List of Needed Knowledge Flashcards

Question

Core - 1B4

Answer 1

Care Recipient Safety (e.g., fall prevention, elopement prevention, adverse events) -Ensuring a culture of safety, in part through appropriate staff training -Implementation of falls prevention programs -Policies, procedures, and/or programming to prevent elopement -Investigating and properly reporting resident incidents, accidents, or other adverse events

Answer 2

Care Recipient (and Representative) Grievance, Conflict, and Dispute Resolution -Have a plan of action for handling complaints from loved ones or patients: -Encourage feedback from patients or patient family -Document all complaints and details -Designate a staff member to be contact between facility and family. Also provide resolution timeline. -Perform an investigation involving both staff and involved persons -Formulate a solution and communicate the solution to the family or patient. -Follow up later (through staff liaison -- messenger) to ensure they are satisfied HANDLING COMPLAINTS ACTIVITY

Answer 3

Care Recipient Advocacy (e.g., Ombudsman, resident, and family council) -Care recipients advocating for themselves or for peers -Family Members -Resident or Family Council recommendations -Ombudsmen MORE INFO AND QUIZ

Answer 4

Care Recipient Decision-Making (e.g., capacity, power of attorney, guardianship, conservatorship, code status, advance directives, ethical decision-making) -Capacity -Power of attorney -Guardianship -Conservatorship -Code status -Advance directives -Ethical decision-making QUIZ

Answer 5

Care Recipient (and Representative) Satisfaction -Being visible -Onsite visits with care recipients and family -Establishment of a meaningful and functional resident and/or family council -Satisfaction surveys -Daily interactions with staff in the form of a stand-up meeting MORE INFO ABOUT STANDUP, MORNING ROUNDS, AND SATISFACTION SURVEYS

Answer 6

Recognition of Maltreatment (e.g., abuse, neglect, exploitation) -Screening before hiring and then training all staff on how to identify signs of maltreatment and the process for reporting. -Prevention - from documenting care recipient vulnerabilities in their care plans to policies that protect them from any predatory offenders. -Promptly and thoroughly investigating any reported incidents of maltreatment. -Reporting any allegations of abuse or maltreatment in accordance with state and federal law.

Answer 7

Mental and Behavioral Health (e.g., cognitive impairment, depression, social support systems) -Cognitive impairment (e.g., Alzheimer's disease, Parkinson's, Huntington's, other forms of dementia, and memory loss) -Depression -Anxiety -Suicide -Loneliness and isolation -Severe and persistent mental health disorders (e.g., schizophrenia, bipolar, personality disorders HAS NUMEROUS LINKS TO RESOURCES ABOUT THESE MENTAL HEALTH ISSUES

Answer 8

Trauma-Informed Care (e.g., PTSD) -Creating a safe environment -Hiring and training trauma-informed employees -Screening care recipients for trauma and involving them in the development of their care plans -Preventing secondary traumatic stress in employees -Engaging in appropriate referral sources

Answer 9

Pain Management -Understanding the negative impacts pain can have on health and well-being -Ensuring the use of adequate pain assessments and management practices to minimize pain and maximize relief OUTLINES PAIN ASSESSMENT TOOLS (dementia pain assessment tool is different)

Answer 10

Death, Dying, and Grief -Providing staff training in the provision of end-of-life care practices -Providing increased support for care recipients and their families during and following a care recipient's dying experience -Developing and providing programs to support residents and staff as they grieve the loss of care recipients who have died

Answer 11

Restraint Usage and Reduction -Emphasizing resident quality of life and well-being and adopting a person-centered care philosophy -Robust care recipient assessment processes to employ alternatives to restraints while mitigating risks -Maintain and regularly review all restrain usage for appropriateness -Ensure staff are well-trained on methods of restraint reduction and alternatives Don't restrain patients. Help them walk, give social activities that will prevent agitation from isolation. Educate on the risks of falling.

Answer 12

Foodservice (e.g., choice and menu planning, dietary management, food storage and handling, dining services) -Offering choices of quality, nutritious meals and snacks -Ensuring systems are in place to manage care recipient's physician orders, dietary restrictions, and care recipient preferences -Following proper food storage and infection control protocols -Providing a pleasant ambiance and overall dining experience -Monitoring food quality and satisfaction to prevent unnecessary weight loss PICTURE ACTIVITY Extensively have patients rate the food to improve their satisfaction.

Answer 13

Social Services Programs -Meeting care recipient's psychosocial needs -Interdisciplinary care planning that meets the care recipient's needs and preferences -Care recipient's rights -Advance directives -Facilitating relationship dynamics -Available support resources

Answer 14

Therapeutic Recreation and Activity Programs -Addressing care recipients' psychosocial needs -Offerings for groups and individuals -Inclusion of both formal and unstructured activities -Options to address care recipients' leisure needs and hobby preferences -Varied programming to meet the functional levels of care recipients -Inclusion of individual assessments of care recipient preferences and documentation of such within their care plans VIDEO Provide intergenerational activities. It benefits all.

