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					               Self Assessment Response Template
               The Continuing Care Accreditation Commission

                                            Overview
Please note that this Microsoft Word document is not password protected and has no
special formatting that should make it difficult to use. If you use Word Perfect, you may
download this template from www.ccaconline.org.

Please use this template for completing your self-assessment. By doing so, you have
the flexibility to:
1. Type your responses directly into one document;
2. Email it to your colleagues;
3. Save it to your hard drive, a floppy disk or a CD;
4. Spell check your work;
5. Print the document from any workstation; and
6. Send the document as an email attachement.

If you have any questions about how to use this template, please call CCAC at (202)
783-7286. You may also download this template from www.ccaconline.org.


                        Instructions for using this template
1. Expandable data boxes with detailed instructions have been provided for each
   standard.
2. Enter your organization’s responses to each standard directly into the boxes in this
   template.
3. Save an electronic version of the template with complete answers at your
   organization.
4. Spell check the completed template.
5. E-mail an electronic version of this completed template, without the Required
   Documents, to: Rhonda Stokes, Manager of Education and Quality, CCAC,
   rstokes@ccaconline.org
6. Refer to your site visit team announcement or call your CCAC staff coach to
   determine the number of hard copies you need to make and to whom they should be
   sent. If you do not have this information, call CCAC at 202-783-7286.
7. Refer to Chapter 3 in the CCAC Accreditation Handbook for detailed hard copy
   submission instructions. Remember to include the hard copies of the Required
   Documents as attachments for each standard. (Please note that all required
   documents are needed to meet the standard.)
8. The self assessment process is complete only after you have submitted both the
   electronic and hard copy information to the appropriate parties as instructed above
   and in the CCAC Accreditation Handbook.

                                                     1
                                 Self-Assessment Template Printed in 2002
      The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                  Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
                              CCAC Accreditation
                          Self Assessment Response
Organization Name:
Mailing Address:
Phone Number:
Accreditation Coordinator Name:
Executive Director/ CEO Name:
Date:


Area I: Governance

Standard I-A: Vision and Mission
The organization has clear vision and mission statements that:
  Provide a frame of reference for every aspect of the organization’s current and future efforts.
  Ensure consistency in the conduct of the organization’s daily activities.
  Help the organization identify its approach to service, unique characteristics and resource allocation
   priorities.
  Are reviewed and approved by the board annually.
The organization provides services that reflect its vision, mission and the needs of the external
   community.

Required Documents
Please place a check mark to verify that a hard copy of each document is attached to your
organization’s self-assessment.

__ Vision and mission statements.
__ Organizational chart. Please note: If your organization is part of a larger system, please ensure that
your organizational chart illustrates where your organization fits into the larger system.


Written Description
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   Describe how the organization’s vision and mission statements are developed, reviewed and
    approved to ensure that they align with the changing needs of residents/clients. Identify who is
    involved in this process.



   Describe how the organization’s vision and mission statements determine its:
      Approach to services.
      Unique characteristics.
      Resource-allocation priorities.
      Daily operations.
      Integrated strategic planning.


                                                      2
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
   Describe what benefits and services your organization provides to the internal and external
    community.




Standard Assessment
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   What success have you had with your process for developing your vision and mission?



   What current or future challenges exist with this process?



   What measurement system are you using to track your success with your vision and mission?



   What were the outcomes of this measurement system and what impact did they have on your
    integrated strategic plan?



   Optional: If you have developed an innovative program or practice in creating or communicating your
    vision and mission, please provide the Commission with a brief description.




                                                      3
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Standard I-B: The Governing Board
Please note: “Governing board” refers to the body that has ultimate authority in your organization. This
could include: owners, stockholders/investors and/or traditional governing boards.

1. The governing board is comprised of individuals who:
      Have backgrounds appropriate to their roles and responsibilities.
      Are fully informed about the organization.
      Actively participate in the board’s work, including monitoring fiscal viability and relationships of the
       organization.
2. The organization conducts a thorough orientation program for new board members.
3. The governing board evaluates its performance at least every three years.
4. The governing board establishes policies that:
      Determine the kinds of services the organization offers.
      Provide for monitoring of the quality of care and services.
      Ensure fiscal viability and sustainability.
      Ensure the organization engages in effective and continuous planning and evaluation.
      Ensure there are internal processes in place to guarantee that the organization’s activities are in
       compliance with all applicable local, state and federal laws and regulations.
5. The governing board ensures that:
      The organization maintains a positive, caring environment for residents/clients, good working
       conditions for staff and effective communication with internal and external constituents.
      Timely consideration is given to ideas and concerns of residents/clients and families.
6. The governing board appoints a chief executive officer (CEO) (or president, executive director,
   administrator, depending on the organization) who is accountable to the governing board and
   monitors his/her performance.
7. The governing board conducts a formal, annual review of the CEO’s performance.
8. The governing board avoids conflicts of interest in accordance with written policies that include at
   least the following provisions:
      Disclosure of actual or potential conflicts by involved parties in writing to the governing board.
      Exclusion of board members from participation in decisions to which conflict of interest policies
       apply.
9. The governing board has a plan for ongoing board development.


Required Documents
Please place a check mark to verify that a hard copy of each document is attached to your
organization’s self-assessment.
___ List of board members with occupations, length of service on the board and committee assignments.


Written Description
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

Multi-site corporate offices only
  Describe how the “ultimate authority board” interacts with any and all subsidiary boards that are
   involved in the accreditation process.



All organizations
   List the criteria the organization uses to recruit, select and orient board members.



                                                      4
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
   Describe the board’s decision-making process, including the establishment of policies to ensure
    matters such as fiscal viability and sustainability.



   Describe how the board evaluates its performance, including the frequency of evaluation.



   Describe how the board monitors and measures the quality of care and services the organization
    provides.



   Describe how the board stays informed about local, state and federal laws and regulations applicable
    to its programs.



   Describe the formal and informal process used to ensure open and frequent communication between
    the governing board, staff, residents/clients, families and external constituents.



