QUALITY IMPROVEMENT
Assisted Living & Memory Care Inspection Outcomes and Takeaways
T
aking your quality assurance pro- grams to the next level requires data and information. What are the top
deficiencies overall, and in your state—and how can you help change those numbers? This 2017 Inspection Outcomes data was
provided by CarePrepare™, the first nation- al assisted living and memory care quality database, which aggregates operational data and regulatory survey information for the majority of providers in the United States. Deficiency data is reported in standard-
ized subcategories which have been devel- oped by an expert team of long-tenured clinicians and former surveyors from the senior housing industry. CarePrepare™ allows benchmarking to
the local market and state for deficiencies and penalties, and includes a Performance Explorer tool to assess prospective lead- ership candidates’ historical regulatory performance.
What’s behind the outcomes? Former Delaware deputy attorney general Loretta LeBar, now a private consultant, offered up a top 10 list of the deficiencies she sees most often. They include: 1. Inadequate care planning. To help min- imize care planning issues, communities should bring residents and their families into the care planning team and commit to working together to make the care plan successful.
2. Inadequate communication with staff. This is especially important regarding care that must be delivered. If the front- line staff do not understand what care to deliver, the care planning system cannot be implemented.
3. Inadequate documentation. If it isn’t documented, it didn’t happen.
32 SENIOR LIVING EXECUTIVE MAY/JUNE 2019
4. Change of condition. For example, if a resident experiences
shortness of
breath, their physicians must be noti- fied promptly.
5. Violation of resident rights and dignity. This area can refer to such things as failure to knock on a resident’s door and ask before entering the room, or a podiatrist taking a group of patients into the activity room to deal with them as a group.
6. Abuse and neglect. Neglect can refer to such things as medication errors and a resident wearing soiled garments for too long. Abuse can come in many forms, from verbal to physical abuse. Cursing
in front of a resident or threatening to withhold services are examples of abuse.
7. Medication errors. These can also play a role in other types of deficiencies.
8. Incident reporting. Incidents must be re- ported to the state. A fall in some states is reportable, while in other states, theft of residents' possessions is reportable.
9. Keeping a resident too long. Sometimes, for instance, a resident must leave a community because it doesn’t offer the services needed.
10. Training deficiencies. There are things staff members must be trained on before they can get started, and criminal back- ground checks must be completed.
TOP 10 DEFICIENCIES IN 2017 BY SUBCATEGORY FOR ASSISTED LIVING & MEMORY CARE
RANK SUBCATEGORY 1
2 3 4 5 6 7 8 9
10
Medication Storage/Administration/Documentation/Errors Safe/Functional/Sanitary/Comfortable Environment Training
Residents Rights Care Plans
Emergency Servcies and Procedures Physical Plant Hiring
Abuse & Neglect Resident Assessment 2017
2,894 1,881 1,487 1,239 1,150 1,073 945 837 803 782
Source: CarePrepare™ as of 1/1/19
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