Quality Management Program

This video program with Jennifer Windram, BSN, RN, former CDPHE-surveyor will engage learners to reach a better understanding of what is expected in the Quality Management Program from a Surveyor perspective. Please note that regulatory updates from Chapter 2, Part 4 are noted in the course entitled 2021 Quality Management Program & Plan.

Course Goals
Attendees will learn skills and tools necessary to apply State Licensure rules in the implementation of a quality management program and avoid common pitfalls.

Workshop Content
This Certificate Workshop will include the following curriculum, with interactive discussions, presentations and case studies. The curriculum includes:

Review of licensing standards for the quality management program
Common survey focus areas and frequently cited deficiencies
Methods to monitor care and services, prevent problems, and maintain compliance with State Licensing rules
Using the PDCA cycle to investigate and improve areas identified as needing improvement
Quality management tools used in analyzing problems and identifying solutions

Agency Oversight and Operations

CDPHE-approved training Skilled Agency Oversight and Operations in video form with Jennifer Windram, RN, BSN and former CDPHE Surveyor.

The program focuses on the governing body and administrative requirements for skilled agencies including effective meeting minutes, PAC, annual agency evaluation, quarterly record reviews, on-call system, and tracking of agency operations such as on-call activities, complaints/incidents, infections, hospitalizations, infections, etc.

Complaint and Incident Processing Part 1

This video program is CDPHE-approved Complaint and Incident Processing – Part 1 with Jennifer Windram, RN, BSN and former CDPHE Surveyor. Attendees will learn skills and tools necessary to apply State Licensure rules in appropriately investigating, resolving, and documenting complaints and incidents

Provision of Skilled Care and Services

This course reviews the requirements for patient care–from referral through discharge with Jennifer Windram, RN, BSN, former CDPHE Surveyor.

Learning objectives for this course:

Review of licensing standards for the provision of care, from referral to discharge, with emphasis on surveyor expectations
Common survey focus areas and frequently cited deficiencies
Formulating policies and procedures for the provision of care and services

Staffing Methodologies and Oversight of Scheduling, Staff Training and Supervision (All About Personnel Part 2)

Join Connie McWilliams in a review of Staffing methodologies, oversight of scheduling, staff training and supervision.

After completing this course, the learner will be able to:

Describe the Administrator role in HR Development and all of its components,
Define the term oversight,
Identify five areas of staffing and scheduling oversight that are often overlooked,
Communicate staffing as it relates to consumer rights and communication,
Analyze oversight issues identified in quality improvement activities,
Examine staffing and scheduling together as one of the largest single factors of poor financial, productivity and quality performance.


Financial Management

This non-audio course explores Basic Financial/Revenue Cycle Management Objectives. Learners will have all fear of this topic removed and understand how simple the root concepts really are!

After this course attendees will be able to:

~ Use the term Financial Management in a sentence to a coworker or colleague.
~ Describe the definition of Revenue Cycle and Cash Flow Cycle
~ Name the key piece of raw data that determines key revenue and expense in any home care agency
~ Distinguish between an Annual Operating Budget and Capital Expenditure Plan
~ Identify Home Care Standards regarding annual operating budget & capital expenditure plan.
~ Define Gross Profit Margin
~ Define Cost of Goods Sold
~ Distinguish between Cash and Accrual methods of accounting
~ Create a budget

Ethics in Home Care

There is an overlapping nature of Ethics, Safety and Quality.  In this non-audio course, the learning objectives include:

•Define ethics

•Understand the benefits of an Ethics Program

•Create strategies to address ethical conflicts at work.

•Identify ethical and unethical behavior.

•Verbalize the objective of an ethics program and code of conduct within

• Discuss the AMA and ANA influence on Home Care Ethics


Behavior Management and Mental Illness

Non-audio course written by Bonnie MacLeod, LCSW. Many home care agencies provide care and services to adults with a mental illness or MI. Although some consumers need specialized care, home care workers should not discount the potential impact of taking time during home visits to minimize behaviors with certain clients. Simple actions such as demonstrating emotional openness, instilling hope, and using active listening can be powerful. With practice, home care workers will feel more confident and effective using the tools described in this course.

