west virginia health care association | charleston ...€¦ · web viewletter of recommendation...

Nominations Are Open!

2017 Awards ProgramWVHCA Annual Convention / May 8, 2018 - Charleston

Bringing recognition to those who make a difference Nominations are due on or before December 7, 2017

WVHCA Members are eligible to submit nominations for all award categories except the Distinguished Administrator and Outstanding Assisted Living Professional award categories. Only AL members can nominate in the Outstanding Assisted Living Professional category. Only nursing facility members can nominate in the Distinguished Administrator Award category:

· Distinguished Administrator Award (Nursing Facility Members Only)· Outstanding Assisted Living Professional (Assisted Living Members Only)· Distinguished Director of Nursing· Youth Volunteer of the Year Award· Adult Volunteer of the Year Award (May be an Individual or Group)· Best Practice Award· NEW: Individual Excellence Award for Operations (dietary, maintenance, office, etc.)· NEW: Individual Excellence Award Direct Care Staff (RN, LPN, CNA, etc.)· NEW: Individual Excellence Therapy· Distinguished Service Award · Distinguished Community Service Award

Nominations also are requested for no-lost-time and deficiency-free status. (Different deadline applies. Please see Rules of Entry.)

Mail, e-mail or fax nominations to:West Virginia Health Care Association / 110 Association Drive / Charleston, WV 25311Phone: 304-346-4575 Fax: 304-342-0519 E-Mail: [email protected]

The Rules of Entry, application and nomination forms follow.

Please carefully read the Rules of Entry. Judges must review numerous entries. To ease the judging process, please use the following guidelines. We want to ensure that your entries will be considered.

FOUR STEPS TO PARTICIPATE:1. Download the forms and save to your computer2. Complete the Application and Nomination Forms and follow the Rules of Entry below 3. Enclose items requested on the application and/or nomination forms4. Send nominations to WVHCA to arrive on or before the following deadlines:

a. Award nominations must arrive at WVHCA on or before: Thursday, December 7, 2017b. Deficiency free and no lost time nominations are due: Thursday, February 1, 2018

FACILITY/NOMINEE REQUIREMENTS: The nominating facility must be in good standing with the West Virginia Health Care Association. Nominees must be currently employed by a member facility and in good standing with his/her

respective licensing board(s), if applicable. A sentence of recommendation must accompany application when requested on the form and be

printed on facility/company letterhead from the employee’s or volunteer’s supervisor. The same person cannot win two different award categories in the same year. A winning candidate from the previous year is not eligible for the same act or service in the same

category for three years. However, if the winning candidate performed a completely different act or service in a category which they won previously, then they may be nominated in the same category.

A list of previous award recipients is available at www.wvhca.org under Quick Links. Click on the WVHCA Awards Program and enter the Member Only password. The Heroes in Long Term Care newsletter and a list of previous winners are available on the website.

APPLICATION AND NOMINATION FORM REQUIREMENTS: Complete the application form and a nomination form for each award category. Type your answer after

each question using the nomination form provided. The nomination form must not be altered in any way (font style/size/order of questions) and cannot exceed two pages in length. Forms must be typed and printed on plain 8 ½ x 11 white paper.

All nomination forms must remain anonymous and must NOT reveal the identity of your nominee or facility. The application is the ONLY place your name, your facility name and the nominee name should be revealed. Some award categories may request copies of news clippings or press releases; we are not concerned about revealing the identity of the facility/staff in these items.

WINNERS: A list of winners will be provided to all facility Administrators by March.SEND NOMINATIONS TO:

WVHCA Awards Committee - Rules of EntryFor 2017 WVHCA Annual Convention Awards Program

http://www.wvhca.org/

mailto:[email protected]

West Virginia Health Care AssociationAttn: WVHCA Awards Program110 Association DriveCharleston, West Virginia 25311Fax: (304)342-0519 / e-mail: [email protected] WVHCA with any questions at (304)346-4575.

Adult Volunteer of the Year Award Application(Individual or Group)

Eligibility and Criteria: This award category is available to both nursing facility and assisted living members. The purpose of this award is to honor the best Adult Volunteer for his or her dedication and service to long- term care residents at our member facilities. The Adult nominees may be either an individual or group. The individual must be 20 or older. “Group” means more than two persons of a nonprofit group or club that provides volunteer services, including a man-and-wife team. Refer to the Rules of Entry for additional requirements. Complete all of the information below. Typewritten answers are required; handwritten forms will not be accepted. Please indicate your name, the nominee name, and/or facility name on this sheet only.Nominee ______

(Indicate individual’s name or group’s name)

List all professional license(s) held by nominee (if applicable):

______ Facility Phone ______

Address Your Name Title ______ Your e-mail address (for confirmation purposes only) ____________

Administrator’s Name Administrator’s e-mail

ENCLOSURES REQUIRED WITH THIS APPLICATION: Typed Nomination Form (on following page) addressing each question (no more than two pages in length) Letter of recommendation from the Administrator/Executive Director on facility/company letterhead (one

page) Mail nominations to WVHCA to arrive on or before Thursday, December 7, 2017.

