by Laurie Cashman, Director of Education
Last year, Mass-ALA launched an initiative to identify industry issues, trends, and training needs; develop advocacy points and strategies; guide our committee work; and pilot new and innovative quality improvement services. This ongoing initiative involves the collection of data through a questionnaire focused on the results of interactions with regulators, including EOEA Assisted Living Certification Specialists, OSHA representatives, or state Ombudsmen.
I’m delighted to see that so many of our members have completed the questionnaire following their contact with regulators and I have data to share about it. From January through June of 2023, we’ve had 90 individuals complete the questionnaire, post-regulator visit. The chart below indicates the breakdown of the types of regulator visits. The details on some of the information shared in the questionnaire are listed below the chart.
January – June 2023
Recertification Visits 65
Other EOEA visit 4
Initial certification 1
Didn’t specify visit type 1
NOTICE GIVEN TO ALR: The majority of respondents who filled out the questionnaire after a recertification visit reported having received notices of more than 24 hours, but less than one week or slightly over one week. Only a few received notices of less than 24 hours and 2 reported receiving no notice at all. All Ombudsmen visits were unannounced, with no notice given prior to the visit.
TIMEFRAME COVERED DURING SURVEY: Recertification answers varied widely, with the longest time covered being 5 years, either 2018 – 2022 or 2019 – 2023. The shortest time covered was 16 months. Most answers fell within the 2019 – 2022 range.
DEFICIENCIES NOTED: One community reported having a “No findings” survey. In all other instances where respondents answered this question, deficiencies were noted.
DURATION OF SURVEY: Answers varied widely on this question, also. The longest duration reported was 2 days. The shortest duration reported was 1 hour and 25 minutes. The average duration was approximately 4 hours.
COMMENTS: The comments provided were overwhelmingly positive in nature, with people expressing an overall appreciation for the cooperative nature of all interactions. Some of the comments provided are listed below.
- Results of the interaction were all very positive.
- They sent an email with all of the information that they needed prior to arrival and they were very pleasant during the visit from the arrival to the departure.
- Care plans were up to date, staff had been trained on policies beforehand. We conducted a SAMM review for all staff leading up to the survey.
- Very positive.
- it was my first year here at this location and that we had major turn over in department heads and with all the change we were able to come out with only 6 infractions which to is great.
- An ombudsman dropped in for a tour and to meet with residents/families.
- Visit was positive experience; the ombudsman spoke with a few residents and one family member.
- It was very well received.
- The ombudsman was very supportive.
- I had all required documents ready before their arrival.
- Overall positive visit – a plan of correction put in place for some findings.
- We met as a team to discuss particular each specific department. We audit our individual departments monthly to keep in compliance.
- The community had been preparing for survey right along since 2019
- They were very friendly.
- We were able to provide them with a lot of information upon arrival.
- We didn’t wait to the last minute. Had most everything waiting for them when they arrived.
- Much better than years before. Very cooperative and informative.
- Surveyor was pleasant and easy to work with.
- Productive, positive.
- Excellent, very helpful.
- They gave us a list of what to provide. Very helpful.
- Very positive and respectful. All required CQI audits, Life Safety Book, Emergency Call System records, CNA skills evaluations, Fall Prevention were all current and up to date and ready for them to review.
- All three of them were uplifting, gave positive feedback along with what they found, friendly, actually felt like a great time of surveyors to talk to and trust.
- We were given the appropriate window of time to complete a plan of correction for their review.
HOW MASS-ALA CAN HELP:
Below are some of the comments regarding future assistance that respondents would like to receive from Mass-ALA.
- No suggestions at this time.
- Educational events focused on what to expect during recertification.
- What to do to prepare for recertification.
- Open communication is key – we strive to deliver high quality services every day and welcome feedback and direction when necessary.
- We had 4 surveyors for 2 days and 2 surveyors for 2 days. I felt that this was too long and was not needed.
- Continue with your education programs on E.O.E.A.
- Keep doing what you’re doing.
- Continue the quality educational programs offered.
- We would love to have an updated set of documents that would help us audit each department. Around 5-10 years ago, Mass ALA gave us a tool that we still use to this day that was helpful for us to ensure compliance in all areas EOEA focuses on during an audit. (Staff note for context on this comment: we think they are referring to the QA/QI toolkit which was updated by Mass-ALA last year and is available here (hyperlink to it).)
We’re grateful that so many of our members took the time out of their busy schedules to complete the questionnaire. These results are from the first half of this year, and I continue to compile results on an ongoing basis so that we may provide a full 2023 report when the year ends. We encourage all of you to continue to complete the post-regulator visit questionnaire for the foreseeable future. Please share your experience by accessing the questionnaire here. The information provided will be compiled and the findings reviewed in the aggregate to meet the goals stated above. Your identity will remain confidential, but the aggregate findings or anecdotal reports of issues may be shared with other members, and/or EOEA, in order to address trends and to offer support and advocacy to our membership going forward.
Your participation in this survey is critical to our being prepared to fully support you and the assisted living industry. Should you have any questions about this questionnaire or any other regulatory or quality improvement concerns, please contact Laurie Cashman, at email@example.com or 781-622-5999 x103.
As we approach the last quarter of the year, I’d like to remind you of the many educational opportunities being offered through December. I’m excited about the Annual Conference being held on November 2nd at the DCU Center in Worcester. We have a robust agenda planned, including dynamic workshops, and engaging, informative, and entertaining keynote addresses. Please visit the Mass-ALA website (insert hyperlink) for more details about the day, which will also include an impressive line-up of exhibitors at our trade show, unprecedented raffle prizes, and multiple opportunities for networking!
As always, if you have ideas on trainings or speakers that you’d like to see offered by Mass-ALA, please email me at firstname.lastname@example.org and I’ll be happy to work toward arranging it for future events.
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