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Getting Down to the Details for Departmental Reviews/Inspections

Getting Down to the Details for Departmental Reviews/Inspections

Do you sometimes wish others would just leave you and your staff alone, so you could get on with interacting with your residents, and provide great programs for them? Sure you do.

However, like everyone in the care process, we are accountable. So whether it is your manager, your care team, family members or inspectors, we must be prepared to provide answers when questioned about our programming efforts.

Different people want to review different aspects of your programming. Let’s focus on everyone’s favorite: The inspectors, and what they typically want to see!

Obviously, inspectors may place different emphasis on a variety of aspects of your programming efforts. Such variances may be based on different state/provincial concerns, or in response to a current public outcry over some concern regarding care practices. Regardless of the circumstances, there are two primary targets, and a few key performance indicators, that you will usually find yourself turning to for most outside reviews or inquiries.

Target #1: The Department “Big Picture” Perspective

The following are key areas that you should be prepared to highlight:

Range of Programs by Domain, Resident Ability, and Gender

Being able to share this type of “broad” perspective of the department shows that you get the big picture – that you have balance in your programs, and that you are responsive to all residents, regardless of ability.

If you use ActivityPro, go to the “Department Multi-Day Report with Filters”, select the date range for the last 12 months, and highlight the “Total Activities Offerings as Percentages” to review programs in the five domains, the percentage distribution of programs offered, based upon resident functional level and by gender.

Resident Contacts, Domain, and Program Size

This is another way to review the scope of your department and the variety of your programs.

Showing how many people attended programs of various sizes, and by domain, helps to demonstrate such things as the number of contacts made one-on-one, or in small groups – which can be very important when dealing with a resident population that is dominated by cognitive impairment to some degree.

More Detailed Departmental Reviews

Be prepared to show your programming by time of day and days of the week. You will often be asked to show how many offerings you have in the evening, or on weekends. Having this information readily available again shows that you have a complete program approach.

If you use ActivityPro, select the “Advanced” button at the top, and you can then select weekend only programs, or evening programs, and create a detailed report.

Target #2: The Resident Level

It is not uncommon for inspectors to want to review the levels and quality of engagement of a few residents. If you are working in long term care (LTC), the inspectors are usually going to direct their attention to the records of the “higher need” people in your home. In other words, residents that are identified as having significant physical and/or cognitive impairment are likely going to be their primary focus.

In today’s LTC environment, most homes fall under the MDS-RAI format for resident documentation. That being the case, the RAI coordinator in your home is the ideal person to talk to when you want to know the most likely residents that the inspectors will be focusing on for an inspection. Armed with this information, you can focus your attention on these residents to start, and expand your scope as time permits.

Resident Multi-Day and Multi-Month Reports

Be prepared to share a specific resident’s participation over the past week, two weeks or month, as well as for a quarter, or up to a full year. Focus on the number of engagements, the variety of engagements by domain, and if you are scoring resident success, the overall average score provides an excellent overview of the person’s quantity and quality of engagement. Point to the average number of engagements per month, and the average score on a month-to-month basis.

Of course, the capture of resident self-directed participation is important, along with merging self-directed and scheduled activity hours and averages by time of day.

If you track resident absences and reasons for not attending, highlight those as well, as it reinforces the attempts you and your staff have made to encourage the reluctant engagers to participate. Any notes will help to explain changes in scores or drops in participation.

Resident Satisfaction Surveys

If you conduct such surveys, referring to this information is a good way to demonstrate that you are meeting resident needs and interests as well, as evidenced by high resident satisfaction scores.

If you use ActivityPro, there is another report that demonstrates to the inspectors how well you are doing relative to the quality and quantity of specific resident engagement: The Resident at Risk Report. Assuming your dashboard report is based on a 30-day lookback, this report will show if any of the residents being reviewed have fallen behind your quality and quantity engagement benchmarks. While in this report, you can simply change the minimum number of engagements to a huge number (such as 1,000!), hit search, and then all of your residents will appear in the report. This is a great way to quickly show an inspector an overview of the level of participation of every resident in your home, as well as their levels of participation by domain. They will be impressed – especially if most of your residents are well above the benchmark.

You Are Prepared!

These are some of the key areas of focus that inspectors are likely to ask you about or be impressed by when your home is under review. By being ready, and proactively generating such information that they may not have even thought to ask about, it shows what a great job you and your staff are doing.

If you are an ActivityPro user, you can pull up all of this information, saving you time and putting you in a great position to demonstrate the quality of your overall programming and the quality of your person-centered approach to care.

Be confident! This kind of information proves the value you and your people add to the lives of your residents and the care process!

If you are not currently using ActivityPro to help you get the details for your departmental reviews and inspections then give us a call to get started today at 1-888-898-0098.