SAVVY on the SOM is an online monthly newsletter for the Administrative staff of Skilled Nursing Facilities.
The goals of SAVVY on the SOM are to:
- Facilitate understanding of the CMS regulations found in the State Operations Manual.
- Facilitate understanding of the CMS survey process from the surveyors perspective and observations.
- Provide research into best practices and review of current potential changes from applicable websites (CMS, CDC, AHCA, AHRQ, etc.).
- Provide practical implementation strategies using the QAPI process.
Leslie Mahoney, RN and CEO for SAVVY on the SOM
Leslie’s strong background, both as an administrator and a clinical nurse, has helped her to develop practical approaches to implementing regulatory requirements in a variety of settings. In addition to 52 years in Nursing, Leslie has worked for the California Department of Public Health, Licensing and Certification for several years. As a Health Facilities Evaluator Nurse her expertise in the Medicare Regulations for Skilled Nursing Facilities made her a strong survey team leader and a thorough investigator when handling complaints. Leslie’s approach to the survey process was one of collaboration and nonjudgmental communication. When finding deficiencies, she made sure the staff and administrators understood the regulatory requirements and what was missing from the facility practice.
In the ICU, Leslie’s leadership led to administrative approval for a unique overlapping shift schedule, all RN staffing for a 24-bed unit, a preceptor orientation program and a turnover rate of less than 5%. Leslie developed and monitored the ICU annual budget of $12,000,000. JCAHO surveyors always had positive comments about this ICU.
When Leslie was asked to start a hospital-based Home Health Department, she gladly accepted the challenge. She developed her own orientation program, learned the Medicare regulatory requirements, developed all of the policies, procedures, budgets, staffing requirements and implemented an EMR (electronic medical record) to interface with the hospital’s new EMR. The Home Health Department received no deficiencies during its JCAHO survey.
During a six month temporary position as Director of Home Health in another state, Leslie did a complete department turnaround. Every policy and procedure was rewritten to meet state, Medicare and JCAHO requirements, a new QAPI committee and EMR were implemented, and the staff was educated in all of the regulatory requirements. The department passed their JCAHO survey with a score of 96%.
Leslie was again challenged to learn the Medicare regulations when she accepted a position as Director of Hospice. The Hospice was preparing for an unannounced JCAHO survey. Leslie worked with consultants and the Hospice staff to ensure the departments readiness for the survey. Leslie ensured the competency of the Hospice staff by completing field visits and clinical observation of each staff member. The JCAHO survey was passed with no revisit required.
In developing SAVVY on the SOM, Leslie has used her understanding of Medicare regulations and a common sense approach to implementation strategies. Leslie and our consultant staff do extensive research into each topic, finding best practices, standards of care, and discipline specific scope of practice to meet the intent of the involved regulations.
Kyle Prescott, Physical Therapist
Kyle received his DPT from Eastern Washington University in 2014. Since then he has worked primarily in outpatient orthopedics and skilled nursing/ short-term rehab. Kyle has interests and training in vestibular and oncology rehab. He loves the outdoors and anything sport-related, which works out well as the father of three active boys.
Sharon Petris, RN and Consultant
A Registered Nurse with over 35 years of experience working in health care, Sharon started her career in the U.S. Army. Her work history includes Home Health, Hospice, Dialysis and hospital experience and she has worked as a CNA, LVN, RN and recently as an interim DON.
Sharon spent six years working for the California Department of Public Health, Licensing and Certification Division, as a Health Facilities Evaluator Nurse. Her last year with the department was in a leadership role working for the Staff Education Quality Improvement Section supervising the Los Angeles County Monitoring Unit. Sharon currently is working as a consultant for a national skilled nursing company and resides in California.
Emilene “Emi” Taylor, MSW – Masters of Social Work, USC
Hospitals, Home Health, and Hospice providing services and emotional support, community resources, family counseling and end of life education to staff and patients.
Provided services to Hospice patients in Skilled Nursing Facilities. Coordinated services with Hospice team members.
Advocate for Hospice services in LTC facilities.
Developed and led 12-week grief support curriculum for family and community members.