Time to get Busy!!

I have spent the last year really perfecting some auditing tools and processes I created to assist me in running a tight ship with compliance and care mirroring each other in stability and correction. I want to be able to share these tools with other young leaders out there who could be finding it difficult to wrap their arms around the true demands of being an Executive Director.

My situation is vastly different than the typical ED in that I am everyone's everything in my building. There is no DON, there is no Activities Director, there is no Social Worker, and there is not a management team. The ED (me) is responsible for EVERY aspect of running the facility both clinical and non-clinical including human resources functions (I do not do payroll thank goodness). The one plus that I do have is I have really amazing nurses that I use to pass medications and supervise the floor rather than med-techs so I have a nurse on sight 24/7. Together we form a pretty amazing team that has harnessed the ability to bring patient care to another level while also remaining deficiency free. The tools I developed have really helped me organize my mind and my day around being so much for so many. We also are not automated so we are still using paper EVERYTHING which is why auditing is so critical as there is no system such as Point Click Care that is holding the nurses accountable without it.

So lets get started....

1. 1st and most important job of my day is clinical and since I am not a licensed nurse, I rely on my education and training and background to really hone in on my ability to speak their language and understand the various aspects of my residents clinical needs.

I start the first week of every month and the last week of every month the exact same:

-I have a tool that divides out patient name, medication, dosage, exp date, and orders. Its hard work but I devote two full days the first and last week of each month to going through my carts with my nurses and auditing the PRN's first, than the Narcotics, than we go through each residents orders and medications. When I first started and was training my team on how to audit to my specifications it took a full week because I wanted to show them what I was looking for.

-When we audit together the nurses are forced to really hone in on their attention to detail to ensure that every order that is written matches the MAR and subsequently matches what is in the cart. It may seem silly but this is one of the biggest ways to avoid some of the most common citations from licensing. Our clinical team writes several orders a day or a week and things can missed, medications may not have removed if discharged, or the pharmacy may not have sent the medication yet. This also helps get the nurses into a routine of learning what I will be looking for, thus what the state is looking for, and as a result they learn to be more proactive in ensuring their carts are up to the standard of expectation.

-Every other month I will take part in crossing over the POS and MAR for the next month. This allows me to ensure things are being properly carried over as well as ensuring that labs are scheduled timely that may be due that month. This also allows me to view any new treatments in the TAR that I may not have been aware of. It is surprising how long treatment orders will be carried out when they should have been discharged without someone questioning it. My results are shared with my nursing team and as a result they have grown to be more diligent in cross over as well as really paying closer attention to the TAR to ensure that it remains accurate and is still beneficial to the patient.

-Our onsite physician comes once a week and will visit our residents and sign any necessary orders. I am the one that files them once he is done so I can see any new orders and be aware of any changes (remember I do not have a DON so a large part of all of this is something that a DON would be responsible for)

-Once a month I go through and check the weights and vitals. I conducted a thorough training of my caregivers and my nurses to understand what significant weight loss is and to notify the nursing team if it is happening. The nursing team was than trained on various ways we can combat significant weight loss and how they can take control of the situation and ultimately decide what is best for the patient with the assistance and guidance of the MD.

-Once a month I round with my nurses to view them do a proper skin check assessment. I am HUGE proponent of preventing skin from breaking down and have held several in service trainings with my staff on diets, creams, rotating sand other methods that assist us in protecting our residents skin as well as checking the entire resident not just their sacrum. I am proud to say that we have not had a single pressure sore ever develop since my start here.

While I know that it is impossible for an ED of a building with 125+ beds to do what I do, I strongly suggest that Executive Directors ensure they take part in at least one or all of the above quarterly so they can keep a hand on the tempo of their nursing staff. I have had a building of 100+ residents and I trained my DON and my Assistant DON on these very methods of auditing to ensure they were not just relying on their automated system to let them know when something wasn't right or wasn't signed. I would than follow behind them once a quarter to ensure that nothing was missed. It may seem like a lot but, your license and your residents lives depend on you being as thorough as possible and training your team to be just as thorough as you.

2. 2nd is the tool I use to audit everything else. I created a form that I can go by to ensure that nothing else is missed this is done every month, the first week of the new month to audit the month prior:

• It goes line by line to check my state inspection binder (Ill talk about that later but it is hugely helpful and a gift from my predecessor).
• Review of all ISP to ensure that they match any current therapies or needs or if those need discharged or changed as well as looking at the Fall Risk Assessment and if that needs updated based on any incidents.
• Review of Staff Files (I have a form that organizes all my staff by who's credentials are getting ready to expire as well as when their First Aid, CPR, and TB are due and this is kept on a clip board on my desk)
• I ensure that the past months in-services were conducted (usually by me on various topics or by a home health agency) and they are filed respectively in the In-Service Binder. I also ensure that the past months on line in-services are printed and filed.
• Review of the Incident Report Binder to conduct any necessary training with my staff on preventing any reoccurrence of future incidents.

3. The State Inspection Binder- This beautiful thing is loved by my state inspector for a few reasons and I will take this idea where ever I go! This is updated once a week.

• The Binder organizes key things that the inspector is going to look for: A copy of the license, a copy of the liability insurance, disclosure statement, mental health provider contract, and  visitors policy.
• It contains separate tabs for census: Under this tab you file your chart that organizes all of your residents and when their Bill of Rights is due and TB/UAI/ISP are due and documentation of the current census for that day is there. Resident Update is there and that is where you document anyone under therapy, anyone under hospice, anyone receiving wound care, and anyone receiving oxygen. This is also where you are keeping up with your admissions and discharges since last survey so it can easily be pulled for your inspector.
• It contains a separate tab for staff where you keep a current list of all of your staff based on hire date, what their shift is, what their position is, etc.  all based on the regulations requirements of information that will be requested. This is also where you keep your most current schedule and past schedules.
• There is a pets tab where you keep your most recent shot records and pet policy if your building has a pet.
• There is an Activity Tab where a copy of your Activity Calendar is kept for each month.
• There is and ALF inspection tab where you keep your food inspection report, your fire inspection and your fire code permit.
• You also have reminders for a separate binder where you keep your healthcare oversights, pharmacy oversights, and dietary oversights.
• There are reminders for your volunteers binder to ensure its kept compliant
• There are reminders for your resident council binder to ensure that it is being kept compliant.

3. Last but not least, when the regulations updated in April 2018 I went through and I documented a year out what is due monthly, quarterly, and annually, as well as every six months. This is really important to track especially with the new Resident Emergencies Plan that must be developed and implemented as well as the new regulations on Resident Emergencies and the Emergency Preparedness Manual. I recommend noting it in your calendar through the year and sharing that with your team so that you can all be sure everything is being done and documented properly as the new regulations made things a lot more confusing in regards to the above mentioned.

• I also keep the following binders that were all re-written when I arrived to ensure accuracy of policy and compliance: Home Health Binder with subsequent policies and Hospice Contracts, Resident Plan for Emergencies Binder with corresponding regulation in front for reference, Emergency Preparedness Plan, Medication Management Plan, and Infection Control. The regulations have changed as far as when all of these need to be reviewed and practiced so that is why it is helpful to go ahead and plan that out for the year so you do not miss anything.

Of course I still leave time to market and drive sales as well as review financials each month as that is the main part of my role.

I know this is a lot but, there a lot of you out there that are opening smaller homes that require your Administrators to do a lot more than the average Administrator normally would so I hope that this can provide some guidance and direction as well as possibly help you organize your month and even get a new DON on the right track. Feel free to reach out with any questions! Have a happy day!