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Managing refurbs and expansions

Training tomorrow’s NHAs 4th quarter marketing strategies CPR legalities



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 130+&$54637*7"- An administrator, a CFO and a designer discuss how a Missouri CCRC underwent major remodeling without bulldozing residents’ lives 

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Long-Term Living is indexed in the Cumulative Index to Nursing and Allied Health Literature® print index. Long-Term Living (ISSN: Print 1940-9958, Online 2168-4561) is published 9 times per year in Jan/Feb, Mar, Apr, May, June/July, Aug, Sept, Oct/Nov and Dec, by Vendome Group, LLC, 216 East 45th Street, 6th Floor, New York, NY. 10017. Periodicals postage paid at New York, NY, and additional mailing offices. © 2014 by Vendome Group, LLC. Long-Term Living is a trademark of Vendome Group, LLC. All rights reserved. No part of Long-Term Living may be reproduced, distributed, transmitted, displayed, published, or broadcast in any form or in any media without prior written permission of the publisher. To request permission to reuse this content in any form, including distribution in educational, professional, or promotional contexts or to reproduce material in new works, please contact the Copyright Clearance Center at [email protected] or 978-750-8400. For custom reprints, please contact Jill Kaletha at Foster Printing; 219-878-6068 or 866-879-9144, ext. 168, or [email protected] EDITORIAL POLICY: Articles and opinions published in Long-Term Living do not necessarily reflect the views of Publisher or the Editorial Advisory Board. SUBSCRIPTIONS: For questions about a subscription or to subscribe, please contact us by phone: 888-873-3566, online: or email: [email protected] Subscription rate per year: $125 domestic, $195 outside the U.S. Single copies and back issues: $23 domestic, $35 outside the U.S. POSTMASTER: Send address changes to Long Term Living, PO Box 397, 2865 S Eagle Rd., Newtown, PA 18940. Printed in U.S.A.

tAUGUST 2014


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 -&("--"/%4$"1& BY ALAN C. HOROWITZ, RN, JD







24 3 Keys to Facility Security Minimize safety risks by incorporating security measures into the overall management plan BY STEVE WILDER, CHSP, STS

26 Embracing QAPI: Part 5 Steps 9 and 10 of QAPI involve creating and documenting performance improvement projects BY NELL GRIFFIN, LPN, EDM

28 Developing Quality Nursing Home Administrators Targeted education grooms students to assume management and leadership roles in long-term care for today and tomorrow BY JENNIFER JOHS-ARTISENSI, PHD, MPH, AND DOUGLAS OLSON, PHD, MBA, NHA, FACHCA

32 Q4 Marketing Evaluating trends and getting feedback from referral partners now can boost marketing plans for 2015 BY LUKE FANNON

34 The Shock of Elder Abuse in Assisted Living A recent survey of LTC executives explores their awareness of elder abuse. The findings may be surprising BY LOIS A. BOWERS, SENIOR EDITOR

35 Technology Roadmap 2014-2016: Get Connected LTC technology groups map out the key tech goals for the next two years

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It cou by a t jurisdic es withis ecially suc ? oth to ld be lity’ h ope ers Newer tion as this.) s rep aud import rate in guidanc ant ave it contractor; , which is the in the pay the com utation and Januar munity Medica and withLONG-TE What can rages. An y, for inste, data and phi . re the natRM LIVIN numerou operati losophy ance, for very inte ional Gt to prepar those in LTC ons . & Medicas years, the Cen the first tim In do platform resting picture person will see It’s very e? e in ters for importa and cha id Services similar for Part A Me of how a faci a Medica the tim nt that (CMS) nged the lity’s or differen re dicare e upd Manua billing But onl they don and the tools we give clinicia t dem l related Medicare Ben ated is to ’t (SNFs). to efit United y half of the ographically. other top make mistake stay up to datens Adminis skilled nursing Policy States facilitie complia so hav PERs, s in the on the ics I mention s. In addition nce pro trators, CFOs, facilities accordin e accessed regulato to the ed, two look at their PEP fess me; the g to CM ry we side what the ionals nee CEOs and deli PEPPER S. right nownew focuses ver d to take make sure the frau curren s are very That surprise and MD care to resi are on d den s connec informa they’re com t documents a the aud prevention states are S accuracy. Sur ts with dem how ted say, mu tion to syst its, so ent they und their team nicating tha I would em and som to manage visit and reviewing the veyors in som ia t e of think tha rs e see retu erstand the cha s and make to see thei and owners a true reprtesting to see record during rned sure nge would t facility r whether the be anx I say to payments and s so they don The first PEPPERs. residen esentation of the iou MD sen ’t s t audit acti the set of PEP ior man number the faci We’ve during that spe condition S is age vity. PERs was litie not had of Medica of dollars you rs: “Look at cally tran s, but now mailed veyors that scru cific time per the ’re the re they before. iod. tiny from you’re inve services, and billing for Par PERreso sferred through ’re electron to So and acti look at t ivities and clinicians, soci the surdefiniti sting in mak how mu A you go web the www.P to look al ons dietary ing EPon at profess workers are bein and the com sure that all ch an acco that website site. Initially, to mak the various g followe of pliance when ways they ionals need e -related the difficult unt for the bui , you have to d. 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Five to ther d cen losoph we con apy SNFs are LTC operat ustry change to seve program tered care, y? sidered ion n years is now ind s skilled or ther um and part of the hea s? ago, wha importa s and commu ividualized apy reh must ope lthcare nication nt CMS also had a broade abilitation serv t nication continu looking right now. ices with acu n the lines of We’re con are really to imp nursing refined the r definitiona pro com te and rove vide l stan defi care base. mu and add individ rs the per tly nition mentati ualizati son standin so that all hav and home care delivery on requ ed some additio of skilled on of care alization g of the e a goo is related app irement goo nal services d underrop so fective d tran doc to that. s for each riate and sing that care Clinicia and guidelin ution flow sitions of care rendered and operati es ns need hav onal pro person. As clin ularly eftAUG to be very expens . Rehospitali and document e to trea fession icians and UST 2014 zations ive and at the als, we are can be elders. mu his or her individual, very dam extremely The reh and no st strive ospitali how the circumstances matter zation aging to what piece will and also elder is perceiv are, appreci be ate necessa think about ing care delivery the typ ry to dea e of serv l with ices special needs. LTL





CPR: L ive or le t die? I


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38 Owners, Beware: Arbitration Provisions May Be Inadequate Careful review of contract agreements can avoid resident confusion and keep a facility out of trouble. BY THOMAS W. HAZLETT AND A. PETER PRINSEN, ESQ.

tAUGUST 2014


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CCRC expectations

EDITORIAL Editor-in-Chief Pamela Tabar Senior Editor Lois A. Bowers

ll hail, consumer demand. These days, senior living companies do plenty of research before they consider expanding into a new market location. They evaluate the potential real estate, dig into the local competition and gaze into the crystal ball of future bed census. They analyze their current customer satisfaction surveys, examine their service lines and conduct community focus groups to discover what today’s older adults want—and expect—in a senior living environment. No consumer expectations are higher than those associated with continuing care retirement communities (CCRCs). Fine dining and bistros instead of cafeterias. Jogging trails, swimming pools, golf and spas for now; with high-quality skilled care handy for later. A range of accommodations—bigger and better than in previous decades—and all with WiFi, please. Various contract choices and fee structures—all negotiable, of course. In short, the perfect CCRC. Build it, and they will come. Lately, companies have been building acres of them—everywhere. I just hope they’ve done the math right. John Locke and Adam Smith may be the best known fathers of microeconomics, but scholars have been talking about the balance between supply and demand since at least the 14th century. Building the supply in anticipation of the demand is both business savvy and risky. Using its Paul Revere voice, the long-term care industry has been saying for years, “The boomers are coming, the boomers are coming.” But no one could have predicted that the economic downturn of the past three years—preventing many seniors from selling their houses to gain the money for the entry fee—would keep so many people from their intended move to a CCRC. Communities, old and new, are beginning to feel the pain of the long drought, forcing some to seek protection from creditors to keep their doors open. The Sears Methodist Retirement System, including eight senior living communities in Texas, filed for Chapter 11 bankruptcy protection in June after struggling to reorder its finances. At least four of its CCRC sites opened or were significantly expanded in the past three years. High-end CCRCs, such as the four-year-old Amsterdam at Harborside on New York’s Long Island, are having an even more difficult time. The CCRC, which has entry fees ranging from $550,000 to $1.4 million, filed for Chapter 11 bankruptcy protection in July while it restructures nearly $220 million in debt. The unexpected turn of economic events also has prompted CCRCs to experiment with new pricing models and alternatives to the hefty entry fees—usually $50,000 to $100,000—traditionally required to secure the guarantee of healthcare and services over time. River Terrace Estates, a 10-year-old CCRC in Bluffton, Ind., filed for Chapter 11 bankruptcy protection in July and plans to test a new pricing model that would provide discounted entry fees to healthy adults, hoping to entice more residents to the community. Meanwhile, some CCRCs are embracing the “some money is better than no money” concept by using the rental model and skipping the hefty entry fee altogether, hoping to draw younger, healthier adults. The Cardinal at North Hills, currently under construction in Raleigh, N.C., plans to use a monthly fee tiered to the type of housing option, without requiring a five- to six-digit entry fee or the purchase of an equity interest. The above examples are all from the past two months, but financial trouble rarely happens overnight. It’s more important than ever for CCRCs to plan finances carefully—including taking a long, hard look at how residents’ entry fees are being used or escrowed— to ensure the community’s financial stability in the long run.


Managing Editor Sandra Hoban Associate Editor, Reader Engagement Megan Combs ART Creative Director Eric E. Collander Art Director Rebecca DeNeau Senior Designer Suzanne Quintero SALES National Sales Manager Bill Rodman 1IPOFt'BY e-mail [email protected] Directory Sales Elana Ben-Tor [email protected] Ph: 216-373-1202 Traffic Manager Judi Zeng Please send IOs to [email protected] All ad materials should be sent electronically to: https://vendome/sendmyadcom ARTICLE REPRINTS 'PSSFQSJOUTBOEMJDFOTJOHQMFBTFDPOUBDU +JMM,BMFUIB 'PTUFS1SJOUJOHtPS  FYUtKJMML!GPTUFSQSJOUJOHDPN CUSTOMER SERVICE MUMWFOEPNF!BETHJOGPt1I REUSE PERMISSION Copyright Clearance Center 1IPOFt'BY FNBJMJOGP!DPQZSJHIUDPNt8FCXXXDPQZSJHIUDPN ADMINISTRATION Chief Executive Officer Jane Butler President .BSL'SJFE Vice President Ron Lowy Vice President, Finance Bill Newberry Vice President, Custom & Strategic Account Services Jennifer Turney Chief Content Officer Charlene Marietti Chief Marketing Officer Dan Melore Director, Digital Marketing Daniel P. Timoney Director, Circulation Rachel Beneventi Director, Production and Web Development ,BUISZO)PNFOJDL LONG-TERM LIVING MAGAZINE ONLINE:








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© Abbott Point of Care Inc. 400 College Road East, Princeton, NJ 08540 (609) 454-9000 (609) 419-9370 (fax) i-STAT is a registered trademark of the Abbott group of companies in various jurisdictions. Lab Solutions – LTC Journal Ad 031920 Rev. A 06/14 Piccolo Xpress® is a registered trademark of Abaxis, Inc. Abaxis Part Number 888-3251 Rev. A

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Small vials*—available only from Lilly—offer versatility in your patient management. Humalog® comes in small vials, sized for individual use and designed to be more versatile than other delivery options. Just one more way the makers of Humalog show we understand the challenges of administering mealtime insulin to each patient during the course of their stay. For more information on training, educational resources, and the many other ways Lilly can help, talk to your Lilly Diabetes representative or visit *Smaller vials contain 3 mL of insulin in a 5 mL vial.

