Regulatory and Licensure Compliance

Risk – Failure to be in compliance with regulatory and licensure requirements including sustainable improvement (repeat deficiencies). This risk has potential legal, licensure, insurance, financial, reputational, and clinical implications for the facility.

Risk Management Strategies:

  • Licensure/Regulatory Compliance – Assign accountability and responsibility for licensure/regulatory compliance through an administrative or quality committee. Have an action plan for identified areas for improvement.

  • Survey Readiness – Complete mock assessments of facility compliance and survey readiness.

  • Incident Tracking – Track and trend incidents and occurrences including, but not limited to: falls, skin injury, wandering and elopement, medication errors, infections, complaints and grievances, abuse and neglect, safety and security events and environment of care events.

  • Quality Committee – Ensure quality committee minutes reflect action and targeted goals for improvement.

  • Plan of Correction – Monitor submitted plan of correction action steps for sustained improvement.