   If the organization uses a management company, describe how the board evaluates and measures
    this company’s performance.



   Describe how the board hires and evaluates the CEO.



   Describe how the organization identifies and discloses potential conflicts of interest involving board
    members and other concerned parties. Provide or describe any policy on exclusion or recusal.




Standard Assessment
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   What current or future challenges exist for maintaining and enhancing board effectiveness?



   What improvements or new developments do you anticipate in your organization’s efforts related to
    board effectiveneess?




                                                      5
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
   Evaluate how well the measurement system you are using to track your board’s success is working.



   What were the outcomes of this measurement system and what impact did they have on your
    integrated strategic plan?



   Optional: Please provide a one-paragraph overview of any innovative program or practice you have
    developed for board activity.




                                                      6
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Standard I-C: Risk Management
1. The organization has a risk management program or function that identifies loss exposures from
   internal and external events.
2. The organization regularly conducts risk assessments that identify risk in the following areas:
       The governing board.
       Building and grounds.
       Financial resources.
       Human resources.
       Quality/resident life.
3. The organization ensures that there are internal processes in place to provide corporate compliance
   and compliance with all local, state and federal laws and regulations.
4. The organization has knowledgeable staff to fulfill the risk management function.
5. The organization:
       Selects the method or combination of methods to be used to assess each exposure and evaluate
        loss.
       Implements preventive and corrective methods or actions to reduce risk.
       Monitors decisions made and implements appropriate changes on an ongoing basis.
       Uses key findings to evaluate and, where possible, prevent future risks.

Required Documents
Please place a check mark to verify that a hard copy of each document is attached to your
organization’s self-assessment.

___ Risk management plan.
___ Corporate compliance plan.
___ Concise summary of the organization’s insurance coverage.


Written Description
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   If the organization is currently involved in any lawsuits, grievances, administrative proceedings,
    governmental actions, investigations or inquiries, please describe.



   List key staff/ team members who work with the risk manager to implement the risk management
    program.



   Describe how and when findings are communicated and:
      Who uses the findings.
      How often findings are reviewed.
      How findings strengthen daily operations.



   Describe how the organization learns from incidents, utilizes information, adopts, assesses and
    considers implications and develops corrective action plans.



                                                      7
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
   Explain how your organization has benefited from having a risk management program.



   Describe the challenges in implementing a risk management program.




Standard Assessment
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   What success have you had with developing your risk management program?



   What current or future challenges exist?




   What improvements or new developments do you anticipate in your organization’s efforts related to
    risk management?



   What measurement system are you using to track your success in managing risk?



   What were the outcomes of this measurement system and what impact did they have on your
    integrated strategic plan?



   Optional: Please provide a one-paragraph overview of any innovative program or practice you have
    developed regarding risk management.




                                                      8
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Standard I-D: Human Resources
1. The organization has a one-year human resources plan that aligns with the integrated strategic plan
   and identifies goals and corresponding activities to address the following issues:
    Staff recruitment.
    Staff retention (including career development, health and well-being).
    Staff satisfaction, empowerment and innovation.
    Staff training and mentoring.
    Succession planning.
    Compensation and benefits.
2. The organization has qualified and competent staff at sufficient levels to meet the needs of all
   residents/clients, and to fulfill the organization’s mission and resident/client contracts.
3. The organization selects, orients and trains all staff to serve resident/client needs.
4. Supervisors and their staff regularly establish individual performance goals. Performance evaluations
   related to these goals are conducted on a regular basis.
5. Human resource policies and procedures, addressing at least the following topics are stated in
   writing, available to all staff, and are in compliance with applicable local, state and federal laws and
   regulations.
    Processes for ongoing communication between human resources and all departments.
    Recruitment and hiring practices.
    Staff training.
    Career development.
    Promotion.
    Grievances.
    Termination.
    Compensation.
    Employee benefits.
    Worker safety.
6. Current position descriptions that describe reporting relationships and responsibilities for exempt and
   non-exempt staff are available to all staff.
7. Staff training is offered regularly to frontline and management staff to enhance their understanding of
   clinical and management issues.
8. The organization provides mechanisms to support direct care workers including, but not limited to,
   team approaches to care delivery, peer mentoring opportunities and career ladder development.

Required Documents
Please place a check mark to verify that a hard copy of this document is attached to your
organization’s self-assessment.

___ One-year human resources plan.

Written Description
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   Describe recruitment and hiring practices for all staff, including the use of background checks and
    credentialing processes.



   Describe how the organization demonstrates ethical practices in the overall hiring process.



                                                      9
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
   Describe future staffing challenges and plans developed to address them.



   Describe the organization’s staff orientation, goal setting and performance evaluation processes.



   Describe the nature of the work environment including lines of authority, the role of teams, and
    mechanisms to support direct care workers including, but not limited to, peer mentoring opportunities
    and career ladder development.



   Describe how the organization actively promotes staff satisfaction, empowerment and innovation.



   Describe how staff is sensitized to the changing needs of older adults.



   Describe employee grievance and termination procedures. Describe how these issues are kept
    confidential.



   Provide a summary of employee grievances over the past year, including their disposition.



   Describe any labor-relations issues that the organization currently has or anticipates. Identify how the
    organization is managing them.



   Describe strategies to ensure worker safety.



Please complete the following chart regarding direct care staffing in your organization.
Information should reflect only one day of staffing.
   For organizations in accreditation Cycle 1, please provide information for April 1 of this year.
   For organizations in accreditation Cycle 2, please provide information for October 1 of this year.




                                                     10
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Position             Day Shift*              Evening Shift             Night Shift         % Turnover
                 Budgeted   Actual         Budgeted  Actual        Budgeted    Actual
RN
LPN
CNA
Other
Total
% Agency
Staff

*Day shift should not include management personnel (e.g., DON/ADONs who are involved in non-nursing
duties).