Indication for Humalog • Humalog is an insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus. Select Safety Information for Humalog • Humalog is contraindicated during episodes of hypoglycemia and in patients who are hypersensitive to Humalog or any of its excipients. • Closely monitor blood glucose in all patients treated with insulin. Change insulin regimens cautiously.

Select Safety Information for Humalog, continued • Hypoglycemia is the most common adverse effect of Humalog therapy. The risk of hypoglycemia increases with tighter glycemic control. Severe hypoglycemia may be life threatening and can cause seizures or death. • Humalog should be given within 15 minutes before or immediately after a meal. Please see Important Safety Information and Brief Summary of Prescribing Information on following pages.

Humalog small vials sized for individual patient care.

Indication for Humalog

Important Safety Information for Humalog, continued

• Humalog is an insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus.

Warnings and Precautions, continued • Mixing of Insulins: Humalog for subcutaneous injection should not be mixed with insulins other than NPH insulin. If Humalog is mixed with NPH insulin, Humalog should be drawn into the syringe first. Injection should occur immediately after mixing. • Subcutaneous Insulin Infusion Pump: Humalog should not be diluted or mixed when used in an external insulin pump. Change Humalog in the reservoir at least every 7 days. Change the infusion set and insertion site at least every 3 days. Malfunction of the insulin pump or infusion set or insulin degradation can rapidly lead to hyperglycemia and ketosis. Prompt correction of the cause of hyperglycemia or ketosis is necessary. Interim subcutaneous injections with Humalog may be required. Train patients using an insulin pump to administer insulin by injection and to have alternate insulin therapy available in case of pump failure. • Drug Interactions: Some medications may alter glucose metabolism, insulin requirements, and the risk for hypoglycemia or hyperglycemia. Signs of hypoglycemia may be reduced or absent in patients taking anti-adrenergic drugs. Particularly close monitoring may be required. • Fluid Retention and Heart Failure with Concomitant Use of PPAR-gamma Agonists: Thiazolidinediones (TZDs), which are PPAR-gamma agonists, can cause dose-related fluid retention, particularly when used in combination with insulin, including Humalog. This may lead to or exacerbate heart failure. Observe patients for signs and symptoms of heart failure and consider discontinuation or dose reduction of the PPAR-gamma agonist.

Important Safety Information for Humalog Contraindications • Humalog is contraindicated during episodes of hypoglycemia and in patients who are hypersensitive to Humalog or any of its excipients. Warnings and Precautions • Dose Adjustment and Monitoring: Closely monitor blood glucose in all patients treated with insulin. Change insulin regimens cautiously. Concomitant oral antidiabetic treatment may need to be adjusted. The time course of action for Humalog may vary in different individuals or at different times in the same individual and is dependent on many conditions, including delivery site, local blood supply, or local temperature. Patients who change their level of physical activity or meal plan may require insulin dose adjustment. • Hypoglycemia: Hypoglycemia is the most common adverse effect of Humalog. The risk of hypoglycemia increases with tighter glycemic control. Educate patients to recognize and manage hypoglycemia. Hypoglycemia can happen suddenly and symptoms may vary for each person and may change over time. Early warning symptoms of hypoglycemia may be different or less pronounced under conditions such as long-standing diabetes, diabetic nerve disease, use of medications such as beta-blockers, or intensified diabetes control. These situations may result in severe hypoglycemia and possibly loss of consciousness prior to the patient’s awareness of hypoglycemia. Severe hypoglycemia may be life threatening and can cause seizures or death. Use caution in patients with hypoglycemia unawareness and who may be predisposed to hypoglycemia. The patient’s ability to concentrate and react may be impaired as a result of hypoglycemia. Rapid changes in serum glucose levels may induce symptoms similar to hypoglycemia in persons with diabetes, regardless of the glucose value. Timing of hypoglycemia usually reflects the time-action profile of administered insulins. Other factors such as changes in food intake, injection site, exercise, and concomitant medications may alter the risk of hypoglycemia. • Allergic Reactions: Severe, life-threatening, generalized allergy, including anaphylaxis, can occur with Humalog. • Hypokalemia: Humalog can cause hypokalemia, which, if untreated, may result in respiratory paralysis, ventricular arrhythmia, and death. Use caution in patients who may be at risk for hypokalemia (eg, patients using potassiumlowering medications or medications sensitive to serum potassium concentrations). • Renal or Hepatic Impairment: Frequent glucose monitoring and insulin dose reduction may be required in patients with renal or hepatic impairment. HI90913


©Lilly USA, LLC 2014. All rights reserved.

Adverse Reactions • Adverse reactions associated with Humalog include hypoglycemia, hypokalemia, allergic reactions, injection-site reactions, lipodystrophy, pruritus, rash, weight gain, and peripheral edema. Use in Specific Populations • Pediatrics: Humalog has not been studied in children with type 1 diabetes less than 3 years of age or in children with type 2 diabetes. Dosage and Administration • Humalog should be given within 15 minutes before or immediately after a meal. Please see Brief Summary of Prescribing Information on adjacent pages. HI HCP ISI 29MAR2013 Humalog® is a registered trademark of Eli Lilly and Company and is available by prescription only.

Humalog® (insulin lispro injection, USP [rDNA origin]) Brief Summary: Consult the package insert for complete prescribing information. INDICATIONS AND USAGE Humalog is an insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus. ADMINISTRATION Humalog has a rapid onset of action and should be given within 15 minutes before a meal or immediately after a meal. CONTRAINDICATIONS Humalog is contraindicated: • During episodes of hypoglycemia. • In patients who are hypersensitive to Humalog or to any of its excipients. WARNINGS AND PRECAUTIONS Dose Adjustment and Monitoring — Glucose monitoring is essential for patients receiving insulin therapy. Changes to an insulin regimen should be made cautiously and only under medical supervision. Changes in insulin strength, manufacturer, type, or method of administration may result in the need for a change in insulin dose. Concomitant oral antidiabetic treatment may need to be adjusted. As with all insulin preparations, the time course of action for Humalog may vary in different individuals or at different times in the same individual and is dependent on many conditions, including the site of injection, local blood supply, or local temperature. Patients who change their level of physical activity or meal plan may require adjustment of insulin dosages. Hypoglycemia—Hypoglycemia is the most common adverse effect associated with insulins, including Humalog. The risk of hypoglycemia increases with tighter glycemic control. Patients must be educated to recognize and manage hypoglycemia. Hypoglycemia can happen suddenly and symptoms may be different for each person and may change from time to time. Severe hypoglycemia can cause seizures and may be life threatening or cause death. The timing of hypoglycemia usually reflects the time-action profile of the administered insulin formulations. Other factors such as changes in food intake (eg, amount of food or timing of meals), injection site, exercise, and concomitant medications may also alter the risk of hypoglycemia) (see Drug Interactions). As with all insulins, use caution in patients with hypoglycemia unawareness and in patients who may be predisposed to hypoglycemia (eg, the pediatric population and patients who fast or have erratic food intake). The patient’s ability to concentrate and react may be impaired as a result of hypoglycemia. This may present a risk in situations where these abilities are especially important, such as driving or operating other machinery. Rapid changes in serum glucose levels may induce symptoms similar to hypoglycemia in persons with diabetes, regardless of the glucose value. Early warning symptoms of hypoglycemia may be different or less pronounced under certain conditions, such as longstanding diabetes, diabetic nerve disease, use of medications such as beta-blockers (see Drug Interactions), or intensified diabetes control. These situations may result in severe hypoglycemia (and, possibly, loss of consciousness) prior to the patient’s awareness of hypoglycemia. Hypersensitivity and Allergic Reactions—Severe, life-threatening, generalized allergy, including anaphylaxis, can occur with insulin products, including Humalog (see Adverse Reactions). Hypokalemia—All insulin products, including Humalog, cause a shift in potassium from the extracellular to intracellular space, possibly leading to hypokalemia. Untreated hypokalemia may cause respiratory paralysis, ventricular arrhythmia, and death. Use caution in patients who may be at risk for hypokalemia (eg, patients using potassium-lowering medications, patients taking medications sensitive to serum potassium concentrations). Renal or Hepatic Impairment—Frequent glucose monitoring and insulin dose reduction may be required in patients with renal or hepatic impairment. Mixing of Insulins—Humalog for subcutaneous injection should not be mixed with insulin preparations other than NPH insulin. If Humalog is mixed with NPH insulin, Humalog should be drawn into the syringe first. Injection should occur immediately after mixing. Do not mix Humalog with other insulins for use in an external subcutaneous infusion pump. Subcutaneous Insulin Infusion Pumps—When used in an external insulin pump for subcutaneous infusion, Humalog should not be diluted or mixed with any other insulin. Change the Humalog in the reservoir at least every 7 days; change the infusion sets and the infusion set insertion site at least every 3 days. Humalog should not be exposed to temperatures greater than 98.6°F (37°C). Malfunction of the insulin pump or infusion set or insulin degradation can rapidly lead to hyperglycemia and ketosis. Prompt identification and correction of the cause of hyperglycemia or ketosis is necessary. Interim subcutaneous injections with Humalog may be required. Patients using continuous subcutaneous insulin infusion pump therapy must be trained to administer insulin by injection and have alternate insulin therapy available in case of pump failure (see Dosage and Administration and How Supplied/Storage and Handling). Drug Interactions—Some medications may alter insulin requirements and the risk for hypoglycemia and hyperglycemia. Some medications may mask the signs of hypoglycemia in some patients. Therefore, insulin dose adjustments and close monitoring may be required. Humalog® (insulin lispro injection, USP [rDNA origin]) ) HI HCP BS 31JAN2014

Fluid Retention and Heart Failure with Concomitant Use of PPAR-gamma Agonists— Thiazolidinediones (TZDs), which are PPAR-gamma agonists, can cause dose-related fluid retention, particularly when used in combination with insulin, including Humalog. Fluid retention may lead to or exacerbate heart failure. Observe patients for signs and symptoms of heart failure and consider discontinuation or dose reduction of the PPAR-gamma agonist. ADVERSE REACTIONS Hypoglycemia and hypokalemia are discussed in Warnings and Precautions. Clinical Trial Experience—Because clinical trials are conducted under widely varying designs, the adverse reaction rates reported in one clinical trial may not be easily compared with those rates reported in another clinical trial, and may not reflect the rates actually observed in clinical practice. The frequencies of treatment-emergent adverse events during Humalog clinical trials in patients with type 1 diabetes mellitus and type 2 diabetes mellitus are listed in the tables below. Table 1: Treatment-Emergent Adverse Events in Patients with Type 1 Diabetes Mellitus (adverse events with frequency ≥5%) Events, n (%) Flu syndrome Pharyngitis Rhinitis Headache Pain Cough increased Infection Nausea Accidental injury Surgical procedure Fever Abdominal pain Asthenia Bronchitis Diarrhea Dysmenorrhea Myalgia Urinary tract infection

Lispro (n=81) 28 (34.6) 27 (33.3) 20 (24.7) 24 (29.6) 16 (19.8) 14 (17.3) 11 (13.6) 5 (6.2) 7 (8.6) 5 (6.2) 5 (6.2) 6 (7.4) 6 (7.4) 6 (7.4) 7 (8.6) 5 (6.2) 6 (7.4) 5 (6.2)

Regular human insulin (n=86) 28 (32.6) 29 (33.7) 25 (29.1) 19 (22.1) 14 (16.3) 15 (17.4) 18 (20.9) 13 (15.1) 10 (11.6) 12 (14.0) 10 (11.6) 7 (8.1) 7 (8.1) 6 (7.0) 5 (5.8) 6 (7.0) 5 (5.8) 4 (4.7)