After this course, you will be able to:
Define the term “mental illness” and what it is and what it is NOT
Discuss the historical perspective of illness and why this is important today
Name two organizations that provide key statistics, information and support on mental illness
Define DSM and how it is used with mental illness
Name at least three mental illnesses
Express how behaviors can impact care
Identify the objective of a Behavior Management Plan (BMP)
Name expectations of a BMP that are unrealistic
Define “Behavior Report (BR)”
Discuss consumer cognitive ability and affect on BMP

Basic 8-hour Administrator Training

The goal of this workshop is to provide the fundamentals of Home Care Management for compliance with both Initial and Annual Training requirements by CDPHE for Administrators, Managers and Alternates. The video course is four sessions of two hours each for a total of eight clock hours of training, with Connie McWilliams, CHC President, who owned and operated an Accredited Skilled and Nonmedical Agency for 20 years in Denver.

This courses sets the stage from which all other courses flow!

Workshop Content

License standards overview, National, State home care & post-acute care provider types,
Key Federal, State & Local Law Review;
Consumer Rights, P&P required for all agency types
Written Notice of Home Care Consumer Rights, Disclosure notice, Demonstrating consumer understanding;
Questions & Answers, Evaluation, Competency Exam

Governing Body Duties, Administrator/Manager Duties, PAC membership and responsibilities,
Survey readiness, Annual Evaluation, Data collection, Complaints, Incidents, Occurrences, Grievances, Contract worker agreement
Quality Management Plan: The Standards, most common deficiencies, concept of organization-wide, Risk management similarities and differences to Quality management.
Questions & Answers, Evaluation, Competency Exam

Workshop Objectives
You will learn the skills necessary to show a clear understanding and appropriate application of Licensure Standards. After this course, you will be able to:
▪ List three reasons for the need for licensure
▪ Identify differences between skilled and non-skilled services
▪ Utilize at least five concepts of written notice of consumer rights in the home care setting
▪ Identify 3 responsibilities of the Governing Board, Administrator/Manager & PAC.
▪ Define ongoing training program components for PCWs, CNAs, Administrators, Managers & Alternates
▪ Demonstrate at least 4 needs of a compliant Quality Management Program
▪ Understand components of the home care / post-acute care industry on both a national and state level
▪ Define the term, “minimum standards” and how it applies to your daily operations,
▪ Describe how to locate Chapter 26 and 2 in the Colorado Code of Regulations and briefly describe the content of each,
▪ Define the term “consumer” as used in Licensure standards,
▪ Compare and contrast License classification types A and B and legal limits of services therein,
▪ Illustrate dually regulated home care and what that means,
▪ Communicate the key points in 18 federal laws that affect the aged, infirm & disabled,
▪ Consider at least 5 components required in handling Complaints/Incidents/Occurrences,
▪ Depict similarities of the Quality & Risk Management Programs,
▪ List at least 10 documents required to present to surveyors upon the initiation of an unannounced survey,
▪ Distinguish between an organization’s bylaws and articles of incorporation (organization),
▪ Describe client rights of LEP or Limited English Proficiency,

Care of the Fragile, Ill & Complex Client

Home Care Agencies face particular challenges in providing services and coordinating care for frail, ill and complex clients. 2 CEU

This non-audio program explores the current landscape of services for patients with complex needs, details characteristics of these clients, addresses the challenges of caring for these clients, and offers programmatic and policy changes that can help Home Care Agencies better deliver services to all clients, including those with the most complex health needs.