Calculate turnover by dividing total number of positions refilled by total number of employees in that
category (e.g., you have 50 total CNAs and have refilled 10 slots during the year (10/50 = 20%)).

Please complete the following chart regarding administration staff in your organization.
Position                               Years Experience    Years Tenure at this Organization
CFO or Comptroller
Director of Marketing
NHA
DON
Social Worker
Service Coordinator
Executive Director (if other than NHA)

Please name your insurance carrier for each of the following:
Professional/General Liability:                   Worker’s Comp:

Fire/Extended Coverage:                                Vehicle/Fleet:



Standard Assessment
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   What success have you had with developing your human resources plan?



   What current or future challenges exist?




   What improvements or new developments do you anticipate in your organization’s human resource
    activities?



   What measurement system are you using to track your success in human resources?




                                                     11
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
   What were the outcomes of this measurement system and what impact did they have on your
    integrated strategic plan?



   Optional: Please provide a one-paragraph overview of any innovative program or practice you have
    developed in human resources.




                                                     12
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Standard I-E: Marketing and Promotional Materials
1. The organization has a one-year written marketing plan that:
    Is consistent with its vision and mission.
    Defines the organization’s target markets.
    Is designed to achieve and sustain optimal occupancy.
    Is the basis for promotional materials and marketing activities.
    Reflects findings from analyses of internal and external influences.
    Contains projected expense and revenue impacts for each marketing initiative.
    Is aligned with the organization’s integrated strategic plan.
2. The organization has a process for updating and evaluating the effectiveness of the marketing plan.
3. The organization’s promotional materials and advertising are in compliance with applicable local,
   state and federal laws and regulations.
4. Before signing a contract, prospective residents/clients receive the organization’s mission statement,
   resident agreement, financial disclosure statement, schedules of current fees and charges for all
   services, refund policy and other essential information.

Required Documents
Please place a check mark to verify that a hard copy of each document is attached to your
organization’s self-assessment.

___ One-year marketing plan that clearly aligns with the organization’s integrated strategic plan. The
marketing plan should include the following elements:
     An environmental scan, including a competitive analysis and the effects of internal and external
        influences.
     Trends and forecasts for the resident/client population, including actuarial studies (if applicable)
        and how these trends and forecasts influence the plan.
     Well-defined and attainable marketing goals, including objectives with timelines, target dates and
        responsible parties.
     Data-tracking methods to record results of marketing efforts.
     Results of latest marketing survey documenting information on those who moved in vs. those who
        did not.
     Process for evaluating the effectiveness of and updating the marketing plan.


Written Description
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   Describe how the organization’s marketing plan is developed and reflects strategic thinking.



   Describe how the organization:
     Orients its admissions and marketing staff to all aspects of the community’s operations.
     Ensures that marketing materials and activities are accurate.
     Determines which local, state and federal laws and regulations are applicable to its marketing
       activities, and how the organization maintains compliance with them.
     Resolves legal questions related to marketing/advertising.




Standard Assessment
                                                     13
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   What success have you had with your marketing plan?



   What current or future challenges exist?




   What improvements or new developments do you anticipate in your organization’s marketing efforts?



   What measurement system are you using to track your success in marketing?



   What were the outcomes of this measurement system, and what impact did they have on your
    integrated strategic plan?



   Optional: Please provide a one-paragraph overview of any innovative marketing program or practice
    you have developed.




                                                     14
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Standard I-F: Agreements and Admissions
Please note: “Agreement” refers to any written document that establishes rights and responsibilities of
residents/clients served at each level of care.

1. The agreement and addenda establish rights and responsibilities of the resident/client served, the
   organization and their obligations to each other.
2. Throughout the application process, the organization clearly states the criteria necessary to qualify for
   admission.
3. The agreement and addenda clearly and fully reflect commitments made by the organization in
   promotional materials, in the admissions process and in actual practice.


Written Description
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

Please provide the number of residents/clients covered by each agreement listed below, along with the
percentage of the total number of agreements:

                                       Current Year                     Prior Year
    Agreement Type                     Number of       % of Total       Number of         % of Total
                                       Residents       Number of        Residents         Number of
                                                       Residents                          Residents
    Extensive
    Modified
    Fee-for-service
    Rental
    Equity
    Other (please describe below)

Agreement Definitions
  Extensive: Includes housing, residential services amenities and unlimited, specific health-related
   services with little or no substantial increase in monthly payments, except for normal operating costs
   and inflation adjustments.
  Modified: Includes housing, residential services and amenities and a specific amount of long-term
   nursing care with no substantial increase in monthly payments.
  Fee-for-Service: Includes housing, residential services and amenities for the fees stated in the
   resident agreement.
  Rental: Allows residents the opportunity to rent their housing and guarantees access to health care
   services paid on a fee-for-service basis.
  Equity: Similar to cooperative housing, whereby residents have membership in the corporation and
   sign a proprietary lease agreement.
  Other: If you offer another type of agreement, please briefly describe it.

     Describe the organization’s application and admissions processes, including:
        Admission guidelines (including health and financial criteria).
        Procedure for qualifying prospective individuals for the waiting list.
        Process for informing individuals on the waiting list about their prospects for admission.



                                                       15
                                    Self-Assessment Template Printed in 2002
         The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                     Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
   State how frequently your organization reviews and revises agreements (including the date of last
    revision for each).



   Describe the most recent revisions to agreements with regard to:
      The internal and/or external environment factors that prompted the revisions.
      How these revisions added value to resident/client understanding or protection.



   Describe, if applicable, the organization’s policies and procedures regarding entrance fee refunds and
    adjustments in entrance and monthly fees.



   For organizations with HUD programs, describe how the organization monitors compliance with
    income targeting requirements for entrance, and provide information on any management reviews
    that indicate eligibility issues and/or recertification of residents/clients served.




Standard Assessment
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   What success have you had with your organization’s resident agreements and admissions?



   What current or future challenges exist?




   What improvements or new developments do you anticipate in your organization’s efforts related to
    resident agreements and admissions?