Table 2: Treatment-Emergent Adverse Events in Patients with Type 2 Diabetes Mellitus (adverse events with frequency ≥5%) Events, n (%) Lispro Regular human (n=714) insulin (n=709) Headache 63 (11.6) 66 (9.3) Pain 77 (10.8) 71 (10.0) Infection 72 (10.1) 54 (7.6) Pharyngitis 47 (6.6) 58 (8.2) Rhinitis 58 (8.1) 47 (6.6) Flu syndrome 44 (6.2) 58 (8.2) Surgical procedure 53 (7.4) 48 (6.8) Insulin Initiation and Intensification of Glucose Control Intensification or rapid improvement in glucose control has been associated with a transitory, reversible ophthalmologic refraction disorder, worsening of diabetic retinopathy, and acute painful peripheral neuropathy. However, long-term glycemic control decreases the risk of diabetic retinopathy and neuropathy. Lipodystrophy Long-term use of insulin, including Humalog, can cause lipodystrophy at the site of repeated insulin injections or infusion. Lipodystrophy includes lipohypertrophy (thickening of adipose tissue) and lipoatrophy (thinning of adipose tissue), and may affect insulin absorption. Rotate insulin injection or infusion sites within the same region to reduce the risk of lipodystrophy (see Dosage and Administration). Weight Gain Weight gain can occur with insulin therapy, including Humalog, and has been attributed to the anabolic effects of insulin and the decrease in glucosuria. Peripheral Edema Insulin, including Humalog, may cause sodium retention and edema, particularly if previously poor metabolic control is improved by intensified insulin therapy. Adverse Reactions with Continuous Subcutaneous Insulin Infusion (CSII) In a 12-week, randomized, crossover study in adult patients with type 1 diabetes comparing Humalog (n=38) to regular human insulin (n=39), the rates of catheter occlusions per month (0.9 vs. 0.10, respectively) and infusion site reactions (2.6% vs. 2.6%, respectively) were similar. In a randomized, 16-week, open-label, parallel design study of children and adolescents with type 1 diabetes, adverse event reports related to infusion-site reactions were similar for insulin lispro and insulin aspart (21% of 100 patients versus 17% of 198 patients, respectively). In both groups, the most frequently reported infusion site adverse events were infusion site erythema and infusion site reaction. Humalog® (insulin lispro injection, USP [rDNA origin]) ) HI HCP BS 31JAN2014

Allergic Reactions Local Allergy—As with any insulin therapy, patients taking Humalog may experience redness, swelling, or itching at the site of the injection. These minor reactions usually resolve in a few days to a few weeks, but in some occasions, may require discontinuation of Humalog. In some instances, these reactions may be related to factors other than insulin, such as irritants in a skin cleansing agent or poor injection technique. Systemic Allergy—Severe, life-threatening, generalized allergy, including anaphylaxis, may occur with any insulin, including Humalog. Generalized allergy to insulin may cause whole body rash (including pruritus), dyspnea, wheezing, hypotension, tachycardia, or diaphoresis. In controlled clinical trials, pruritus (with or without rash) was seen in 17 patients receiving regular human insulin (n=2969) and 30 patients receiving Humalog (n=2944). Localized reactions and generalized myalgias have been reported with injected metacresol, which is an excipient in Humalog (see Contraindications). Antibody Production In large clinical trials with patients with type 1 (n=509) and type 2 (n=262) diabetes mellitus, anti-insulin antibody (insulin lispro-specific antibodies, insulin-specific antibodies, cross-reactive antibodies) formation was evaluated in patients receiving both regular human insulin and Humalog (including patients previously treated with human insulin and naive patients). As expected, the largest increase in the antibody levels occurred in patients new to insulin therapy. The antibody levels peaked by 12 months and declined over the remaining years of the study. These antibodies do not appear to cause deterioration in glycemic control or necessitate an increase in insulin dose. There was no statistically significant relationship between the change in the total daily insulin dose and the change in percent antibody binding for any of the antibody types. USE IN SPECIFIC POPULATIONS Pregnancy—Pregnancy Category B. All pregnancies have a background risk of birth defects, loss, or other adverse outcome regardless of drug exposure. This background risk is increased in pregnancies complicated by hyperglycemia and may be decreased with good metabolic control. It is essential for patients with diabetes or history of gestational diabetes to maintain good metabolic control before conception and throughout pregnancy. In patients with diabetes or gestational diabetes insulin requirements may decrease during the first trimester, generally increase during the second and third trimesters, and rapidly decline after delivery. Careful monitoring of glucose control is essential in these patients. Therefore, female patients should be advised to tell their physicians if they intend to become, or if they become pregnant while taking Humalog. Although there are limited clinical studies of the use of Humalog in pregnancy, published studies with human insulins suggest that optimizing overall glycemic control, including postprandial control, before conception and during pregnancy improves fetal outcome. Nursing Mothers—It is unknown whether insulin lispro is excreted in human milk. Use of Humalog is compatible with breastfeeding, but women with diabetes who are lactating may require adjustments of their insulin doses. Pediatric Use—Humalog is approved for use in children for subcutaneous daily injections and for subcutaneous continuous infusion by external insulin pump. Humalog has not been studied in pediatric patients younger than 3 years of age. Humalog has not been studied in pediatric patients with type 2 diabetes. Geriatric Use—Of the total number of subjects (n=2834) in eight clinical studies of Humalog, twelve percent (n=338) were 65 years of age or over. The majority of these had type 2 diabetes. HbA1c values and hypoglycemia rates did not differ by age. Pharmacokinetic/pharmacodynamic studies to assess the effect of age on the onset of Humalog action have not been performed. OVERDOSAGE Excess insulin administration may cause hypoglycemia and hypokalemia. Mild episodes of hypoglycemia usually can be treated with oral glucose. Adjustments in drug dosage, meal patterns, or exercise may be needed. More severe episodes with coma, seizure, or neurologic impairment may be treated with glucagon or concentrated intravenous glucose. Sustained carbohydrate intake and observation may be necessary because hypoglycemia may recur after apparent clinical recovery. Hypokalemia must be corrected appropriately. STORAGE Do not use after the expiration date. Unopened Humalog should be stored in a refrigerator (36° to 46°F [2° to 8°C]), but not in the freezer. Do not use Humalog if it has been frozen. In-use Humalog vials, cartridges, pens, and Humalog KwikPen® should be stored at room temperature, below 86°F (30°C), and must be used within 28 days or be discarded, even if they still contain Humalog. Protect from direct heat and light. PATIENT COUNSELING INFORMATION: See FDA-approved patient labeling and Patient Counseling Information section of the Full Prescribing Information. Humalog® and Humalog® KwikPen® are registered trademarks of Eli Lilly and Company.

Marketed by: Lilly USA, LLC, Indianapolis, IN 46285, USA Copyright © 1996, 2011, Eli Lilly and Company. All rights reserved. Additional information can be found at

HI HCP BS 31JAN2014 Humalog® (insulin lispro injection, USP [rDNA origin]) )



CPR: Live or let die? by Alan C. Horowitz, RN, JD


t’s 6:45 a.m and you are almost finished with your shift at the nursing home. As you enter a resident’s room, you notice that the resident’s skin seems ashen and mottled. You quickly realize the resident is not breathing and has no pulse. What do you do? This hypothetical scenario plays out in virtually every nursing home with variations on the theme. Life and death hang in the balance. Decisions have to be made within seconds, and a wrong decision regarding cardiopulmonary resuscitation (CPR) may have dire consequences. Unfortunately, there is no shortage of cases in which a skilled nursing facility (SNF) was held responsible for failing to perform CPR. Many SNFs also have been held responsible for performing CPR when it should not have been performed or for not performing CPR properly. A good review of policy and procedures begins with the applicable regulations and current standards of care.

REGULATORY REQUIREMENTS At the time of admission, residents must be notified of their rights, including the right

The gold standard for CPR is the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.4


as evidenced by signs such as rigor mortis or livor mortis.


of self-determination.1 Along with other rights, residents have a right to formulate advance directives.2 Few decisions are as important as the right to choose—or forgo—CPR. When a resident has expressed his/her preference regarding CPR, those preferences must be followed—except in very narrow circumstances, as described below. Further, the regulations require that the services provided “must meet professional standards of quality.”3

STANDARDS OF CARE The gold standard for CPR is the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.4 The guidelines explain the proper technique for CPR as well as when CPR may be withheld or withdrawn. For example, once CPR is initiated, it may only be withdrawn under one of the following circumstances: (1) the victim has a spontaneous return of circulation and breathing, (2) the victim has been pronounced dead by an individual with the authority to make that determination, (3) another trained rescuer relieves the person performing CPR or (4) the rescuer is either in imminent danger or too exhausted to continue. CPR may be withheld if (1) the victim has a valid Do Not Resuscitate (DNR) order or (2) irreversible death has occurred

In an actual case that began in 2006, the Centers for Medicare & Medicaid Services (CMS) determined that CPR-related deficiencies existed at a SNF and imposed a civil money penalty (CMP).5 The SNF appealed and the case was assigned to an Administrative Law Judge (ALJ). The issue was whether the facility staff performed CPR appropriately. In this case, an 84-year-old resident has been seated near the nurse’s station when he suddenly developed an upper airway obstruction known as stridor. He did not have a DNR order or an advance directive indicating that he did not want CPR.6 (Note: the absence of a DNR order or advance directive requires that a resident receive CPR, unless irreversible death has occurred.) Two registered nurses were nearby and paged a respiratory therapist. All three clinicians moved the resident to his room. Within minutes, the resident stopped breathing and was placed in bed. The nurse’s notes and the testimony at the hearing stated that “two cycles of chest compressions were done,” an effort that normally takes less than one minute. Following two cycles of chest compressions, the nurses and therapist ceased providing CPR. No one called 911. At the hearing, it was claimed that one of the facility’s nurses “pronounced the resident dead,” although no one could recall who made that pronouncement. It would not have mattered. There was no justification for terminating CPR. The facility argued that its policy recognized the “professional judgment exception” whereby a nurse can terminate CPR if she/he feels it is appropriate. (There is no such exception in a case such as this.) LONG-TERM LIVINGt


The facility also asserted that the resident’s acted within the standards of care. Howcardiopulmonary arrest was “expected” ever, CMS’ witnesses, Steve Levinson, MD, and thus, it was relieved of its obligation to CMD, and Margie Pierce, RRT, testified perform CPR. The administraon the standards for CPR and tor attempted to justify not that the facility had deviated calling 911 by claiming it takes from those standards. 10 to 15 minutes for an ambuThe ALJ agreed with CMS’ lance to arrive, and when the legal arguments and accepted emergency technicians arrive, the American Heart Associathey “complain about being tion’s guidelines as the standard called to pick up dead people.”7 of care. A further appeal Even if this were true, the ALJ affirmed the ALJ’s decision correctly noted that the facility against the SNF. Alan C. Horowitz, RN, JD “should have continued CPR The most important lesson for the 10–15 minutes it would have taken learned from this unfortunate case is to for the emergency team to arrive.” adhere to the standards of care. Residents The administrator testified that 911 was deserve no less. not called because the resident “died so quickly.” The facility also asserted that CPR SPECIFIC RECOMMENDATIONS need not be given because the resident was FOR CPR POLICY IN SNFS dead. That circular argument fails to recog- t 3FDPHOJ[F BEPQUBOEBEIFSFUPUIF nize the obvious—CPR is never adminisstandards of care for CPR (e.g., Ameritered to a living person, since the lack of a can Heart Association or American Red heartbeat and spontaneous respirations are Cross). requirements for CPR to be administered. t /PUFUIBUTPNFBTQFDUTPGUIFTUBOEBSET One of the nurses testified that as the of care changed in 2010.8 resident was being wheeled into his room, t &OTVSFDPNQMJBODFXJUIBQQSPQSJBUF she asked him if he wanted to go to the Policies and Procedures regarding adhospital and “he shook his head and said vance directives, DNR status and CPR. ‘No.’” On cross-examination, neither the t )BWFBMMTUBêDFSUJëFEJO$13 SFDFSUJGZ other nurses nor the respiratory therapist as needed). would say they heard her ask that. There is t &OTVSFUIBUTUBêDMFBSMZVOEFSTUBOE no evidence that communication actually when it is permissible to withdraw CPR occurred. It would not have made a differand under what circumstances CPR ence. As the ALJ stated, asking the resident may be withheld. if he wanted to go to the hospital when he t "TLSFTJEFOUTBOEPSSFTQPOTJCMFQBSUJFT couldn’t breathe “was simply an inappropriat the time of admission if an advance ate time to discuss” treatment options. directive has been completed and place The county coroner and noted patholoa copy in the resident’s chart. gist, Cyril Wecht, MD, JD, who testified t %PDVNFOUFBDISFTJEFOUT%/3TUBUVT for the facility, said that the facility had in easily accessible locations, including the care plan. t "TDFSUBJOJGZPVSTUBUFQFSNJUTOVSTFT to determine “medical futility” for purposes of withholding CPR. If so, document how nurses meet the criteria. t %PDVNFOUBMMSFMFWBOUJOGPSNBUJPO regarding whenever CPR is performed (or withheld) in a timely, accurate way. t &EVDBUFTUBêBCPVUNFEJDBMBOEQIZTJcian orders for life-sustaining treatment (MOLST and POLST), if applicable in your state.9

