Performance Improvement Indicator Efficiency:
Risk Management 2023

Since risk management at Whitemarsh House is a generalized procedure with overall facility goals, it is not necessary to incorporate separate plans for the Residential cluster and the Home and Community cluster. These standards and procedures continue to apply equally to all residents, staff and visitors to the facility and to the overall sound fiscal planning necessary to support operations.

Risk Management activities at Whitemarsh House are documented in the policy and procedure and the quality assurance meeting agendas as recorded by the Executive Director who chairs these meetings. These reports are provided under separate cover. Risk management activities may also be ascertained through interviews with the Executive Director, Controller, Clinical Director, Personal Care Home Administrator, and Nurse Manager.

This report serves as a supplement to those activities as a general overview of the efficiency of the risk management process.

Goals Achieved from Prior Plan (2020) and from Relevant CARF Recommendations.

1. Risk Management Plans were assessed at least annually by facility Administration. Achieved and Ongoing

2. Assured that Executive Director convened and documented the Quality Assurance Reviews and that this was attended by facility management personnel. Also reviewed documentation of the agenda regarding these meetings. Achieved Winter 2020 and Ongoing

3. Management continued to assess implementation of risk management measures described in first paragraph above. Achieved January 1, 2020 and Ongoing

4. Input on risk management was solicited from families and other stakeholders as well as various team meetings and administrative contacts. Achieved through Satisfaction Surveys (See Satisfaction Performance Improvement Report) Families Input Achieved but Stakeholder Input Not Achieved 2020

5. Obtained input on risk management activities from residents. Achieved 2020 and Ongoing

6. Educated staff and obtained input from staff on risk management. Achieved: Ongoing

Performance Improvement Targets 2023

1. Substantial risk is presented by the Coronavirus. Ongoing consideration and assessment of the wide-ranging implications touching all facets of operations will be part of all quality improvement activities. Target Date: March 19, 2023 and Ongoing.

2. A full risk management plan will only be implemented after consideration of input from residents, families, stakeholders and staff, update current risk management procedures. Target Date: April 1 2023

3. Share the risk management plan with residents, families, stakeholders and staff. This will be accomplished via the web site and through the other means described above. Target Date: March 1, 2023

4. Be prepared for further revision of this “final” set of procedure in the event that this publishing of the procedure provokes further suggestions for revision. Target Date: April 22, 2023

5. Continue with all risk management activities as described in #1-4 above. Target Date: April 22, 2023

6. Continue to implement revised feedback loop from line staff on critical resident incidents. Target Date: Ongoing