Harmony Healthcare International (HHI) Blog

2017 AHCA Provider Lounge Series: Facility Assessment, A Baseline Measurement for the SNF



Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

Interview with Pam Duchene, VP of Education/Training at Harmony Healthcare International

Kris Mastrangelo, President of Harmony Healthcare International (HHI) interviews Pam Duchene, Vice President of Education and Training at Harmony Healthcare International (HHI), in the 2017 AHCA Provider Lounge.  Pam discusses not only the importance of having the facility assessment process in place, but also utilizing the facility assessment as a baseline measurement to bring skilled nursing facilities to the next level.   (Audio transcription below).


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Transcribed Audio:

Kris Mastrangelo: Welcome to the 68th Annual American Health Care Convention AHCA/NCAL. I'm pleased to interview Pam Duchene, Vice President of Education and Training for Harmony Healthcare International. Welcome Pam.

Pam Duchene: Thank you. It's great to be here.

Kris: We're meeting with a lot of people and we're talking about the regulatory and the reimbursement changes. I know that you're all over the country and what are you really focusing on…what's the hot topic?

Pam: One of the hot topics clearly is facility assessments and having the process in place. That's due, as you know, phase two…it's due by November 28 of this year; the facility assessment should be in place. And it's a comprehensive assessment of the organization, really looking at the services provided, the resources available. Their risks for hazards and vulnerabilities and then taking that a step farther and looking at competencies and how you are staffed in order to prepare your facility for the next level.

Kris: So, I know that you are assisting multiple providers with this and how are you guiding them, how are you helping them? And could they do it on their own? What is it that you add?

Pam: Well certainly an organization could do it on their own but I think it helps to have some outside eyes, you know some fresh eyes, look at things…to make sure that we're not missing the obvious. You know and sometimes within an organization they're not aware of the cultural differences that are present within that organization or what they have that's really unique; what creates that niche performance for them.

Kris: And talk to me a little bit about when…so this facility assessment will be completed, it will be in a binder but it's a living document.

Pam: Right. So, you take that facility assessment and it's like what next…? So, from that facility assessment the leadership team needs to pull together and develop that SWOT analysis. Look at where they're taking the organization to the next level, but in particular, look at what they need in terms of staffing resources. Making sure that their staff are competent for their niche products and that they're able to meet the needs of their patient population as well as look to what next, what should they do next. It's also good to use that facility assessment on an ongoing basis so to have that as a baseline measurement of where you are right now and then where do you want the organization to go and then revisiting that facility assessment so that it's an ongoing process.

Kris: That's fantastic information and once it is done and you're going to use it refining. Can you go a little bit deeper on the refinement aspect? I understand the competencies, I understand the staffing but keep going on that a little bit more because I think that when reading the regulations many a provider may have stopped short of I have to do the tool but they don't know that there's actually another end game.

Pam: The facility assessment is a snapshot in time. It is not intended to remain a snapshot in time, it's intended to be something that you use on an on-going basis so that it provides a plan for the future. It also provides a great opportunity to really look at what you're doing but then you're going to need to repeat that facility assessment. So, build on it, you know go beyond that. In terms of the competencies too - this really begins to look at the overall adequacy of staffing within the facility, which is something that's part of the five-star program but looking at the overall adequacy of staffing goes directly hand-in-hand with competency assessment - making sure that you have sufficient, and it's not just sufficient from the standpoint of administration, but also sufficient staffing resources from the perspective of the staff members, as well as from the patients in the resident population that we serve.

Kris: One last question to share with the viewers. Competencies - we hear what a competency is, but can you describe what is the practical application of a competency.

Pam: Yes. I think that there are a lot of organizations out there that are trying to tell you what competencies are. The most important aspect of that is understanding from that organization's perspective what you need in order to be competent. How do you know when a nurse is qualified to be providing care for an orthopedic patient or for a patient who's at end of life or someone who's has end-stage renal disease? How do you know when that nurse or that staff member is competent to be able to provide that care? And that's what you need to focus on. So, however you choose to do that within the organization is how you need to be able to document that…and then you have to take it to the next level and make sure that you have that competent staff member providing care.

Kris: That is great and just a little bit of last comment on it as well because you have created and presented this wonderful PHI, HIPAA PowerPoint and then you have a test at the end of it. Do you think that's something that we're going to be seeing more of in the next decade or so?

Pam: Definitely. It really is all about compliance, I mean the facility assessment is a really important piece of that but you're going to take that and you're going to build on that. Your compliance plan, similarly, you need to take that compliance plan and make sure that that's also a living breathing document within your facility and then as part of that compliance plan it includes looking at HIPAA and really making sure that you are protecting that healthcare information.

Kris: Right. And the final comment is that with the PHI, the protected health information, you can't expect the employee to abide by the rules if they don't know what PHI is. You wrote that eloquent 18-point…you know there's 18 elements of PHI, including a photograph of the patient…SO they take the class and then they do the PowerPoint, and the buildings can use it but that's a competency. They are showing that they learned something.

Pam: Exactly that's a great way of illustrating how you test competencies.

Kris: Thank you so much for talking about the facility assessment. We’re happy to see you.

Pam: Thanks.

harmony20 October 29-30 2020 Encore Boston Harbor

Topics: Facility Assessment

Kris Mastrangelo, OTR/L, LNHA, MBA


Kris Mastrangelo, OTR/L, LNHA, MBA

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