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NURSING HOME ADMINISTRATOR LICENSUREEXAM REVIEW COURSE

National Exam ◘ MODULE 4

FORM B

referencsect

Administration

Speed ReaderExamination 1

Examination 2

Examination 3

Examination 4

Stan Mucinic, LNHA

Module 4 Administration Copyright © 2005-2012 by Stan Mucinic. All rights reserved. 0 of 26

Legal NoticesStudents enrolled in the “National Nursing Home Administrator Licensing Course” are purchasing the professional knowledge of the instructor to assist the student to prepare for the national licensure exam administered by the National Association of Boards of Examiners (NAB).

This is a 5-week intensive independent study program designed to provide students a unique personalized and structured learning environment where progress is monitored by the instructor through email to help students maintain focus and complete scheduled assignments timely.

THE INSTRUCTOR MAKES NO EXPRESS OR IMPLIED WARRANTY OR REPRESENTATION OF ANY KIND THAT COMPLETION OF THIS OR ANY LICENSURE PREPARATION COURSE OFFERED BY INSTRUCTOR WILL GUARANTEE A PASSING SCORE ON ANY LICENSING EXAM. An individual’s ultimate success in passing the licensure exam is dependent on an individual’s professional experience, academic preparation, and the time and energy the individual can commit to exam study and preparation. A student’s work schedule or other commitments may require more time to prepare for an exam than allotted. The student is solely responsible for licensing exam registration/testing and retesting fees.

HOW TO USE THE STUDY GUIDES

Step 1 – VERY IMPORTANT - The personalized test organizer that comes with the program is the key to your success and sets this program apart from any other. It is critical you follow the instructions and score each exam, and file the completed exams into your binder. Try to keep to the schedule and email your test results to the instructor to stay focused.

Step 2. - Speed Reader – Read the speed reader for each module once or twice before taking the module exam(s). Read the speed reader over and over again until you familiarize yourself with its contents. THE MORE TIMES YOU LOOK IT THE MORE LIKELY YOU ARE TO REMEMBER IT.

Step 3 – Exam Packet - The exam packet contains questions designed to measure your comprehension and retention of the material you read. Take each exam over and over again until you score 100%. Make sure you score each exam and record the results in your organizer or you will not be able to gauge your progress.

The exam questions are cross referenced to the speed reader to allow you to quickly find and review material you missed on the exam as follows:

Thus, the specific material would be found on page 2 of the speed reader, section 1.8, subparagraph 13.

Contact InformationEmail Stan Mucinic at [email protected] with any questions and after you score each practice exam


2/1.8(13)Page Number Section number

mailto:[email protected]

Administration - Table of Contents

1 Quality of Care 42 Measures of Quality 43 Federal and State Standards 44 Management Information Systems 55 Medical Staffing Model 56 Management Functions Model 57 Important Trends – Forecasting 58 Important Trends – Organizing 59 Important Trends – Planning 5

10 Important Trends – Staffing 611 Important Trends – Directing 612 Important Trends – Evaluating 713 Important Trends – Controlling Quality 714 External Forces 715 Important Trends – Innovating 716 Important Trends – Marketing 717 Marketing Strategy 818 Marketing Challenges 819 Marketing and Public Relations 820 Consumer Decision Model 821 Decision to Enter Facility 822 Marketing Tools 923 Buyer Readiness States 924 Consumer Satisfaction Surveys 925 Conflict Resolution 926 Grievance Procedures 927 Oral/Written Communication 928 Barriers to Communication 1029 Tailor Communication to Individual 1030 Formal/Informal Communication 1031 Flow of Communication 1032 Communication Technology 1033 Risk Management 1034 Survey and Licensure Process 1135 Survey Process 1136 Quality Indicator Reports 1137 Online Survey Certification Reports (OSCAR) 1138 Survey Outcomes 1139 Severity Levels of Non-Compliance 1140 Scope of Deficiencies 1241 Substandard Quality of Care 1242 Remedies of Non-compliance 1243 Informal/Formal Dispute Resolution 1244 Accreditation Organizations 1245 Organizational Concepts 1246 Systems Theory 1347 Policies and Procedures 1348 Leadership Theories 1349 Management Theories 1450 Systems Theory 1651 Norms, Values and Employee Motivation 1552 Delegation of Authority 1753 Command Concepts 17


Administration - Table of Contents (Cont’d)

54 Line vs Staff Authority 1756 Management Levels 1757 Nursing Home Management 1758 Departments Functions 1859 Facility Organization Chart 1960 Governing Body Duties 1961 Administrator Duties 2062 Federal Rules 2063 Nurse Aide Education/Training 2064 Professional Organizations 2165 OBRA ‘87 2166 Survey Deficiencies 2267 Resident Care 2268 Ownership Patterns 2269 Payor Sources 2270 Legislation 2271 Occupancy Statistics 2372 Demographics 2373 Technology 2374 Medical Director 2375 Quality Assessment and Assurance Committee 2376 CMS Quality Standards 2377 Demming 2478 Technological Support 2479 Miscellaneous 3180 Financial terms


AdministrationSECTION 1 - QUALITY OF CARE1.1 - QUALITY OF CARE

1. Every facility uses some quality improvement model2. Must monitor quality indicators, identify problems and fix them3. Quality of care indicators:

a. Resident rightsb. Quality of lifec. Financial performanced. Consumer satisfactione. Infection rates

4. Various Quality Improvement Models:

a. Performance Improvement Model

1. Least involved and effective model2. Involves making small changes3. Is not a comprehensive or interdisciplinary approach

b. Quality Assurance Model

1. Has its roots in quality assurance committee2. Focused mainly on clinical issues3. Not typically comprehensive or interdisciplinary

c. Continuous Improvement Model

1. Requires involvement of senior managers2. Focuses on continuously improving consumer satisfaction3. Involves an interdisciplinary effort

d. Total Quality Management Model (TQM)

1. Most effective and comprehensive2. Comprehensive, interdisciplinary approach to continuously improve all facets of

operations and consumer satisfaction3. Takes 5-10 years to implement4. Requires total involvement of management5. Empowers frontline staff6. Requires intensive training of staff7. Objective is to exceed customer expectations8. Must improve quality totally, continuously and forever

SECTION 2 - MEASURES OF QUALITY2.1 - MEASURES OF QUALITY

1. Structure – Staff, building equipment2. Process – Policies and procedures3. Outcome – Quality of life of residents (pressure sores, dehydration)

SECTION 3 - FEDERAL/STATE STANDARDS3.1 - FEDERAL/STATE STANDARDS


1. Federal/State standards supersede corporate policies2. Survey and inspections are an important form of external feedback on quality


SECTION 4 – MANAGEMENT INFORMATION SYSTEMS4.1 - MANAGEMENT INFORMATION SYSTEMS

1. Must have a system to organize and prioritize flow of information in facility2. Must determine what information to receive, where it comes from, the priority and process to receive it.