Answer 15

Community Resources, Programs, and Agencies (e.g., meals on wheels, housing vouchers, Area Agencies on Aging, Veterans Affairs) -Meals on Wheels or other meal service programs -Housing vouchers -Transportation services -Area Agencies on Aging or other local aging resources -Ombudsman -Case management -Legal aid services -Veterans Affairs -Community support groups ACTIVITY

Answer 16

Psychosocial Needs (e.g., social, spiritual, community, cultural) -Resident psychosocial needs in areas including social, spiritual, community, and cultural domains -Quality of life -Activities that meet the needs and interests of residents

Answer 17

Person-Centered Care and Comprehensive Care Planning -Ability to make treatment decisions -Participation in care planning -Right to have personal property -Accommodation of needs and preferences -Roommate choice -Self-determination

Answer 18

Care Recipient Bill of Rights and Responsibilities -Resident Rights -Dignity -Self-Determination -Access -Visitors -Advocacy -Records -Privacy -Confidentiality of records -Communication -Informed Consent -Visitation

Answer 19

Care Recipient Safety (e.g., fall prevention, elopement prevention, adverse events) -Examining and addressing residents at risk for falls such as: -Medication side effects -Dehydration -Environmental hazards -Identification of and intervention for resident elopement risk

Answer 20

Care Recipient (and Representative) Grievance, Conflict, and Dispute Resolution -Conflict resolution -Timely resolution -Establishing a grievance policy -Identifying a grievance official -Written grievance decisions -Taking appropriate corrective action -Grievance retention

Answer 21

Care Recipient Advocacy (e.g., Ombudsman, resident, and family council) -Ombudsman rights -Visitation or right to resident access -Ombudsman notice requirements -Right to establish family council -Resident council requirements

Answer 22

Care Recipient Decision-Making (e.g., capacity, power of attorney, guardianship, conservatorship, code status, advance directives, ethical decision-making) -Informed Consent -Competency level/determination -Legal rights and responsibilities -Power of Attorney -Guardianship -Legal Guardian -Health care proxy -Advance directive requirements

Answer 23

Recognition of Maltreatment (e.g., abuse, neglect, exploitation) -Residents' right to be free from: -Abuse and neglect -Involuntary seclusion -Misappropriation/Exploitation -Physical and Chemical Restraints -Develop and implement abuse/neglect policies and procedure -Reporting requirements -Reasonable suspicion of a crime -Alleged violations -Investigate, prevent, and correct alleged violations

Answer 24

Mental and Behavioral Health (e.g., cognitive impairment, depression, social support systems) -Behavioral health issues -Availability of behavioral health services -Training and hiring competent staff -Treatment and services for mental health concerns -Behavior management -Availability of medically related services

Answer 25

Trauma-Informed Care (e.g., PTSD) -Resident preferences -Resident prior experience -Elimination or mitigation of resident triggers

Answer 26

Pain Management -Recognition and management of pain -Strategies for pain management -Pharmacological and non-pharmacological interventions -Care plan assessment and monitoring

Answer 27

Death, Dying, and Grief -Reporting a resident's death -Coordination of appropriate palliative care and/or hospice care services

Answer 28

Restraint Usage and Reduction -Reduction and elimination of medications that may sedate or subdue the resident -Rationale for medications -Gradual dose reduction -Requirements for use -Reduction and elimination of physical restraints -Rationale for usage -Least restrictive alternative -Evaluation of appropriateness -Monitoring frequency of use

Answer 29

Foodservice (e.g., choice and menu planning, dietary management, food storage and handling, dining services) -Meeting the resident's needs regarding dietary choices (including care recipient education and consent) -Menu preparation -Food appearance and temperature -Mealtimes and frequency -Specialized diets -Personal food policy -Sanitation practices within food prep areas

Answer 30

Social Services Programs -Qualifications of a social worker -Regulatory requirements for the social worker position

Answer 31

Therapeutic Recreation and Activity Programs -Ensuring activities are structured to meet the individual needs of the residents. -Qualifications for activity professionals

Answer 32

Hospice and Palliative Care -Policies and procedures for the provision of hospice and palliative care -Providing or coordinating hospice and/or palliative care -Understanding hospice and palliative care -Differentiate between hospice and palliative care ACTIVITY

Answer 33

Specialized Medical Equipment (e.g., oxygen, durable medical equipment) -Policies and procedures for the provision of specialty equipment -Providing or coordinating with third-party service providers -Durable medical equipment (e.g., canes, walkers, splints, wheelchairs) -Oxygen concentrator -Specialty beds

Answer 34

Transportation for Care Recipients -Policies and procedures for the provision of transportation -Providing or coordinating with third-party transportation providers -Identification of emergency transportation resources -Securing the appropriate transportation to meet the needs of the care recipient

Answer 35

Telemedicine (e.g., e-health) -Policies and procedures for the provision of telemedicine -Contracting with telemedicine providers -Coordinating telemedicine visits for care recipients -Securement of necessary equipment and technology -Ensuring privacy of care recipient during telehealth visit -Documentation of telemedicine visits

Answer 36

Diagnostic Services (e.g., radiology, lab services) -Policies and procedures for the provision of diagnostic services -Providing or coordinating with third-party diagnostic services -Contracting with diagnostic services providers -Coordinating diagnostic services for care recipients

Answer 37

Dental and Oral Care Services -Policies and procedures for the provision of dental and oral care -Contracting with providers of dental and oral care -Coordinating dental and oral care for the care recipient