WV Health Care Association / Attn: Awards Program110 Association Drive / Charleston, WV 25311

Phone: 304-346-4575 / Fax: 304-342-0519 / e-mail: [email protected]

Office Use Only: ___ Letter of Recommendation Enclosed ___Confirmed Application

Adult Volunteer of the Year Award Nomination Form(Individual or Group)

Nomination Form: Type your answer after each question below using this form. To maintain consistency, please do not change the format of the document. The completed nomination form must not exceed two pages. Follow the guidelines on the Rules of Entry page to explain why this nominee should be the recipient of the award based on the criteria below.

1. Is your nomination for an individual or group?

2. How long has/have your candidate(s) volunteered at the facility (number of years) and how many times per month do they visit the facility?

3. Provide specific examples of how this nominee shows dedication and reliability.

4. What distinguishes this nominee from others, noting special talents or emphasis?

5. Why should this volunteer or group of volunteers be selected for the award?

Youth Volunteer of the Year Award Application

Eligibility and Criteria: This award category is available to both nursing facility and assisted living members. The purpose of this award is to honor the best Youth Volunteer for his or her dedication and service to long-term care residents at member facilities. Eligibility for nominees includes a Volunteer who must be between the ages of 10-19. Refer to the Rules of Entry for additional requirements. Complete all of the information below. Typewritten answers are required; handwritten forms will not be accepted. Please indicate your name, the nominee name, and/or facility name on this sheet only.

Nominee

Facility Phone

Address ______

Your Name Title Your e-mail Address (for confirmation purposes only)


ENCLOSURES REQUIRED WITH THIS APPLICATION: Typed Nomination Form (on following page) addressing each question (no more than two

pages in length) Letter of recommendation from the Administrator/Executive Director on facility/company

letterhead (one page) Send nominations to WVHCA to arrive on or before Thursday, December 7, 2017.




Youth Volunteer of the Year Award Nomination Form

Nomination Form: Type your answer after each question below using this form. To maintain consistency, please do not change the format of this document. The completed nomination form must not exceed two pages. Follow the guidelines on the Rules of Entry page to explain why this nominee should be the recipient of the award based on the criteria below.

1. How long has your candidate volunteered at the facility (number of years) and how many times per month does he/she visit the facility?

2. Provide specific examples of how this nominee shows dedication and reliability.

3. What distinguishes this nominee from others, noting special talents or emphasis?

4. Why should this volunteer be selected for the award?

Best Practice Award Application Eligibility and Criteria: This award category is available to both nursing facility and assisted living members. The purpose of this award is to recognize a member facility’s unique program that has achieved significant positive results and a desired outcome for other facilities to mimic. Facilities may submit more than one Best Practice nomination, although the nomination must be submitted separately for each Best Practice. Best Practice nominations submitted may focus on anything that has achieved significant positive results and a desired outcome for other facilities to incorporate. A few Best Practice topics may include but are not limited to: survey management preparedness, culture change, safety priority program, team-building project, unique orientation program, or anything that improved customer satisfaction or quality of care at your facility. Refer to the Rules of Entry for additional requirements. Complete all of the information below. Typewritten answers are required; handwritten forms will not be accepted. Please indicate your name, the nominee name, and/or facility name on this sheet only. Name of Best Practice Facility Phone Address Your Name Title Your e-mail Address (for confirmation purposes only)



pages in length) Send nominations to WVHCA to arrive on or before Thursday, December 7, 2017.



Office Use Only: ___Confirmed Application

Best Practice Nomination Form

Nomination Form: Type your answer after each question below using this form. To maintain consistency, please do not change the format of this document. The completed nomination form must not exceed two pages. Follow the guidelines on the Rules of Entry page to explain why this Best Practice should be the recipient of the award based on the following criteria:

1. What is the goal of the Best Practice?

2. Please describe the Best Practice.

3. What are the major implementation steps?

4. What resources are required?

5. Were there any unexpected outcomes or achievements as a result of this Best Practice?

6. Did this Best Practice come out of addressing a particular problem? If so, what was the problem and was it solved?

7. What is unique about this Best Practice?

8. Explain how this Best Practice gave a positive view of your facility's and the long-term care profession's public image. How did you promote this Best Practice and the successful outcome within your facility and publicly? Did you submit a press release to the local newspaper? Did you receive media coverage? If so, please copy your press releases and news clippings that highlight your facility’s Best Practice on 8.5 x 11 sheets and submit with your nomination.

