Created 7/17/2024
Facility Management
Network requirements for facilities, separate from EQRS/QIP but required as part of the Network Agreement.
Emergency Preparedness Critical Access Survey: Updated annually each September by facility, includes emergency contacts and planned activities.
Network/Facility Agreement of Participation: Required to complete upon initial CMS certification, available to update as needed.
Coalition: Groups of facilities assigned special projects for 6-month duration. Once C1 ends, C2 begins, then when C2 ends, C3 begins, etc.
OY IPRO Learn Compliance Completed Rate: Learning Management System required for facilities to participate. Each year resets the score, counting completion rate of required activities that year.
Facility QIP Score
Most current facility rate and prior year rate, with payment reduction over time.
Immediate Jeopardy Information
Immediate Jeopardy (IJ): (State Survey Agency Terminology) situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death.
Dates and outcomes of any Patient Immediate Jeopardy cases opened by/at the facility.
If table blank = none.
Patient Experience of Care (PEoC) Case Types
Types and quantities of patient care cases opened by/at the facility during this CMS contract – broken out by years.
Access to Care: Patient is “at-risk” or “confirmed” losing their admission status at a facility, or has difficulty accessing care due to: behavior, medical need, or facility refusal.
Clinical Quality of Care: The rights of two or more patients have been violated OR service received from a facility did not meet professionally recognized standards of clinical care and/or professional conduct.
Facility Concern: Patient/staff have a concern related to the facility, that does not meet criteria of Grievance nor Access To Care case.
General Grievance: Communication from a patient/representative alleging that the facility did not meet professionally recognized standards with respect to safety, civility, patient rights, and/or clinical standards of care.
Immediate Advocacy (IA): Simple, generally non-quality of care cases that can be completed in 10 calendar days or less
Patient Concern: General concern from a patient that does not meet criteria of Grievance nor Access To Care case.
QIA Facility Report Card Details
CMS-required, Network-assigned annual facility goals. Network sends monthly Report Cards to all facility staff on file, with detailed progress towards goal.
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