Answer 38

Healthcare Partners and Clinical Providers (e.g., MD/DO, Nurse Practitioner, Psychiatrist, Podiatrist, Dentist) -Policies and procedures for the provision of physician and ancillary provider services -Providing or coordinating with third-party clinical provider services -Contracting with providers of medical care -Coordinating medical care for the care recipient ACTIVITY

Answer 39

Volunteer Programs -Policies and procedures for volunteer programs -Volunteer programs related to wellness, activities, and recreation -Maintaining compliance with volunteers -Mitigating the risks associated with volunteers VOLUNTEER TRAINING MATERIALS

Answer 40

Hospice and Palliative Care -Arrangement of services -Agreements with hospice providers -Hospice responsibilities (e.g., communication, plan of care, etc.) -Notification of change of condition

Answer 41

Transportation for Care Recipients -Arrangement of services (emergency and non-emergency) -Agreements with transportation providers -Transportation Responsibilities

Answer 42

Diagnostic Services (e.g., radiology, lab services) -Arrangement of services -Agreements with third-party providers -Notification and documentation of services provided and test results

Answer 43

Dental and Oral Care Services -Arrangement of timely routine and emergency services -Agreements with third-party providers -Documentation of services provided

Answer 44

Healthcare Partners and Clinical Providers (e.g., MD/DO, Nurse Practitioner, Psychiatrist, Podiatrist, Dentist) -Arrangement of services -Agreements with third-party providers -Appropriately qualified health care professionals -Documentation of services provided CROSSWORD OF DEFINITIONS

Answer 45

Volunteer Programs -Coordination and oversight for volunteers and their programming -Adequately screen, orient, and train all volunteers

Answer 46

Budget and Forecasting -Develop, implement, and evaluate necessary budgets (e.g., operating, capital, and cash budgets). -Anticipate and estimate projected revenues and expenses, both short-term and long-term. -Identify fixed vs. variable expenses for budgeting and projections. -Managing revenues and expenses (e.g., census, occupancy, cost control, etc.). -Monitor the budget on a regular basis to track financial status. -Review financial data in relationship to the budget. -Develop and implement a system to periodically monitor and adjust your financial performance. ACTIVITIES

Answer 47

Financial Analysis (e.g., ratios, profitability, debt, revenue mix, depreciation, operating margin, cash flow) -Utilization of per patient day (PPD) and per unit data -Familiarity with commonly used financial ratios (e.g., current ratio, equity ratio, quick ratio, current ratio, debt service coverage, days in accounts receivable, cash on hand) -Profitability and operating margin calculations and benchmarks -Depreciation -Revenue mix -Breakeven point -Budget variance analysis ACTIVITY

Answer 48

Revenue Cycle Management (e.g., billing, accounts receivable, accounts payable, collections) -Procedure for timely and accurate billing -System for receiving and tracking payments -Process for accounts receivable collections -Manage and monitor payroll ACTIVITY

Answer 49

Financial Statements (e.g., income/revenue statement, balance sheet, statement of cash flows, cost reporting) -Generally Accepted Accounting Principles (GAAP) -Accounting Equation (e.g., assets, liabilities, equity/net worth) -Return on Investment (ROI) -Trial Balance -Balance Sheet -Income Statement/Profit & Loss (P&L) -Cash Flow Statement -Cost reporting ACTIVITY

Answer 50

Revenue and Reimbursement (e.g., PDPM, PDGM, ACOs, HMOs, Medicaid, private payors) -Medicare (Parts A, B, C, D) -Medicaid -Veterans Administration -Private Insurance -Long Term Care Insurance -Private Pay -Payment Models (e.g., indemnity, HMOs, Accountable Care Organizations (ACOs), managed care organizations) CROSSWORD

Answer 51

Financial Reporting Requirements (e.g., requirements for not-for-profit, for-profit, and governmental providers) -Proper reporting in the areas of: -Payroll -Accounts Receivable -Billing -Accurate record keeping, etc. -Tax filing and reporting, including: -Cost reports -Employee tax credit reporting -Sales tax reporting -Contractor reporting (e.g., 1099s) -Non-profit reporting (e.g., 990s)

Answer 52

Integration of Clinical and Financial Systems (e.g., EMR/EHR, MDS) -Clinical services that drive reimbursement -Electronic medical records (EMR) EMR and EHR are different. The Electronic Medical Records are the legal records that are a source of data for the EHR. Electronic Health Records represents the ability to share a patient's health info across different facilities and to have that info follow them based on their name and other basic info.

