Quality of Care Review Program. The Compliance Committee shall ensure that, within 120 days after the Effective Date, Extendicare establishes and implements a program for performing internal quality audits and reviews (hereinafter “Quality of Care Review Program”). The Quality of Care Review Program shall be designed to determine:
i. whether the residents at Extendicare are receiving the quality of care and quality of life consistent with professionally recognized standards of care, 42 C.F.R. Part 483, and any other applicable federal and state statutes, regulations, and directives;
ii. whether Extendicare is effectively reviewing quality of care related incidents and completing root cause analyses;
iii. whether Extendicare’s action plans in response to identified quality of care problems are appropriate, timely, implemented, and enforced; and
iv. whether Extendicare’s nursing staff is of the quantity, quality, and composition necessary to consistently meet resident care needs.
Quality of Care Review Program. The Compliance Committee shall ensure that, within 120 days after the Effective Date, UHS has a program for performing internal quality audits and reviews (hereinafter “Quality of Care Review Program”) that complies with the following requirements:
i. make findings as to whether the patients at the Behavioral Health Facilities are receiving the quality of care and quality of life consistent with professionally recognized standards of care and applicable federal and state statutes, regulations, and directives;
ii. review quality of care related incidents and analyze root causes for those incidents; and
iii. develop corrective action plans in response to identified quality of care problems and track the implementation and effectiveness of those plans.
Quality of Care Review Program. The Compliance Committee shall ensure that, within 180 days after the Effective Date, Xxxxxxx Lutheran establishes and implements a program for performing internal quality audits and reviews (hereinafter Xxxxxxx Lutheran Corporate Integrity Agreement “Quality of Care Review Program”). The Quality of Care Review Program shall make findings as to:
a. whether the residents are receiving the quality of care and quality of life consistent with professionally recognized standards of care, 42 C.F.R. Part 483, and any other applicable federal and state statutes, regulations, and directives;
b. whether Xxxxxxx Lutheran is effectively reviewing quality of care related incidents and completing root cause analyses; and
c. whether Xxxxxxx Lutheran’s action plans in response to identified quality of care problems are appropriate, timely, implemented, and enforced.
Quality of Care Review Program. The Compliance Committee shall ensure that, within 120 days after the Effective Date, Spring Gate establishes and implements a program for performing internal quality audits and reviews (hereinafter “Quality of Care Review Program”). The Quality of Care Review Program shall make findings as to:
i. whether the residents at Spring Gate are receiving the quality of care and quality of life consistent with professionally recognized standards of care, 42 C.F.R. Part 483, and any other applicable federal and state statutes, regulations, and directives;
ii. whether Spring Gate is effectively reviewing quality of care related incidents and completing root cause analyses; and
iii. whether Spring Gate’s action plans in response to identified quality of care problems are appropriate, timely, implemented, and managed.
Quality of Care Review Program. The Compliance Committee shall ensure that, within 120 days after the Effective Date, Vanguard establishes and implements a program for performing internal quality audits and reviews (hereinafter “Quality of Care Review Program”). The Quality of Care Review Program shall make findings as to:
i. whether the residents at Vanguard are receiving the quality of care and quality of life consistent with professionally recognized standards of care, 42 C.F.R. Part 483, and any other applicable federal and state statutes, regulations, and directives;
ii. whether Vanguard is effectively reviewing quality of care related incidents and completing root cause analyses; and
iii. whether Vanguard's action plans in response to identified quality of care problems are appropriate, timely, implemented, and reviewed for effectiveness.
Quality of Care Review Program. The Compliance Committee shall ensure that, within 120 days after the Effective Date, GGNSC establishes and implements a program for performing internal quality audits and reviews, (hereinafter “Quality of Care Review Program”).
i. The Quality of Care Review Program shall utilize MDS Quality Indicator and Quality Measure (QI/QM) data to generate reports, including:
(a) Facility reports, showing the facility-level QI/QM values and information on the MDS assessments underlying these values;
(b) Facility Comparison Reports: a summary table that includes QI/QM values for each facility covered by the CIA, permitting comparison of QI/QM values among facilities;
(c) District Comparison Reports: a summary report comparing District 63’s QI/QM values to other Districts’ QI/QM values; and
(d) Resident Reports: a resident-level report showing which QI/QM values were triggered by each resident in the District 63 Facility Report.
ii. Utilizing the internal quality audits and reviews, the QI/QM reports, and analysis of survey data, the Quality of Care Review Program shall make findings as to:
(a) whether the residents in District 63 are receiving the quality of care and quality of life consistent with professionally recognized standards of care, 42 C.F.R. Part 483, and any other applicable federal and state statutes, regulations, and directives;
(b) whether GGNSC is effectively reviewing quality of care related incidents and completing root cause analyses within District 63; and
(c) whether GGNSC’s action plans in response to identified quality of care problems within District 63 are appropriate, timely, implemented, and enforced.
Quality of Care Review Program. The Compliance Committee shall ensure that, within 120 days after the Effective Date, SavaSeniorCare Administrative and Consulting, LLC establishes and implements a program for performing internal quality audits and reviews (hereinafter “Quality of Care Review Program”). The Quality of Care Review Program shall:
i. assess whether the residents at Sava Facilities are receiving the quality of care and quality of life consistent with professionally recognized standards of care, 42 C.F.R. Part 483, and any other applicable federal and state statutes, regulations, and directives;
ii. review quality of care related incidents and complete root cause analyses; and
iii. develop corrective action plans in response to identified quality of care problems and track the implemention and effectiveness of those plans.
