Andrew Community

Andrew Connection:

A newsletter for Family and Friends of Andrew Residents!

Compliance and Ethics Reporting

Concerns reported here are reviewed by the Andrew Residence Compliance Officer. Concerns may be provided anonymously. Please share as much information as possible regarding your compliance or ethics concerns.

Feedback for Quality Assurance and Performance Improvement

Opportunities for Improvement and Quality Concerns
As part of our Quality Assurance Performance Improvement program we invite feedback from resident family members and representatives and others to share their quality concerns and suggestions for improvement. Information received is reviewed by the Quality Assurance Performance Improvement Committee.

Facility Assessment Input

 

Dear Resident, Family, Responsible Party,

The Federal agency, the Centers for Medicare & Medicaid Services (CMS), oversees Medicare and Medicaid certified nursing homes, which includes our facility. The Centers for Medicare and Medicaid Services (CMS) released the final rule providing guidance on requirements for CMS certified nursing homes. One key component of the final rule (first to be implemented) includes the facility assessment requirements.

What is a Facility Assessment:

The facility assessment is facility wide document which determines what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents require.

What are the components of a facility assessment:

Examples of the facility’s resident population, includes, but not limited to:

    • Number of residents
    • Care required by the resident population considering the types of diseases and conditions.
    • Staff training necessary to provide the level and types of care needed.
    • Physical environment, equipment, services, and other physical plant considerations
    • Ethnic, cultural, or religious factors that may potentially affect the care provided.

The facility assessment also addresses the facility’s resources, including but not limited to:

    • Buildings and/or other physical structures and vehicles.
    • Equipment (medical and non-medical)
    • Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies
    • All personnel
    • Health information technology resources

Who is involved with the development of the facility assessment:

Facility leadership and management must be actively involved in the Facility assessment process, including direct care staff, business agents, community organizations, etc. which was previously not required.

The facility must also solicit and consider input received from residents, resident representatives, family members, and representatives of direct care staff, which was previously optional.

How is the facility assessment utilized:

These assessments determine the resources and staff competencies each nursing facility should have for compliance with CMS requirements for meeting the current needs of residents.  We solicit and consider feedback from direct care staff, residents, families, leadership, etc. to cover the various components of this tool for managing those under our care and services.

We believe in transparent communication and would value your input updating our facility assessment.  Additionally, your input will be considered for recruitment and retention of direct care staff. We will address this topic and obtain feedback at Andrew Staff meetings, Resident Council meetings, and Advisory Committee meetings. You may reach out to the Director of Clinical Services with any questions and feedback.

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