The three person panel needs to investigate all complaints or concerns that are presented to the Board. Typically, any administrative tag will result in an inquiry by the committee. The board must investigate complaints but takes into consideration compliance history, tenure of employment as the Administrator of Record, and the individual complaint received. Sometimes, it closes the case without inquiry, other times it must get the administrator perspective as to why this happened and compare the response to the community or peer standard.
Any OHFC finding that involves resident rights or a MDH substandard care finding in quality of care, quality life or Facility Practices and resident rights will be reviewed by the SOPC. The standard response from the SOPC is to request the administrator perspective of why the finding was identified while focusing on administrative systems only.
Be brief and to the point in the response. The committee desires that you involved your team, looked at the root cause of the problem and identify how to achieve system correction. They know it's a challenge, but expect you to think resident first and make progressive changes.
Not necessarily. The board does receive all substandard quality of care, quality of life and resident behavior and facility practices findings per federal requirements. The three person complaint panel looks at the findings to determine if those findings are significantly out of industry or community standards. How do they compare to the industry trends, what is the facility and administrator history for compliance, and how did the facility respond? The SOPC is concerned with a forward response and action to resident centered improvements. The administrator should be engaged in the QI/QA process using all of the multidisciplinary teams talents to work towards continuous improvement of this and other issues presented. The committee will ask for the administrators assessment of the identified problem, solutions presented and action plans delivered. A lack of action is inexcusable. A planned, coordinated, best effort is usually assessed as acceptable.
The complaint becomes public if formal action is warranted by the committee, is written in a formal document that is eventually agreed upon by the licensee and the board. Information is only public when classified as public and investigatory material is considered private or confidential, neither of which can be made public unless a formal agreed upon stipulation and order is determined.
Just Culture is a model of assuring accountability and responsibility without assigning individual blame for all cases that the BENHA believes creates transparency and accountability. For some cases, an individual is the only person that should and will be held individually accountable. For most cases, the system or unintentional actions by an individual need to be coached, counseled and educated for changes within the system. Just Culture originated in the airline industry where it was determined that individual blame produces more cover ups, avoidance of large issues and consequences which ultimately creates an unsafe environment.
The Best Practices-Change Package for Administrators is a great tool developed by Stratis Health, as the Quality Improvement Organization (QIO) contracted with the Center for Medicare and Medicaid Services. This tool kit can help reinforce a seasoned administrator as well as assist a newer administrator with basic reminders of proven action steps to reinforce the administrators global core competencies. Stratis Health is an excellent partner for the Executive Administrator of Long Term Care Supports and Services with various quality improvement projects, www.stratishealth.org.