Document each resident’s DNR status in easily accessible locations, including the care plan.


t &OTVSFUIBUBMMTUBêSFDPHOJ[FUIBU every minute wasted before performing CPR significantly decreases the chances of successful resuscitation. t .BJOUBJODPQJFTPGDVSSFOUTUBOEBSETPG care and make themn accessible to all staff. t $POTJEFSQFSJPEJDBMMZDPOEVDUJOHNPDL drills for CPR emergencies. t 3FDPHOJ[FUIBUOP.FEJDBSFBQQSPWFE nursing facility is allowed to have a “No CPR” policy.10





BWBJMBCMFBUDNT HPW.FEJDBSF1SPWJEFS&OSPMMNFOUBOE $FSUJýDBUJPO4VSWFZ$FSUJýDBUJPO(FO*OGP %PXOMPBET4VSWFZBOE$FSU-FUUFS QEGLTL Alan C. Horowitz, JD, RN, is a partner at Arnall Golden Gregory. He is a former assistant regional counsel, Office of the General Counsel, U.S. Department of Health and Human Services. As counsel to the Centers for Medicare & Medicaid Services, he was involved with hundreds of enforcement actions and successfully handled appeals before administrative law judges, the board and in federal court. He also has clinical healthcare experience as a registered respiratory therapist and registered nurse. He can be reached at [email protected] 888-5-."(";*/&$0.


Project Survival


888-5-."(";*/&$0. 888-5-. "("; */& $0.

By Pamela Tabar, Editor-in-Chief


101 E

Are remodels or construction upheavals in your future? Intelligent project planning can get your refurbs done without bulldozing your residents’ lives

xpansions an and nd renovations ar aaree a necessary part of life f att continui continuing uin ng care retirement ccenters en nte t rss ((CCRCs), CCRCs), but handling them m properl properly r y can n ma make ke aalllll the he d difference. iff fferrence. Long-Term Living’s Editor-in-Chief Edi diittoor-in-Chiief e Pam mel elaa T aba b r spoke wi ith h key mem mbers of a Pamela Tabar with members ma ajo jor, ffour-ye y arr rren novattion/ n/ne n w constr ne ruc ucti tiion tion np r je ro j ct about buildmajor, four-year renovation/new construction project ingg toward in d tthe he fu utur ure wi ith thou o t de ou dest stro royi yingg tthe he ccurrent urrent bus bbusiness—or usiness—or future without destroying drivingg th thee cu curr rrren ent resi side deent nts ou oout ut th tthee do door or. current residents door. Lac La cled edee G rovess, a Lu Luth th ther hera erran an Senio or Se SServices rvicces C rv CCR CRC, C has been Laclede Groves, Lutheran Senior CCRC, oper operating rat atin i g on its 65-ac 65-acre a re ccampus ampu am pus in SSt. t. Louis, Mo., since 11972. 972. 97 Thee h hallmark allm al l arkk buildi building ing oon n th the si sit site te is a repurposed 1920s convent convent, nt, ccomplete co mp pleete w with ith a stunning vault-arch chapel. But Laclede’s housing envi en environments v ronm ments and service lines needed major overhauls, despite the


fact tha that h t the CC CCRC CRC w was as still enjoying a near-f near-full -ful ull oc occupancy ccupa p ncy rate rate. te. Th si The site’s ite’s’ sk skilled killed nursing (SNF) section, h housed oused d in the he old d convent, conv vent, was sti still t ll “ward-based” with narro narrow, row, w ins institutional stitu t tional ccororridors and shared rooms—worlds away fr from om the personn-centered person-centered care model predominant today. Thee p rojeect c team alsoo wanted to project rethink the site’s assisted living u nitts,, add ni d memory ry care beds and units, th her erapy spaces and expand with h a new w iindepen end dent living structherapy independent ture e—a —allll aactions that Lacl cled e e’s ex exec ecutives bel elieved were necessary ry ture—all Laclede’s executives believed in n oorder rder to keep tthe rd he C CCR CRC C ma mark ketablee w wit ithi h n the greater co ommCCRC marketable within community. De D spit ite th he ma m ny bbusiness usiness dr driv ivers contributing to wh w Despite the many drivers whyy the camp ca pus needed major changes, the he project needed to be se sen nsit itive campus sensitive to the 700 00 res rresidents e idents who alrea ady lived there. already


COVERSTORY Four years later, Laclede had built 80 new independent living apartments and an underground parking garage, added 45 new memory care units, created several new dining venues, and had completely renovated the old convent SNF space using a neighborhood model, while also adding rehab/therapy spaces as an expanding business segment. In the following roundtable discussion, Laclede Executive Director Valerie Cooper, Lutheran Senior Services CFO Paul Ogier and Dan Cinelli, FAIA, principal and executive director at the design firm Perkins Eastman describe how they got the overhaul done and what lessons they learned along the way.

THE CHALLENGES Laclede’s executives realized that accomplishing the primary goals of new independent living and new memory care spaces—not to mention a complete overhaul of the SNF wing—would impact the entire campus. Hiring an architect is one step, but managing a project like this can be another matter. Cooper: We had an amazing reputation that kept us full. But we very much had a community siloed by levels of care. We had our independent living residents and the residential care and the skilled nursing, but community crossovers didn’t happen very often. We worked hard to create a sense of community. Ogier: We were content with [our site] back then, but when we look back now, it was pretty horrible. It was a thoroughfare

The 80-unit IL has underground parking. t"6(645

Valerie Cooper

Paul Ogier

with no privacy in the care center. To get anywhere, you had to go through the rehab area. We also were lacking the amenities that our competitors were bringing in for different types of care. We had good outcomes and great quality of care, but it wasn’t really an acceptable physical environment; and we were surviving on our reputation. As others were building “nicer and newer” [sites], they may not have been providing the same care we do. But so many people don’t understand that, and they’re sold on perception. Cinelli: [The site] had an independent living building, then it had the convent and the skilled-care wing, but to get to that you had to go through the old bowels of the building. So there really was no sense of “where does everyone get together?” You have a continuum of care, but you felt like there were distances both psychologically and physically between all of these pieces.

Photo: Chris Cooper

Dan Cinelli

And then, the most beautiful space in the entire campus is the old convent chapel—an incredible building that you couldn’t really get to. Cooper: One of the main focus areas was on our skilled nursing, and converting that from an institutional model to the household model. We also wanted to create common spaces both inside and out for people to congregate for socialization and friendships. We also wanted to add amenities, larger independent living apartments and dedicated memory care environments. How do you stay focused and avoid scope creep? Cinelli: Many times, when projects first come to the table everybody has their own list of what they want done. There’s immediate scope creep, and everybody wants the world and the sun and stars. And then Paul [the CFO] comes along and says, “Yeah, but we have to

New IL units reflect residents' changing expectations.

Photo: Chris Cooper 888-5-."(";*/&$0.


New patio/grilling area

be able to afford all of that.” When it comes down to it, [the executive team members] have to get together and say, “Here’s what we want and here’s what we feel we can do.” We also have to deal with the fact that we have a lot of residents who are living here every day and we can’t just toss everyone out. Ogier: How do you [re-envision] this old building that had lots of flaws and needed lots of improvements? We also had about 200 independent living apartments that were built in the early 1980s and were state of the art then, but now they’re [considered] too small…. We did have discussions on whether to tear things down and start over, which would have been a whole different price issue. Cinelli: Everyone had to submit their wants vs. needs list. Then we had high, medium and low priority items. Then Paul would come back and massage it and keep us on track.

Photo: Sarah Mechling, Perkins Eastman

New courtyard with fine dining room (left)

Photo: Chris Cooper

THE CONVERSATIONS Renovations and construction always raise the current residents’ hackles. Residents wonder: Will their rates go up? What inconveniences will they have to deal with in their daily lives? Communicating openly and often with residents is the key, the team says. Cooper: Getting feedback from the current residents and their families was one of the biggest contributors to our success, getting our current residents completely in tune with the whole project. We had 10 or 12 independent living residents we’d contact monthly and include them in decisions related to construction. So anything that we could take to them and put a face on how we did something was huge for the buy-in and good feedback Former courtyard and patio WWW.LTLMAGAZINE.COM

Photo: Perkins Eastman LONG-TERM LIVINGt

COVERSTORY work. Had we waited longer, maybe we wouldn’t have had the ability to work through the concerns of this very long process that was an inconvenience to the residents…. [Our site] was full—it stayed full, and it was making money. But someone could have dug their heels in and said, “Why are we going to invest 60 million dollars on something that’s doing pretty good for us?”



The former SNF ground floor (see inset) was replaced with a town center lobby.

for us, too; because we needed to hear from them what we could do differently. We also did a trip to another community with some certified nurses and others—about 12 people—on a road trip. We also held a contest where we had three or four nursing staff who actually lived as residents in our care center, so they could teach the rest of our staff what it was like

Photo: Chris Cooper

to live a day in our nursing home. Ogier: One of the toughest issues was the cost of changing the product. If someone is in an older apartment they still have so many more amenities now, but we really didn’t feel like we could make people who had moved in before pay for that. We were financially able to make it

Part of Laclede’s project planning involved re-examining how residents move between spaces. A great town center can lose its communal purpose if residents who are least ambulatory are housed the furthest away. The team chose to orient the site’s central common spaces nearest to the high-acuity care areas, with new wayfinding to draw in those who live in outlying independent housing and assisted living. But the biggest challenge was managing the current residents, many of whom were inconvenienced by the construction and some of whom had to be relocated for up to six weeks. Cooper: While we were converting the skilled nursing to a household model and doing a major facelift to that area, I think we did 19 moves in total of our skilled nursing residents. That obviously affects quality of life for the short term, when they have to move from their home. So communication with the residents and the families was key. We also did hands-on-deck efforts to make sure that our residents and our families were comfortable, and we invited the families to come in to help with this transition and to encourage communication. We wanted to make sure that they knew our focus wasn’t just about the building, but about making sure that we were still going to deliver quality of care.

