Assisted Living Enforcement Process Improvement Project

Swimlane StepsUnderstanding complexity & consequences

 Mike Cook, Assistant ChiefLong Term Care Service

Protective Health Services

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Swimlane Process Map

ResponsibilitiesProcesses

DelaysMistakesInefficiency

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Swimlane Assignments• Survey Staff• Enforcement Staff• LTC Leadership• General Counsel• Assisted Living Center• Admin Law Judge

Responsibilities

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Swimlane Assignments• Survey Staff• Enforcement Staff• LTC Leadership• General Counsel• Assisted Living Center• Admin Law Judge

Optimum Example• No Delays• No Mistakes• Efficient

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Survey Staff• conduct & review survey• complete state forms Enforcement Staff

Enforcement Staff• review the state forms for Harm, SIC or CNC.• if no conditions then Opportunity to Correct (OTC),

prepare state forms & letters Facility

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Assisted Living Center• review state forms• complete the Plan of Correction (POC) Enforcement Staff

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Enforcement Staff• receives the POC from the Facility Survey Staff

Survey Staff• reviews the POC• if POC meets all 6 conditions, the POC is accepted• Enforcement is notified of acceptance

Enforcement Staff• notifies Facility of POC acceptance

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Survey Staff• schedules the revisit• conduct the revisit & review the survey• complete state forms Enforcement Staff

Enforcement Staff• review state forms• cycle 1 survey closed, no penalty, send notice to Facility

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DelaysMistakesInefficiency

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No Opportunity to Correct• Harm• Serious and Immediate Concern• Continuing Non-compliance

Penalties, Legal Counsel, IDRs, Extended Time Delays

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Deficiencies – Not Corrected

Continuing Non-compliance, Penalties, Legal Counsel, IDRs, Extended Time Delays

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Swimlane Assignments• Survey Staff• Enforcement Staff• LTC Leadership• General Counsel• Assisted Living Center• Admin Law Judge

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Plan of Correction – Not Accepted

Survey Staff Notify Enforcement Staff Notify Facility Facility prepares a new POC Submits POC to Enforcement Staff Survey Staff for review

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Areas of Delays, Mistakes & Inefficiency• No Opportunity to Correct• Deficiencies – Not Corrected• Plan of Correction – Not Accepted

Areas of Opportunity• Reduction in Enforcement Actions• Reduction in Penalties• Reduction in Legal Counsel• Reduction in Time Delays

Optional Plan of Correction Tool• designed to walk Assisted Living Center through all the required elements

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ThankYou !

Mike Cook, Assistant ChiefLong Term Care Service

Protective Health Servicesmikec@health.ok.gov