State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Florida

05/15/2003

Application for Nursing Home Gold Seal1

Refer to sections 400.235, Florida Statutes and 59A-4.200, Florida Administrative Code for regulations. Attach additional pages as necessary to respond to information requested.

Please send letter of recommendation and completed application to: 
Agency for Health Care Administration Long-Term Care Unit 
2727 Mahan Drive, MS 33 
Tallahassee, FL 32308 
Phone (850) 488-5861   Fax (850) 410-1512
Office Use Only 
Perm ID: _____________ 
Area: ________________ 
Date received: _________

A. Nursing Home Information

Please complete this section for the nursing home being recommended for the Gold Seal Award.

Facility Name: ______________________________________________________________________
Address: __________________________________________________________________________
Telephone: _____/_________________________ Web Site: _______________________________
Facility Licensee Name: _______________________________________________________________
Parent Company: _________________________ Chief Executive Officer: ____________________

Facility Contact Person for Gold Seal Information

Name: __________________________________ Title: ___________________________________
Telephone: _____/_________________________ E-mail: __________________________________

B. Recommending Person or Organization

Name: ____________________________________________________________________________
Profession / Type of Organization: ______________________________________________________
Relationship to Facility: _______________________________________________________________
Mailing Address: ___________________________________________________________________
Contact Person: __________________________ Title: ___________________________________
Telephone: _____/_________________________ E-mail: __________________________________

C. Regulatory History

The information provided and the quality of care requirements in rule will be verified by the Agency for Health Care Administration prior to proceeding with application review.

1. Section 400.235(7), Florida Statutes -- A facility must be licensed and operating for 30 months before it is eligible to apply for the Gold Seal Program. The agency shall establish by rule the frequency of review for designation as a Gold Seal Program facility and under what circumstances a facility may be denied the privilege of using this designation. The designation of a facility as a Gold Seal Program facility is not transferable to another license, except when an existing facility is being relicensed in the name of an entity related to the current licenseholder by common ownership or control, and there will be no change in the management, operation, or programs at the facility as a result of the relicensure.

a. Has the facility been licensed and operating for the past 30 months? Yes     No

b. Date the current licensee became licensed to operate this facility: _________________________

2. Section 400.235(5)(a), Florida Statutes -- Facilities must have no class I or class II deficiencies within the 30 months preceding application for the program.

a. Has the applicant facility been cited for any Class I or Class II deficiencies within the 30 months preceding this application? Yes     No

b. If yes, please describe why the facility should be eligible for the Gold Seal Award:

_____________________________________________________________________ 
_____________________________________________________________________ 
_____________________________________________________________________

3. Section 400.235(5), Florida Statutes -- A facility assigned a conditional licensure status may not qualify for consideration for the Gold Seal Program until after it has operated for 30 months with no class I or class II deficiencies and has completed a regularly scheduled relicensure survey.

a. Has the facility been issued a Conditional license in the preceding 30 months? Yes     No

b. If yes, please describe why the facility should be eligible for the Gold Seal Award:

_____________________________________________________________________ 
_____________________________________________________________________ 
_____________________________________________________________________
_____________________________________________________________________

D. Financial Soundness and Stability -- Section 400.235(5)(b), Florida Statutes and 59A-4.203, Florida Administrative Code

Attach evidence of financial soundness and stability in accordance with the protocol contained in agency rule 59A-4.203.

E. Consumer Satisfaction -- Section 400.235(5)(c), Florida Statutes

Facility must participate consistently in the required consumer satisfaction process as prescribed by the agency, and demonstrate that information is elicited from residents, family members, and guardians about satisfaction with the nursing facility, its environment, the services and care provided, the staff's skills and interactions with residents, attention to resident's needs, and the facility's efforts to act on information gathered from the consumer satisfaction measures.

a. Describe the approach to assessing consumer satisfaction in the facility.

_____________________________________________________________________ 
_____________________________________________________________________ 
_____________________________________________________________________

b. Once AHCA has initiated a consumer satisfaction survey in the facility, describe the facility's participation in the AHCA survey process, refer to section 400.0225, F.S. and applicable rules.

_____________________________________________________________________
_____________________________________________________________________

F. Community / Family Involvement -- Section 400.235(5)(d), Florida Statutes

Present evidence of the regular involvement of families and members of the community in the facility.

_____________________________________________________________________ 
_____________________________________________________________________ 
_____________________________________________________________________

G. Stable Workforce -- Section 400.235(5)(e), Florida Statutes and 59A-4.204, Florida Administrative Code

Facility must have a stable workforce, as evidence by a relatively low rate of turnover among certified nursing assistants and registered nurses within the 30 months preceding application for the Gold Seal Program, and demonstrate a continuing effort to maintain a stable workforce and to reduce turnover of licensed nurses and certified nursing assistants. Include the following staff for information requested in this section: certified nursing assistants, licensed nurses (registered nurses and licensed practical nurses), director of nursing and administrator.

Present evidence of meeting at least one of the following to demonstrate a stable workforce: have a turnover rate no greater than 85 percent for the most recent 12-month period ending on the last workday of the most recent calendar quarter prior to submission of an application (turnover rate will be computed in accordance with s. 400.141 (15)(b), Florida Statutes); or have a stability rate indicating that at least 50 percent of its staff have been employed at the facility for at least one year (stability rate will be computed in accordance with s. 400.141 (15)(c), Florida Statutes).

_____________________________________________________________________
_____________________________________________________________________

H. Targeted In-service -- Section 400.23(5)(g), Florida Statutes

Facility must have targeted in-service training provided to meet training needs identified by internal or external quality assurance efforts.

Describe how in-service training meets the training needs identified by internal or external quality assurance efforts.

_____________________________________________________________________ 
_____________________________________________________________________ 
_____________________________________________________________________

I. State Long Term Care Ombudsman Council Review -- Section 400.23(5)(f), Florida Statutes

In accordance with s. 400.23(5)(g), Florida Statutes and 59A-4.205, Florida Administrative Code, the State Long-Term Care Ombudsman Council will also review this application.

J. Best Practices

Describe the facility's best practices and the resulting positive resident outcomes.

_____________________________________________________________________ 
_____________________________________________________________________ 
_____________________________________________________________________

K. Letters of Recommendation

Please attach relevant letters of recommendation for the Gold Seal Award.

L. Presentation to the Governor's Panel on Excellence in Long Term Care

a. Would you like an opportunity to make a presentation to the Governor's Panel on Excellence in Long Term Care regarding this facility? Yes     No

b. Person(s) who will present this recommendation to Gold Seal Panel:

__________________________ 
Name
__________________________ 
Title
__________________________ 
Affiliation with Facility
__________________________ 
Name
__________________________ 
Title
__________________________ 
Affiliation with Facility

M. Site Visit by Panel Members -- Preferable time frame for site visit: _________________________

______________________________________________________ 
Signature of Person Completing Application
__________________________ 
Date
______________________________________________________ 
Printed Name
__________________________ 
Title

  1. AHCA Form 3110-0007 (August 01). AHCA LTC, 2727 Mahan Dr MS 33, Tallahassee, FL 32308 (850)488-5861

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