SECTION 5 - FACILITY MEDICAL STAFFING MODELS5.1 - FACILITY MEDICAL STAFFING MODELS

1. Open Staff Model – Any physician can attend residents (most used)2. Closed Staff Model – Only approved group of doctors can see residents – used in facilities with hundreds of

patients

SECTION 6 - MANAGEMENT FUNCTIONS MODEL6.1 - MANAGEMENT FUNCTIONS MODEL

1. Forecasting – Project trends and needed resources and services2. Planning – Identify objectives and desired outcomes3. Organizing – Determine the structure of the organization and ensure work is done without duplication4. Staffing – Hiring the right people for the right job5. Directing – Explain what needs to be done and help staff accomplish it6. Evaluating – Compare actual results to planned results7. Controlling Quality – Taking necessary corrective action8. Innovating – Constantly improving the ways things are done9. Marketing – Attracting people to the facility

SECTION 7 - IMPORTANT TRENDS – FORECASTING7.1 - IMPORTANT TRENDS – FORECASTING

1. Prior to 1987 and the shift to the prospective payment system, change was slow and gradual2. Retrospective payment Is based on actual expenses and produced huge profits for nursing facilities3. Rapid changes can be expected now and in the future4. During 70’s and 80’s, administrators could make long term decisions and plans5. Today, change happens too quickly to know what reimbursement rates be tomorrow6. Lifespan of new technology is 18 months7. The core business of long term care may be entirely different in 20208. Nursing staff is experiencing culture shock9. Mankind’s knowledge is expected to double every 5 years10. Survival tomorrow is based on accurately forecasting trends11. Must change constantly to adapt to changes in environment12. If you don’t fix it all the time, it will break

SECTION 8 - IMPORTANT TRENDS – ORGANIZING1. Ensuring work gets done2. Breaks work into tasks to be handled by one person3. Ensures no duplication of work

SECTION 9 - IMPORTANT TRENDS – PLANNING9.1 - IMPORTANT TRENDS – PLANNING

1. Planning expresses organizational goals


2. Planning involves an integrated decision system3. Planning aids managers in coping with uncertainty4. Planning makes possible comparing expected results with actual results5. Strategic planning is critical to survival6. Planning forces an assessment of what services the market will need tomorrow7. Planning moves from the general to the specific

SECTION 10 - IMPORTANT TRENDS – STAFFING10.1 - IMPORTANT TRENDS – STAFFING

1. Staffing involves hiring the right person for the right job2. A job interview is not a predictor of future performance3. Adequate staffing is critical to success in a nursing home4. Resident interaction with staff determines resident quality of life5. Resident acuity level determines staffing needs6. Must hire department heads with expertise because of the complexity of regulations7. The number of registered nurses is key to quality care

SECTION 11 - IMPORTANT TRENDS – DIRECTING11.1 - IMPORTANT TRENDS – DIRECTING

1. Directing involves communicating to employees what needs to be done2. Directing involves developing policies and procedures that allow employees to make the same decisions

given the same circumstances3. It is possible to develop policies and procedures to direct employee behavior 24 hours a day and

communicate exactly what management expects

SECTION 12 - IMPORTANT TRENDS – EVALUATING12.1 - IMPORTANT TRENDS – EVALUATING

1. Must compare expected results to actual results2. Policies and plans of action are the guidelines to compare outcomes to expectations3. Policies are broad statements of goals4. Guidelines are step-by-step instruction on how to do something5. A plan of action has specific procedures to implement a policy6. Benchmarking involves:

a. Comparing current business practices with the “best practices” of other organizationsb. Benchmarking process involves:

1) Deciding what to benchmark2) Forming a team3) Selecting partners4) Collecting and analyzing info5) Implementing new methodologies

c. Should adapt the “best practices” of other organizations and must not adopt them in total since they may not work the same way for your organization (different culture)

d. Enablers are practices leading to exceptional performance

7. Controlling quality has always been an elusive aspect of successful management8. Organizational pathology deals with illnesses that affect an organization

9. Key quality indicators of a nursing home:


a. The number of registered nursesb. The nursing process itself

SECTION 13 - IMPORTANT TRENDS – CONTROLLING QUALITY13.1 - IMPORTANT TRENDS – CONTROLLING QUALITY

1. Control is the act of taking corrective action after evaluating expected to actual results2. Control involves modifying policies and processes3. Need to provide clear and accurate info to employees4. Corrective action must be taken consistently and timely5. Make clear what is relevant and what can be discarded6. Control mechanisms must be seen as legitimate and relevant7. Managers who avoid confrontation fail to take action

SECTION 14 - EXTERNAL FORCES14.1 - EXTERNAL FORCES

1. Opportunities in the environment include an aging population and managed care contracts2. Constraints in the environment include government regulation

SECTION 15 - IMPORTANT TRENDS – INNOVATING15.1 - IMPORTANT TRENDS – INNOVATING

1. If you don’t fix it all the time, it will break2. The administrator does not need to be the innovator but must foster change and be an agent of change3. Do not make policies but give employees a sense of direction4. Do not make policies that inhibit change5. Make policies that foster innovation6. Tom peters - Innovation is critical to success and must be continual7. Government standards are now considered maximal standards as opposed to minimal standards8. Staff will only become agents of change if they believe changes are necessary9. Implement both good and bad employee suggestions10. Must make changes even if staff is not ready (change is not a comfortable process)

SECTION 16 - IMPORTANT TRENDS – MARKETING16.1- IMPORTANT TRENDS – MARKETING

1. Must attract higher paying customers2. Must market services that customers need and are willing/able to pay for3. When a facility reaches premium status – staff tends to slack off and the facility falls to the bottom of the

pack4. In 1997, the U.S. supreme court ruled illegal the self imposed advertising ban on nursing homes5. Competition is when 2 or more organizations seek to serve the same customer6. Average occupancy rate was 82% in 1992; a facility needs 90% occupancy to break even7. Market sharing – Fighting for a slice of an existing market8. Market creation – Creating new services not offered by anyone else9. Medicaid is the largest payor for long term care10. Private pay is the second largest payor source for long term care