Individual Excellence Direct Care Award Application

Eligibility and Criteria: This award category is available to both nursing facility and assisted living members. The purpose of this award is to recognize outstanding employees who perform their work in Direct Care to residents. A Direct Care employee is someone in the nursing department who works directly with residents. A Direct Care employee may be a Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistant, MDS Coordinator, or Restorative Aide. The goal is to honor outstanding employees who are compassionate, caring, and innovative in dealing with residents, families, and staff in the delivery of nursing care and long-term care services. Refer to the Rules of Entry for additional requirements. Complete all of the information below. Typewritten answers are required; handwritten forms will not be accepted. Please indicate your name, the nominee name, and/or facility name on this sheet only.

Nominee Title: List all professional license(s) held by nominee: Facility Phone Address ______ Your Name Title Your e-mail Address (for confirmation purposes only)



pages in length) Letter of recommendation from your candidate’s supervisor on facility/company letterhead

(one page) Mail nominations to WVHCA to arrive on or before Thursday, December 7, 2017.




Individual Excellence Direct Care Award

Nomination Form: Type your answer after each question below using this form. To maintain consistency, please do not change the format of this document. The completed nomination form must not exceed two pages. Follow the guidelines on the Rules of Entry page to explain why this nominee should be the recipient of the award based on the following criteria: 1. How many years has your candidate worked in the long-term care profession?

2. What skills separate this nominee from his or her peers?

3. Describe one way this nominee makes your facility a good place to work.

4. What attributes or special qualities are exhibited by this nominee?

5. How does this employee demonstrate exceptional performance?

Individual Excellence for Operations Award Application

Eligibility and Criteria: This award category is available to both nursing facility and assisted living members. The nominee must be an Operations employee. The purpose of this award is to recognize outstanding an Operations employee in a long-term care member facility. An Operations Employees provide support to staff members who work directly with residents. They may include Maintenance, Dietary, and Office Staff. The goal of this award is to honor outstanding employees who work in support of the delivery of care in their facilities. Refer to the Rules of Entry for additional requirements. Complete all of the information below. Typewritten answers are required; handwritten forms will not be accepted. Please indicate your name, the nominee name, and/or facility name on this sheet only.









Individual Excellence in Operations Award

Nomination Form: Type your answer after each question below using this form. To maintain consistency, please do not change the format of this document. The completed nomination form must not exceed two pages. Follow the guidelines on the Rules of Entry page to explain why this nominee should be the recipient of the award based on the following criteria: 1. How many years has your candidate worked in the long-term care profession?





Individual Excellence Therapy Award Application

Eligibility and Criteria: This award category is available to both nursing facility and assisted living members. The nominee must be an employee involved in therapeutic services. The purpose of this award is to recognize an outstanding Therapy employee in a long-term care member facility. Nominees may include Physical Therapists, Occupational Therapists, Speech Therapists, Physical Therapist Aide, Respiratory Therapist, and Rehabilitation Department Director. The goal is to honor outstanding employees who are compassionate, caring, and innovative in dealing with residents, families, and staff in the delivery of care. Refer to the Rules of Entry for additional requirements. Complete all of the information below. Typewritten answers are required; handwritten forms will not be accepted. Please indicate your name, the nominee name, and/or facility name on this sheet only.









Individual Excellence Therapy Award

Nomination Form: Type your answer after each question below using this form. To maintain consistency, please do not change the format of this document. The completed nomination form must not exceed two pages. Follow the guidelines on the Rules of Entry page to explain why this nominee should be the recipient of the award based on the following criteria:

1. How many years has your candidate worked in the long-term care profession?





Outstanding Assisted Living Professional Application Eligibility and Criteria: This award category is open to assisted living members only. The purpose of this award is to recognize outstanding individuals who demonstrate exceptional performance in an assisted living community. Refer to the Rules of Entry for additional requirements. Complete all of the information below. Typewritten answers are required; handwritten forms will not be accepted. Please indicate your name, the nominee name, and/or facility name on this sheet only. Nominee Title List all professional license(s) held by nominee:

Facility Phone Address Your Name Title Your e-mail Address (for confirmation purposes only)




(one page) Send nominations to WVHCA to arrive on or before Thursday, December 7, 2017.




