A0030 – Resident Care – Rights & Facility
Procedures o Rule: 59A-36.007(5) FAC; 429.28(1-2) FS 429.27 o Regulatory Information: Pages 40 to 45 of the Florida AHCA State Regulations PDF.
Resources for this Scenario:
How to locate the specific regulations for this scenario: You can you the Control F function on your PC or the Command F function on your Mac to search for a particular regulatory standard/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:
Florida Agency for Health Care Administration (AHCA) ALF State Regulations: Florida AHCA State Regulations PDF
Website link to Florida ALF Statutes: Florida ALF Statutes Website
Option B: South Carolina Home Health Agencies and Services
If Option B was Assigned to You, then you will be provided with One of the Following HHAs:
HHA Option 1: Amedisys Home Health of Lexington, located in Lexington, South Carolina
HHA Website: Amedisys HHA in Lexington, South Carolina
Company Website – Main Page: https://www.amedisys.com/
HHA Option 2: Carolinas Home Health in Florence, South Carolina
HHA Website: Carolinas Home Health Part of LHC Group in South Carolina
Company Website – Main Page: https://lhcgroup.com/locations/carolina-home-care/
HHA Option 3: Prisma Health Home Health is located in Greenville, South Carolina
HHA Website: Prisma Health Home Health of Greenville SC
Company Website- Main Page: https://prismahealth.org/
If the HHA Option was Assigned to You, then you will be provided with One of the Following HHA Regulations:
HHA Regulation Option 1: Federal CMS HHA Regulatory Condition: 484.50 Patient Rights
Regulatory Reference and Standard: Be free from abuse. 484.59(c)(2)
Regulatory Tag: G430
Regulatory Information: Page 1 of the CMS 2018 HHA G Tag Information and 11 of the CMS State Operations Manual Appendix B for HHAs.
HHA Regulation Option 2: Federal CMS HHA Regulatory Condition: Quality assessment/performance improvement (484.65)
Regulatory Reference and Standard: 484.65 Participate in the HHA’s QAPI program
Regulatory Tag: G640
Regulatory Information: Page 3 of the CMS 2018 HHA G Tag Information and Page 40 of the CMS State Operations Manual Appendix B for HHAs.
HHA Regulation Option 3: Federal CMS HHA Regulatory Condition: Home health aide services 484.80
Regulatory Reference: 480.80(d) 12 hours in-service every 12 months
Regulatory Tag: G774
Regulatory Information: Page 4 of the CMS 2018 HHA G Tag Information and Page 56-57 of the CMS State Operations Manual Appendix B for HHAs.
HHA Regulation Option 4: Federal CMS HHA Regulatory Condition: Emergency Preparedness 484.102
Regulatory Reference: 484.102(a) Emergency Plan
Regulatory Tag: E-0004
Regulatory Information: Page 3 to 4 of the CMS 2018 HHA G Tag Information and Page 12 to 15 of the E-Tags Emergency Preparedness CMS State Operations Manual Appendix Z for All Certified Federal Level Providers.
HHA Regulation Option 5: Federal CMS HHA Regulatory Condition: Personnel qualifications 484.115
Regulatory Reference: 484.115(a) Administrator
Regulatory Tag: G1052
Regulatory Information: Page 6 of the CMS 2018 HHA G Tag Information and 83 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 the Command F function on your Mac to search for a particular 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 PDF
E-Tags Emergency Preparedness CMS State Operations Manual Appendix Z for All Certified Federal Level Providers PDF
Website link to CMS Provider Compare– Main Page: CMS Provider Compare Search Page
Website link to CMS – Emergency Preparedness Rule Page: CMS Emergency Preparedness Rule Landing Page
Option C: Maryland Skilled Nursing Facilities
If Option C was Assigned to You, then you will be provided with One of the Following SNFs:
SNF Option 1: Autumn Lake Healthcare at Ballenger Creek, located in Fredrick, Maryland
SNF Website: https://autumnlakeballengercreek.com/
Company Website – Main Page: https://autumnlakehealthcare.com/
SNF Option 2: Chesapeake Shores, located in Lexington Park, Maryland
SNF Website: https://www.ltcrevolution.com/find-a-facility/chesapeake-shores/
Company Website – Main Page: https://www.ltcrevolution.com/
SNF Option 3: Waldorf Center located in Waldorf, Maryland
SNF Website: https://www.genesishcc.com/waldorf
Company Website – Main Page: https://www.genesishcc.com/
If the SNF Option was Assigned to You, then you will be provided with One of the Following SNF Regulations:
SNF Regulation Option 1: Federal CMS SNF Regulation: Resident Rights 483.10
Regulatory Reference: Safe/Clean/Comfortable/Homelike Environment 483.10(i)
Regulatory Tag: F584
Regulatory Information: Page 1 of the CMS SNF F Tags June 2021 PDF and Pages 62 to 66 of the CMS State Operations Manual Appendix PP for LTC Facilities.
SNF Regulation Option 2: Federal CMS SNF Regulation: Freedom from Abuse, Neglect, and Exploitation 483.12
Regulatory Reference: Reporting of Alleged Violations 483.12(b)
Regulatory Tag: F608
Regulatory Information: Page 1 of the CMS SNF F Tags June 2021 PDF and Pages 141 to 150 of the CMS State Operations Manual Appendix PP for LTC Facilities.
SNF Regulation Option 3: Federal CMS SNF Regulation: Food and Nutrition Services 483.60
Regulatory Reference: Provided Diet Meets Needs of Each Resident 483.60
Regulatory Tag: F800
Regulatory Information: Page 2 of the CMS SNF F Tags June 2021 PDF and Pages 564 to 565 of the CMS State Operations Manual Appendix PP for LTC Facilities.
SNF Regulation Option 4: Federal CMS SNF Regulation: Infection Control 483.80
Regulatory Reference: Influenza and Pneumococcal Immunizations 483.80(d)
Regulatory Tag: F883
Regulatory Information: Page 2 of the CMS SNF F Tags June 2021 PDF and Pages 708 to 749 of the CMS State Operations Manual Appendix PP for LTC Facilities.
SNF Regulation Option 5: Federal CMS SNF Regulation: Emergency Plan for LTC Facility 483.73(a)
Regulatory Reference: 483.73(a) Emergency Plan. Develop and maintain an emergency preparedness plan that must be reviewed and updated annually.
Regulatory Tag: E-0004
Regulatory Information: Page 12 to 15 of the E-Tags Emergency Preparedness CMS State Operations Manual Appendix Z for All Certified Federal Level Providers.
Resources for this Scenario:
How to locate the specific regulations for this scenario: You can you the Control F function on your PC or the Command F function on your Mac to search for a particular 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 PDF
CMS State Operations Manual Appendix PP for LTC Facilities PDF
E-Tags Emergency Preparedness CMS State Operations Manual Appendix Z for All Certified Federal Level Providers PDF
Website link to CMS Provider Compare– Main Page: CMS Provider Compare Search Page
Website link to CMS – Emergency Preparedness Rule Page: CMS Emergency Preparedness Rule Landing Page
