Clinical Quality, Compliance and Accreditation Services.

At LHS, the performance improvement process expands beyond standard quality assurance methods by implementing evidenced-based systems to improve patient care. Our consultants include many highly skilled professionals in nursing, nutrition, social work and rehabilitation services who can design and formulate a comprehensive performance improvement program. Below is a partial list of the performance improvement services that our clients most often request:

• Infection control
• Pain Management
• Nutritional assessment, planning and evaluation
• Social work interventions
• Physical, Occupational and Speech therapy management and outcomes
• MDS and comprehensive care planning
• Therapeutic recreation
• Dementia care
• Pressure Ulcer Prevention

LHS has been preparing facilities for surveys by the Joint Commission, Departments of Public Health, and other governmental agencies since 1993. Once the survey is complete, LHS can design the processes necessary to maintain the regulatory standards. The LHS team brings the clinical, operational and financial expertise needed to achieve your organization's goals. Our proven strategies will result in the highest quality of care for your residents. The regulatory experts at LHS have assisted many facilities in the following areas:

Joint Commission

• Preparation for Joint Commission accreditation

o Current information about accreditation policies and procedures
o Assessment of readiness for survey
o Clarification of the interpretation of standards
o Reduction of documentation burden
o Compliance with measurable standards for care
o Evaluation and/or enhancement of systems for coordination and
   communication between departments
o Designing plan of action for compliance with implementation measures

• Ongoing support to ensure continued compliance with Joint Commission standards.

o Monthly on-site meetings
o Detailed recommendations related to maintaining substantial compliance
o Planning and implementation to exceed Joint Commission standards

• Joint Commission continuous improvement services

o Credentialing and granting of clinical privileges for licensed independent
   practitioners
o Organizational Safety
o Point of Care Testing
o Pain Management programming

Our consultants are experts in all areas of healthcare compliance. We provide long term care facilities with up to date systems to maintain government compliance with OIG and HIPAA regulations. Services include:

• Systems assessment and program development
• Design and implementation of plans to achieve compliance
• Training and Education for all levels of staff
• Ongoing monitoring to exceed compliance standards

• Department of Public Health Survey (DPH) Preparation and ongoing support

o Full-scale mock surveys to assess readiness in all departments
o Detailed review of areas of weakness and action plan to correct potential
   deficiencies
o Supervision by LHS clinical specialist with the correction plan prior to survey
o Medical record audits and recommendations
o Evaluation of the effectiveness of internal committees and systems required
   by DPH regulations

The Landmark consulting team has successfully implemented numerous dedicated dementia units and has assisted clients with enhanced programming, staffing, recreational therapy and supportive services for memory impaired residents and their families. Services for clients include:

• Therapeutic environmental assessment
• Recommendation for space configuration for optimal programming
• Staff training for Alzheimer’s Association certification
• Program design of full-spectrum, failure free therapeutic recreation program
• Safety assessment and plan of action
• Implementation of individualized and group memory enhancement programs
• Performance improvement for dementia services

The team of nurse consultants at LHS includes many clinicians with exceptional experience as well as proven teaching skills. Education and training programs are available in the three major areas: clinical quality processes and prevention; clinical issues in reimbursement (e.g., Medicare PPS, RAI and MMQ management) and core training for nursing management. The education programs offered by LHS can include a combination of useful tools, clinical models, ongoing supervision, individual mentoring and facility or regional training- depending on the needs of the individual client. Services for clients include:

• Clinical Quality Processes

o Pressure Sore Prevention, Assessment and Management
o Dementia Training, based upon the Alzheimer’s Association Training program
o Fall Prevention
o Delirium- Understanding the Phenomena, Interventions and Risk Management


• Nursing Management Training

o The Unit Manager – operations, leadership and clinical skills
o Nursing Leadership for the New DON
o Training for the Staff Development Coordinator


• Essential Nursing Knowledge for Quality of Care and Reimbursement

o CMI & MMQ Management
o Medicare PPS
o MDS/RAI Process and Documentation
o Continuous Quality Improvement- Beyond the QA Committee
o How to prepare the Plan of Correction after DPH Survey

Revenue collection is a continuously changing process as the Centers for Medicare and Medicaid implement new and more complex rules. Landmark’s business office specialists have designed comprehensive systems to maximize financial strength by integrating accurate and timely clinical information into the process. Evaluation, training and implementation services include:

• Interdisciplinary team structure, meetings, procedures and information flow
• Pre-admission data collection- CWF screening
• Medicare Part A UB 04 Claims

o Current information about accreditation policies and procedures
o All required codes
o Editing and triple check procedures

• Medicare Part B Billing

o Documentation for rehabilitation services
o Condition and complexity coding
o Use of Modifier 59