Answer 53

Internal Financial Management Controls (e.g., segregation of duties, access) -Segregation of financial duties -Accounting checks and balances to identify and prevent fraud and abuse -Auditing of internal financial controls -Access controls to bank accounts and financial information ACTIVITY

Answer 54

Supply-Chain Management (e.g., inventory control) -Inventory control -Contractual agreements -Responsibilities of vendors/contractors -Negotiation of pricing

Answer 55

Resident Trust Accounts for Personal Funds -Tracking of care recipient deposits and expenses -Policies for administration of trust funds -Designation of responsible parties -Procedure for auditing of the trust fund account

Answer 56

Revenue and Reimbursement (e.g., PDPM, PDGM, ACOs, HMOs, Medicaid, private payors) -Medicare (Parts A, B, C, D; Medicare Advantage Plans) -Medicaid -Veterans Administration -Knowledge and understanding of the PDPM reimbursement system -Optimization of applicable payment sources -Consolidated billing -Value-based purchasing -Understanding the difference between: -fee-for-service -prospective payment systems -other payment methodologies (e.g., cost-based vs price-based, case mix index)

Answer 57

Financial Reporting Requirements (e.g., requirements for not-for-profit, for-profit, and governmental providers) -Government and third-party cost-reporting

Answer 58

Integration of Clinical and Financial Systems (e.g., EMR/EHR, MDS) -Accuracy and integration of MDS in payment systems

Answer 59

Resident Trust Accounts for Personal Funds -Surety Bonds -Policies and procedures in alignment with regulatory requirements for administration of resident trust funds QUIZ

Answer 60

OSHA Rules and Regulations -Requirements to protect the health and safety of all individuals in the workplace -Requirements to protect the health and safety of the care recipients -Education of staff to understand the requirements for OSHA compliance QUIZ

Answer 61

Worker’s Compensation -Workers’ Compensation insurance -Reporting of incidents -Claims and payments -Risk management program ACTIVITY

Answer 62

Ethical Conduct and Standards of Practice -Policies and procedures to prevent and detect criminal, civil and administrative violations -Written compliance standards for conduct -Method for reporting incidents -Disciplinary standards for violations Staff education on ethics ACTIVITY

Answer 63

Compliance Programs -Policies and procedures for compliance -Process for monitoring compliance -Knowledge of action for non-compliance ACTIVITY

Answer 64

Risk Management Process and Programs -Programs to minimize or eliminate risk exposure -Policies and procedures to ensure a safe workplace -Identification of key areas of risk -Education of all staff on safety training and risk management -Protocols for incident reporting -Establishment of a Safety Committee VIDEO

Answer 65

Quality Improvement Processes (e.g., root cause analysis, PDCA/PDSA) -Utilization of effective improvement processes to ensure quality of care. -Monitoring to assess the impact on the quality of life and care for care recipients. -Involvement of the relevant stakeholders in any quality improvement processes. TOOLS AND ACTIVITY

Answer 66

Scope of Practice and Legal Liability -Identify areas of potential liability. -Develop policies and procedure to identify, prevent, or respond to any incidents. -Communicate all stakeholders how to proactively reduce areas of risk. -Develop a risk management program to mitigate any legal expose. -Utilize corporate compliance to evaluate practices. ACTIVITY

Answer 67

Internal Investigation Protocols and Techniques (e.g., incidents, adverse events) -Documentation processes for any action or event that occurs. -Action plan to determine when legal representation is needed. -Communication to all parties who might be involved.

Answer 68

Mandatory Reporting Requirements (e.g., incidents, adverse events, abuse, neglect, financial exploitation, fraud) -Sexual Abuse -Harassment -Discrimination -Theft -Physical, mental, or verbal abuse

Answer 69

Insurance Coverage (e.g., liability, property) -General Liability -Fidelity Bond -Property Insurance -Professional Liability -Surety Bond -Director and Officers Insurance ACTIVITY

Answer 70

Healthcare Record Requirements (e.g., confidentiality, disclosure, safeguarding, HIPAA, HITECH) -Retention and backup of records -Secured transmission of records -Policies and procedures to safeguard protected health information -Regulatory requirements for the collection and sharing of resident information ACTIVITY AND QUIZ

Answer 71

Security (e.g., cameras, monitoring systems, locks, staff location reporting) -Security Cameras -Door locking systems -Secured units -Alarm system

Answer 72

Contracted Services (e.g., roles, responsibilities, oversight, background checks) -Contracts for any third-party services -Process for approval of contracted services -Monitoring and evaluation of contracts -Oversight of contracted parties -Process for handling any breach of contract

Answer 73

OSHA Rules and Regulations -Work-related accidents, injuries, or death of employees -Accidents, injuries, or death to a resident ACTIVITY

Answer 74

Compliance Programs -Staff education -Development of a Safety Committee -Documentation of occurrences -Reporting of accidents, illnesses, and death MORE INFO

Answer 75

Scope of Practice and Legal Liability -Cleaning materials -Biohazards -Contaminated waste -Hot water -Unattended medication carts ACTIVITY AND QUIZ

Answer 76

Internal Investigation Protocols and Techniques (e.g., incidents, adverse events) -Questioning of staff regarding the incident/adverse event -Review of any documentation of the event -Review of any security videos that might be available. -Law enforcement notification when warranted or required VIDEO (some of these aren't entirely accurate lmao if there's something here, there's something extra than the bullet points to know.)