Outstanding Assisted Living Professional Nomination Form

Nomination Form: Type your answer after each question below using this form. To maintain consistency, please do not change the format of this document. The completed nomination form must not exceed two pages. Follow the guidelines on the Rules of Entry page to explain why this nominee should be the recipient of the award based on the following criteria: 1. How many years has your candidate worked in the assisted living profession?

2. State the position held by the nominee.

3. What skills does this person possess?

4. What are the activities of this person that make him or her so remarkable?

5. How does this nominee demonstrate exceptional performance?

6. If known, provide their professional experience, community service and past awards received.

Distinguished Administrator Award Application Eligibility and Criteria: This award category is available to nursing facility members only. This award honors an administrator from a member nursing home who is nominated by his or her employees, peers, owner or facility official. The purpose of the award is to recognize an administrator for his or her outstanding efforts in a respective member facility. The nominee must be the Administrator of the facility. Refer to the Rules of Entry for additional requirements. Complete all of the information below. Typewritten answers are required; handwritten forms will not be accepted. Please indicate your name, the nominee name, and/or facility name on this sheet only. Nominee Title

List all professional license(s) held by nominee:

Facility Phone Address Your Name Title Your e-mail Address (for confirmation purposes only) ______

Administrator’s e-mail

ENCLOSURES REQUIRED WITH THIS APPLICATION: Typed Nomination Form (on the following page) addressing each question (no more than

two pages in length) Letter of recommendation from your candidate’s supervisor on facility/company letterhead


WV Health Care Association / Attn: Awards Program 110 Association Drive / Charleston, WV 25311



Distinguished Administrator Award Nomination Form Nomination Form: Type your answer after each question below using this form. To maintain consistency, please do not change the format of this document. The completed nomination form must not exceed two pages. Follow the guidelines on the Rules of Entry page to explain why this nominee should receive the award based on the following criteria:


2. Describe one way your nominee makes your facility a good place to work.

3. At which managerial skills does your nominee excel?

4. Describe one innovative program your nominee created to help residents.

5. What attributes or qualities does your nominee convey or demonstrate as exceptional performance?

6. If known, provide professional experience, past awards received and community service of your nominee.

Distinguished Director of Nursing Application Eligibility and Criteria: This award category is available to both nursing facility and assisted living members. This award honors a Director of Nursing from a member facility who is nominated by his or her employees, peers, owner or facility official. The purpose of the award is to recognize a Director of Nursing for his or her outstanding efforts in their respective member facility. The nominee must be the Director of Nursing of the facility. Refer to the Rules of Entry for additional requirements. Complete all of the information below. Typewritten answers are required; handwritten forms will not be accepted. Please indicate your name, the nominee name, and/or facility name on this sheet only. Nominee Title

List all professional license(s) held by nominee:

Facility Phone Address

Your Name Title Your e-mail Address (for confirmation purposes only)

Administrator’s Name Administrator’s e-mail ENCLOSURES REQUIRED WITH THIS APPLICATION: Typed Nomination Form (on following page) addressing each question (no more than two






Distinguished Director of Nursing Nomination Form

Nomination Form: Type your answer after each question below using this form. To maintain consistency, please do not change the format of this document. The completed nomination form must not exceed two pages. Follow the guidelines on the Rules of Entry page to explain why this nominee should receive the award based on the following criteria:


2. Describe one way your nominee makes your facility a good place to work.

3. At which managerial skills does your nominee excel?

4. Describe ways your nominee fosters teamwork.

5. What attributes or qualities does your nominee have that demonstrate exceptional performance?

6. If known, provide professional experience, past awards received and community service of your nominee.

Distinguished Service Award Application Eligibility and Criteria: This award category is available to both nursing facility and assisted living members. This special award is designed to recognize an individual, facility, business, volunteer, organization, or group that has made an outstanding positive impact or contribution to long-term care in West Virginia. Nominees may be an owner or employed by a member facility, retired from or associated with a member facility, or an associate member at the time of nomination. The nominee need not be an employee of the nominating facility. Refer to the Rules of Entry for additional requirements.

Complete all of the information below. Typewritten answers are required; handwritten forms will not be accepted. Please indicate your name, the nominee name, and/or facility name on this sheet only. Nominee Title List all professional license(s) held by nominee:

Facility Phone Address Your Name Title Your e-mail Address (for confirmation purposes only)



pages in length) Letter of recommendation from your candidate’s supervisor or the Administrator/Executive

Director on facility/company letterhead (one page) Send nominations to WVHCA to arrive on or before Thursday, December 7, 2017.




