1. Action Tracker · Status Report | Bill Moss, Assistant SecretaryOct 09, 2015 Aging & Long-Term Support Administration Background Strategic Plan Goal / Commitment 3: Improve quality in nursing facilities and other long-term services and supports settings Strategic Objective: Timely quality assurance and oversight activities to ensure evidence of compliance with federal, state and program requirements. Measure #/ Strategic Objective # : AAR.6/3.3c or 3.3 Measure Title : Percent of nursing home deficiencies sent within 10 working days. ID#Problem to be solvedStrategy/Approach Task(s) to support strategyLeadStatusDueExpected OutcomePartners 3.3c.1 Development of the audit tool and system Present Statement of Deficiency (SOD) audit process to Residential Care Services (RCS) management Draft process for SOD audit in the field and present to RCS management for feedback. Design audit tool and develop audit system Delores UseaComplete7/2015Audit tool will ensure consistency in measuring the SOD process across the state. 3.3c.2 Baseline identifying whether standards for SOD being sent to providers are being met Report from ASPEN to determine timeliness of SODs being sent to providers Develop SOD report from ASPEN Verify that Management Services Division (MSD) staff are using correct databases and logic to develop reports Monthly status reviews until task is completed Scott BirdComplete9/2015SOD report is created 3.3c.3 Recommendations for RCS-driven curriculum focusing SOD writing across all service line programs Train staff on principles of documentation (POD), including examples from examples where SODs were overturned Conduct second session of POD training Lisa YanagidaComplete11/2015Existing staff have refresher on basic principles of documentation training 3.3c.4 Recommendations for RCS driven curriculum focusing on investigatory skills that can be used across all service line programs Train staff on principles of investigationGather data for appropriate curriculum Procure vendor for this staff training Candy GoehringOn track12/2015Existing will have completed refresher course on principles of Interviewing 3.3c.5 Internal controls over retaining nursing home (NH) documentation to support that the state verified the correction of deficiencies. Quarterly quality assurance checks for acceptable evidence of compliance per CMS guidelines. Conduct audits of post revisits from a sample of SODS from each region. Delores UseaOn track11/2015Post revisits are being documented in accordance with Standard of Operation (SOP). 3.3c.6 Timely entry of SOD delivery within 10 days Assess and evaluate gaps in data entryMonitor data entry weekly using SOD tracking reports. Write standard operating procedure (SOP) for SOD delivery Bett SchlemmerOn track11/2015Timely mailing of SODs within 10 days 3.3c.7 Implement the Statement of Deficiencies audit system Delores UseaComplete9/2015One SOD audit systems used statewide Proposed Action Type of Status Report Strategic Plan SO 3.3 NH-SODs Last modified 10/09//2015