Governance & Staffing

MANDATORY

5 criteria

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [31] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, require sufficient nursing staff determined by resident assessments, individual care plans, and the number, acuity, and diagnoses of the facility's actual resident population.

A fixed staffing number that doesn't account for how sick or dependent the current resident population actually is can look adequate on paper while genuinely failing residents whose real care needs have increased — the resident count alone tells you far less than resident acuity does about whether staffing is actually sufficient.

1 The facility assessment exists and is periodically updated but staffing decisions don't consistently reflect its findings.

An assessment that doesn't genuinely inform staffing provides limited real protective value.

2 Staffing adjusts for major acuity changes but not for the cumulative effect of smaller changes across the resident population.

Gradual, cumulative acuity changes deserve the same genuine responsiveness as a single major change.

3 Staffing is adequate for day shifts but less clearly matched to acuity for evening and overnight coverage.

Resident acuity and care needs don't diminish outside daytime hours.

Week 1 Review current facility assessment for genuine currency and connection to staffing.

Week 2 Establish a systematic process connecting acuity changes to staffing adjustment.

Week 3 Review staffing adequacy specifically across evening and overnight shifts.

Ongoing Update the facility assessment and staffing determination as the resident population genuinely changes.

Ask administration for a specific example of staffing adjusting in response to a genuine acuity increase.

A real, specific example reveals whether the connection between acuity and staffing is genuine, not just described in policy.

Check staffing levels specifically during evening and overnight shifts.

This is where staffing-to-acuity matching is most likely to show real gaps.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [32] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, require regular, genuinely accurate public reporting of nurse staffing information, including actual hours worked by each category of licensed and unlicensed nursing staff.

Publicly posted staffing data exists specifically so residents, families, and visitors can see the facility's actual staffing reality, not an idealized version — data that's inaccurate or simply not posted defeats the entire transparency purpose this requirement exists to serve.

1 Posting happens consistently but the location isn't genuinely visible or accessible to visitors.

A technically posted notice that's hard to find doesn't achieve genuine public transparency.

2 Data is generally accurate but occasional discrepancies exist between posted and actual hours.

Even occasional inaccuracy undermines the genuine reliability this transparency requirement is meant to provide.

3 Retention is maintained but not easily retrievable when specifically requested.

Data that's retained but difficult to access doesn't provide the practical transparency retention is meant to ensure.

Week 1 Review current staffing posting location for genuine public visibility.

Week 2 Establish a verification process cross-checking posted data against actual timekeeping.

Week 3 Confirm staffing data retention meets the genuine 18-month requirement.

Ongoing Audit posted data accuracy against actual records periodically.

Physically locate the posted staffing information as a visitor would.

This tests genuine visibility and accessibility, not just technical compliance.

Cross-check a specific day's posted data against actual timekeeping records.

A specific, real comparison reveals genuine accuracy, not assumed correctness.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [33] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, require an effective, comprehensive, data-driven quality assurance and performance improvement program with documented evidence of systematic identification, investigation, and prevention of adverse events.

A quality improvement program that exists only as required paperwork, without genuinely using real data to identify and act on actual problems, provides none of the systematic improvement this requirement is meant to drive — the entire value of a data-driven approach depends on the data genuinely informing real action, not just being collected and filed.

1 Data collection is thorough but analysis doesn't consistently translate into genuine corrective action.

Data without genuine action doesn't provide the real improvement this program is meant to drive.

2 The annual project addresses a real area but scope doesn't match the facility's actual size and complexity.

A project's scope should genuinely reflect the facility's own actual services and resources, not a generic template.

3 Improvement is documented but not clearly measured against a specific, quantifiable baseline.

Without a genuine, measurable baseline, it's difficult to confirm real improvement actually occurred.

Week 1 Review current quality improvement program for genuine, data-driven practice versus documentation alone.

Week 2 Select or confirm an annual improvement project genuinely targeting a real high-risk area.

Week 3 Establish specific, measurable baselines for tracking genuine improvement.

Ongoing Review quality improvement outcomes against measurable baselines to confirm genuine improvement.

Ask for the specific, real data behind the current annual improvement project.

Real, specific data reveals whether the program is genuinely data-driven, not just documented as such.

Ask for measurable evidence that a past quality improvement project produced genuine improvement.

A real, measurable outcome distinguishes genuine improvement from activity recorded for compliance alone.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [34] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, establish that the governing body or executive leadership is responsible and accountable for ensuring a quality improvement program is sustained during transitions in leadership and staffing, and is adequately resourced.

A quality improvement program that depends entirely on one particular leader's personal commitment is genuinely fragile — real institutional accountability, held by the governing body itself rather than any single individual, is what allows a quality improvement program to survive leadership turnover without losing its actual substance.

1 Governing body accountability is documented but genuine engagement in practice is inconsistent.

Documented accountability without genuine, active engagement provides limited real protection against program fragility.

2 The program has weathered smaller staffing changes but hasn't yet been tested by a major leadership transition.

Genuine resilience is best confirmed by how the program holds up under a real, significant transition, not assumed from smaller changes alone.

3 Resourcing is generally adequate but technical training for quality improvement-specific skills is limited.

Adequate resourcing includes the specific technical training quality improvement work genuinely requires, not just general staff time.

Week 1 Review current quality improvement accountability structure for genuine governing body ownership.

Week 2 Establish documented processes ensuring program continuity through future transitions.

Week 3 Assess and strengthen resourcing, including quality improvement-specific technical training.

Ongoing Review program continuity and resourcing whenever a genuine leadership transition occurs.

Ask the governing body directly about their own role in quality improvement accountability, not just administration.

A specific, confident answer from governance itself reveals genuine institutional ownership.

Ask about a real, past leadership transition and how the quality improvement program held up.

A real example reveals genuine resilience, not just an assumption the structure would hold.

ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.

REFERENCES

1. [35] Established long-term care regulatory principles, recognized in various forms across many countries' care standards, prohibit employing individuals with a documented, substantiated finding of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property, verified through the relevant national or regional screening mechanism.

A resident's safety depends fundamentally on the people caring for them not having a documented history of abuse or neglect, and a background screening process that's inconsistent or incomplete can allow exactly the risk this requirement exists to prevent to walk through the door.

1 Screening is thorough for direct care staff but less consistent for support or contracted staff.

Anyone with resident access deserves the same genuine screening, regardless of their specific role.

2 State registry checks are performed but not consistently documented as verified.

Undocumented verification is difficult to distinguish from a check that wasn't genuinely completed.

3 Initial screening is thorough but periodic rechecking isn't consistently performed.

A finding entered after initial hire wouldn't be caught without genuine periodic rescreening.

Week 1 Review current background screening practice for completeness across all staff roles, including contracted staff.

Week 2 Establish consistent, documented registry verification for every hire.

Week 3 Establish a periodic rescreening schedule beyond initial hire.

Ongoing Audit screening completeness and documentation for new hires.

Ask to see the actual background screening documentation for a specific, recent hire.

A specific, real record is the genuine evidence of a functioning process, not an assumed one.

Ask specifically about screening practice for contracted or agency staff, not only direct employees.

This is where screening consistency most commonly shows real gaps.