Learning Objectives for this 2 CEU Course:
Who are complex, frail and ill clients?
Explain why the plan of care requires additional components with the Frail and Elderly.
Examine external influences that impact care of the fragile and ill.
Recognize special training and staffing considerations.
Identify KEY data elements for the Quality Management Program (QMP).
Competency Exam
Course Evaluation

Behavior Management of the Client with Dementias or Cognitive Disorders

Many home care agencies provide care and services to an adult with a cognitive (brain) impairment. Cognitively-impaired people have difficulty with one or more of the basic functions of their brain, such as perception, memory, concentration, and reasoning skills. Common causes of cognitive impairment include Alzheimer’s disease and related dementias, stroke, Parkinson’s disease, brain injury, brain tumor, or HIV-associated dementia. Although each disorder has its own unique features, family members and caregivers often share common problems, situations, and strategies.

This non-audio program is written by Bonnie MacLeod, LCSW.

Care About Care Coordination

In this non-audio course (coming soon), Attendees will learn skills and tools necessary to apply State Licensure rules in daily operations, understand why care coordination is necessary, what makes it effective, and typical barriers.

Review of licensing standards for Care Coordination,
Common survey focus areas and frequently cited deficiencies,
Challenges to monitoring Care Coordination efforts,
Understand Care Coordination barriers, measures of effectiveness, evaluation of your policy and procedure for today’s care settings.

After this course, you will be able to:

 Discuss the minimum standards for care coordination
 List at least two current trends in citing deficiencies
 Identify weakness in your agency relative to two common challenges in any Care Coordination program
 Demonstrate an understanding of Care Coordination and patient/client/family communications

Care About HIPAA, Privacy & Confidentiality

In this non-audio course we learn Administrators have a duty to ensure all workforce members understand their responsibility to abide by HIPAA rules. When co-workers become careless, the resulting damage affects the agency as well as our own personal reputation.

This Certificate eLearn course offers clear student progress indicators and unlimited replays of course material. Resume learning exactly where you left off, on your mobile, tablet, laptop or any device. The curriculum includes:

Privacy and Security Rules Reputational costs of HIPAA breach
Identifiers which create PHI Questions & Answers
Protecting privacy and security

After this course, you will be able to:

Distinguish between Privacy and Security rules,
Recognize situations in which confidential and protected health information can be mishandled,
Identify practical ways to protect the privacy and security of sensitive information,
Outline the duties of the Privacy Official,
Learn the costs of HIPAA breach when co-workers become careless,
Understand how mishandled confidential or protected health information is the responsibility of every worker.

Care About Immunity

The immune system uses several tools to fight infection. Join instructor Barbara Buehner, RN, BSN in this non-audio course.

Learning Objectives for this 2 CEU Course:

Explain the relationship between disease transmission and client safety
Describe the general function of the immune system
Describe the general function of the lymphatic system
Explain the differences between specific and nonspecific immunity
Explain the differences between inherited (passive) and acquired immunity and common vaccines used today
List the steps necessary to report a contagious disease

Complaint and Incident Processing Part 2

In Part 2 of this program, Jennifer Windram, RN, BSN provides CDPHE-approved training on Complaint and Incident Processing on common deficiencies as well as incorporating agency action taken into the QMP.

The program includes:

Conducting a thorough investigation and finding the best resolution,
Common survey focus areas and frequently cited deficiencies,
Incorporating complaints, incidents and occurrences into your QMP.

Personnel Qualifications, Experience, Competency and Evaluations (All About Personnel, Part 1)

Video program with Connie McWilliams to include Policy and procedure, risk areas, administrator role in human resource management, organizational chart function, personnel qualifications and experience, job description role, personnel record, surveyor probes, contractor use in direct care, direct care documents that are missing or expired, training and education policy, special skills training and client diagnoses, and the need for ongoing training – it never stops.

After completing this course, Administrator staff will:

Describe implications of personnel policies on daily duties,
Define Policy components for organizational structure, oversight, qualifications, competency, staffing, missed visits,
Discuss surveyor probes used to ascertain agency compliance with personnel standards or regulations,
Evaluate agency policy content as a method for directing client activities as well as verifying compliance with regulations

Understanding the Survey Process

In this non-audio program entitled Understanding the Survey Process for both skilled and non-skilled agencies to ensure Administrators are prepared for the next surprise, onsite survey. Written by Jennifer Windram, RN, BSN and former CDPHE Surveyor.