Answer 77

Mandatory Reporting Requirements (e.g., incidents, adverse events, abuse, neglect, financial exploitation, fraud) -Notification of state licensure agency -Notification of law enforcement -Documentation of occurrence -Notification of resident’s representative

Answer 78

Healthcare Record Requirements (e.g., confidentiality, disclosure, safeguarding, HIPAA, HITECH) -Secured transmission network -Policies for recordkeeping -Agreements for sharing of personal healthcare information with other parties MORE INFO

Answer 79

Security (e.g., cameras, monitoring systems, locks, staff location reporting) -Electronic door locks -Security cameras in communal areas -Resident space security cameras if allowed -Staff call system ACTIVITY

Answer 80

Contracted Services (e.g., roles, responsibilities, oversight, background checks) -Background checks -Drug screening -Therapists -Mental health counselors -Consultant Dieticians -Consultant Pharmacists -Medical Director

Answer 81

Federal Human Resources Laws, Rules, and Regulations (e.g., ADA, FMLA, Wage and Hour, FLSA) -Human resource laws, rules, and regulations such as: -American with Disabilities Act (ADA) -Disabilities Covered -Accommodations -Benefits -Family Medical Leave Act (FMLA) -Qualifications -Length of unpaid leave -Department of Labor -Wage and Hour -Fair Labor Standards Act (FLSA) -Unemployment Compensation -Workers' Compensation -Consolidated Omnibus Budget Reconciliation Act (COBRA) QUIZ

Answer 82

Selection and Hiring Practices (e.g., EEOC, interviewing, adverse impact, protected classes, occupational qualifications) -Budgeting necessary employee FTEs in all departments based on care needs and financial constraints. -Hiring employees with appropriate credentials to fill budgeted vacancies through various recruitment and employment strategies such as examples below: -Job qualifications -Job postings -Advertisements -Agency staffing -Ensuring that interview, application, and hiring practices are in accordance with FLSA and Equal Employment standards -Interviewing techniques -Job application – acceptable and unacceptable questions -Completion of pre-employment qualifications such as: -Criminal background checks -Physical examinations -Drug Testing -Adhering to applicable laws related to selection and hiring procedures, examples being: -Equal Employment Opportunity Commission (EEOC) -Protected classes ACTIVITY

Answer 83

Compensation and Benefits Programs (e.g., time off, healthcare insurance, employee pay and payroll) -Establishment of, and compliance with, policies and procedures -Development of compensation and benefit packages within budget and competitive allowances, including but not limited to: -Time off – personal leave, sick leave, holidays, etc. -Vacation -Healthcare insurance -Uniform allowances -Wellness programs -Other Benefits (e.g., flexible spending accounts (FSA), retirement accounts) -Compensation -Pay scales -Minimum wage -Merit system -Shift differentials -Overtime (40-hour week vs. 8/80) MORE INFO

Answer 84

Organizational Staffing Requirements and Reporting (e.g., PBJ) -Staffing requirements (as applicable) to meet the needs of care recipients -Reporting requirements

Answer 85

Staff Certification and Licensure Requirements -Professional staff licensing and credentialing -Administrator -Nurses, i.e., RNs, LPNs, LVNs -Social Workers -Physicians -Therapists, i.e., physical, occupational, speech, respiratory -Dieticians -Staff certifications and/or qualifications -Activity professionals -Nurse aides/personal care attendants -Dietary managers

Answer 86

Professional Development (e.g., maintenance of credentials, continuing education) -Internal and external opportunities for employees to develop themselves professionally -Continuing education programs to maintain and expand competencies MORE INFO

Answer 87

Employee Training and Orientation -Federal training and competency regulations -Policies and procedures to guide new employee orientation and ongoing training -Effective onboarding processes ACTIVITY

Answer 88

Performance Evaluation -Development of policies and procedures for conducting periodic formal evaluations of employee performance -Policies and procedures outlining the processes that will occur should a staff member’s performance not adhere to expected practices. -Training for managers in skills necessary for carrying out performance evaluation systems, such as: -Tools/approaches for conducting performance evaluations -Methods of delivering timely and effective feedback -Coaching strategies -Informal evaluation loops to communicate areas of poor performance -Identifying, communicating, and further developing employees who meet or exceed standards QUIZ

Answer 89

Human Resource Policies (e.g., drug-free workplace, discipline, job classification, photography and video, social media usage, mobile phone usage) -Clear employee communications regarding roles and responsibilities -Written job description and expectations of each role -Workplace rules -Appropriate and sufficient continuing education -Standards to objectively measure employee performance (routinely and when employee performance or behavior does not meet standards) -Fair and accurate communication methods with employees when performance does not meet expectations. This may include: -Making employees aware of an allegation that their performance or behavior does not meet expectations -Allowing the employee to explain their performance or behavior - give their side of the story, so to speak -Offering the employee opportunity to present witnesses or evidence that will support their view and provide a written statement -Considerations for inclusion of policies such as: -Drug-free workplace -Use of cameras (photography) -Use of video equipment or video taping -Social media usage, i.e., appropriate use of posting photos or videos, sharing of care recipient information, etc. -Mobile phone usage while on the job ACTIVITY

Answer 90

Employee Record-Keeping Requirements -Which agencies or statues require employee record-keeping -What type of records must be maintained -For how long various records must be maintained -An understanding of what information must be included in a personnel file and what may need to be stored separately -Applicable confidentiality requirements relative to certain employee information ACTIVITY

