1. Action Tracker · Status Report | Bill Moss, Assistant Secretary Oct 09, 2015 Aging and Long-Term Support Administration Background Group Topic / Strategic Plan Goal / Commitment 3: Improve quality in nursing facilities and other long-term services and supports settings Sub Topic / Strategic Objective: Affirm Adult Family Homes, Assisted Living Facilities and Nursing Homes are providing quality care and residents are safe through timely licensing re-inspections. Measure # / Strategic Objective # : AAR.1/3.1 Measure Title : Timely licensing re-inspections of adult family homes, assisted living facilities and nursing homes ID#Problem to be solvedStrategy/ApproachTask(s) to support strategyLeadStatusDueExpected OutcomePartners 3.1.1Maintaining the percentage of timely re-inspection at 99% Utilize existing reports to meet inspection survey schedules. Create calendars/update and monitor as needed to leverage resources to meet schedules. Bett SchlemmerOn track Monthly through June 2017 Maintain timely inspection/survey activities at 99 percent 3.1.2Staff turnover has impacted the ability for timely inspection/survey Investigate why staff leave Institute exist interviews for departing employees Delores UseaCompleteFall 2015Decrease staff turnover by assessing and using information gleaned from exit surveys and staff survey to guide future actions Collect, analyze data and write a report with recommendations based on data collected from exist interviews On trackMay 2016 3.1.3Documentation ToolsEase paperwork burden Policy has worked with technology taskforce to pilot Adult Family Home (AFH) forms. Training is occurring in the field offices on use of these forms. Bett SchlemmerOn trackFall 2015Increase accuracy of information received, decreasing rework and improving processing time 3.1.4Staffing ratios were insufficient to address the increased number of investigations coming into Residential Care Services (RCS) Division. This in turn created a backlog of cases. Appropriately calculate the need for staff based on more recent history; hire sufficient staff to deal with initial turnover so that actual staffing is closer to budgeted levels. Create a workload model needed to determine FTEs based on investigation history reflecting growing workloads. Bett SchlemmerCompleteJuly 2015Consideration for additional staff following results of workload analysis study 3.1.5 Inconsistent timeliness of documentation of data entry of initiation of complaint investigations into TIVA. Assess and evaluate gaps in data entry Implement standards for data entry by staff for consistency Develop process where administrative support staff can assist in data entry. This will be addressed in the VSM Bett SchlemmerOn trackNovember 2015Timely entry of initiation data 3.1.6Documentation RequirementsImprove data systems to meet business needs Use IT governance structure to make ongoing change requests Scott BirdCompleteApril 30, 2015Ensure data systems continue to meet the business and reporting needs of the program Monthly meetings to review and address need On trackJune 2016 Proposed Action Type of Status Report Strategic Plan SO 3.1 Licensing Re-Inspections Last modified 10/092015 1

2. Action Tracker · Status Report | Bill Moss, Assistant SecretaryOct 09, 2015 Aging and Long-Term Support Administration Background Group Topic / Strategic Plan Goal / Commitment 3: Improve quality in nursing facilities and other long-term services and supports settings Sub Topic / Strategic Objective: Affirm Adult Family Homes, Assisted Living Facilities and Nursing Homes are providing quality care and residents are safe through timely licensing re-inspections. Measure # / Strategic Objective # : AAR.1/3.1 Measure Title : Timely licensing re-inspections of adult family homes, assisted living facilities and nursing homes ID#Problem to be solvedStrategy/Approach Task(s) to support strategyLeadStatusDueExpected OutcomePartners 3.1.7Strengthen the nursing home revisit standard operating procedure Provide guidance and training to NH surveyors and establish standardized practices. Clearly communicate operational requirements for nursing home documentation and on-site revisits Re-issue Management Bulletin clearly spelling out guidelines Establish internal controls for document retention needed to support verification of correction of deficiencies Statewide training on the revisit process, also included in new hire training, and available for staff who miss the training Bett SchlemmerCompletedApril 2015Clear and consistent operational standards for nursing home revisits Proposed Action Type of Status Report Strategic Plan SO 3.1 Licensing Re-Inspections Last modified 10/09/2015 2