   What measurement system are you using to track your success in fulfilling resident agreements and
    maintaining sufficient admission levels?



   What were the outcomes of this measurement system and what impact did they have on your
    integrated strategic plan?



   Optional: Please provide a one-paragraph overview of any innovative program or practice you have
    developed regarding resident agreements and admissions.

                                                     16
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
                                              17
                           Self-Assessment Template Printed in 2002
The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
            Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Standard I-G: Organizational Ethics
1. The organization has a set of ethical beliefs and values that:
      Guide the development and implementation of all policies and procedures (e.g., legal, financial,
       staff, resident care and resident rights).
      Promote preferred behaviors and appropriate relationships of all individuals involved with the
       organization.
2. The organization’s underlying ethical beliefs and values are made public by means appropriate to the
   organization’s constituencies so that all persons have an understanding of mutual expectations.
3. In promoting and protecting the interests of residents/clients, sponsors and the public, the governing
   board clearly describes, in writing, its relationships and responsibilities in legal, financial and ethical
   areas.
4. The organization maintains an effective process to address and resolve ethical issues that arise.
5. The organization informs residents/clients of their right to accept or refuse treatment and to prepare
   advance directives (i.e., living wills, durable powers of attorney, etc.) and ensures that mechanisms
   are in place to honor such advance directives.

Required Documents
Please place a check mark to verify that a hard copy of each document is attached to your
organization’s self-assessment.
___ Provide the organization’s written philosophy that serves as the foundation for ethical decision-
making with respect to:
     Developing and communicating policies and procedures.
     Hiring, evaluating and terminating staff.
     Providing information about the organization and the admissions process.
     Monitoring quality and improvement of services and care.
     Informing residents/clients about their rights regarding treatment decisions and advance
       directives.
     Implementing palliative and end-of-life care.

Written Description
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   In promoting and protecting the interests of residents/clients, sponsors and the public, describe how
    the governing board ensures that the organization follows ethical principles in fulfilling its mission in
    all its practices and policies. Please describe the following, in particular:
     Admission process.
     Promotional materials.
     Human resources practices.
     Legal, financial and health care rights and obligations of residents/clients and responsible parties.



   Describe the organization’s policies and practices regarding ethical decision-making in health, life and
    wellness, with special emphasis on:
     Resident/client involvement in decisions concerning their care and quality of life.
     Policies and practices regarding advance directives.
     Policies on life-sustaining treatment and end-of-life care.



   Describe how the organization ensures review of legal, financial and ethical issues.

                                                     18
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Standard Assessment
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   What success have you had in addressing organizational ethics?



   What current or future challenges exist?




   What improvements or new developments do you anticipate in your organization’s efforts related to
    addressing organizational ethics?



   What measurement system are you using to track your success in addressing ethical issues
    appropriately?



   What were the outcomes of this measurement system and what impact did they have on your
    integrated strategic plan?



   Optional: Please provide a one-paragraph overview of any innovative program or practice you have
    developed regarding organizational ethics.




                                                     19
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Standard I-H: Information and Technology Strategy
1. The organization has a three-year information technology plan, reviewed annually, that aligns with the
   organization's integrated strategic plan and addresses required infrastructure enhancements (for
   example, telecommunications, hardware, operating system, etc.) and core/collateral applications.
2. The organization has policies and procedures for information management and technology use that
   include:
    Routine system maintenance including adding and deleting users, security, data backup and
        recovery, and virus protection.
    Timely and accurate data collection and maintenance for hard copy files and databases.
    Monitoring access to sensitive data, including fiscal records, personnel files and resident/client
        profiles and medical records to prevent fraud and abuse.
    Maintaining an inventory of technology products and current software licenses.
    Staff training on information management and technology use.
    The organization’s acceptable use policies for network users.
3. The organization has a disaster recovery plan for business continuity so that in the event of a disaster
   with partial or total loss of data/functionality, they can continue operations, on or off-site, as specified
   by the plan.
4. The organization’s mission critical applications are kept current through periodic updates provided by
   the software vendor.
5. The organization is in compliance with all local, state and federal laws and regulations pertaining to
   information management, dissemination and security, including the Health Information Portability and
   Accountability Act (HIPAA).

Required Documents
Please place a check mark to verify that a hard copy of each document is attached to your
organization’s self-assessment.
___ Three-year information technology plan.
___ Disaster recovery plan.

Written Description
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   Describe the training provided to staff to ensure that accurate data is collected in a timely fashion.



   Describe monitoring systems that help the organization safeguard against fraud and abuse.



   Describe how the organization complies with all local, state and federal laws and regulations
    regarding information management and technology.



Standard Assessment
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   What success have you had with your organization’s information management practices and
    technology planning?

                                                     20
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
   What current or future challenges exist?




   What improvements or new developments do you anticipate in your organization’s efforts to
    incorporate technology into business practices?



   What measurement system are you using to track your success with using technology?



   What were the outcomes of this measurement system and what impact did they have on your
    integrated strategic plan?



   Optional: Please provide a one-paragraph overview of any innovative program or practice you have
    developed related to information management and/or technology.




                                                     21
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
                      Area II: Finance and Strategy
Standard II-A: Current Financial Position: Financial Information and Disclosure
1. The organization’s current financial position and resources are adequate to meet its obligations.
2. The organization has a clearly defined process by which it develops and monitors the budget.
3. The organization discloses information to residents/clients, sponsors and other appropriate parties
   that explains its assets and liabilities, reflects the position and responsibilities of any parent or
   sponsoring organizations and discloses any material and legal relationships with other entities.
4. An independent audit of the annual financial statement is in accordance with GAAP and is completed
   within 120 days of the end of the fiscal year.
5. Interim financial statements are generated at least 45 days after the end of each quarter. These
   statements are in a format consistent with the audited financial statements and include a statement of
   financial position, a statement of activities and a statement of cash flows.
6. The organization has appropriate management information and assistance to utilize and provide a
   basis for determining, monitoring, analyzing and controlling its financial operations.

