Compliance and State Survey Readiness Presented by: Dave Scifres Director of Environmental Services Apostolic Christian Restmor, Inc Morton, IL

“Let me stop what I’m doing to work on your problem!”

PM Worx to the rescue!

Fire Safety Survey Report 2000 Code Health Care Medicare – Medicaid (CMS) State and federal surveyors use this federal guideline to perform state surveys

Survey form available by entering CMS2786R on Google and selecting first link ( [PDF] MEDICARE MEDICAID) handout Required documentation for CMS survey 22 Item Checklist CMS Survey Forms

Document Organization Set up your facility-specific compliance binder to include the following: Use divider tabs Label each tab with specific documentation title Set up before the first of the year (January to December) Add documentation as it is acquired Prepare new binder for each year

When you receive a deficiency tag, CMS requires you to: Show documentation of how the deficiency was corrected Identify other locations in the facility with the same deficiency Show documentation of how you will prevent the deficiency from recurring You’ve Been Tagged: Now What?

Plan of Correction (POC) A PM Worx plan of correction will include: A completed PM Worx work order showing deficiency was corrected A completed PM Worx work order showing an inspection of the building searching for other locations with the same deficiency A scheduled recurring PM Worx work order showing inspections to prevent deficiency from happening again Example: non-latching door

Hot Topics for CMS Emergency Water Plan Emergency water agreement not enough A comprehensive written plan is required Generator Inspection Form 75 to 100 item weekly checklist

A few tips to help ensure PM Worx is a success: All employees have access to “COWS” All facility computers have a PM WORX icon on the desktop The single biggest thing you can do to ensure PM WORX is successful is to NOT accept work requests in any other form including notes, s, or verbal requests. Ask politely for requests to be entered into PM WORX. EXCEPTIONS: Safety or compliance issues, resident or family member direct request, or the Big Cheese Helpful Hints

Questions? Feel free to contact me directly if you have other questions: Dave Scifres (309)