SECTION 17 - MARKETING STRATEGY17.1 - MARKETING STRATEGY


1. Market Audit – Involves gathering data from the external environment to assess the facility’s needs and includes:

a) Performing a demographic breakdownb) Identifying services in demandc) Assessing environmental constraints

2. Potential market – Customers express some interest in services

a. Potential Market – All potential customers who express some interest in a product offeringb. Available Market- Those have an interest but lack the money to buy your productc. Qualified Available Market – Those that have an interest but additionally the money and access to buy

the product or service offeredd. Served market – Those who a facility made an effort to attract to the facilitye. Penetrated market- Actual customers who have bought your products

3. Market Segmentation – Involves slicing the market into subgroups – income, age and demographics4. Market Mix – Choose which services to market

a. Product mix – Various product linesb. Product line – Mix of product itemsc. Product item – Single service or product

5. Implement and evaluate marketing plan – Create awareness among consumers6. Creating a new service not offered by competitors is called market creation

SECTION 18 - MARKETING CHALLENGES18.1 - MARKETING CHALLENGES

1. Intangibility – Customer cannot experience services before entering a facility2. Inconsistency – Quality of services vary from shift to shift, and from day to day3. Inseparability – Cannot separate perception of poor service by one employee from other services provided by

facility4. Inventory – Each unoccupied bed bears costs

SECTION 19 - MARKETING AND PUBLIC RELATIONS19.1 - MARKETING AND PUBLIC RELATIONS

1. Must have a marketing and public relations plan and update it annually2. Marketing is promoting the sale and distribution of a service3. Public relations is communicating information about the facility to the community and consumers

SECTION 20 - CONSUMER DECISION MAKING MODEL20.1 - CONSUMER DECISION MAKING MODEL

1. Problem recognition2. Information search3. Alternate evaluation4. Post purchase evaluation

SECTION 21 - DECISION TO ENTER FACILITY21.1 - DECISION TO ENTER FACILITY

1. A decision to enter a facility is based on the belief that the facility can meet the resident’s needs2. Subliminal perceptions from a facility tour is the key to deciding whether to enter a facility


SECTION 22 - MARKETING TOOLS22.1 - MARKETING TOOLS

1. Key referral sources

a) Doctors and hospital discharge plannersb) Word of mouth

2. Most effective advertising – Word of mouth3. Least effective advertising – Radio/TV4. Most effective marketing tools – Tour of the facility5. Paid media (TV/newspaper ads) are impersonal forms of advertising

SECTION 23 - BUYER READINESS STATES23.1 - BUYER READINESS STATES

1. Cognitive – Consumers aware of the facility2. Affective – Consumer selects a facility after comparing it with others3. Behavioral (Consumer is convinced choice was right)

SECTION 24 - SURVEY CONSUMER SATISFACTION24.1 - SURVEY CONSUMER SATISFACTION

1. Short term residents – Should survey short term residents of satisfaction within 30 days after discharge2. Long term residents – Should interview short term resident satisfaction annually3. Families focus on food quality4. Discharge planners focus on rehab5. Physicians focus on their relationship with nursing staff

SECTION 25 – CONFLICT RESOLUTION25.1 - CONFLICT RESOLUTION

1. First clarify the issue2. Identify what each person wants3. Identify a solution4. Negotiate a solution5. Confirm the agreed upon solution with the parties6. Any resolution should have positives for both sides

SECTION 26 - GRIEVANCE PROCEDURE26.1 - GRIEVANCE PROCEDURE

1. Document all grievance complaints2. Respond to grievances as quickly as possible 3. Use the resident council for feedback

SECTION 27 - ORAL/WRITTEN COMMUNICATION27.1 - ORAL/WRITTEN COMMUNICATION

1. Communication is the transmission of meaning2. A message must be sent and received, decoded and understood for communication to take place3. Communication is power and so is withholding information4. The closer to the center of power, the more important the communication5. Active listening is listening intently, with empathy and acceptance6. Communication is the heart of the management process


SECTION 28 - BARRIERS TO COMMUNICATION28.1 - BARRIERS TO COMMUNICATION

1. Agenda Carrying – Employees skew information based on personal needs2. Selective Hearing - Employees filter unpleasant information (incapable of understanding)3. Differences in Knowledge – People perceive information differently based on knowledge4. Filter Effect – Tells manager only what they think the manager wants to hear5. Subgroup Allegiance – A subgroup demands allegiance from its members (nurses, kitchen staff)6. Status difference – Staff hesitant to approach a member of a higher status – nurse aide to doctor7. Language barrier –Staff does not understand technical jargon8. Self protection- Staff withholds information that reflects negatively on themselves9. Information overload - Too much information and staff shuts down

SECTION 29 - TAILOR COMMUNICATION TO INDIVIDUAL29.1 - TAILOR COMMUNICATION TO INDIVIDUAL

1. Written information reinforces oral communication

SECTION 30 - FORMAL/INFORMAL COMMUNICATION30.1 - FORMAL/INFORMAL COMMUNICATION

1. Formal Communication – Communicating through memos, meetings and follows lines of the organization chart2. Informal Communication – Staff chatting informally in the break room

SECTION 31 - FLOW OF COMMUNICATION31.1 - FLOW OF COMMUNICATION

1. Downward Communication – Communication from a superior down to a subordinate2. Upward Communication – Communication from a subordinate up to a superior3. Horizontal Communication – Communication between peers4. Grapevine – The company rumor mill

SECTION 32 - COMMUNICATION TECHNOLOGY32.1 - COMMUNICATION TECHNOLOGY

1. Email – Electronic communication through internet or intranet2. Firewire – Transfers video recorded on a camcorder to a computer3. Blue tooth – Connects cell phones and keyboards to a computer (wireless communication)4. High frequency radios (i.e., walkie talkies)