Required Documents
Please place a check mark to verify that a hard copy of each document is attached to your
organization’s self-assessment.
___ Audited financial statements for your organization for the last three years.
___ If you are part of a larger system, audited financial statements for the parent organization, for the last
three years.
___ Most recent interim financial statements, including a statement of financial position, statement of
activity and statement of cash flows.
___ Please indicate if your organization has a management letter. ___ yes ___ no If yes, please include
a copy.

Please complete the following data box.
     Financial Covenants            Required Covenant Target                Covenant Compliance
 Debt Service Coverage Ratio                                                       Yes                No
 Days Cash on Hand Ratio                                                           Yes                No
 Operating Ratio                                                                   Yes                No
 Occupancy Percent                                                                 Yes                No
 Other (please describe below)                                                     Yes                No

 Utilization statistics and payor mix by level of care for the last two years.
Last Year
Level of Care              % Private Pay     % Medicare         % Medicaid          % Other
Independent Living
Assisted Living
Skilled Nursing
Other

Year Before Last
Level of Care             % Private Pay       % Medicare          % Medicaid         % Other
Independent Living
Assisted Living
Skilled Nursing

                                                     22
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Other

   If your organization is rated by a credit agency, attach a copy of the rating letter and respond below.
    (Please note: The rating should be directly related to the organization itself. Ratings on the bank
    issuing a letter of credit and ratings on the bond insurer are both not applicable.)
         Rating Agency                      Current Rating                    Prior Year Rating




Written Description
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   Describe how and when annual financial information about the organization is presented to
    residents/clients. To whom are audited financial statements made available?



   Describe and evaluate the organization’s budget development, approval and exception process.
    Specify the roles of department heads in this process.



   Describe the process for reviewing the management letter and the follow-up procedures the
    organization employs in addressing the letter.



   If the organization is legally required to provide operating support or guarantee debt of another
    organization, please explain the relationship.



   If another organization is legally responsible for providing operating support or guaranteeing your
    organization’s debt, please explain the relationship.




Standard Assessment
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   What success have you had with your budgeting process?



   What current or future challenges exist?




   What improvements or new developments do you anticipate in your organization’s efforts to maintain
    an adequate current financial position?

                                                      23
                                   Self-Assessment Template Printed in 2002
        The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                    Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
   What measurement system are you using to track your success regarding your current financial
    position?



   What were the outcomes of this measurement system, and what impact did they have on your
    integrated strategic plan?



   Optional: Please provide a one-paragraph overview of any innovative program or practice you have
    developed in maintaining your organization’s current financial information.




                                                     24
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
  Standard II-B: Long-Term Financial Resources
1. The organization’s long-term financial resources are projected to be adequate to meet its obligations.
2. The organization demonstrates the ability to quantify the financial impact of strategic initiatives and
   trends affecting their organization.
3. The organization’s planning includes projected financial statements. These statements are prepared
   in a format consistent with the content of the organization’s annual audited financial statements. The
   financial statements include statements of financial position, statements of activities, statements of
   cash flows and key assumptions. Key assumptions include, but are not limited to:
       Occupancy by level of care. For multi-site organizations, this information is broken out by site.
       Payor mix (private pay, Medicare and Medicaid). For multi-site organizations, this information is
        broken out by site.
       Inflation rate.
       Benevolent care.
       Contributions.
       Fee adjustments.
       Expansions.
       Capital repairs and replacements.
       Sources of any significant non-operating revenue.
4. The revenue and expense impacts of the initiatives identified in the integrated strategic plan are
   included in the five-year financial plan. The organization establishes and maintains adequate cash
   and investments, or other financial assets, for long-term financial viability.

Required Documents
Please place a check mark to verify that a hard copy of each document is attached to your
organization’s self-assessment.
___ Five-year projected financial statements integrated with the following:
     Three-year integrated strategic plan.
     Five-year capital plan.
     One-year marketing plan.
     One-year human resources plan.
     Three-year information technology plan.
___ Ratios calculated on RatioPro for the three most recent audited years and the five-year projections.
___ One-page narrative explaining the trends in your actual and projected financial ratios.
___ If you are subject to a state filing requirement, please attach a copy of the most recent/last three
years filing.
___ Detailed list of key assumptions including those in #3 above.

Please complete the following chart with occupancy information:

                    Occupancy: Residential Living Units (per site for MSOs)
                  Fiscal Year        Number of               % of Units/Beds      Number of People
                                                                                            nd
                  End                Available               Occupied             (include 2 person if
                                     Units/Beds                                   more than one occupant)
 Prior year
 Current year
 Next year 1
 Next year 2
 Next year 3
 Next year 4



                                                      25
                                   Self-Assessment Template Printed in 2002
        The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                    Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
    Next year 5


                   Occupancy: Assisted Living or Personal Care (per site for MSOs)
                     Fiscal Year        Number of               % of Units/Beds      Number of People
                                                                                               nd
                     End                Available               Occupied             (include 2 person if
                                        Units/Beds                                   more than one occupant)
    Prior year
    Current year
    Next year 1
    Next year 2
    Next year 3
    Next year 4
    Next year 5
                           Occupancy: Nursing Care Beds (per site for MSOs)
                     Fiscal Year        Number of               % of Units/Beds      Number of People
                                                                                               nd
                     End                Available               Occupied             (include 2 person if
                                        Units/Beds                                   more than one occupant)
    Prior year
    Current year
    Next year 1
    Next year 2
    Next year 3
    Next year 4
    Next year 5
Occupancy: Other, please describe: ___________________________________ (per site for MSOs)
                     Fiscal Year        Number of               % of Units/Beds      Number of People
                                                                                               nd
                     End                Available               Occupied             (include 2 person if
                                        Units/Beds                                   more than one occupant)
    Prior year
    Current year
    Next year 1
    Next year 2
    Next year 3
    Next year 4
    Next year 5


Written Description
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

      Describe any required statutory or debt-related reserve funds.



