Assisted Living Enforcement Process Improvement Project Swimlane Steps Understanding complexity & consequences Mike Cook, Assistant Chief Long Term Care Service Protective Health Services

2 Swimlane Process Map Responsibilities Processes Delays Mistakes Inefficiency

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

4 Swimlane Assignments Survey Staff Enforcement Staff LTC Leadership General Counsel Assisted Living Center Admin Law Judge Optimum Example No Delays No Mistakes Efficient

5 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

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

7 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

8 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

9 Delays Mistakes Inefficiency

10 No Opportunity to Correct Harm Serious and Immediate Concern Continuing Non-compliance Penalties, Legal Counsel, IDRs, Extended Time Delays

11 Deficiencies – Not Corrected Continuing Non-compliance, Penalties, Legal Counsel, IDRs, Extended Time Delays

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

13 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

14 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

15 Thank You ! Mike Cook, Assistant Chief Long Term Care Service Protective Health Services