SECTION 33 – RISK MANAGEMENT33.1 - RISK MANAGEMENT

1. Risk management involves managing the risks of negative outcomes in the workplace2. Risk is an event that could lead to financial loss or damage3. The main focus is to prevent injury, theft, malpractice and negligence4. The Federal Employer Liability Act holds employers directly financially responsible for injuries to employees5. A facility usually has a risk management committee6. The facility is responsible for damage caused by employees to others under “Respondeat Superior” (The

employer must answer for the acts of their employees)7. The facility is not responsible for acts of independent contractors8. Assault and battery is the leading cause of lawsuits (includes providing treatment without informed consent)9. Effective Risk Management Program includes:

a. Early interventionb. Completed incident reports and tracking trends


c. An active safety committee

10. The U.S. tort system is ineffective because malpractice drains money from resident care and doctors order unneeded tests and practice “defensive medicine”

SECTION 34 - SURVEY AND LICENSURE PROCESS34.1 - SURVEY AND LICENSURE PROCESS

1. The government licensure process helps the nursing home industry to maintain standards and quality, and to reduce lawsuits

2. All facilities must be licensed by the state 3. Medicare and Medicaid facilities must be certified to receive reimbursement 4. The inspection process focuses on OUTCOMES (quality of resident life) 5. Before OBRA 1987, the focus was “process”6. The federal survey program has 5 different survey types

SECTION 35 - SURVEY PROCESS35.1 - SURVEY PROCESS

1. Task 1 – Offsite prep (review OSCAR, complaints, ombudsman reports, waivers)2. Task 2 – Entrance Conference (meet with staff, discuss survey)3. Task 3 – Initial Tour (walk through facility)4. Task 4 – Sample Selection (collect targeted resident records)5. Task 5 – Info Gathering (collect findings from survey team)6. Task 6 – Info Analysis (review findings of the team and violations)7. Task 7 – Exit conference (discuss survey finding with facility staff)

SECTION 36 - QUALITY INDICATOR REPORTS FROM CMS36.1 - QUALITY INDICATOR REPORTS FROM CMS

1. Facility characteristics2. Facility quality indicator profile3. Resident level summary

SECTION 37 - ONLINE SURVEY CERTIFICATION REPORTS (OSCAR)37.1 - ONLINE SURVEY CERTIFICATION REPORTS (OSCAR)

1. Report #3 = facility compliance history2. Report #4= Last survey report

SECTION 38 - SURVEY OUTCOMES – REPORT TO ADMINISTRATOR38.1 - SURVEY OUTCOMES – REPORT TO ADMINISTRATOR

1. Notice of isolated deficiencies (minimal problems, no plan of correction needed)2. Form 2567 (non compliant deficiencies, plan of correction required, maybe resurvey)

SECTION 39 - SEVERITY LEVELS OF NON-COMPLIANCE39.1 - SEVERITY LEVELS OF NON-COMPLIANCE

1. Level 1 - No more than minor negative impact2. Level 2 - Minimal physical, mental or psychosocial discomfort3. Level 3 – Compromised the resident’s ability to maintain highest practical level of functioning4. Level 4 – Risk of immediate injury, harm or impairment or death to a resident


SECTION 40 - SCOPE OF DEFICIENCIES40.1 - SCOPE OF DEFICIENCIES

1. Isolated – Affects a limited number of individuals/locations2. Patterned – Affects more than a limited number of individuals/locations3. Widespread – Entire population of facility is impacted

SECTION 41 - SUBSTANDARD QUALITY OF CARE41 - SUBSTANDARD QUALITY OF CARE

1. The facility will be cited for substandard care if cited for non-compliance for resident behavior, facility practices, quality of life and quality of care standards

2. There must be evidence of immediate jeopardy of injury or death

41.2 - Letter coding on F Tags Tags G and above are substandard care – actual harm

NO ACTUAL HARM BUT POTENTIAL FOR HARM

A - no harm no potential harm just a few affectedB - no harm no potential harm - more than a few affected C - no harm- no potential harm most affected D - no harm -potential harm just a few affected E - no Harm - potential for harm- more than a few affectedF - no harm - potential or harm - most people affected

SUBSTANDARD CARE – ACTUAL HARM

G -actual harm- just a few affected- no immediate JeopardyH - actual Harm - more than a few affected- not IJI - actual harm - most people affected- no IJJ - actual harm - limited affected - IMMEDIATE JEOPARDYK- actual harm - More than a few- IMMEDIATE JEOPARDYL Actual Harm - Most affected - IMMEDIATE JEOPARDY

SECTION 42 - REMEDIES FOR NON-COMPLIANCE42.1 - REMEDIES FOR NON-COMPLIANCES

1. Level 1 Remedy – a) Directed plan of correction, b) State monitor, c) Required in-service2. Level 2 Remedy – a) Denial of payment of new admissions and b) Daily fine of $3000-$50003. Level 3 Remedy – a) Temporary receiver, b) Termination of contract and c) Daily fine $3050 -$10,000

SECTION 43 - INFORMAL/FORMAL DISPUTE RESOLUTION43.1 - INFORMAL/FORMAL DISPUTE RESOLUTION

1. Informal dispute resolution– Appeal by writing a letter to challenge surveyor findings2. Formal dispute resolution – Request a hearing before an administrative judge

SECTION 44 - ACCREDITATION ORGANIZATIONS44.1 - ACCREDITATION ORGANIZATIONS

1. JCAHO – A private voluntary organization which accredits nursing homes, hospitals and other facilities, conducts inspections every 3 years, and imposes money fines for non-compliance, facilities accredited by JCAHO are exempt from state inspection

2. CARF – Commission on Accreditation of Rehabilitation facilities accredits rehab and therapy facilities3. Membership in both attracts managed care contracts and is a seal of high quality

SECTION 45 – ORGANIZATIONAL CONCEPTS45.1 - ORGANIZATIONAL CONCEPTS

1. Organizational growth is unlimited2. Entropic Process – All organisms move toward death3. Negative Entropy – Re-energizes an organization with life and money4. Organizations must grow by bringing in more resources than they expend5. Unrestricted resources foster unrestricted growth (i.e. Medicare dollars)


6. As they grow, organizations force the world around them to accommodate their needs7. Organizations tend to resist change8. Arteriosclerosis is organizational hardening of the arteries resulting from resistance to change9. A company on top today can quickly find itself fall tomorrow because of a deep reservoir of outmoded attitudes and policies10. Organizations commonly respond to change by:

a. Firing employees who agitate for changeb. Maintaining the status quoc. Ignore signs for the need to changed. Buying out the competitione. Policies and procedures are sacred cows and cannot be changed

11. The following promote positive outcomes for troubled organizations:a. Decreasing costs but not valueb. Putting the right person in the right jobc. Out position the competition