THE RESULTS By mid-2013, Laclede had survived its four-year refurb/rebuild project—adding a new 80-unit independent living building, 45 dedicated memory care beds (with Renovations improved access to the 1920s convent chapel, a hidden gem


Photo courtesy of Laclede Groves


NFL Concussion Settlement All Valid Claims of Retired NFL Football Players to be Paid in Full for 65 Years 0RQHWDU\$ZDUGV%DVHOLQH0HGLFDO([DPVDQG2WKHU%HQHÀWV3URYLGHG The NFL and NFL Properties have agreed to a class action Settlement with retired players who sued, accusing them of failing to warn of and hiding the dangers of brain injury associated with playing football. The Settlement does not establish any wrongdoing on the part of the NFL or NFL Properties.

Who is included in the Settlement?

The Settlement Class generally includes all retired players of the NFL, AFL, World League of American Football, NFL Europe League and NFL Europa League. The Settlement Class includes immediate family members of retired players and legal representatives of incapacitated, incompetent or deceased players.

What does the Settlement provide?


Baseline medical exams to determine if retired players suffer from neurocognitive impairment and are entitled to additional testing and/or treatment ($75 million),


Monetary awards for diagnoses of ALS (Lou Gehrig’s disease), Alzheimer’s Disease, Parkinson’s Disease, Dementia and certain cases of chronic USBVNBUJD FODFQIBMPQBUIZ PS $5& B OFVSPQBUIPMPHJDBM mOEJOH  EJBHOPTFE after death. The maximum monetary awards range from $1.5 million to $5 million depending on the diagnosis. All valid claims will be paid in full for 65 years; and


Education programs and initiatives related to football safety ($10 million).

How can I get benefits? :PVXJMMOFFEUPSFHJTUFSGPSCFOFmUTBGUFSUIFmOBMBQQSPWBMPGUIF4FUUMFNFOU:PV may provide your contact information now at the website or phone number below to ensure that you receive additional notice about the registration process. Retired players do not have to prove that their injuries were caused by playing NFL football to get money from the Settlement.

What are my rights? You do not need to do anything to be included in the Settlement Class. All Settlement Class members will be bound by the Settlement and give up the right to sue the NFL individually. If you want to keep your right to sue the NFL, you must exclude yourself from the Class by October 14, 2014. If you exclude yourself, you will not SFDFJWFBOZCFOFmUTVOEFSUIF4FUUMFNFOU*GZPVTUBZJOUIF$MBTT ZPVNBZPCKFDU to the Settlement by October 14, 2014. The Court will hold a hearing on November 19, 2014 to consider whether to approve the Settlement. You do not have to attend. However, you and/or your own lawyer may attend and request to speak at the hearing at your own expense. At a later date, the attorneys will ask the Court for an award of attorneys’ fees and reasonable costs. The NFL and NFL Properties have agreed not to oppose or object to the request if the request does not exceed $112.5 million. The money would be paid by the NFL and NFL Properties in addition to the payments described above.

Please Share this Notice with Other Players and Their Families -VY4VYL0UMVYTH[PVUHUK[V9LNPZ[LYMVY)LULÄ[Z! 1-855-887-3485 or

COVERSTORY space to upgrade to 63 in the future), several new dining venues, and a completely redesigned front entrance. Learning the value of resident feedback, the organization also formed a permanent resident association that crosses all care segments to provide feedback and new ideas. Keeping a clear vision on the project—and its financial scope—are crucial, but managing staff input also is key to the success of a major project, especially when caregivers will be asked to apply new care models within the new work environments. What were some of the lessons learned during this project? Cinelli: This project started with storytelling. We said, “Let’s say it’s 2020. When you drive up to the front door and get out of the car, what do you see, and what is the new consumer thinking about you?” Being able to have those sorts of high-level discussions drove everything we touched after that. It was


“You can change the buildings, but changing the culture and the mindset of why you need to change was the most difficult.” Valerie Cooper

a lot easier to bring everybody into those conversations because we had all the department heads at those [early] meetings about storytelling. Ogier: I don’t think we have any [service] shortcomings now. There are a few amenities I’d like to see in a bigger build [later], but the real lesson is that we could have decided to do this sooner. You need to do projects like this before you get into trouble. It’s too late by then. Cooper: You can change the buildings, but changing the culture and the

mindset of why you need to change was the most difficult. It was difficult to be doing a huge construction project and also be changing the way that we take care of people in skilled nursing. I wish we could have been a little more ahead of the game on the personcentered care concept through philosophies before we started making changes to the building. I think we would have had an easier buy-in from the staff. LTL





ecent events have created a new awareness of the value and importance of quality security management programs in long-term care (LTC) facilities. Most of us can remember a time not long ago when the term “healthcare security” referred only to hospitals, and the role of security officers usually amounted to tasks that could not be assigned to other disciplines. These tasks often included running errands across town, providing in-house courier services, delivering meals after hours, picking up and delivering mail and performing other duties not at all associated with providing a safe and secure environment. Today, if you’re an LTC facility administrator, you should be looking seriously at security operations issues, ensuring that security is an integral part of your overall management plan. How can you accomplish this goal? Let’s look at some ways.

1. ASSESS VULNERABILITY At least annually, perform a comprehensive security vulnerability assessment in all areas of operations as well as in all buildings and on the grounds. You may choose to

Before you hire an outside security consultant, make sure he or she has the experience and expertise in healthcare to qualify him or her to work for you. t"6(645

perform this assessment yourself or retain an outside consultant. Both approaches have benefits and drawbacks. Some argue that a self-assessment is the preferred approach, believing that an LTC facility staff is more prepared than an outsider to look at operations. Others believe that an outside agency is more objective and has fewer propensities to overlook and minimize deficiencies. You must decide which approach is best for your facility and what you intend to do with the information that results from the assessment. One word of caution to administrators: Do your homework before hiring an outside agency. Because of changes in society, “security experts” seem to be “coming out of the woodwork.” Working in the security field for years does not necessarily qualify someone. It is doubtful, for instance, that you would want a former mall security officer trying to assess your facility, considering issues such as resident security and resident rights.

Just the same, being an active or retired police officer does not necessarily qualify one to be considered proficient or qualified in security. With all due respect, ask a police officer about the proper type of closed circuit TV camera to use or the proper type of locking hardware to consider and you likely will agree. Before you hire an outside security consultant, make sure he or she has the experience and expertise in healthcare to qualify him or her to work for you. Although many outstanding consulting agencies exist, a growing number of agencies simply look to make a quick dollar at the facilities’ expense. In addition, even well-established agencies do not necessarily have expertise or working knowledge of the differences between hospitals and LTC facilities.

2. TRAIN ALL STAFF MEMBERS It’s difficult enough to find time to train your people in all of the subject areas in which they are required to be trained, 888-5-."(";*/&$0.



Editor’s note: This is the fifth article in a series offering advice on successfully implementing Quality Assurance Performance Improvement in your organization. “In God we trust; all others bring data,” said W. Edwards Deming, a global figure in statistics and management sciences. He is credited for his transformational role in quality improvement. Deming was a pioneer at transforming data into knowledge providing the basis for action. The datadriven premise of Quality Assurance Performance Improvement (QAPI) depends on data. Data, however, are not knowledge. They have to be transformed into knowledge, which is the basis for successful action. Like the rest of the world, nursing homes (NHs) are drowning in data. To translate data into action, opportunities for improvement have to be identified and prioritized. This process is discussed in QAPI Step 9: Prioritize Quality Opportunities and Charter PIPs.

QAPI RESOURCES The Centers for Medicare & Medicaid Services (CMS) is responsible for both promulgating the QAPI regulation and providing technical assistance to NHs. Within a year of the promulgation of the

Within a year of the promulgation of the QAPI regulation, NHs will be required to have acceptable written QAPI plans. t"6(645

QAPI regulation, NHs will be required to have acceptable written QAPI plans. Accessing these sites helps NHs with the drilldown process to identify and prioritize quality opportunities and navigate the chartering of Performance Improvement Projects (PIPs).


After a purposeful review and discussion of data sources, the Steering Team charters a PIP team to focus on the area that presents the most urgent process improvement opportunity. One of the tools CMS provides is a Brainstorming, Affinity Grouping and MultiSTEP 9: PRIORITIZE Voting Tool, which helps NH QUALILTY teams collaborate, generate OPPORTUNITIES, ideas and make decisions CHARTER PIPS about process improvement NHs already hold routinely and priorities. Nell Griffin, LPN, EdM scheduled meetings to discuss Not all identified probdata. Tracking data, such as falls and preslems, complaints or issues require PIPs. sure ulcers, is already a part of what they The frequency, level of risk or impact on do. Seeing these incidents as opportunisystems drives the decision for chartering ties instead of problems is not a common PIP teams. The Steering Team decides mindset. whether a PIP charter is necessary based Deciding the area on which to focus on data, a history of negative outcomes improvement actions on is a function of and the potential for resident harm. CMS the QAPI Steering Team. Improvement op- uses the word “charter” deliberately for PIP portunities arise from various sources, such formation. PIP charters are specific written as when an NH’s publicly reported quality missions to solve a specific problem. CMS measures are vastly deficient compared has released tools, including a Worksheet with the state or national rate. The chance to Create a Performance Improvement to move closer to the state or national rate Project, to help NHs visualize the mission. also presents an opportunity to exceed The worksheet establishes the goals those rates. and scope in the overview section, which Complaints create the chance to provides the PIP team with information improve satisfaction by improving the such as the problem and the reasons the process. With improved processes, staff steering team decided to charter a PIP to can work more efficiently, increasing job address them. A timetable and the roles satisfaction and decreasing turnover. Data PIP team members are also defined on this showing high risk for harm and patterns tool. The Steering Team may select persons of high frequency offer improvement opto invite to participate on the PIP, but portunities the Steering Team can discuss certain roles should be assigned as part of and decide the priority of efforts. Data the charter. Usually, the Steering Team will showing negative impact on residents’ select a leader for the PIP, but a member psychosocial well-being, daily life choices of the Steering Team must be the point of or autonomy should be included in the contact. prioritization discussion. As part of the vision for the project, this 888-5-."(";*/&$0.

POLICYMATTERS tool helps the Steering Team proactively plan the PIP by thinking through the barriers that could block the successful completion of the mission. It also engages leadership to commit to the success of the PIP. Leadership support is vital to the success of the mission. An NH’s leadership has to create the space for the PIP to succeed as part of the charter. The leadership supports the PIP with the time needed to participate, secures any supplies and provides the physical accommodations to complete the mission. One of the major responsibilities of the leadership is to establish the expectation that staff will work on PIPs and that co-workers will support and adjust their schedules to accommodate PIP team members. Leadership is expected to know the status of the PIPs chartered at the NH. CMS has posted the Performance Improvement Project (PIP) Inventory online tool to help. It assists NHs with tracking their PIPs. List chartered PIPs on this tracking template. Assigning a person to be responsible for updating the template at regularly scheduled intervals allows the Steering Team and leadership to have a means to be informed of the status of each PIP. Once chartered, the PIP team is entrusted with the mission. Being part of a PIP is an important task that everyone working at, living in or frequenting the NH should take seriously. Whether chosen by the Steering Team or by the PIP team itself, the PIP leader guides the team through an analysis of the data and establishes a proposed timeline for completing the mission. The Goal-Setting Worksheet, located in the appendix of QAPI at a Glance, is another of the technical tools issued by CMS that can help PIP teams move their missions forward. This worksheet helps establish appropriate goals for Plan Do Study Act (PDSA) cycles, organizational quality measures or improvement initiative as well as PIPs. Planning is one of the keys to QAPI.

based practices intended to reduce variations in care practices among staff, which have proven to be contributing factors in errors, adverse events and deficiencies. Planning is an integral part of a structured process. Testing the process, before folding it into the care system, increases the probability of successful integration.