Answer 91

Employee Grievance, Conflict, and Dispute Resolution -Establishing clearly outlined steps (and due process) for reporting and resolving conflicts or grievances -Understanding various approaches to handling grievances (e.g., utilization of a hierarchy process, employee review hearing, acceptance of anonymous complaints) -Conflict resolution strategies -De-escalation techniques -Clear feedback loops within the process of resolution

Answer 92

Employee Satisfaction, Engagement, and Retention -Employee Satisfaction Surveys -Types -Collection of data -Interpretation of data -Implementation of results to improve employee satisfaction -Employee engagement and empowerment -Mentoring programs -Employee Retention Methods -Exit Interviews -Methods for reducing absenteeism -Turnover -Rate calculation -Cost of turnover – direct and indirect QUIZ AND ACTIVITY

Answer 93

Cultural Competence and Diversity Awareness -Creation of training programs related to diversity and cultural competency -Establishing a culture of inclusivity that encourages employees to embrace employee and care recipients' rights -Reporting procedures for employees to report any violations of resident and employee rights by state or federal law. QUIZ AND ACTIVITY

Answer 94

Labor Relations (e.g., union, collective bargaining [CBA], contract/pool staff) -Union maintenance agreements -Collective Bargaining -Contracted staff -National Labor Relations Act (NLRA) -Negotiation -Arbitration -Mediation CROSSWORD

Answer 95

Organizational Staffing Requirements and Reporting (e.g., PBJ) -Sufficient staffing -Nursing -Dietary -Reporting requirements -Vaccine (as required) -Payroll based Journal (PBJ) -Staff posting requirements ACTIVITY

Answer 96

Staff Certification and Licensure Requirements -Staff Licensing requirements -Administrator -Social Worker -Staff certifications -Certified Nursing Assistants -Feeding Assistants -Activity professionals

Answer 97

Professional Development (e.g., maintenance of credentials, continuing education) -Nurse aide required continuing education -Staff competencies -Licensed nurses -Nurse aides -Behavioral services -Dietary staff

Answer 98

Employee Training and Orientation -Staff orientation requirements -Mandatory In-services, i.e., abuse, advance directives, fire safety, infection control, resident rights, etc. -Nurse Aide Requirements -Required training and testing -Time frames for certification completion -Nurse Aide Registry -Recertification

Answer 99

Performance Evaluation -Nurse aide performance evaluation requirements -Staff evaluation of performance to meet the requirements of the position

Answer 100

Employee Record-Keeping Requirements -Confidentiality of employee information, i.e., protected health information (PHI), release of photos, etc ACTIVITY

Answer 101

Cultural Competence and Diversity Awareness -Ensuring team members are aware of cultural preferences and respect both employee and residents rights -Recognize and develop training specific to cultural competencies including: -Knowledge -Religious beliefs -Dietary preferences ACTIVITY

Answer 102

Federal Codes and Regulations for Building, Equipment, Maintenance, and Grounds -National Fire Protection Association (NFPA) -Life Safety Code (LSC) -American National Standards Institute (ANSI) -Safe Medical Devices Act -International Building Code -Centers for Medicare and Medicaid Services (CMS) -Food and Drug Administration (FDA) -Environmental Protection Agency (EPA) -Americans with Disabilities Act Accessibility Guidelines (ADAAG) -Occupational Health and Safety Administration (OSHA) QUIZ

Answer 103

Person-Centered Environment (e.g., home-like environment) -Lighting -Temperature -Sound -Room Design -Space Personalization

Answer 104

Safety and Accessibility (e.g., ADA, safety data sheets) -Safety Data Sheets -Americans with Disabilities Act (ADA) -Water Temperatures -Ventilation -Fire Systems/Sprinklers -Secure Doors/Locking Systems -Proper use of Chemicals and Products -Nurse Call Systems -Bed Rails ACTIVITY

Answer 105

Facility Management and Environmental Services -Linens Supply -Groundskeeping -Supply Management (e.g., paper towels, toilet paper, etc.) -Cleaning Schedule -Cleaning Process (e.g., floor surfaces, walls etc.)

Answer 106

Information Systems Infrastructure (e.g., configurations, data security, technical controls) -Backup Systems -External Data Storage Areas -Preventative Maintenance for Computer Hardware -Cybersecurity and Monitoring -Software Updates/Upgrades MORE INFO

Answer 107

Preventative and Routine Maintenance Programs (e.g., pest control, equipment, mechanical systems) -Temperature Checks and Logs -Lock Out Tag Out -Pest Control -Work Orders -Maintenances Log -Physical Appearance (e.g., painting, floor maintenance, grounds upkeep, etc.) -System Upkeep (e.g., water, electrical, plumbing, etc.) -Company Vehicles PICTURE CLICK ACTIVITY

Answer 108

Infection Control and Sanitation -Linen Handling -Handwashing -Healthcare-acquired Infections -Kitchen Sanitation -Infection Prevention and Control -Handling of Hazardous Materials -Isolation Procedures ACTIVITY

Answer 109

Disaster and Emergency Planning, Preparedness, Response, and Recovery (e.g., Appendix Z) -Disaster/Emergency Plan -Fire Drills -Emergency Generators -Evacuation Routes -Emergency Supplies -Hazard Identification -Emergency Equipment Testing and Maintenance -Transfer, Transportation, and Relocation Agreements ACTIVITY

