Week 9 Assignment 4: The Regulatory Environment – Survey Readiness
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.
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.
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.
Aspect A: Introduction Slide(s)
APA Cover Page – Include the presentation’s title, your instructor’s name, course name, your assigned LTC facility or setting, your assigned regulation, and the 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 to create 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 residents.
The other stakeholders you present as part of your evaluation may be internal or external.
Include at least two of the valuable 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 (f.) importance of the stakeholder.
Identify at least three specific leadership roles involved in the mock survey process and provide an analysis of the assigned facility-level or service-level leaders involved in the 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 you assigned from your scenario and provide an assessment of this regulation to your designated LTC facility or setting.
You must include the regulatory standard, condition, rule, and tag in the assessment.
Include an evaluation of the mock survey process for the assigned regulation, applying this information to your designated 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 fake survey process.
Aspect E: Conclusion Slide(s)
Highlight your presentation’s key takeaways and explain why the information presented in the PowerPoint is essential for the staff to know.
Include one call to action and share any next steps for the upcoming mock survey with your team.
Aspect F: APA Reference Page Slide(s)
Provide the list of all references presented in the PowerPoint, formatted in APA 7th Edition.