QIOs monitor official, unofficial public and private data sources for trends to proactively engage healthcare providers as early as possible. The goal is to interrupt

QAPI is comprised of structured processes and consistent practicing of evidencedWWW.LTLMAGAZINE.COM

SELECT DATA SOURCES For process improvements to be datadriven, data have to be understood and used. Data identify the improvement opportunities. One of the roles of the QAPI Steering Team is to decide what data sources to use. Team members discuss and interpret the data’s meaning and regularly review them. When the data indicate that an NH is performing below state, national or its own expectations in any measured area, the Steering Team may decide to charter a PIP team, which is designed to learn more about a specific area and determine what will improve the performance. The Steering Team charters a PIP and provides a clearly defined scope and focus to its team members. CMS offers a Worksheet to Create a Performance Improvement Project Charter, which provides the PIP team with directions by defining team members’ roles, responsibilities, goals, scope and timing.

SETTING GOALS The goal of the Steering Team when chartering the PIP is the overall goal. The PIP team establishes small goals to move the team forward and meet the overall goal. One of the PIP team’s first goals is to schedule meetings. Doing so can be challenging when the team members work different shifts and different times. NHs must maintain a high-functioning staffing level 24/7.


Testing the process, before folding it into the care system, increases the probability of successful integration. patterns indicating negative outcomes. As an example, pressure ulcer prevention remains a focus of CMS and QIOs. Each Medicarecertified NH’s quality measures are posted on Nursing Home Compare on the Medicare website (www.medicare/gov/nursinghomecompare), which is updated regularly. The national percent of long-stay, high-risk residents with pressure ulcers is 6.1, while the state percentage in Illinois, for example, is 6.6 percent. The pressure ulcer rate for Illinois is slightly higher than the national rate, but history has shown that pressure ulcer rates tend to increase, meaning that residents continue to develop pressure ulcers while in the care of healthcare professionals. Some pressure ulcers are unavoidable due to multiple debilitating medical conditions that negatively impact nutrition and mobility. These occur in the sickest of residents and are not the norm. Other pressure ulcers are avoidable. Whenever a resident develops a pressure ulcer, a root cause analysis (RCA) should be conducted to determine if it was avoidable. Every NH should have a process for selecting events or issues to undergo an RCA. The development of a pressure ulcer should always be one of those events. An RCA is a systematic process to determine the underlying causes or true causes of a problem for the purpose of correcting it. When one resident develops a pressure ulcer, an RCA should be done to learn more. When more than one resident develops a pressure ulcer, however, this could indicate a problem with the current pressure ulcer prevention process, suggesting that a PIP could be chartered to focus more attention on the Continued on page 30 LONG-TERM LIVINGt



lthough there is a great deal of variability in nursing home administrator (NHA) licensure requirements across state lines, most states require specialized education—an applied field experience commonly referred to as an AIT program—and passing scores on federal and state licensure exams. The content, length and model for these experiences have been largely driven by the National Association of Long Term Care Administrator Boards (, who recommended NHA requirements and organizational managerial/technical needs. Even with these recommendations, standards still vary widely from state to state. Educational requirements range from a high school education to a bachelor’s degree, and AIT requirements range from 0 hours in a handful of states, to 2,000 hours and beyond in others. During a practicum experience, the AIT has an opportunity to rotate through each

Contemporary research has found preliminary evidence that the AIT experience is critical to the effective development of administration competencies and leadership skills. t"6(645

administration competencies and leadership skills. A recent NAB-funded study that we just completed, in concert with coauthors from University of Pittsburgh, George Washington University and St. Joseph’s College of Maine, has further linked the important educational component of the AIT experience with administrator Jennifer Johs-Artisensi, PhD, MPH competency and quality. Our initial analysis found that an optimal level of education and training positively impacts the development of successful LTC administrators, as well as facilities’ five-star ratings. Using education and training stringency scores developed for each state based FIELD EXPERIENCE: on its NHA licensing requireITS RELATIONSHIP TO ments, and NAB licensing QUALITY Douglas Olson, PhD, exam data from 2001 through LTC administration has MBA, NHA, FACHCA 2009, we found that both an employment cliff: More higher degree requirements and longer people are leaving the field than are enterAIT requirements were correlated with ing it. Couple that with NHAs being better exam scores. Although we believed under increasing pressure to transform that exam performance was a good proxy their communities. These two issues are for measuring competency, we wanted to occurring against a backdrop of rising know whether that higher competency consumer demands and dwindling fiscal translated to better quality in practice. resources. The AIT program is an essential As such, we identified the five-star rateducational component serving as a career ings of nursing homes in 17 states where transition between student and employment status, and it’s completion is essential these recent licensees were employed. We found that NHAs who earned higher to the success of potential administrators. licensing exam scores were leading facilities Contemporary research has found prewith better overall five-star ratings, health liminary evidence that the AIT experience inspection ratings and had fewer total is critical to the effective development of facility department, developing an understanding of frontline service staff roles, the responsibilities of the departmental managers, and how each department integrates with the rest to provide both effective and efficient personcentered care. Students also spend significant time learning about several administrative functions, such as managing the survey process, human resources, financial and information systems and, in many programs, they develop their leadership skills by participating in projects that effect change and produce favorable results.


TRAININGMATTERS To best prepare future leaders, there are several training site characteristics that offer the highest quality experiential learning. These include:

A student gets hand-on learning with a resident.

enforcement actions counts in their current facilities.  Although this is just a preliminary study, this research strongly suggests that an optimal level of education and field training leads to better prepared NHAs, resulting in a higher level of quality care and service. It is clear that new administrators need quality practicum/AIT experiences to ensure that they are well prepared for their future careers.

WHAT DOES A QUALITY EXPERIENCE LOOK LIKE? Although, as educators, we have a subjective sense about which practicum sites are excellent, which are good and which are lessthan-ideal, we wanted more information to aid in the selection of the best possible sites and preceptors with whom to partner. We also developed resources and practices to support these practitioner-educators to best develop future administrators. With funding from the Commonwealth Fund and NAB Foundation, we conducted a study that helped us discern that the quality of the AIT or practicum experience is influenced by the environment in which the trainee learns. We determined that the experience of the trainee’s preceptor and the “spirit of learning” embodied by the practicum site are two of the most significant driving forces. WWW.LTLMAGAZINE.COM

t ɨFJOEJWJEVBMTFSWJOHBTUIFQSFDFQtor makes a significant difference in the student’s learning experience. The number of years the preceptor has been with his or her organization, the number of students he or she has mentored, how involved they are in their profession and their level of education are all significant factors towards the student’s success. t "QPTJUJWFMFBSOJOHFOWJSPONFOU‰ an atmosphere that communicates the student is wanted, accepted and encouraged to engage with the work of the organization encourages a climate of learning. In addition, stability of department head teams and the level of organizational support encouraging professional development were also important factors. Conversely, instability among staff or leadership teams probably served as distractions to the preceptor and inhibited student development. t 0SHBOJ[BUJPOTUIBUFNQIBTJ[FUIFBEvancement of culture change, have high customer satisfaction and participate in the Advancing Excellence in America’s Nursing Homes (Advancing Excellence) campaign also seemed to better position students for future success. t 'JOBMMZ UIPTFTUVEFOUTXIPXFSFCFTU prepared to lead LTC organizations had obtained their education and training at sites where a variety of services, such as skilled nursing, assisted living, dementia care, senior housing and other community-based services were provided.

OPPORTUNITIES AHEAD It is imperative we develop high-impact practices to support the education and training of a new generation of leaders in PVSëFME0VSSFDFOUSFTFBSDIIBTZJFMEFE several findings that can be leveraged by

AIT training helps students gain administrative and business experience.

state licensing boards, academic programs and corporate AIT directors. There is ample opportunity for all stakeholders to work together to develop core competency criteria and standardized tools to help advance quality clinical training experiences for future administrators. Some areas ripe for collaboration might include consideration of: t "EWBODJOHOBUJPOBMMJDFOTVSFSFRVJSFments or accreditation guidelines regarding educational curriculum, length and structure of AIT experiences. This was also called for by a broad representation of key stakeholders, as part of legislative forum recently held at the National Emerging Leadership Summit in affiliation with the Senate Special Committee on Aging. t &TUBCMJTIJOHBQQSPQSJBUFDSJUFSJBGPSTJUF and preceptor selection, such as preceptor experience minimums. Additionally, sites which offer diversity in their scope of services, are in good regulatory standing, are embracing resident-centered care philosophies and are actively involved in quality initiatives like the Advancing Excellence campaign provide superior training opportunities. t 1SPWJEJOHSFTPVSDFTBOETUSBUFHJFTUP help cultivate an organization’s learning environment. NAB could take a leadership role with this effort by encouraging these practices through its accreditation process and sharing these best-practice resources with states, schools and other interested partners. LONG-TERM LIVINGt


POLICYMATTERS Continued from page 27





Jennifer Johs-Artisensi, PhD, MPH, is the Education Committee Chair for NAB, an Associate Professor and Program Director for the Health Care Administration Program at the University of Wisconsin–Eau Claire and Associate Director of the Center for Health Administration and Aging Services Excellence. Douglas Olson, PhD, MBA, NHA, FACHCA, is the Director of the Center for Health Administration and Aging Services Excellence and an Associate Professor for the Health Care Administration Program at the University of Wisconsin–Eau Claire. He serves on the Board and the Academy for Long Term Care Leadership and Development for the American College of Health Care Administrators and also serves on the Board of Overseers for the American Health Care Association’s National Quality Award program.  Photos courtesy of the University of Wisconsin–Eau Claire.














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he fourth quarter is quickly approaching, and soon, administrators in long-term care will be developing their marketing plans for next year. If you’re in this position, now is the time to evaluate the health of your referral relationships. In fact, it’s the most important factor for you to examine as you create next year’s marketing plan. Skilled nursing facilities (SNFs) and home healthcare agencies receive most of their referrals from healthcare entities, whereas assisted living facilities (ALFs) receive a significant percentage of inquiries from professional referral sources, both in healthcare and others areas, such as elder law attorneys and geriatric care managers. In my experience with ALFs, professional referrals convert at twice the rate of other classes of inquiries, such as advertising, site and signage and word of mouth, so healthy relationships are important. Here are three steps to help you improve or solidify your standing.

1. EVALUATE TRENDS Start your appraisal by looking for trends in the number of referrals you receive from each source. If you have been maintaining a referral log—that’s a best practice, so if you aren’t doing it now, plan to start—you will be able to break down this information by month as well as at least the past two years to glean these trends: t .POUIPWFSNPOUISFGFSSBMUSFOE TJODF+BO. Are referrals up, down or flat since the beginning of the year? t :FBSPWFSZFBSSFGFSSBMUSFOET. Look at historical data from 2013 and, if possible, 2012, comparing them with data from the same time period this year. For instance, what’s the referral trend for January when you look at 2012, 2013 t"6(645

and 2014? How does the entire year of 2014 compare with 2013 and 2012? Are those trends positive, flat or negative? Remember that you are looking for trends related to individual referral sources such as a hospital, physician’s office or home healthcare agency. The referral trends you discover will provide you with insights into what may be happening with all of your referral sources. What valuable insights can you gain? t 0QQPSUVOJUJFTUPFYQBOEZPVSCVTJ OFTTA slight increase in a referral activity from established sources could suggest an even larger opportunity that you need to uncover. And if you had a newreferral source in 2014, that sug-

gests a new expansion opportunity that you must nurture and develop. t ǰSFBUTUPFYQBOEJOHZPVSCVTJOFTT. Obviously, a decline in referrals suggests that challenges exist to maintaining your census. A decline in referrals could mean that a case manager or physician who was a consistent referral source has left an organization, or it could suggest something much more significant, including a negative perception about your facility or the presence of new competitors in the market. If referral trends have not changed, then look at your data within the context of what is occurring at each referral source. Is the entity growing, declining or remaining the same? If your referral source is a 888-5-."(";*/&$0.