                                                         26
                                      Self-Assessment Template Printed in 2002
           The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                       Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
   Describe the procedure used to evaluate the existence of a future service obligation (FSO).



   Describe and evaluate the organization’s policy regarding residents/clients who need financial
    assistance, including how the organization projects for and funds this need.



   Provide information of any pending or settled lawsuits, fines or other sanctions from the Centers for
    Medicare and Medicaid Services (CMS).



   Describe the adequacy of your long-term cash and investment balances.




Standard Assessment
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   What success have you had with ensuring a positive long-term financial position for your
    organization?




   What current or future challenges exist?



   What improvements or new developments do you anticipate in your organization’s efforts related to
    ensure that its resources are adequate to meet future obligations?



   What measurement system are you using to track your success in maintaining a positive long-term
    financial position?



   What were the outcomes of this measurement system and what impact have they had on your
    integrated strategic plan?



   Optional: Please provide a one-paragraph overview of any innovative program or practice you have
    developed for establishing a positive long-term financial position for your organization.



                                                     27
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
                                              28
                           Self-Assessment Template Printed in 2002
The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
            Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Standard II-C: Integrated Strategic Planning
Overview of Integrated Strategic Planning (For reference only)
  The integrated strategic plan (ISP) is the centerpiece of the self-assessment process for CCAC
   accreditation. For any organization, it is a collaborative and creative effort that engages and involves
   the participation, creative thinking and innovation of key stakeholders and constituencies; e.g., staff,
   board, residents/clients, families, partners, vendors, external community including neighbors,
   competitors and potential customers. It is the organization’s process for mapping out key factors
   necessary for successfully meeting its vision and mission. Integration is shown through constructive
   relationships among the ISP’s stated purposes, its resources and all programs as reflected in the
   aforementioned operational plans.
  The ISP is the product that results from the planning process.
  The CCAC standards relate to both the planning process and the final product.
  The Commission requires an ISP that projects at least three years into the future, is reviewed and
   updated annually and is approved by the governing board/ultimate authority.
  The Commission assumes that the ISP is used continually by the governing board and staff to guide
   operations and create a context for strategizing, decision-making and creative problem solving.

Standard: The Integrated Strategic Planning Process
1. The organization analyzes its external environment and develops an understanding of the
   opportunities, challenges and innovation necessary for future success. The organization does this by
   using data collection tools; e.g., SWOT analysis, competitive analysis, scenario planning or others
   that it finds useful.
2. The organization continuously assesses achievements and challenges related to the organization’s
   vision and mission.
3. The organization supports the planning process by inviting appropriate participation by its
   constituencies, including:
       Board.
       Staff.
       External community.
       Residents/clients and their families.
       Other appropriate parties.
4. Operational plans (as outlined in below “minimum requirements of a three-year ISP”) are generated
   during the planning process to achieve key strategic objectives, including the allocation and
   integration of required resources.
5. The planning process provides information that enables the organization to review priorities and
   prepare for changing circumstances.

Standard: The Integrated Strategic Plan
1. The organization’s three-year Integrated Strategic Plan (ISP) includes at least the following minimum
   requirements:
    The organization’s vision and mission.
    Assumptions about the internal and external environment, including market and non-market
       forces, impacting the organization.
    The overarching organizational strategies reflecting the external analysis developed during the
       above planning process.
    Operational plans, including:
        One-year human resources plan (refer to Standard I-D).
        One-year marketing plan (refer to Standard I-E).
        Three-year information technology plan (refer to Standard I-H).
        Five-year financial plan (refer to Standard II-B).
        Five-year capital repair and replacement plan (refer to Standard III-E).

Required Documents


                                                     29
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Please place a check mark to verify that a hard copy of each document is attached to your
organization’s self-assessment.
___Integrated strategic plan (ISP). The Commission will look for these key elements in the ISP:
       Vision and mission statements.
       Findings of an external analysis with financial and other trends and forecasts.
       Specific strategic implementation costs, timelines and responsible persons.
       Integration with the:
         One-year human resources plan (refer to Standard I-D).
         One-year marketing plan (refer to Standard I-E).
         Three-year information technology plan (refer to Standard I-H).
         Five-year financial plan (refer to Standard II-B).
         Five-year capital repair and replacement plan (refer to Standard III-E).


Written Description
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   Describe the process the organization uses to develop, evaluate and update the ISP. Specify who is
    involved and how changes are recommended and implemented. How does the organization insure
    that planning is an ongoing process?




Standard Assessment
   What success have you had with your organization’s integrated strategic planning process?



   What current or future challenges exist?




   What improvements or new developments do you anticipate in your organization’s strategic planning
    process?



   What measurement system are you using to track the effectiveness of your integrated strategic plan?



   What were the outcomes of this measurement system and what impact did they have on your
    integrated strategic planning process and resulting plan?



   Optional: Please provide a one-paragraph overview of any innovative program or practice you have
    developed for strategic planning.




                                                     30
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
                               Area III: Health and Wellness

Standard III-A: Health and Wellness Philosophy
1. The organization has a written health and wellness philosophy, reviewed annually by the governing
     board that:
      Serves as the framework for all health and wellness services across the continuum.
      Is consistent with the organization’s vision and mission.
      Addresses the physical, mental, social, spiritual and intellectual needs of residents/clients and the
       related commitments contained in the resident/client contract.
      Is clearly communicated to applicants, residents/clients, families, staff and board.

Required Documents
Please place a check mark to verify that a hard copy of this document is attached to your
organization’s self-assessment.
___ The organization’s health and wellness philosophy statement.

Written Description
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   Describe how the health and wellness philosophy statement is:
     Developed.
     Reflected in policies and practices.
     Reviewed to ensure consistency with the organization’s services and contracts.



   Describe how the health and wellness philosophy statement includes all levels of care.



   Describe how the health and wellness philosophy statement is communicated to applicants,
    residents/clients and staff.




Standard Assessment
   What success have you had with developing a health and wellness philosophy?