SECTION 46 - SYSTEMS THEORY46.1 - SYSTEMS THEORY

1. Companies start out simple and then become complex; i.e. chain mergers2. It is difficult to predict how companies will react3. Systems theory gives managers tools to understand the relationship between an organization and its

environment4. Administrators tend to resist change and instead embrace outmoded polices and attitudes

SECTION 47 - POLICIES AND PROCEDURES47.1 - POLICIES AND PROCEDURESS

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1. Policies are written by upper and middle management2. Procedures are written at the middle and lower management levels3. Staff must follow all policies and procedures

SECTION 48 - LEADERSHIP THEORIES48.1 - LEADERSHIP THEORIES

1. Passion makes an exceptional leader and fosters employee commitment2. Leadership continuum

a. Dictatorial – Manager issues edicts to employeesb. Democratic – Manager leads by consensusc. Laizze Faire – Manager sets the big picture and delegates details to staff

3. Effective Leaders:

a. Mediate temperb. Promote loyaltyc. Care and respect employeesd. Share decision making powere. Behave in different leadership styles

4. Successful managers make right decisions and no disastrous ones5. Great Leadership Theory – History is shaped by great leaders6. Charismatic Leadership theory - charismatic leaders have a magical presence, their decisions are unexamined


and people have strong confidence in that person7. Management and leadership are not the same8. Leaders change while managers merely adapt9. Management focuses on performance and results10. Managers must take external action when required11. Home health care is the fastest growing sector in the health care industry12. Leaders challenge the status quo and inspire staff by vision13. The key role of an administrator – make decisions14. Primary focus of decisions – resident care and welfare – not profits15. All managers use some theory of management16. Managers believe they can manage anything17. Need administrators because plans go awry and someone needs to respond18. Any employee can sabotage a company by following policies to the letter19. Once hired, employees turn to co-workers for knowledge of what to do

SECTION 49 – MANAGEMENT THEORIES49.1 - QUALITATIVE/QUANTITATIVE MANAGEMENT

1. Quantitative management method – managing through reports2. Qualitative management method – motivating, empowering and challenging staff

49.2 - MANAGEMENT BY WALKING AROUND (MBWA)

1. Walk around each day and observe – DO NOT MAKE ANY CHANGES on the spot2. Naïve listening3. See first hand how things are working4. Maintain the chain of command5. Gather info and pay attention to detail

49.3 - MANAGEMENT BY OBJECTIVES

1. Objectives defined by the bottom and then moved to the top decision makers2. Purpose is to get buy-in from staff with upper management making final decision3. Focus is on setting clear goals with definite timeframes

49.4 - MANAGEMENT BY EXCEPTIONS

1. Respond only to exceptions and variances

49.5 – PERT (PROGRAM EVALUATION AND REVIEW TECHNIQUE

1. Shows relationship of elements in a project (renovating a wing/Gantt chart)

49.6 - SCIENTIFIC MANAGEMENT THEORY

1. Using time and motion studies to improve efficiency

49.7 - HUMAN RELATIONS MANAGEMENT THEORY

1. Recognize the need to meet employee psychological and social needs and the power of social groups

49.8 - COMPUTER MANAGEMENT THEORY

1. Use computer software to analyze data and manage facility systems (MDS, Budgeting)

49.9 - EFFICIENCY/EFFECTIVENESS CONCEPTS

1. Efficiency is producing results with minimum expense2. Effectiveness is producing quality work in relation to the effort expended3. Increasing number of staff (cost) will not necessarily produce better outcome (effectiveness) as staff divides

work to ease burden on them all -not exert greater effort4. Must achieve balance between efficiency and effectiveness, cannot focus on one at the expense of the other


49.10 - MASLOW’S HIERACHY OF NEEDS

1. Five levels of need:

a. Food-water-airb. Safety and securityc. Love-acceptanced. Power-worth-recognitione. Fulfill potential

2. Cannot motivate employees with higher needs (acceptance) unless they have food to feed their family (must meet primary needs first)

3. Relationships between co-workers is a key motivating factor

49.11- MCGREGOR’S X-Y THEORY

1. Theory X – (X = No/Negative response)

a. The manager believes workers naturally dislike workb. The manager uses fear and punishment to motivate workers

2. Theory Y – (Y=yes/positive response)

a. The manager views workers as responsible and want to do a good jobb. The manager uses positive rewards and reinforcement to achieve goals

49.12 - HERZBERGERS TWO FACTOR THEORY

1. Hygiene factors – causes only dissatisfaction does not foster satisfaction/retention

a. Attractive work environmentb. Necessary computer and work toolsc. Clean and safe environmentd. Basic benefits

2. Motivators – fosters job satisfaction

a. Recognition of work effortsb. Promotions

49.13 - THEORY Z

1. Worker motivation dependent on shifting societal values2. Workers in a facility placed in moratorium for dangerous resident care may feel shame and dissatisfaction in

working for the facility and leave the job

49.14 - TOM PETERS THEORIES (DEVELOPED MANAGEMENT BY WALKING AROUND)

1. 4 key management functions

a. Care of customersb. Constant innovationc. Turned on peopled. Leadership

2. Critical factors to superior performance


a. Exceptional care and constant innovation

3. A facility sells excellent customer service and not good financial reports4. Key management attributes

a. Blinding flash of the obviousb. People skills and common sense

49.15 - KREIGEL’S THEORIES

1. The time to change is when you don’t have to2. Be totally committed to the job and burn with a passion3. Constantly push limits and challenge everyone4. Do not wait to effect change when staff is ready5. Expect to wipeout (fail) several times each day (don’t play it safe)6. Take nothing for granted7. Prepare for the unexpected8. Look for the waves on the horizon (opportunities in the future)9. If it ain’t broken today it will be tomorrow10. Don’t get lost in dealing with today’s problems11. There may be bigger and better opportunities on horizon; don’t limit options12. Stay ahead of changes and anticipate opportunities ahead13. Never surf alone because you need people to succeed14. The future belongs to those who welcome change15. Change is a continuous process16. Resisting change and innovation will allow you to survive but not thrive

49.16 - PETER DRUCKER’S THEORIES

1. No area offers more rich opportunity for success for innovation than the unexpected2. The unexpected (change) cannot be controlled3. You can only change your attitude and expectations4. Accept change is integral to living, and embrace it and use it to your advantage

