2017 WVHCA Annual Convention

Nominations Are Open!

2017 WVHCA Annual Convention

Awards Program

May 9, 2017 - Morgantown, West Virginia

Bringing recognition to those who make a difference

Nominations are due on or before Dec. 7, 2016

WVHCA Members are eligible to submit nominations for all award categories with the exception of the Distinguished Administrator and Outstanding Assisted Living Professional award categories:

· 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

· Individual Excellence Award (May be a Direct Care or Ancillary Employee)

· Distinguished Service Award

· Distinguished Community Service Award

PLEASE NOTE: Details matter in your nominations. Please provide as much information possible in your applications.

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 25311

Phone: 304-346-4575 Fax: 304-342-0519 E-Mail:

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 computer

2. Complete the Application and Nomination Forms and follow the Rules of Entry below

3. Enclose items requested on the application and/or nomination forms

4. Send nominations to WVHCA to arrive on or before the following deadlines:

a. Award nominations must arrive at WVHCA on or before: Wednesday, December 7, 2016

b. Deficiency free and no lost time nominations are due: Wednesday, February 1, 2017

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:

West Virginia Health Care Association

Attn: WVHCA Awards Program

110 Association Drive

Charleston, West Virginia 25311

Fax: (304)342-0519 / e-mail:

Call 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 their 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 Wednesday, December 7, 2016.

WV Health Care Association / Attn: Awards Program

110 Association Drive / Charleston, WV 25311

Phone: 304-346-4575 / Fax: 304-342-0519 / e-mail:

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)

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)

· Send nominations to WVHCA to arrive on or before Monday, December 7, 2016.

WV Health Care Association / Attn: Awards Program

110 Association Drive / Charleston, WV 25311

Phone: 304-346-4575 / Fax: 304-342-0519 / e-mail:

Office Use Only: ___ Letter of Recommendation Enclosed ___Confirmed Application

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)

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)

· Send nominations to WVHCA to arrive on or before Wednesday, December 7, 2016.

WV Health Care Association / Attn: Awards Program

110 Association Drive / Charleston, WV 25311

Phone: 304-346-4575 / Fax: 304-342-0519 / e-mail:

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 Award Application

(Direct Care Employee or Ancillary Employee)

Eligibility and Criteria: This award category is available to both nursing facility and assisted living members. The nominee may be either a Direct Care employee or an Ancillary employee. The purpose of this award is to recognize outstanding employees who perform their work in Direct Care to residents or as an Ancillary employee in a long-term care member facility. A Direct Care employee is someone in the nursing department who works directly with residents. A Direct Care employee may be a Certified Nursing Assistant, Registered Nurse or Licensed Practical Nurse. The Ancillary employee is someone who provides support to the staff members who work directly with residents. Ancillary employees may include Social Worker, Consultant, Environmental Staff, Dietary Staff, Business Office Manager, Marketing Admissions Coordinator, etc. 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)

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 your candidate’s supervisor on facility/company letterhead (one page)

· Mail nominations to WVHCA to arrive on or before Wednesday, December 7, 2016.

WV Health Care Association / Attn: Awards Program

110 Association Drive / Charleston, WV 25311

Phone: 304-346-4575 / Fax: 304-342-0519 / e-mail:

Office Use Only: ___ Letter of Recommendation Enclosed ___Confirmed Application

Individual Excellence Award Nomination Form

(Direct Care Employee or Ancillary Employee)

1. Is your candidate a Direct Care Employee or Ancillary Employee?

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

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

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

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

6. How does this employee demonstrate exceptional performance?

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: