HIPPA
RISK
COMPLIANCE/ETHICS
QAPI
CODE OF CONDUCT
100

HIPPA applies to:

What is All of the above - Kendal at Lexington employees, volunteers, and contractors such as therapy staff

100

What are the goals of the Risk Management Program?

What are

  • Continuously improve Culture of Safety and prevent the occurrence of accidents, injuries and other adverse events to residents, staff, volunteers, visitors, and others, through proactive risk and quality management activities
  • Minimize adverse effects of injuries or accidents when they do occur
  • Minimize losses to the organization overall by proactively identifying, analyzing, and intervening in potential clinical, business, and operational risks. Also, to protect human and intangible resources (e.g., reputation)
  • Facilitate compliance with regulatory, legal, and accrediting agencies
100

Who is the Compliance Official?

Who is Noelle Guill

100

What does QAPI stand for?

Quality Assurance Performance Improvement 

100

The Code of Conduct is a guide to:

What is appropriate workplace behavior

200

What are examples of Protected Health Information (PHI)?

What is birthday, picture, address, social security number - anything that can identify a person and their health information.

200

What are the Risk Management Program components? 

What are

  • Direction under Senior Level Executive
  • Written Risk Management policy and plan
  • Consistent risk management activities in all settings and locations
  • Centralized communication and analysis of risk
  • Sharing of lessons learned across levels of care and facilities
200

What is the goal of the compliance program?

What is prevent, detect, and correct fraud, waste, and abuse; to help everyone make the right decisions if you are not sure how to respond to a situation; to serve residents while following all applicable local, state and federal laws, regulations and guidelines. 

200

What is QAPI?

QAPI is a comprehensive approach used in nursing homes to maintain and improve the quality and safety of the care we provide. It combines two aspects: Quality Assurance (QA), which involves setting standard and ensuring the care meets these standard, and Performance Improvement (PI), which focuses on continuous effort to improve care and services. 

200

The Code of Conduct states our commitment as:

What is committed to providing care and services that are ethical, lawful, and professional. Every employee and individual is expected to act with integrity, follow applicable healthcare laws and regulations, and protect the safety, dignity, and well-being of residents, coworkers, and the organization.

300

What rights do residents have under HIPPA?

What is right to restrict who see their health information, right to request a copy of their medical records, right to receive a notice of privacy practices, right to view medical record, right to file a complaint with us or OCR without retaliation, right to receive confidential information in a specific format, right to request an amendment/correction if personal information is incorrect, right to know who has access to their medical information. 

300

What is the Risk Management Process?

What are 

1. Identify the Risk

2. Analyze the Risk

3. Evaluate or rank the Risk

4. Treat the Risk

5. Monitor and review the Risk

300

What is the Compliance Hotline?

All of the above - It is a way to report an illegal, irresponsible, or ethically questionable situation; is available 24 hours/day, 7 days/week, 365 days per year; it can be anonymous; it is an avenue to report situations without fear of reprisal, retaliations, or punishment. 

300

What are the 5 elements of QAPI?

What is

1. Design and scope

2. Governance and leadership

3. Feedback, data systems, and monitoring

4. Performance improvement projects (PIPs)

5. Systematic analysis and systematic action

300

Who must abide to the Code of Conduct?

What are employees, board members, physicians, and contractors. 

400

How does Kendal at Lexington work to prevent breaches?

What is keep PHI away from public access, shred paper with PHI, keep conversation private away from resident or family areas, use screen savers on computers while unattended, do not share passwords, do not take pictures of residents, do not discuss anything about residents or Kalex on social media, do not text any information about residents on your personal phone. 

400

What are Risk Management examples?

What are falls; UTI; behavioral concerns; new admissions; antibiotics; skin/wounds; CHF (congestive heart failure)

400

To make a compliance program effective, everyone needs to do their part by: 

All of the above - conduction audits and reviews in their area; correcting errors and/or processes when identified; offer suggestions for improvement; report known or suspected violations. 

400

What are the staff roles in QAPI?

What is

1. Reporting and feedback

2. Participation

3. Continuous learning

400

What are the 6 aspects of the Code of Conduct?

What are Residents rights and care; Professional conduct; Workplace safety; Documentation and billing; Confidential and proprietary information; Accountability; Reporting concerns.

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