My secret sauce to Regulatory Compliance
Aysha Kuhlor MSN, RN, BA,PAC-NE
Chief Nurse Executive |VP Clinical Operations|Healthcare Coach|National Speaker|Healthcare Consultant |Strategist| LinkedIn Healthcare Voices|Author
Starting the New Year Right: A Month-by-Month Guide for Nursing Home Leaders and Staff
As a nursing home leader and consultant, my goal is to help facilities like Sunrise Meadows Nursing Home develop proactive strategies to ensure compliance, improve quality care, and foster a positive, resident-centered environment. With a structured, month-by-month focus, I worked closely with Sunrise Meadows to implement key regulatory areas, address deficiencies, and enhance performance. Below is the month-by-month guide I used to assist them in navigating the regulatory landscape and achieving sustained success.
?January: Foundation and Planning
Best Practice Example: In January, I worked with Sunrise Meadows to review their facility’s strategic plan, focusing on ensuring all staff were trained on resident rights and understanding new abuse prevention regulations. We implemented monthly compliance huddles where department heads could track progress and share challenges. This resulted in a 10% improvement in documentation accuracy and staff engagement around resident rights.
?February: Staff Development and Competencies
Best Practice Example: To address staff competencies at Sunrise Meadows, I helped design a comprehensive staff training plan that covered mandatory topics like infection control, dementia care, and medication administration. We incorporated hands-on training sessions and interactive e-learning modules. As a result, staff competency scores increased by 15%, and employee retention improved significantly by the end of the quarter.
?March: Quality Assurance and Performance Improvement (QAPI)
Best Practice Example: In March, I facilitated a QAPI meeting to assess Sunrise Meadows' progress toward their goals. Using data from recent audits, we identified gaps in pain management and care coordination. I helped Sunrise Meadows develop specific action plans for these areas, which included revising care plans and increasing staff training on pain management protocols. This targeted approach resulted in a 12% improvement in pain management documentation compliance.
?April: Emergency Preparedness and Safety
Best Practice Example: I conducted a comprehensive safety audit at Sunrise Meadows in April, ensuring that fall prevention measures were in place and that emergency preparedness plans were up to date. We ran mock drills for staff to test readiness for natural disasters and infectious disease outbreaks. This proactive approach led to the identification and correction of potential hazards, decreasing fall incidents by 20% over the next few months.
?May: Survey Readiness
Best Practice Example: In preparation for the annual survey in May, I led Sunrise Meadows through a series of mock surveys that focused on the core areas of resident dignity, food and nutrition services, and staffing levels. We identified key areas for improvement, such as ensuring more individualized care plans and addressing food service delivery delays. After implementing corrective actions, Sunrise Meadows achieved a smooth survey with only minor citations.
?June: Mid-Year Compliance Check
Best Practice Example: During our mid-year review in June, I worked with the leadership team to audit clinical records, focusing on the accuracy of ADLs and overall documentation. We identified discrepancies in care plan updates and made necessary revisions. By involving the interdisciplinary team in the audit process, we improved documentation accuracy by 18%, ensuring compliance with professional standards and improving overall care delivery.
?July: Infection Prevention and Control
Best Practice Example: To strengthen infection control practices at Sunrise Meadows, I conducted a training refresh focused on emerging best practices in IPC, including new CMS guidelines for infection prevention. I helped develop a tracking system for COVID-19 testing and immunization records. The implementation of these protocols helped reduce infection rates by 25% over a three-month period.
?August: Resident Care and Clinical Practices
领英推荐
Best Practice Example: In August, I assisted Sunrise Meadows in reviewing their pressure injury prevention and treatment protocols. By collaborating with the wound care team, we developed a more streamlined process for assessing and documenting pressure injuries, which led to better outcomes for residents. We also provided additional staff training on pain management and nutrition, which improved overall resident satisfaction scores.
?September: Fall Season Readiness
Best Practice Example: In September, we focused on fall prevention, ensuring that Sunrise Meadows’ protocols were aligned with current best practices. I assisted in revising care plans for high-risk residents, implementing daily rounds to assess fall hazards, and ensuring appropriate medication management to minimize side effects that could contribute to falls. These changes led to a noticeable reduction in falls, and staff became more vigilant in monitoring residents' safety.
?October: End-of-Year Preparation
Best Practice Example: I worked with Sunrise Meadows to plan for the busy holiday season by ensuring that infection control measures were reinforced and staffing levels were adjusted for the increased resident needs. We reviewed the QAPI program’s year-to-date performance and identified areas of improvement. As a result, Sunrise Meadows was well-prepared for the seasonal influx of residents and staff managed workloads effectively.
?November: Gratitude and Reporting
Best Practice Example: In November, I facilitated staff appreciation events and assisted Sunrise Meadows in conducting a thorough review of discharge planning processes. We identified opportunities for improvement in transitioning residents from hospital to home or other facilities, and staff received additional training on preventing accidents related to transfers. Environmental audits were also completed, resulting in several key safety upgrades.
?December: Reflection and Reset
Best Practice Example: In December, I assisted Sunrise Meadows in conducting a comprehensive year-end evaluation of their QAPI program. We used data collected throughout the year to assess improvements and identify areas for continued focus in the upcoming year. This evaluation helped Sunrise Meadows set measurable goals for 2025, including a renewed emphasis on vaccination compliance and ensuring more consistent oversight by the medical director.
For your 2025 Regulatory Compliance Needs, reach out. Let's avoid F- Tags
Aysha Kuhlor MSN, RN, PAC-NE
Chief Clinical Advisor
Phone: 808-688-7459
Email: [email protected]
Website: www.theinspac.com
Courses: https://courses.theinspac.com- explore our courses and certifications
Linktree: https://linktr.ee/theinspac to book an appointment
Contact: [email protected]
?
Market President-Special Projects
1 个月Really appreciate you sharing your knowledge and experience. This helps all of us make a positive impact in our industry!
Infection Preventionzist | School Nurse | Chronic Care Nurse | Medical Chart Review, EHR, HEDIS, Utilization Management | Compliance Rockstar
1 个月Love this
Program Manager - COE for Behavioral Health
1 个月Very nicely articulated and well done! Kuddos to you and the team at Sunrise Meadows!
Healthcare Administrator at Covenant Living | Expert in Health Care Administration
1 个月I attempted to download the f-tag document from your website but it says "file not found". Could this be sent to me through LinkedIn?
Administrator at College Park Rehab
1 个月Thank you