Distinguished Service Award Nomination Form

Nomination Form: Type your answer after each question below using this form. To maintain consistency, please do not change the format of this document. The completed nomination form must not exceed two pages. Follow the guidelines on the Rules of Entry page to describe what service, activity, program or projects for which the nominee was responsible and explain why this nominee should be the recipient of the award based on the following criteria. Please explain why your nominee should be the recipient of the award and include the following: 1. A description of the contribution this nominee has made to long-term care in West Virginia.

2. What separates this person from his or her peers in terms of their skills, attributes and performance?

Distinguished Community Service Award Application Eligibility and Criteria: This award category is available to both nursing facility and assisted living members. The award is designed to recognize a facility for its involvement and service to their community between October 1, 2016-October 1, 2017. Refer to the Rules of Entry for additional requirements. Complete all of the information below. Typewritten answers are required; handwritten forms will not be accepted. Please indicate your name, the nominee name, and/or facility name on this sheet only. Community Project Name Facility Phone

Address _____ Your Name Title Your e-mail Address (for confirmation purposes only)



pages in length) Send nominations to WVHCA to arrive on or before Thursday, December 7, 2017.

WV Health Care Association / Attn: Awards Program110 Association Drive

Charleston, WV 25311Phone: 304-346-4575 / Fax: 304-342-0519

Distinguished Community Service Award Nomination Form

Nomination Form: Type your answer after each question below using this form. To maintain consistency, please do not change the format of this document. The completed nomination form must not exceed two pages. Follow the guidelines on the Rules of Entry page to explain why your facility should receive the Distinguished Community Service Award based on the following criteria: 1. How did your facility work together with community groups and organizations to enhance

both the facility and its community?

2. Please give examples of community service-type activities. Some examples of community service projects include Relay for Life, Alzheimer’s Walk, health fair screenings, blood sugar checks, blood drives, making quilts for area hospitals, literacy classes, hosting legislative visits, etc.

3. Please demonstrate how the facility integrates with community groups to positively represent the long-term care profession.

4. Explain how your community service projects gave a positive view of your facility's and the long-term care profession's public image. How did you promote your community service projects and the successful outcome within your facility and publicly? Did you submit a press release to the local newspaper? Did you receive media coverage? If so, please copy your press releases, news clippings, pictures of events, or letters from community groups that highlight your facility’s community service projects on 8.5 x11 sheets and submit with your nomination.

West Virginia Health Care Association

Nomination Form

Deficiency FreeTypewritten answers are required. Download and save the forms to your computer before entering information (MS Word format). Your facility will be recognized during the Membership Meeting at the WVHCA Annual Convention if your facility was deficiency free in health or life safety. If your facility was deficiency free in both surveys, then your facility will be recognized at the Awards Banquet and will be invited to come forward during the Awards Program to receive an award.

Facility name: (Use proper name to appear on certificate)

Address:

City: State: WV Zip: Phone: Nominated by: Date Submitted: Administrator’s Name: Administrator’s e-mail:

(to confirm receipt) ___Yes, our facility has been deemed deficiency free as verified by the Office of Health Facility Licensure and Certification for surveys conducted between January 1, 2017, and December 31, 2017. Date of Survey:

Health Life Safety

The WVHCA awards structure matches that of the current Federal certification: health and life safety. Environment is part of both health and life safety surveys and is not a separate survey. *Important: Please submit your completed survey with final results issued to the facility along with this form by the deadline date.

Comments:

This form must arrive at WVHCA by Wednesday, February 1, 2017.

Office Use Only: ___Copy of completed survey with results enclosed

West Virginia Health Care AssociationNomination Form

No Lost-Time Injuries

Typewritten answers are required. Download and save the forms to your computer before entering information (MS Word format). Your facility will be recognized during the Membership Meeting at the WVHCA Annual Convention.

Facility name: (Use proper name to appear on certificate)

Address:

City: State: WV Zip: Phone: Nominated by: Date Submitted: Administrator’s Name: Administrator’s e-mail:

(to confirm receipt)

Definition of no lost-time injuries: No missed shifts due to injury.

Have you gone from January 1, 2017 – December 31, 2017 with no lost time injuries?If you check yes, then you do not need to answer any other questions.

Yes No

Have you gone six consecutive months or more with no lost time injury between

January 1, 2017 – December 31, 2017?

Yes No

If so, list how many consecutive months that you had no lost time injuries:

This form must arrive at WVHCA by Thursday, February 1, 2018.

west virginia health care association | charleston ...€¦ · web viewletter of recommendation...

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