MARKETINGMATTERS dynamic, evolving organization that is you and your staff members during the growing but your referrals are flat, you may referral process.” be missing an opportunity to grow. Don’t confuse this tactic with what I Another aspect of your call the “What can I do to referrals is their quality. If get more of your business?” you are an administrator approach. Although sales at a SNF, are you seeing an professionals in many indusincrease in managed care-retries use this approach, the lated referrals and a decrease typical healthcare professional in Medicare-related referrals? perceives it as a crass attempt If you are an administrator to develop a relationship with at an ALF, are you seeing an him or her. increase in financially unTo avoid falling into the Luke Fannon qualified referrals? Changes “more business” trap, ask your in payer mix and diagnoses suggest opreferral sources specific types of questions. portunities or dangers depending on your As indicated by the wording of the request, programs and services and the managed query them about their perceptions of the care contracts you have. quality of your services; your reputation with their patients/clients and their caregiv2. CALL SOURCES ers; your follow-up and communication The other tactic you can use to assess the with their staff members; your acceptance health of your referral relationships is to of their patients/clients with complex schedule customer service marketing calls cases; and the speed with which you turn with key individuals at your sources. The around referrals. Also ask them to describe goal of these telephone meetings is to gain their biggest challenges when addressing honest feedback about your reputation patient/client needs and when discharging with residents, potential residents and them into the community. Finally, ask, “If caregivers as well as the referral source’s there were no restrictions, what service or perception of your customer service. product you would like us to offer you and I developed this tactic in my first job your staff?” with Bryn Mawr Rehab Hospital outside of Philadelphia. After working with my 3. RESPOND TO FEEDBACK referral sources for a while, I realized that The answers you receive will vary, but your I needed a way to ensure that Bryn Mawr customer service marketing calls will reveal and I were meeting their needs and the that referral sources fall into three basic needs of their patients. After trying this categories: those who view their relationtactic for the first time, I immediately ship with you as excellent and provide little discovered that case management directors, negative feedback; those who view their physicians and their staff members, and relationship with you as positive, although elder law attorneys were happy to provide they do give some specific negative feedfeedback about our services. Rarely were back; and those who offer nothing but they unwilling to schedule such meetings highly negative feedback, suggesting that with me. you have a disaster on your hands or one The key to successfully executing this in the making. Obviously, your response to tactic is your approach when requesting the an individual referral source will depend on meeting. Your appeal should go something which category it falls into. like this: “I’d like to schedule a meeting For those sources that view their with you to get some honest, constructive relationship with you as excellent, your feedback on the quality of our services; our evaluation of referral trends now becomes reputation; and the follow-up, commuan important part of your response. If the nication and customer service we provide referral trend is positive, then focus on the WWW.LTLMAGAZINE.COM

source’s wish list and create a plan to meet its advanced needs. Even with entities with which you have very health referral relationships, opportunities may present themselves to increase your business. If the referral trend is negative, then you can start a conversation about why referrals may be falling or why quality is changing (show the source your referral data). These changes are occurring despite the facts that the referral source is very pleased with your services and your reputation is stellar. This discussion should provide you with information that will enable you to adjust your marketing strategy and increase referrals from this source. In the case of a referral source that has a mixed perception of you, your response should include focusing on the entity’s advanced needs and wish list and creating solutions to the minor problems that may be negatively affecting your relationship. Remember, issues that seem small can develop into significant problems if not treated. In the case of a referral source that has a very negative perception of you (now you know why referrals have been decreasing for the past two years), first you must apologize for the problems your facility has created and then commit to developing a plan of correction based on the source’s feedback. Fixing the problems identified by the input should improve your ability to increase referrals from such a source. The referral trend evaluation and customer service marketing call—and careful response to them—are techniques that will enable you to assess the health of your referral relationships and create new opportunities to increase referrals from all of your referral sources regardless of the current quality of those relationships. LTL Luke Fannon is the founder and principal at Premier Coaching and Training, Unionville, Pa. PCT provides long-term and healthcare sales and marketing training, admissions and marketing team coaching and other strategic consulting services. For more information, visit www.pctmarketing. com. LONG-TERM LIVINGt




xecutive directors of assisted living communities may not be aware of all of the cases of elder abuse—especially sexual incidents—occurring in their communities. That’s the conclusion of Marguerite “Marti” DeLiema, a doctoral candidate at the University of Southern California’s (USC’s) Davis School of Gerontology. DeLiema discussed elder abuse with the more than 100 people attending the Assisted Living Federal of America (ALFA) Executive Director Leadership Institute (EDLI), held in conjunction with ALFA’s annual meeting in May. As part of her session, she polled attendees about their observations or suspicions of staff members’ physical mistreatment of residents, mismanagement of resident medication (stealing residents’ medication for themselves, giving medication intended for one resident to another resident or withholding medication from a resident) and inappropriate sexual behavior with residents within the past year. When it came to physical mistreatment of residents or mismanagement of

Elder abuse takes many forms—financial, sexual, physical and emotional/ psychological abuse as well as neglect.

medication, EDLI participants’ reporting of observed or suspected incidents was similar to that of assisted living nurse aides surveyed by Nicholas Castle, PhD, and Scott Beach, PhD, for a large study published in the Journal of Applied Gerontology. Concerning sexually inappropriate behavior between a staff member and a resident, however, the executive directors reported a much lower frequency of this type of abuse than did the nurse aides, DeLiema says. All but one responding executive director said they had never observed or suspected a staff member of such behavior, she says; one reported observing or suspecting one case. By comparison, the Castle and Beach study of nurse aides, DeLiema says, had “a lot more shocking results.” For instance, three percent of the nurse aides

surveyed said they knew of staff members’ “unwelcome fondling” of a resident, and seven percent said they were aware of staff members who had exposed a resident’s body part as a form of abuse. “What really surprised me was the reaction of the audience to the Castle and Beach study results” related to sexual abuse, DeLiema says of EDLI participants. “They were really shocked by how high those rates were. They were shaking their heads and putting their hands over their mouths. They were really surprised. So that speaks to the fact that they just are not aware that this is going on in their communities.” Why does this apparent discrepancy exist between executive directors and nurse aides? One possibility, she says, is that the aides are closer to the delivery of care and so may see more incidents of inappropriate sexual interaction. “It’s my guess that it’s just that [the executive directors are] further removed,” DeLiema says. “These nursing aides are literally with [residents] 24/7, and they are the ones who have to manage the more difficult behaviors and do all of the personal care work. You would hope that the executive director would hear about these things if they’re being reported, but perhaps not.” Also, DeLiema adds, perhaps some incidents of abuse are handled within the nursing department and are not communicated to the executive director. Or perhaps the EDLI survey-takers hesitated to respond honestly to the question, even though they were submitting their answers electronically and anonymously during the EDLI session. Continued on page 37




Technology roadmap 2014–2016: Get connected Mobile technology and shared data dominated the LTPAC Health IT Summit BY PAMELA TABAR, EDITOR-IN-CHIEF


lectronic health record? Check. ADL assessment software? Check. Remote resident monitoring? Check. Now what? The Long-Term and Post-Acute Care Collaborative has announced its 2014–2016 Roadmap for technology adoption, a goals-based strategy treatise on how technology is primed to touch and enhance the people, places and service lines in long-term/post-acute (LTPAC) settings. With the skyrocketing prevalence of mobile and wireless devices, it’s no surprise that the theme of this roadmap is connectedness, focusing specifically on how technology can be used to connect people, partners and processes. The roadmap, officially announced on the final day of the 2014 Long-Term and Post-Acute Care Health IT Summit (LTPAC HIT) in Baltimore, encompasses five key sections: connected workers, connected partners, connected residents and caregivers, connected health intelligence and connected business imperatives. Not afraid to take a hearty bite into complex issues, the document outlines in great detail

With the skyrocketing prevalence of mobile and wireless devices, it’s no surprise that the theme of this roadmap is connectedness. WWW.LTLMAGAZINE.COM

the opportunities for technology use in each category as well as the challenges to be embraced by providers, payers and vendors.

KEY RATIONALES AND GOALS Connected workers. The prevalence of mobile devices lends itself to connecting workers to their tasks and customer relationships. “The connected worker is a key enabler of a person-centered health and wellness enterprise,” the draft rationale states. “Connectedness supports accountability, teamwork, learning and attention. [Workers’] access to knowledge and context allows them to further add value to each customer interaction.”

Connected partners. Now that datacollection among LTPAC partners has gained ground, the industry must focus on interoperability standards for not only data exchange but data understanding. This includes care coordination, of course, but also reaches into deeper goals like chronic disease management and right-data-at-the-right-time information exchange between acute and long-term care (LTC) settings. Connected residents and caregivers. Empowering residents in care plans and wellness initiatives with engagement tools can have a dramatic effect on cost and outcomes, not to mention customer satisfaction. Connectedness between the LONG-TERM LIVINGt

TECHNOLOGYMATTERS LTPAC population and caregivers creates new ways for technology (remote monitoring, telehealth and self-monitoring) to keep residents out of higher levels of care longer. But it asks the industry to take the concept of care coordination several steps further, into longitudinal and truly portable records between care stages, which, for many providers, means further growth in IT infrastructure. The writers of the roadmap admit that this category is perhaps the most long-range section, because so many of its initiatives need to be road-tested first. Still, it contains prime fodder for vendorprovider partnerships. Connected health intelligence. Intelligent data-sharing goes far beyond the handoff of discharge summaries and the dutiful charting of activities of daily living. The ultimate goal is data that follow the person from one care stage to all others. Capturing—and exchanging—such data opens up brand

new doors to providers for benchmarking. This, too, is a hefty goal, requiring standards and data element-mapping between still-siloed coding systems across the care continuum. Connected business imperatives. Benchmarking, service line expansion, surviving regulatory cost squeezes…none of this can happen without strategic alignment of business imperatives, including the new world that stretches across care segments. The payment bundling initiatives are here to stay, most say—and that means risk-sharing. What your partners are doing matters—from now on.

LTPAC TECH: A WORK IN PROGRESS The collaborative makes no bones about the roadmap being a work in progress and sought the input of summit attendees on the current and future goals for technology in the LTPAC arena, identifying many challenges that need to be addressed.

The new LTPAC technology roadmap goals are here. The road is steep, but the benefits are vast. One of the biggest challenges is the lack of “mapping”—or an understanding of gathered data elements that are the same—between the disparate coding systems used within acute and LTPAC. Nursing homes use the Minimum Data Set (MDS) coding system, whereas acute care uses completely different coding systems. These coding systems may use many of the same data elements (like collecting vitals), but each system also has its unique elements. LTC hospitals have their own coding system, LTCH-CARE.