Answer 110

Federal Codes and Regulations for Building, Equipment, Maintenance, and Grounds -National Fire Protection Association (NFPA)/Life Safety Code (LSC) Chapters 18 and 19¨ -Centers for Medicare and Medicaid Services (CMS) State Operations Manual, Appendix PP -Centers for Medicare and Medicaid Services (CMS) State Operations Manual, Appendix Z -National Fire Protection Association (NFPA) 101, Life Safety Code¨ -National Fire Protection Association (NFPA) 99, Standards of Health Care Facilities¨

Answer 111

Person-Centered Environment (e.g., home-like environment) -Adequate and Comfortable Lighting Levels -Glare reduction -Use of Daylight -Extra lighting -Night lighting -Comfortable and Safe Temperature Levels -Comfortable Sound Levels -Overhead paging -Chair and Bed alarms -Physical Layout -Safety considerations -Personalization -Closet space -Use of personal belongings, (e.g., bedspreads, curtains, recliner, lamps, etc.) -Maximizing independence -Room Size ACTIVITY

Answer 112

Safety and Accessibility (e.g., ADA, safety data sheets) -Importance of Ventilation -Outside ventilation -Mechanical ventilation -Resident Call Systems -Bed Rails -Appropriate use -Entrapment Risk -Installation and Maintenance ACTIVITY

Answer 113

Facility Management and Environmental Services providing a physical environment that: -promotes resident independence without posing safety risks. -protects residents’ property from loss or theft. -provides housekeeping/maintenance tasks that maintain an orderly, sanitary internal environment. -Linen Conditions -Groundskeeping -Maintain free of hazards -Upkeep

Answer 114

Preventative and Routine Maintenance Programs (e.g., pest control, equipment, mechanical systems) A good preventative maintenance plan is important as it usually provides a long term cost savings because it: -avoids breakdowns that can be costly to fix when rushed. -delays the need to replace equipment that may otherwise wear out earlier than expected. -minimizes interruption in vital services provided to residents. -Pest Control – Maintaining an effective pest control program

Answer 115

Infection Control and Sanitation (e.g., linens, kitchen, hand washing, healthcare-acquired infections, hazardous materials) -Linen -Handling -Process (e.g., clean linen, dirty linen, etc.) -Having an Infection Preventionist on staff including: -Their role and qualifications for hiring -Proper onboarding and ongoing training requirements -Kitchen employee safe contact with food to avoid infections (e.g., proper handwashing, washing of food/utensils before cooking, and cleaning food prep. surfaces) QUIZ

Answer 116

Disaster and Emergency Planning, Preparedness, Response, and Recovery (e.g., Appendix Z) -Disaster/Emergency Planning -Emergency Power Supply -Emergency Equipment Testing and Maintenance -Transfer Agreements with Hospitals for emergency situations -Written -Timing -Use

Answer 117

Federal Healthcare Laws, Rules, and Regulations -Centers for Medicare and Medicaid Services (CMS) -Centers for Disease Control and Prevention (CDC)

Answer 118

Government Programs and Entities (e.g., Medicare, Medicaid, waivers) -Knowledge and coverage of Government programs and entities such as: -Medicare -Medicaid -Home and Community Based Waivers -Policy & Memos to States and Regions | CMS – As new interpretations are issued through CMS, you can find these policy memos here pertaining to all lines of service. ACTIVITY

Answer 119

Federal Healthcare Laws, Rules, and Regulations -Nursing Homes | CMS -Centers for Disease Control and Prevention (CDC) -Omnibus Budget Reconciliation Act (OBRA) of 1987 -State Operations Manual for Nursing Homes - Appendix PP -Policy & Memos to States and Regions | CMS - As new interpretations are issues through CMS, you can find these policy memos here pertaining to all lines of service. -QSEP - Driving Healthcare Quality (cms.gov) – Training videos provided by CMS can be found here. -Social Security Law of 1965 -Elder Justice Act

Answer 120

Government Programs and Entities (e.g., Medicare, Medicaid, waivers) -Knowledge and coverage of Government programs and entities such as: -Medicare -Medicaid -Waivers - Home and Community Based -Other waivers -Life Safety Code (LSC) -Room Requirements -Staffing

Answer 121

Certification and Licensure Requirements for the Organization -Requirements for licensure to operate and receive government funds -Closure of a facility - voluntary and involuntary -Certifications and recertifications -Swing Beds QUIZ

Answer 122

Regulatory Survey and Inspection Process -providing needed information to surveyors or inspectors, -being able to access and share any documents the surveyors or inspectors request, and -cooperating with the inspection in a non-defensive manner. -Survey Procedures as prescribed by CMS in Appendices P and PP (e.g., protocols, frequency, interpretive guidelines, etc.) -Types of surveys, i.e., unannounced, complaint, extended, partial extended, standard, etc. -Statements of Deficiency (2567) -Elements of an acceptable Plan of Correction Survey terminology such as: -Immediate Jeopardy (IJ) -Substandard Quality of Care (SQC) -Substantial Compliance (SQ) -Scope and Severity (SS) -Allegation of Compliance (AOC) Enforcement Remedies such as: -Civil Money Penalties (CMPs) -Loss of Nurse Aide Training -Denial of Payment for New Admissions -Termination -Directed Plan of Correction -Temporary Manager -Directed In-Service Training -State Monitoring Key Time Frames such as: -Imposition of Civil Money Penalties (CMPs) Due dates for 2567 -Notice requirements -Mandatory imposition dates, i.e., automatic termination, automatic denial of payment for new admissions ACTIVITY

