• The IJ That Wasn’t


    A death occurred at a facility. The resident, a hospice patient, had been actively dying. When the director of nursing reconciled medication after the death, unaccounted doses of oral liquid narcotic was noted.


    Facility leadership and governance contacted 24K for assistance in completing the investigation. The state regulatory agency was notified, who handled this as a Priority One reportable.


    Our Interventions:

    • Conducted a root cause analysis evening of event, including interview of involved staff.
    • Ruled out drug diversion as a root cause, as a result of investigation.
    • Assisted with notification of resident family and kept medical director informed and in the loop.
    • Developed corrective plans, to demonstrate substantial compliance before state regulators arrived next day.
    • Interviewed staff involved and prepared them for interview with state.
    • Present on-site during Priority One survey.
    • Drafted Plan of Correction.


    The Results:

    • Scope and Severity turned out to be a D.
    • Plan of Correction accepted by state regulatory agency and desk reviewed.
  • Employee Turn-Over Reduced


    Facility concerned with skyrocketing employee turn-over of 78%. They asked for help in reducing this and saving money on training.


    Our Interventions:

    • Redesigned New Employee Orientation.
    • Implemented 24K Team Values™.
    • Conducted employee satisfaction survey and provided feedback to governance, administration, and staff.
    • Implemented Peer Interviews for key positions.


    The Results:

    • In two years, employee turn-over fell to 48% and continues to trend downward.
  • From 13 to 4 Tags. In one year.


    In 2018, facility’s annual survey resulted in 13 deficiencies and a $12,000 one-time fine. Retained 24K for management of facility.


    Our Interventions:

    • Completed Mock-SurveyPlus
    • Implemented 24 Karat PDSA Action Plans
    • Implemented 24K Team Values
    • Monitored for compliance with Mock SurveyPlus ™ Action Plans


    The Results:

    • 2019 annual survey: 4 tags (3 E tags, 1 F).
    • No fine.
  • Help! We are in SQC


    On last day of annual survey, facility administrator was informed they were in SQC, with 15 potential tags discussed during the exit conference. 24K retained to assist with SQC plan of correction and drafting of POC.


    After engagement, facility received federal look-back survey. The CMS team was present for two days.


    Our Interventions:

    • Immediately worked with facility staff to develop PDSA-based Action Plans to show substantial compliance with potential SQC items.
    • 24K worked with HHSC regional staff, updating them on facility efforts for compliance.
    • Ownership desired new LNFA, DON, ADON. 24K assisted with recruitment and selection of these key staff members.
    • Our team on-site during federal look-back survey.
    • Developed POC and oversaw implementation of POC.


    The Result:

    • No changes resulting from CMS Federal Look-back survey.
    • SQC not listed in final 2567.
    • Actual tags written were 11 (down from 15 proposed in exit conference).
    • POC accepted by state and cleared on revisit.
  • We Need Fall Reduction Program


    Facility fall count was increasing for three consecutive months. The month we were engaged to partner with them to develop a fall program, the number of falls were 22.


    Our Interventions:

    • Developed employee education program for all facility staff.
    • Implemented Call Don’t Fall Program.
    • Routine monitoring and continued education.



    • Falls reduced from 22 to 4 in just 4 months.


Our team has a passion for working along-side our clients in establishing and growing a 24 Karat CultureTM which results in a transformation which truly empowers teams to respond the challenges facing our industry and gives residents a voice and choice™ in their care.

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24 Karat Ventures, LLC

12402 Slide Road, Suite 306

Lubbock, Texas 79424


Phone: 806.780.7000

Fax: 806.780.7400


© 2019 24 Karat Ventures, LLC