It is critical to address and mitigate adverse events and potential adverse events. An action plan, otherwise known as a mitigation plan, is a necessary response to adverse events and potential adverse events. For many such events, it is important to respond and start the mitigation process immediately. AHCA/NCAL has a new set of resources to help you put steps in place to address an adverse event or potential adverse event and link it with your QAPI process.

Examples of adverse events/potential adverse events include:

• Falls (not following the care plan, use of gait belt, one vs. two-person transfers)
• Falls with a mechanical lift
• Elopement
• Allegation of abuse or neglect
• Water too hot
• Smoking (supervised vs. unsupervised, with oxygen, defined smoking area, all about safety)
• Bedrails (entrapment, assessment for use)
• Significant medication errors such as cardiac medications, chemo, insulin, morphine, Coumadin
• Infection Control – outbreaks (e.g. scabies, bedbugs, MRSA, C-Difficile, Noro Virus, Legionella)
• Lack of timely or complete evaluation of a change in condition
• Pressure ulcer – lack of prevention or following prevention measures
• Grievances and resident/tenant council feedback

The resources include assisted living-specific:

• Action Plan Description and Objectives
• Initial Mitigation Plan
• Abuse Allegation Initial Mitigation Plan Sample
• Mechanical Lift Mitigation Plan
• Mitigation Action Plan QAPI Process

Use the following link to access the free tools on ahcancalED:

• Assisted Living Action Plan Response for Adverse Events

Note: These tools were initially developed by members of AHCA’s Survey/Regulatory Committee and adapted for assisted living communities to assist providers in addressing adverse events and potential adverse events, documenting and tracking the steps they have taken, and identifying best practices for ongoing improvement. Communities may use different titles or terms than the action plans, such as director of health services instead of director of nursing, or service plan instead of care plan. Please adapt the plans to reflect your AL community.