Answer 123

Procedures for Informal Dispute Resolution (IDR) -Informal Dispute Resolution (IDR) -Purpose -Elements -Independent Informal Dispute Resolution (IIDR) -Purpose -Elements -Qualifications

Answer 124

Centers for Medicare and Medicaid Services (CMS) Quality Measures -Purpose -Types -Short Term -Long Term -Five Star Rating System -Care Compare MORE INFO

Answer 125

Quality Assurance and Performance Improvement (QAPI) -Quality Assurance and Assessment (QAA) Committee -Purpose -Members -Records -Quality Improvement -Data Collection -Monitoring -Root cause analysis -Responsibility -Activities VIDEO

Answer 126

Bed-Hold Requirements -Policy -Notice -Readmission

Answer 127

Pre-Admission Screening and Resident Review (PASRR) -Purpose -Types -Level I -Level II -Coordination -Exceptions -Referrals -Timing of Completion -Definitions -Intellectual Disability (ID) -Mental Disorder (MD) -Persons with Related Conditions -Rehabilitative Services for MD or ID -Specialized Services for MD or ID

Answer 128

Facility Assessment -Intent -Elements -Resident population -Resources -Community-based Risk Assessment -Completion and update requirements

Answer 129

Organizational Structures (e.g., departments, functions, systemic processes) Establishment of a functional organizational structure is crucial as it: -facilitates the grouping of people and activities -assigns roles and responsibilities to requisite individuals and/or departments -establishes proper lines of delegating and reporting among groups of people -Policies, procedures, and skills related to compliance with applicable federal and state laws, rules, and regulations -Effective communication strategies -Quality improvement measures and processes -Organizational structure and lines of reporting -Roles and Responsibilities of various departments -Coordination of departments to effectively deliver care -Process and systemic improvement ACTIVITY

Answer 130

Organizational Change Management -Policies, procedures, and skills related to assessing organizational needs -Strategically develop effective methods to meet those needs -Communicate the need for change to individuals affected -Monitor process improvements to meet goals and objectives -Recognition of the role of leadership in change management ACTIVITY

Answer 131

Organizational Behavior (e.g., organizational culture, team building, group dynamics) -Policies, procedures, and skills related to assessing organizational culture -Assessment of the organizational culture -Defining and driving the desired organizational culture -Team building and employee engagement -Managing group dynamics

Answer 132

Leadership Principles (e.g., communication, styles, mentoring, coaching, personal professional development) -Modeling effective leadership skills -Appropriate mentoring and coaching of managers and staff – ACHCA's Mentoring program -Leadership programs that develop managers, leaders, and all employees -Effective written, oral, interpersonal, and electronic communication skills -Development of personal leadership skills ACTIVITY

Answer 133

Governance (e.g., board of directors, governing bodies, corporate entities, advisory boards) -Policies, procedures, and skills related to ensuring compliance with applicable federal and state laws, rules, and regulations. -Identifying different types of governing structures depending on the organizational type (e.g., for-profit vs. non-profit; corporate vs. stand-alone) -Rules and responsibilities of governing bodies Managing board and stakeholder relationships ACTIVITY

Answer 134

Professional Advocacy and Governmental Relations -Advocating for educational standards -Advocating for standards of practice -Advocating for changes in governmental oversight and regulations -Advocating to government entities on behalf of the organization

Answer 135

Mission, Vision, and Value Statements -Varied approaches and skills for leading stakeholders in the development of the mission, vision, and values of the organization. -Communicating and facilitating “buy-in” to the mission, vision, and values. -Creating an atmosphere of confidence and execution of the mission, vision, and values. ACTIVITY

Answer 136

Strategic Business Planning (e.g., new lines of service, succession management, staffing pipeline) -Methods and skills relevant to developing a strategic plan. -Conducting effective business practices with the endorsement of the governing body. -Conducting community needs assessments. -Analyzing the internal organization and the external market. -Involvement of appropriate stakeholders in the strategic planning process. ACTIVITY

Answer 137

Business Analytics (e.g., evidence-based practice, data analytics) -Utilization of practices based on measurable evidence. -Usage of feasibility studies to determine a market strategy. -Using quantitative methods to interpret data. -Incorporating internal and external data in planning and decision-making. ACTIVITY

Answer 138

Business Development (e.g., sales, marketing, partnerships, ACOs, contracts and agreements, negotiations) -Developing and executing a successful marketing plan. -Growing consumer awareness of available options. -Identifying and engaging in partnerships with a variety of health-care entities. -Exploring opportunities for collaboration. -Understanding negotiations. MORE INFO

Answer 139

Public Relations and External Stakeholders (e.g., hospitals, referrals sources, local community, donors) -Awareness of the spectrum of care services available in their community. -Skills related to fostering positive stakeholder relationships. -Community engagement strategies. -Public relations practices.

List of Needed Knowledge Flashcards

(163 cards)