49.17 - TANNENBAUM’S THEORY

1. Managers must be able to react to employees appropriately, and should not have a fixed response to all situations

49.18 - TYPES OF POWER

1. Legitimate power – Is conferred by title, rank and the org chart 2. Reward power – Motivates behavior through promotions/bonus3. Punishment power – Uses demotions, terminations, and suspensions to motivate workers4. Referent power – Is based on liking, respecting or identifying with another person5. Expert power - Recognition and respect is based on a manager’s perceived skills and knowledge6. Expert and Referent power should be used most often by managers and are also available to workers as well

SECTION 50 – SYSTEMS THEORY50.1 SYSTEMS THEORY

1. Provides a model for the daily management of a facility2. A system is an organized or complex whole3. Allen uses a model with the following elements

a. Inputs – Are people, money, patients, supplies


b. Processors – Work actually accomplished by facility – patient care, clean floors, mealsc. Outputs – Results of work performed – prevention of bedsores, tasty meals, odor freed. Control of quality – Action taken to correct deficienciese. Plans of action and policies- Guidelines used to compare actual results to planned resultsf. Feedback – External response to outputs (resident council, annual survey)g. Environment – All external forces affecting the facility (opportunities such elderly people moving into

surrounding community) and constraints (mandated min staffing)

4. Output from one system become the input for another system

Output Input Patient released from hospital Admitted to nursing home for rehab Resident released from SNF Home health care agency provides in-home services

SECTION 51 – NORMS, VALUES, EMPLOYEE MOTIVATION51.1 – NORMS, VALUES, EMPLOYEE MOTIVATION

1. Values (vague ideal) are general or vague statements regarding expected behavior (i.e. , respect resident’s dignity)

2. Norms are specific standards of specific behavior (address residents by name at all times in a normal calm voice)

3. Norms and values are used to develop employee loyalty to a facility and to control behavior4. An administrator must have zero tolerance for less than excellent resident care; uncompromising5. An administrator must lead by example and workers will follow their example6. Visions and dreams are more inspiring than slogans and goals7. Motivating statements should come from facility staff not the corporate office8. Corporate culture is overall manner facility staff interact with each other 9. Cannot expect employees to give their job undivided attention10. Problems outside the job have an impact on worker morale and their focus on their jobs (partial

inclusion/segmental involvement described employees focused on other parts of life beside their job)11. Workers can’t split personal and work lives12. The bond between workers is critical to motivating them13. Workers view a facility from the narrow perspective of their own work area14. Employees usually have no contact with upper management

SECTION 52 - DELEGATION OF AUTHORITY 52.1 - DELEGATION OF AUTHORITY

1. Decisions should be made at the lowest appropriate level2. Authority is mostly delegated to middle and lower managers3. Should delegate authority to people with the most knowledge and best judgment4. The administrator is still ultimately responsible for all actions of their subordinates5. The main problem with delegation is that employees can make wrong decisions

SECTION 53 - COMMAND CONCEPTS 53.1 - COMMAND CONCEPTS

1. Span of Control – The maximum number of people one manager can manage 2. Short Chain of Command – The maximum levels of command3. Balance Concept – The balance between departments re: standardized polices, scope of duties 4. Unity of Command – Each worker should be responsible to only one supervisor

SECTION 54 - LINE VS STAFF AUTHORITY1. Line Authority – Any individual empowered by the administrator to make decisions on behalf of the facility- i.e.,


the DON, asst administrator, and department heads2. Staff /advisory function – Staff with no authority to act for a facility – housekeeper, nurse aide, charge nurse,

dietician, medical director – have staff or advisory role

SECTION 55 – EMERGENCY LINE AUTHORITY 1. Ordinarily, corporate staff have only an advisory status while in a facility, but in emergency, corporate officers

can exercise line authority and give staff direct orders

SECTION 56 - MANAGEMENT LEVELS1. Upper management – The administrator is the upper management level

a) Interacts with the governing board/ownerb) Makes policy that affects all employees

2. Middle Management – the DON and department heads

a) Policies only impact employees in their own departmentb) Reports to upper managementc) Needs good communication skills to deal with upper and lower management

3. Lower management – Charge nurse and front line supervisors

a) Direct supervisory role over direct care staff

SECTION 57 - NURSING HOME MANAGEMENT57.1 - NURSING HOME MANAGEMENT

1. The administrator’s authority is constrained by the presence of licensed personnel in a facility2. Power is the ability to control others3. Administrators have real power4. Power is a complex concept in our society

5. 100 bed facility typically has

a. 17 departmentsb. 8-9 department heads

6. 200 bed facility and larger will have:

a. Six mid-level managers

7. An assistant administrator has line authority8. An administrative asst to the administrator has no line authority9. The nursing home administrator:

a. Develops budgetsb. Leads staffc. Is responsible for quality of care

SECTION 58 – DEPARTMENTS/FUNCTIONS58.1 – DEPARTMENTS/FUNCTIONS

1. Administration Departmenta. Monitors financial performanceb. Hires key staffc. Develops the budget


d. Coordinates all work in the facility2. Advisory or allied health department includes the:

a. Resident councilb. Medical director

3. Medical records department is responsible to:

a. Maintain clinical recordsb. Must have a full-time records person

4. Admissionsa. Screen patients to determine medical conditionb. Consult with DON to verify if facility can meet needs of prospective new admissionc. Markets services to doctors and the community

5. Dietary department is responsible to:a. Responsible for nutritious and appetizing mealsb. Long term residents tire of same food week after week

6. Social Services department is responsible to:

a. Help residents adjust to facility lifeb. Monitor resident’s psycho-social well beingc. Work closely with activities director

7. Housekeeping department is responsible to:

a. Maintain Infection controlb. Keeps facility clean and odor free

8. Laundry department is responsible to:

a. Ensure linens, table cloths towels clean and good conditionb. Minimize spread of germs

9. Maintenance department is responsible to:

a. Ensure facility and equipment are maintained in good working orderb. To perform preventative maintenance

10. Business office is responsible to:

a. Maintain payroll recordsb. Maintain financial records (clinical records kept by nursing dept)c. Maintain accounts receivable and payablesd. Generate financial reports

11. Personnel/Human Resources department is responsible to:

a. Maintain personnel records, resumes, references, background checks (no payroll records)

