Quality Management and Improvement Plan 2023
It is the intention of this Plan to ensure that personal care services and related therapies provided by Whitemarsh House are maintained at a standard of care which is satisfactory to residents and meets all compliance requirements. This plan outlines the commitment towards implementing compliance standards to prevent, detect, and resolve operational issues while observing both company-specific and statuary regulations. The Quality Management and Improvement (QM&I) Plan is the vehicle for facilitating the highest quality and continuous improvement of care, services, and outcomes for residents in accordance with our mission.
For this reason, the following quality management and improvement procedures will be implemented as part of this Plan:
Goals Achieved from Prior Plan (2020) and from Relevant CARF Recommendations.
1. A quarterly review of reportable incidents and other critical care issues, including the quality of the conditions under which services are provided, medication administration and management and plans of correction will be conducted by the management team on a quarterly basis. Continuous compliance with all aspects of the corrective action plan will be maintained at 100%.
2. The Resident Council will meet monthly to give voice to resident/consumer issues. Resident Council meeting will be attended by more than one member of the management team once a quarter. The PCH Administrator will maintain data from meetings in the form of minutes.
3. The procedure for forwarding resident suggestions and complaints to the management team through the Resident Council will include having the PCHA and the Safety Officer attend the Resident Council meetings to survey resident satisfaction; the minutes of this meeting will be distributed to the QM Team for discussion at its quarterly meeting.
4. A review of all complaints and the documentation of the resolution. The PCH Administrator will track the resolution of complaints. Resident satisfaction or dissatisfaction with the resolution of the complaint will be tracked. The goal will be to achieve 90% resident satisfaction with complaint resolutions.
5. Staff training on issues of quality management and improvement will be provided as part of an on-going training program(s) which address issues of personal care and treatment of residents vis-a-vis all PCH and OLTL regulations.
6. A review of staff training to include all required training is done and documented. This will include a review of all training topics. The PCH Administrator will compile all sign-in sheets and any other required data to assure all staff have been trained.
7. The management team will develop a specific set of indicators designed to measure the quality of services provided and address those areas in need of improvement during periodic review and evaluation of services; these may include, Food & Meal Preparations, Environment and Housekeeping, House rules and Resident Satisfaction.
8. A random audit of billing will review the type, scope, frequency and duration of billable services. This will be done in addition to the every 10-day review done by the PCH and the Controller. 100% compliance.
9. A review of facility compliance with criminal background checks. 100% of new hires will be screened and 100% of personnel files will include required documentation of the criminal record. Data will be reviewed via personnel file audit under the supervision of the PCH Administrator.
10. A review of facility compliance with Social Security Number verification and monthly checking of employees for exclusion. The Controller will maintain and track records for 100% compliance.
11. This Quality Plan will be reviewed and monitored as part of the quality process. The quarterly meetings will be reflected in minutes.
12. A quarterly report will be given to the Board of Directors on quality assurance activity.
13. A report on the progress in meeting facility goals and objectives will be completed in the form of an annual review of programs.