   What current or future challenges exist?




   What improvements or new developments do you anticipate in your organization’s efforts related to
    the health and wellness philosophy?




                                                     31
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
   What measurement system are you using to track the impact of your health and wellness philosophy?



   What were the outcomes of this measurement system, and what impact did they have on your
    integrated strategic plan?



   Optional: Please provide a one-paragraph overview of any innovative program or practice you have
    developed regarding your organization’s health and wellness philosophy.




                                                     32
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Standard III-B: Health and Wellness Programs
1. The organization:
      Provides an environment that enhances the personal dignity, privacy and safety of
       residents/clients and protects individual independence and self-determination.
      Regularly offers opportunities for residents/clients to provide feedback.
      Demonstrates evidence of quality management and improvement.
      Develops and implements plans for ongoing improvement of its programs across the continuum
       of care.
      Promotes a restraint-free environment.
2. The well-being of the organization is sustained through involvement of residents/clients in responsible
   and constructive self-governance and activities planning.
3. The organization provides a variety of interrelated health and wellness programs that:
      Serve the physical, intellectual, social and spiritual needs of residents/clients and address their
       quality of life throughout the continuum of care.
      Promote choice and facilitate informed decision-making.
      Encourage residents/clients to make the most of their abilities.
4. Programs are provided by staff with appropriate training, knowledge and experience to meet the
   health and wellness needs of residents/clients.
5. Quality improvement/quality assurance program data is used to guide delivery of programs and care.
6. For HUD organizations only
    The organization offers the services of a qualified resident services coordinator.
    The organization provides linkages to the local aging services network and/or home and
       community-based services.

Required Documents
Please place a check mark to verify that a hard copy of each document is attached to your
organization’s self-assessment.
___ Copies of all licensure or certification decisions and related survey reports for the past three years.
Include corrective plans of action and evidence of acceptance by the state or federal agency.
___ A completed Centers for Medicare and Medicaid Services (CMS) Scope and Severity Grid for the
most recent survey.
___ Your organization’s CMS Quality Indicator/Clinical Markers report.


Written Description
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   Describe how the organization’s environment fosters resident dignity, privacy, safety, autonomy and
    independence.



   Describe how residents/clients are involved in making choices and decisions affecting their plan of
    care.



   Describe the organization’s quality improvement/quality assurance program including:
     The process for ensuring that appropriately trained and knowledgeable staff is providing life,
       health and wellness programs.



                                                     33
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
         The process for ensuring that the organization takes effective action when performance does not
          meet its standard.



     Describe the health and wellness programs across the continuum, including how the organization
      makes them accessible to residents/clients.



     Describe how the health and wellness program has improved the quality of life for residents/clients.



     Describe how the results of the quality improvement/quality assurance program are used to improve
      current programming and care.




  Please complete the following tables regarding all residents residing in your skilled nursing or
  comprehensive care unit.
     For organizations in accreditation Cycle 1, please provide information for April 1 of this year.
     For organizations in accreditation Cycle 2, please provide information for October 1 of this year.
  Note: All organizations, even those not participating in Medicare or Medicaid, should complete
  this section.

Your Provider         # of Medicare           # of Medicaid          # of Other             Total Residents
Number                Residents               Residents              Residents



   Activity of Daily Living    # Who Are Independent             # Who Require             # Who Are Dependent
                                                            Assistance from 1-2 staff
  Bathing
  Dressing
  Transferring
  Toileting
  Eating

  Please indicate the number of residents in each of the following categories.
  Bowel/Bladder Status                                 Mobility Status

  ____ With indwelling or external catheter                ____ Bedfast all or most of the time
  Of total number of residents with catheters:
  ____ Were present on admission                           ____ In a chair all or most of the time

  ____ Use incontinence products                           ____ Independently ambulatory

  ____ On individually written bladder training program    ____ Ambulate with assistance or assistive device

  ____ On individually written bowel training program      ____ Physically restrained



                                                        34
                                     Self-Assessment Template Printed in 2002
          The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                      Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Mental Status                                            Skin Integrity Status

____ With documented signs and symptoms of               ____ With pressure sores (exclude stage 1)
depression
____ Dementia: multi-infarct, senile, Alzheimer’s type   ____ Receiving preventive skin care
or other than Alzheimer’s type

____ With behavioral symptoms

Special Care                                             Medications

____ Receiving hospice care benefit                      ____ Receiving any psychoactive medication

                                                         ____ Receiving antipsychotic medication
Other
                                                         ____ Receiving anti-anxiety medication

____ With advance directives                             ____ Receiving antidepressant medication

____ Received influenza immunization                     ____ Receiving hypnotic medication

____ Received pneumococcal vaccine                       ____ On pain management programs


Standard Assessment
   What success have you had with developing and/or implementing resident health and wellness
    programs?




   What current or future challenges exist?




   What improvements or new developments do you anticipate in your organization’s efforts to offer
    appropriate health and wellness programs?



   What measurement system are you using to track your success in this area?



   What were the outcomes of this measurement system and what impact did they have on your
    integrated strategic plan?



   Optional: Please provide a one-paragraph overview of any innovative program or practice you have
    developed regarding health and wellness programs.




                                                      35
                                   Self-Assessment Template Printed in 2002
        The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                    Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Standard III-C: Resident/Client Services and Amenities
1. The organization provides residents/clients with written materials that clearly and accurately describe
   and outline all resident/client services and amenities.
2. Resident/client services and amenities, including but not limited to dining, housekeeping and
   maintenance, are consistent with resident/client needs, market feedback, written agreements,
   resident/client feedback and other available resources.
3. The organization coordinates and/or provides transportation services for all residents/clients.
4. The organization is in compliance with all local, state and federal laws and regulations.
5. The organization conducts a satisfaction survey that includes respondents from each continuum level,
   at least every three years.

Required Documents
Please place a check mark to verify that a hard copy of each document is attached to your
organization’s self-assessment.
___ Satisfaction assessment and/or measurement tool(s) the organization uses, including recent results.