SECTION 59 - FACILITY ORG CHART59 - FACILITY ORG CHARTS

1. Each facility must have an organization chart2. Solid lines indicate direct authority over an individual


3. A dotted line indicates an advisory role (dietician, medical director)

SECTION 60 - GOVERNING BODY DUTIES60.1 - GOVERNING BODY

1. A facility must have a governing body or designated person to establish and implement policies to operate the facility

2. The governing body appoints a licensed administrator3. The governing body is responsible to manage the facility4. The governing body has legal responsibility for the operation of the facility (i.e., adopt policies and hire an

administrator and to ensure proper operation of the facility)5. The governing body creates and adopts the mission statement6. The governing body is ultimately responsible for the operation of the facility7. The governing body has authority to make critical decisions for the facility8. The governing body establishes the organization’s mission9. The governing body establishes the basis for strategic planning 10. The governing body evaluates the facility and the administrator’s performance11. The governing body has both express and implied authority

a) Express authority– Conferred by statute or lawb) Implied authority – Conferred by corporate bylaws

12. The governing body is not personally liable for the wrongs of employees 13. The governing body is specifically responsible for:

a) Compliance with all state and federal lawsb) To ensure the administrator is licensedc) Provide adequate staff and insuranced) To ensure financial stabilitye) To safeguard patient valuablesf) To require competitive biddingg) Provide quality and timely treatment

SECTION 61 – ADMINISTRATOR DUTIES61.1 – ADMINISTRATOR/GOVERNING BODY DUTIES

1. Administrator is responsible for the day-to-day operation of facility2. Administrator carry out policies set by the governing body3. Administrator’s authority is delegated by the board4. Administrator fine tunes the boards strategic plans5. The foundation of the organization is the Philosophy 6. Bylaws specify organizational structure and are the governance of a corporation – “by these laws we run this

corporation” and specifies the

a) Board composition b) How the corporation is to be run and how to resolve common management issuesc) Place and time of board meetingsd) Number of shares of stock to be issued

SECTION 62 - FEDERAL RULES62.1 - FEDERAL RULES

1. Must administer the nursing facility efficiently and effectively to maintain residents’ highest practicable physical, mental and psychosocial well being

2. The facility must be licensed under state law and display all necessary licenses and permits to operate a facilityModule 4 Administration Copyright © 2005-2012 by Stan Mucinic. All rights reserved. 21 of 26

3. The facility must employ on a full-time, part-time or on a consultant basis, all staff needed to provide required services

4. Professional staff must be licensed or certified as required by law5. If a facility does not employ any required professionals, they must contract to do so and assume full responsibility

for the services performed by a contractor6. Facilities that are Certified for Medicare and Medicaid must surveyed according to federal standards; facilities not

certified for Medicare and Medicaid are subject to state standards only

SECTION 63 - NURSE AIDE EDUCATION/TRAINING 63.1 - NURSE AIDE EDUCATION/TRAINING

1. To serve as a nursing assistant in any nursing home, a person must be either a(n):

a) Certified as a nursing assistant b) Registered nurse or practical nursec) Applicant for nurse licensure permitted to practice nursing

2. Temporary Service – 4 months or less

a) Individuals who are not certified nursing assistants may be employed for 4 months if: 1. The individual is enrolled in or has completed, a state-approved nursing assistant program; or2. The individual is verified as actively certified and on the registry in another state with no findings of

abuse, neglect, or exploitation in that state; or 3. The individual has preliminarily passed the state's certification exam.

STATE CERTIFICATION MUST BE COMPLETED WITHIN 4 MONTHS AFTER INITIAL EMPLOYMENT

3. Aide Screening Requirements

a) Must require each nursing aide to provide a complete employment history b) The facility must verify employment history unless not possiblec) Background screening is required for all employees or prospective employees whose responsibilities may

require them to: 1. Provide personal care or services to residents; 2. Have access to resident living areas; or 3. Have access to resident funds or other personal property.

4. Aides are required to have an annual performance review

a) Nursing aides employed 12-months or longer must submit to a performance review every 12 months b) Nursing aides must receive regular in-service education based on the outcome of such review each year

5. Aides must have 16 hours of initial training to be certified in: (state certification course)

a) Communication skillsb) Infection controlc) Safety and emergency proceduresd) Promote resident independencee) Respect resident rightsf) Basic nursing and personal care skillsg) Mental health needsh) Social services needsi) Cognitively impaired residentsj) Resident rightsk) Restorative services

6. Must have a minimum of 12 hours of in-service training each year to maintain certification


7. Must address areas of weakness identified in nursing assistant performance reviews and may address the special needs of residents as determined by the nursing home facility staff.

8. State surveyors determine whether a nurse aide is competent9. Nurse aides are supervised by RN’s and Lon’s10. Volunteers, student nurses and private duty aides are not nursing aides and cannot be used as such.

SECTION 64 - PROFESSIONAL ORGANIZATIONS64.1 - PROFESSIONAL ORGANIZATIONS

1. American Health Care Association (AHCA)

a) Represents 12,000 for-profit/non profit LTC facilitiesb) Focuses on political and economic issues

2. American Association of Homes and Services for the Aging

a) Primarily represents non-profits

3. American College of Health Care Administrators

a) Represents long term care administrators

SECTION 65 – OBRA ‘8765.1 – OBRA ‘87

1. OBRA 1987 also known as the “Nursing Home Reform Act”2. OBRA 1987 dramatically decreased reimbursement to facilities via the Prospective Payment system3. Retrospective payment is reimbursement of full costs after services provided4. Prospective payment is a fixed amount based on acuity5. OBRA 1987 set forth uniform licensing requirements for administrators6. The American Academy of medicine did a study that documented poor care in nursing homes and lead to enactment of OBRA 19877. OBRA stands for Omnibus Budget Reconciliation Act8. OBRA 87 switched focus of surveys from process to outcomes 9. Hundreds of hospitals closed in late 80’s due to OBRA 1987

SECTION 66– DEFICIENCIES66.1 – DEFICIENCIES

1. Major citation for dietary was for unsanitary conditions2. Only 3% of facilities are cited each year for resident rights violations3. 50% of residents are chair bound4. Percentage of bed bound residents between 1993-1999 remained unchanged

SECTION 67 – RESIDENT CARE67.1 – RESIDENT CARE

1. New residents see placement in a nursing home as a loss of independence2. 40% of nursing home residents do not require nursing home care

SECTION 68– OWNERSHIP PATTERNS68.1– OWNERSHIP PATTERNS

1. Size and type of ownership have no impact on resident care2. No expected increase in the number of new nursing homes over the next 5 years3. More nursing home beds are in the north than the south4. The expected rise in the elderly population does not mean a rise in demand for long term care5. There are approximately1.6 million nursing home beds in U.S.


