CLTM cheat sheet
CLTM · Keep the key ideas within reach.
Long-Term Care Service Delivery and Operations Management
Continuum levels: independent living, assisted living, memory care, skilled nursing facility (SNF), and home- and community-based services (HCBS).
Nursing hours per resident day (HPRD) = total direct-care nursing hours ÷ resident census days; commonly reported per facility day.
Occupancy rate = occupied bed days ÷ available bed days × 100%; census is a point-in-time count of residents.
Case-mix index (CMI) expresses average resident acuity relative to a reference; higher CMI predicts higher staffing and supply needs.
Average daily census (ADC) = total resident days in a period ÷ number of days in the period.
Staffing ratio example: RN coverage required 8 consecutive hours per day, 7 days per week in SNFs (federal minimum).
Functional status is classified using ADL/IADL dependency counts; ADL = bathing, dressing, toileting, transferring, eating, continence.
Service delivery models: primary nursing, team nursing, functional/task assignment; choice affects continuity and handoff frequency.
Person-Centered Care Planning and Coordination
Care plan is developed by an interdisciplinary team (IDT) with the resident and, if chosen, family representative; resident goals drive interventions.
Minimum Data Set (MDS) assessment is the standardized resident assessment instrument; care plans must reflect identified needs and risks.
SMART goal format: specific, measurable, achievable, relevant, time-bound; each problem statement pairs with measurable objectives.
Care conferences should include resident preferences, advance directives, and discharge/transition planning.
Person-centered elements: resident choice, dignity, autonomy, self-determination, and cultural/spiritual preferences documented.
Care plan review occurs at least quarterly and with any significant change in condition; revisions are dated and signed.
Coordination includes medication reconciliation, fall-risk review, and communication with external providers at transitions of care.
Restraint use requires documented assessment, alternatives tried, time-limited orders, and monitoring; chemical restraints are not for staff convenience.
Human Resources and Workforce Management
FTE (full-time equivalent) = paid hours ÷ standard full-time hours (commonly 40 per week or 2,080 per year).
Turnover rate = separations ÷ average headcount × 100% over a defined period.
Vacancy rate = vacant positions ÷ budgeted positions × 100%.
Recruitment cycle time = days from requisition approval to accepted offer.
Orientation and competency validation must be documented before independent assignment; nurse aide training hours are federally specified.
Performance appraisal cycle typically annual with documented coaching; progressive discipline steps: verbal, written, suspension, termination.
Staffing plan balances HPRD requirements, acuity, and budget; overtime and agency use are leading indicators of burnout.
Employee retention drivers: scheduling flexibility, recognition, career ladders, and safe staffing levels.
Financial Management, Budgeting, and Reimbursement
Net operating margin = (operating revenue − operating expenses) ÷ operating revenue × 100%.
Days cash on hand = unrestricted cash ÷ (annual operating expenses ÷ 365).
Accounts receivable days = (average AR ÷ net revenue) × 365; higher values indicate slower collections.
Reimbursement sources: Medicare (Part A SNF prospective payment), Medicaid (state per-diem or case-mix), private pay, and managed care contracts.
Medicare SNF prospective payment uses per-diem rates adjusted by case-mix; therapy and nursing components are bundled.
Medicaid reimbursement is state-specific; many states use case-mix or RUG-based payment systems.
Budget variance = actual − budgeted; favorable if revenue exceeds or expense is below budget.
Labor cost per resident day = total nursing labor cost ÷ resident days.
Regulatory Compliance, Licensing, and Quality Improvement
Survey process: standard survey, complaint survey, and revisit; citations are assigned scope and severity on a grid (A–L).
Immediate jeopardy (IJ) = situation causing serious injury, harm, impairment, or death; requires immediate corrective action.
Plan of Correction (POC) must state corrective action, monitoring, responsible person, and completion date.
Quality Assurance and Performance Improvement (QAPI) is a required ongoing program with data-driven priorities and measurable goals.
Quality measures (QMs) such as falls with major injury, pressure ulcers, and antipsychotic use are tracked and publicly reported.
Civil money penalties, denial of payment for new admissions, and termination are enforcement remedies for noncompliance.
Licensure requires current facility license, administrator licensure, and compliance with life safety and infection control codes.
Root cause analysis (RCA) is used after sentinel events to identify system failures and prevent recurrence.
Risk Management, Safety, and Resident Rights
Resident rights include dignity, privacy, choice, access to records, grievance process, and freedom from abuse, neglect, and exploitation.
Abuse categories: physical, sexual, verbal, mental/emotional, financial exploitation, involuntary seclusion, and neglect.
Mandatory reporting: suspected abuse or neglect must be reported to the administrator and state agency within required timeframes.
Fall risk tools (e.g., Morse, Hendrich) guide interventions: bed alarms, toileting schedules, and environmental modification.
Pressure injury prevention: repositioning schedules, support surfaces, nutrition/hydration, and skin assessments.
Infection control: hand hygiene, isolation precautions, and surveillance of healthcare-associated infections.
Incident reports are internal quality tools and are not placed in the resident's clinical record; documentation remains factual.
Restraint reduction and least-restrictive alternatives are required; restraint use triggers monitoring and reassessment.
Leadership, Communication, and Interprofessional Collaboration
SBAR handoff: Situation, Background, Assessment, Recommendation; used for structured clinical communication.
TeamSTEPPS core skills: communication, leadership, situation monitoring, mutual support, and team skills.
Conflict resolution stages: identify issue, gather facts, discuss, agree on action, and follow up.
Leadership styles: transformational (vision/inspiration), transactional (rewards/penalties), and situational (adapts to context).
Change management (Kotter) steps: urgency, coalition, vision, communication, empowerment, short-term wins, consolidation.
Effective IDT includes nursing, therapy, dietary, social work, activities, medical, and administration with defined roles.
Just culture distinguishes human error, at-risk behavior, and reckless behavior; response differs by category.
Communication barriers: hearing/vision loss, language, cognition, and cultural differences; interpreters and teach-back improve comprehension.
Quality Improvement and Performance Measurement
PDSA cycle: Plan, Do, Study, Act; iterative testing of changes on a small scale.
Quality indicator example: rate = number of events ÷ number of residents at risk × 100 (or per 1,000 resident days).
Control charts distinguish common-cause (random) variation from special-cause (assignable) variation.
Benchmarking compares performance to internal targets or external peers; percentiles indicate relative standing.
Data sources include MDS, incident reports, infection logs, satisfaction surveys, and staffing records.
Run charts display a measure over time; a shift of 6+ points or a trend of 5+ points signals a non-random change.
Sustainability requires standardizing the change, monitoring, and embedding in policy and training.
QAPI plan includes measurable objectives, data collection, analysis, and performance improvement projects (PIPs).