Written Description
   Describe how the dining service program responds to residents’/clients’ choices.



   List the housekeeping and maintenance services residents/clients receive in each level of care.



   Describe how the organization provides, arranges, refers or contracts for transportation services to
    enable all residents/clients, including those with mobility or behavioral issues, to participate in
    community events, outings, shopping and appointments.



   Describe how the organization assesses resident/client satisfaction (including family members and
    surrogate decision-makers) at all levels of care and how the organization responds to the information
    collected.




Standard Assessment
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   What success have you had with offering various services and amenities?



   What current or future challenges exist?




   What improvements or new developments do you anticipate in your organization’s efforts related to
    offering services and amenities that meet resident/client needs?

                                                     36
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
   What measurement system are you using to track your success in offering services and amenities
    that are preferred by residents/clients ?



   What were the outcomes of this measurement system, and what impact did they have on your
    integrated strategic plan?



   Optional: Please provide a one-paragraph overview of any innovative program or practice you have
    developed for gauging resident/client interest in or satisfaction with specific services and amenities.




                                                     37
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Standard III-D: Care Coordination Within the Continuum
The organization:
1. Strives to maintain residents/clients in the least restrictive environment.
2. Has written guidelines that clearly define the consideration used in admission to each level of care
   and its response system for health care emergencies
3. Has processes for transfer decision-making between levels of care that include the resident/client,
   staff and, as necessary, the resident’s/client’s representative.
4. Reviews transfer guidelines annually with residents/clients and, as necessary, the resident’s/client’s
   representative.

Required Documents
Please place a check mark to verify that a hard copy of each document is attached to your
organization’s self-assessment.
___ Written guidelines for transfer decision-making between levels of care (both in-house and through
contracts).
___ Written guidelines for admission to each level of care.
___ Written guidelines for services provided in each level of care.

Written Description
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   Describe the criteria used to promote individuals remaining in the least restrictive environment.



   Describe how the organization addresses the needs of residents/clients who do not require nursing
    care but have difficulty living independently. Include how the organization addresses both health-care
    needs and assistance with ADLs and IADLs.



   Describe the decision-making process, procedures and considerations used when transferring a
    resident/client to another level of care in the organization, to a hospital or to other diagnostic or
    treatment locations. Indicate the frequency and process used for reviewing these guidelines with each
    resident/client and, as necessary, the resident’s/client’s representative.



   Describe the organization’s response system for health-care emergencies.



   Describe how the organization meets the needs of residents/clients, including short-term nursing care
    needs for acute illness or surgery recovery.



   Describe how the organization provides long-term care beds, either within the organization or in
    another location. Describe how the organization makes residents/clients aware of this process.



                                                     38
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
   Identify what services (if any) for which your organization contracts, including:
     Home health care.
     Skilled nursing.
     Comprehensive nursing.
     Assisted living.
     Care coordination services.



   For above contract services, describe how the organization coordinates services with other health-
    care providers and monitors service quality.




Standard Assessment
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   What success have you had in ensuring that residents/clients are maintained in the least restrictive
    setting?




   What current or future challenges exist?




   What improvements or new developments do you anticipate in your organization’s efforts related to
    this standard?



   What measurement system are you using to track your success in this area?



   What were the outcomes of this measurement system, and what impact did they have on your
    integrated strategic plan?



   Optional: Please provide a one-paragraph overview of any innovative program or practice you have
    developed for care coordination and/or resident transfers between levels of care.




                                                     39
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Standard III-E: Physical Environment
1. The organization has a five-year capital repair and replacement plan that aligns with the integrated
   strategic plan and is included in the five-year financial plan.
2. The organization’s physical environment is well maintained and attractive and in compliance with all
   local, state and federal laws and regulations pertaining to access and health and safety at all levels of
   care.
3. The organization periodically evaluates the quality of its physical environment and maintains an
   appropriate plan for preventive maintenance and emergency preparedness.

Required Documents
Please place a check mark to verify that a hard copy of each document is attached to your
organization’s self-assessment.

___ HUD organizations: If you are including your HUD housing as part of the accreditation process,
submit the required HUD Inspection Reports. CCAC will deem a score of 60 to 100. A score of 45 to 59
requires the full survey summary report. A score of 45 or below results in a show cause.
___ Five-year capital repair and replacement plan.

Written Description
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   Describe how the organization provides a physical environment that is safe, well maintained and
    accessible to residents/clients with varying physical needs.



   Describe how the vehicles owned, rented or leased for transporting residents/clients are maintained.




   Describe how drivers licenses are verified and driving records reviewed for all staff transporting
    residents/clients.




   Describe the training for transportation staff that addresses needs of residents/clients, safety,
    accidents and handling of emergencies.




   Describe the organization’s emergency preparedness plan. Key elements of the plan should include,
    but are not limited to: natural disasters, fire, floods, loss of power, loss of water, elopement of
    resident, physically aggressive behaviors, physical hazards, bomb threats, violence, infectious
    outbreaks or other emergencies.




Standard Assessment


                                                     40
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org
Please type your responses directly into the boxes provided. As you type your information, the
boxes will expand to fit the responses.

   What success have you had with enhancing your organization’s physical environment?



   What current or future challenges exist?



   What improvements or new developments do you anticipate in your organization’s efforts to offer a
    safe and attractive physical environment?



   What measurement system are you using to track your success in maintaining your organization’s
    physical environment?



   What were the outcomes of this measurement system, and what impact did they have on your
    integrated strategic plan?



   Optional: Please provide a one-paragraph overview of any innovative program or practice you have
    developed for cost-effectively maintaining an attractive physical environment.




                                                     41
                                  Self-Assessment Template Printed in 2002
       The Continuing Care Accreditation Commission, 2519 Connecticut Ave., NW, Washington, DC 20008
                   Phone (202) 783-7286 Fax (202) 220-0022 Website www.ccaconline.org

				
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