6. There are approximately 17,000 licensed nursing homes, 15,000 are certified7. Approximately 1.5 million people live in nursing homes8. 56% of homes are chain owned9. There was a large number of bankruptcies of nursing homes in 200010. 1.5 %of seniors 65 and older live in a nursing home11. There are 1,570,000 certified Medicare nursing home beds

SECTION 69– PAYOR SOURCES69.1 – PAYOR SOURCES

1. Medicaid pays 68% of long term care 2. Private pay is second largest pay source for long term care3. Medicaid beneficiaries must spend down all but $2000 of assets 4. Home health care is the largest growing sector in health care5. Both Medicare Part A and B pay for home health care6. Nursing homes must shift costs to private pay residents

SECTION 70 – LEGISLATION70.1 – LEGISLATION

1. The Hill Burton Act pumped billions into building new hospitals and nursing homes2. The National Health Planning and Resources Act requires a Certificate of Need before building

a hospital or nursing home 3. Title 20 of the Social Security Act of 1974 created a home health care benefit4. OASAI – Old Age Survivors Disabled program was the precursor to the social security act5. The Kerr Mills Act was the precursor to Medicaid – health benefits for the poor6. Medicare and Medicaid passed in 1965 as an amendment to the Social Security Act7. An amendment to the Social Security Act of 1967 required licensing of all administrators8. Utilization review is done to determine if treatment provided to patients was effective and cost

efficient9. A Certificate of Need is issued if it is determined the community can absorb the additional beds

– must avoid under and over capacity 10. The CMS stands for the Center for Medicare and Medicaid Services

SECTION 71– OCCUPANCY STATISTICS71.1 – OCCUPANCY STATISTICS

1. Occupancy rates in nursing homes continue to drop2. A facility needs a 90% occupancy rate to breakeven3. Average occupancy in 1999 was 82%4. Average Medicaid and private pay stay in nursing homes is 1000-1100 days5. Average Medicare stay is 30 days6. Total Medicare stays per year 971,967 days

SECTION 72– DEMOGRAPHICS72.1 – DEMOGRAPHICS

1. Old age 85+ is the largest growing sector of population2. 1 in 5 age 65 and older will spend sometime in nursing home3. The average size of a nursing home facility is 104 beds4. 1 in 20 Americans between 65-74 reside in an institution5. 1 in 10 Americans between 75-84 reside in an institution6. By 2030 18-20% of population will be 65 and older (1 in 5)7. Most nursing home residents are female


SECTION 73 – TECHNOLOGY73.1 – TECHNOLOGY

1. Every 10 years 25% of all knowledge is outdated2. Technology is outmoded every 18 months

SECTION 74 - MEDICAL DIRECTOR74.1 - MEDICAL DIRECTORS

1. The medical director is responsible to implement resident care policies2. The medical director must ensure the residents’ medical needs are met3. The medical director can substitute for an attending physician in an emergency4. The medical director must counsel physicians not meeting federal, state and professional

responsibilities5. Medical director assists the DON in providing care

SECTION 75 – QUALITY ASSESSMENT AND ASSURANCE COMMITTEE75.1 – QUALITY ASSESSENT AND ASSURANCE COMMMITTEE

1. Must have the DON, a physician (maybe the medical director), and three members of staff on the committee

2. The administrator is not required to be a member of the committee3. The committee must meet at least quarterly4. Must identify deficiencies with respect to resident care and resident services

SECTION 76 – CMS QUALITY STANDARDS 76.1 – CMS QUALITY STADARDS

1. Quality standards mandated by the CMS (centers for Medicare and Medicaid Services) are considered de juere (required by law))

SECTION 77 – DEMMING

77.1 – DEMMING

1. Optimize team efforts2. Emphasize quality over price3. Eliminate production quotas4. Teach leadership skills

SECTION 78 – TECHNOLOGICAL SUPPORT SYSTEMS 78.1 – TECHNOLOGICAL SUPPORT SYSTEMS

1. Nursing homes can use technological support and information systems to track

a) Infection ratesb) Referral sourcesc) Skin condition

2. The administrator must analyze and use the quality data collected


SECTION 79 – MISCELLANEOUS 79.1 – MISCELLANEOUS

1. Long term care includes

a) Assisted livingb) Nursing home carec) Continuing care communities

2. Managing is a complex task that is not fully understood by the social sciences3. An intentional act or threat causing fear in another with reasonable expectation of harm is called

assault4. Nursing home administrators should develop a culture of commitment5. Administrators must use a combination of leadership and management skills6. Administrators must focus on results and operations7. Management and leadership are not the same8. Administrators must handle daily operations ad take action when required9. The current focus is to move individuals from institutional care to home health care which is less

expensive10 National Institute Occupational Safety and Health provides research for OSHA11. Intentional touching of another person without their consent is called battery12. Civil law focuses on torts and disputes between private individuals13. The fundamental law of the U.S. that establishes the responsibilities and rights of federal courts is the U.S. Constitution14. The rate of increase in total nursing homes between 2005-2020 is likely to level out

SECTION 80 – KEY TERMS

Term DefinitionDecentralization Decentralizing decision making in an organization increases

efficiency and allows for greater expansion and growth as middle and lower managers share responsibility for managing operations

Minimum square footage of a resident room

The square footage of resident room does not include the hallway, vestibule, closet and bathroom since this is not usable living space

Practice Control Acts State laws that control licensed nurses

Resident Charts Surveyors are less concerned with the frequency of charting than they are with documentation of sufficient progress in chart

Resident Rights Resident rights are spelled out in OBRA 1987 and actually include a Resident Bill of Rights that specifies what every resident in every nursing home is entitled to (i.e. 80 sq feet per person in a semi private room.)

Survey Types Standard survey - annual survey (every 15 months) Abbreviated Standard Survey - for a complaint survey Extended survey - where substandard care is cited in an annual survey Partial Extended Survey - Where substandard care is found during


a complaint survey Resurvey - where the survey time re-enters and verifies citations were correct from initial survey

Width of Resident Bedroom

The width of a bedroom is determined by the state. How many residents can be placed in a room is determined by federal law.


Study Notes

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