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

APPENDIX F. Facility Recognition Programs

FLORIDA: Application for Nursing Home Gold Seal Award

NOTES

FLORIDA

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

NOTES

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

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Table of Contents

APPENDIX A. State Reports

APPENDIX B. Public Reporting Systems

APPENDIX C. Technical Assistance Programs

APPENDIX D. Best Practices

APPENDIX E. Provider Training Programs

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APPENDIX G. Funding of Quality Improvement Programs