Building a code set library The Centers for Medicare & Medicaid Services (CMS) is attempting to solve one of long-term care’s biggest headaches—lack of standardization among assessment data gathered across the care continuum. Coding, once used solely as a way to classify services for billing purposes, is taking on far greater roles in healthcare documentation, especially when it comes to resident assessment data. Longitudinal assessment records are the holy grail for long-term care, both for chronic disease management and for cost utilization benchmarking. But reaching those goals requires data elements that are comparable across care settings. Every segment of long-term and post-acute care uses a coding system to document care actions and health statuses. Nursing homes use the Minimum Data Set (MDS) coding system, but with MDS 3.0 encompassing more than 9,000 codes, some say it should be called the maximum data set instead. Meanwhile, home healthcare, long-term care hospitals and rehab


facilities have their own coding systems. With the new pressure on data standardization, which code set will prevail? Perhaps parts of all of them, said Tara McMullen, MPH, health analyst in divisions of chronic and post-acute care, in a session at last month’s Long-Term and Post-Acute Care Health IT Summit in Baltimore. “The lack of data harmonization has been a huge problem for CMS and providers,” McMullen said. Although each coding system has its unique elements, some data elements, like vital signs, are captured at nearly every care stage, providing fertile ground for standardization efforts at a national level. CMS is building a code set library of sorts, the first comprehensive collection of data elements to reach across the links in the LTC chain. The CMS Assessment Data Element Library will include mapping for all assessment questions and responses, standardized under codes that CMS will accept across any stage in the postacute care continuum. The work will no doubt

use what CMS learned in building the CARE tool, an early attempt at standardized coding following the 2005 Deficit Reduction Act, which mandated the collection of data within acute and long-term care. Once completed, the assessment data element library will help to reduce the translation barriers that have plagued data-sharing between care environments, McMullen said. Having a central library of codes also will assist the vendor community in developing IT systems and tools that optimize the ability to analyze data for benchmarking and other business needs. “I get questions from providers every day, asking, ‘How will quality affect payments?’ I think the day is coming when CMS will begin signalling, but for now there’s a lot of work on standardization,” McMullen said. CMS plans to launch the data element library in 2015. —Pamela Tabar, Editor-in-Chief


AWARENESSMATTERS Continued from page 34

Home healthcare uses OASIS. Then there’s IRF-PAI coding for inpatient rehabilitation facilities. Each coding system grew out of the unique needs for each care segment. But now that data exchange between care levels has become the industry nirvana, finding a way to understand the data fields collected by each care stage—and be able to exchange them in a meaningful way—has become paramount. Another huge subject is quality measures. Each segment of the care continuum tends to have its own ways of measuring outcomes and quality benchmarking—and, therefore, the impending reimbursement factor. The roadmap refers to the need for “harmonizing” quality measures across the spectrum, to the greater goals of all care stages. Several attendees in the roadmap workshops voiced frustrations, saying that data exchange with hospital partners isn’t always a two-way street. Too much data exchange is rooted in the hospital getting its reimbursement needs taken care of, but not always exchanging what the LTC facility needs, noted one workshop attendee. The timely exchange of data is another issue, another attendee added. Continuity of care documents (CCDs) have to be exchanged quickly between acute care and skilled nursing; there’s little point in receiving a CCD several days after the patient has been transferred. “We’ve had hospitals striving to provide the CCD within one day after discharge. But what are we supposed to do with that patient for that day?” noted Doron Gutkind, chief software architect at Lintech, who attended a workshop session. Just getting access to the IT systems needed to improve data exchange is a challenge, especially for smaller providers trying to get into health information exchanges (HIEs). “It seems that software vendors make the partnerships and then we’re part of that,” one workshop attendee commented. “I don’t know how else to do it, as a small operator. Because sometimes the HIE thing seems primarily to solve the hospital’s need for meaningful use.” The take-home messages: The new LTPAC technology roadmap goals are here. The road is steep, but the benefits are vast. And for standards-making initiatives and box-breaking pilots between vendors and providers, the time is now. LTL


Elder abuse takes many forms—financial, sexual, physical and emotional/psychological abuse as well as neglect. What can be done to prevent and address such abuse in long-term care (LTC) settings, whether it be perpetrated by a staff member, a family member or another resident? Increased awareness—through educational programs such as the EDLI and events such as World Elder Abuse Awareness Month, observed every June, and World Elder Abuse Awareness Day, observed every year on June 15— is one solution. Others, according to DeLiema: t %FWFMPQBOENBJOUBJOBHPPEXPSLJOHSFMBUJPOTIJQ with the LTC ombudsman in your state. “Sometimes, the cases we see, the facility can only do so much. They really need to pull someone in from the outside, and sometimes, the best option is more of a mediator than the police or adult protective services,” she says, noting that ombudsmen usually take a person-centered approach. t &EVDBUFSFTJEFOUT GBNJMZBOETUBêNFNCFSTUIBU reporting abuse is a good thing. “You really need buy-in from the older adults if you’re going to try to ‘protect’ them,” DeLiema says. “And the same with physicians, getting them to feel that reporting is the best option” rather than trying to address incidents directly themselves. t 5SBJOEJSFDUDBSFTUBêXIPXPSLXJUIDPNCBUJWF residents so that they don’t react in an abusive way to behaviors that, because of a cognitive disease process, may be beyond a resident’s control. “It’s important that they have a good understanding of the disease process,” DeLiema says. Training, she adds, can answer these questions: “What is cognitive impairment, how does it manifest, what kind of behaviors can they expect?” t &TUBCMJTIBTZTUFNUPBEESFTTTVTQFDUFEPSDPOëSNFE incidents of staff mistreatment of residents to ensure that such incidents don’t recur. The USC Davis School of Gerontology touts that it is the oldest and largest such school in the world. DeLiema also points executive directors and others to the school’s website ( and its Guide for Elder Abuse Response (GEAR) app ( as additional resources. The app, she notes, has some elements of particular interest to those working in California, but it also contains information of wide potential interest. LTL



Owners, beware: Arbitration provisions may be inadequate Reviewing admission contracts can save time, money and litigation by a resident’s power of attorney BY THOMAS W. HAZLETT AND A. PETER PRINSEN, ESQ.

ssisted living (AL) communities, long-term care (LTC), rehabilitation facilities and other businesses that contract for ongoing health services with the elderly or others that may be mentally impaired, must deal with the litigation risk of arguments that their agreements with the individuals they serve are invalid and unenforceable. Analyzing such risk is complicated by the potential involvement of a power of attorney acting on behalf of the impaired individual. A recent decision by a Pennsylvania trial court clarifies the enforceability of contracts between LTC and rehabilitation facilities and their residents/patients, and specifically the enforceability of arbitration provisions, but it also illustrates the limitations of such agreements.

ARBITRATION PROVISION: VALID AND ENFORCEABLE, BUT LIMITED In Lipshutz v. St. Monica Manor,1 the Court of Common Pleas of Philadelphia County ruled that a nursing home/rehabilitation facility’s contract with a patient, which was signed by one of the powers of attorney, was valid and enforceable but was limited in its application to the patient’s claims only. In Lipshutz, the plaintiffs’ mother suffered a stroke and, after being discharged from a hospital, was admitted to the defendant’s nursing and rehabilitation facility. One of the plaintiffs, as her mother’s power of attorney, signed the facility’s standard admission contract, which included an arbitration provision. The plaintiffs’ mother subsequently died, and they, as executors of their mother’s estate, filed suit against the facility, alleging claims t"6(645

for their mother and for themselves as beneficiaries of their mother’s estate. The facility moved to dismiss the case pursuant to the arbitration provision in the admission contract. The court first found that the power of attorney was effective, despite the plaintiffs’ failure to obtain certifications from two doctors documenting that the plaintiffs’ mother was mentally impaired, which was required by the plain terms of the power of attorney document. Despite the plaintiffs’ oversight, the court looked beyond the “formalities” of the power of attorney document to the “totality” of the circumstances because “if healthcare facilities were required to wait for formal certifications, patients would be forced to await formalities before desperately needed care was provided. In the case of seriously ill or injured patients, this is literally the difference between life and death.” After concluding that a valid contract existed between the facility and the plaintiffs’ mother, the court turned to the scope of the contract’s arbitration provision. Although the admission contract applied to any claims of the plaintiffs’ mother, the court concluded that it did not apply to any claims by the beneficiaries of the mother’s estate (i.e., plaintiffs and their siblings) because they were not parties to the contract. Under Pennsylvania law, an estate’s beneficiaries’ wrongful death claims and the decedent’s claims for injury that survive his or her passing must be tried together. The court found that this requirement of Pennsylvania law was preempted by federal law, however, because, “if [the] Court

ordered the wrongful death and survival actions to remain in Court [together], the decedent’s arbitration agreement… would be nullified,” which is contrary to the requirements of the Federal Arbitration Act. Accordingly, the court split the case, allowing the wrongful death claims to proceed in the Court of Common Pleas but dismissing the survival claims in favor of arbitration.

LESSONS LEARNED Lipshutz raises two very important issues for healthcare facilities that deal with the elderly or others that may be mentally impaired: 1. A power of attorney may prove valid even when documentation was incomplete. A power of attorney may be valid, even when “formalities” have not been completed. This means that, in urgent circumstances, healthcare facilities should consider all the evidence of a prospective patient/resident’s condition when determining whether the individual or the individual’s legal representative may execute a contract for admission to the facility. In simplest terms, admissions officers should not let formalities in a power of attorney document get in the way of letting a power of attorney sign an admission contract so that a patient/resident can be admitted and start receiving needed care.  Admissions officers, however, should still look at what the substance of the power of attorney document says about the person’s condition and then review available medical records, discharge notes, etc., to make an informed decision on the person’s 888-5-."(";*/&$0.

condition. Although this step may seem like an additional burden on a facility, it is a small percentage of cases where all the formalities in a power of attorney document have not been completed, so the need to exercise this additional discretion is small. 2. A valid arbitration agreement may not prevent two separate cases. In the event a patient/resident dies and a claim is made, even a valid arbitration agreement between a facility and its patient/resident may not prevent the beneficiaries of the patient’s /resident’s estate from pursuing their own claims in court, even while the patient/resident’s claims proceed separately through arbitration. The prospect of having to defend two separate cases in two venues (arbitration and court) may change the calculus of whether an agreement to arbitrate really represents a cost and time savings for a healthcare facility that is a potential defendant in such cases.

TAKE ACTION Facility owners and managers should review their facilities’ admission contracts to determine whether arbitration of disputes is required. Then, consult with legal counsel and insurance professionals to determine whether it is best for the facility to continue with arbitration (knowing that you may face two claims in different forums in the event of a death claim) or remove the arbitration provision, thereby having all disputes submitted to the courts in a single action. Because this issue generally only arises in death claims (where the claims of the beneficiaries may differ than those of the estate), retaining an arbitration provision may be the better course. This decision, however, should be made with the assistance of legal and insurance professionals who can review a facility’s claim history to analyze whether the claims were mostly billing disputes or if there were also negligence/wrongful death cases. Addressing such issues will help facility owners and managers make informed decisions with regard to arbitration clause revisions. LTL Thomas W. Hazlett is Partner, Schnader Harrison Segal & Lewis LLP. He can be reached at [email protected] or (215) 751-2345. Peter Prinsen, Esq., CPCU, RPLU, ASLI, AIC is Vice President and General Counsel at The Graham Co. He can be reached at [email protected] or (215) 701-5284.


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Disclaimer: This article is not an attempt to provide legal, accounting or consulting advice. Such advice should be obtained from licensed and qualified professionals.



Tech Wholesale ...........................................................................39 Wound Care Education Institute ..................................................25 This index is provided as a reader service. The publisher does not assume any liability for errors or omissions.


the boardroom

One-on-one with… Leah Klusch L eah Klusch, RN, BSN, FACHCA, founder and executive director of the Alliance Training Center (www.tatci. com), an Ohio-based educational foundation and consultancy, recently spoke with LongTerm Living Senior Editor Lois A. Bowers about operational and care-related issues that are—or should be—on the minds of longterm care (LTC) clinical and operational leaders to delivery optimal care, maximize reimbursements and stay off auditors’ radar.

What issues are especially important right now? Newer guidance, data and philosophy. In January, for instance, for the first time in numerous years, the Centers for Medicare & Medicaid Services (CMS) updated and changed the Medicare Benefit Policy Manual related to skilled nursing facilities (SNFs). Administrators, CFOs, CEOs and compliance professionals need to take a look at what the current documents say, make sure they’re communicating that information to their teams and make sure they understand the changes so they don’t see returned payments and audit activity. I say to senior managers: “Look at the number of dollars you’re billing for Part A Medicare services, and look at how much you’re investing in making sure that all of the definitions and the compliance-related rules are being followed. That must correlate.”

Does any guidance especially seem to surprise people? CMS’ guidance related to therapy is now very specific. Five to seven years ago, what we considered skilled rehabilitation services or therapy had a broader definitional base. CMS also refined the definition of skilled nursing and added some additional documentation requirements and guidelines related to that. Clinicians need to be very tAUGUST 2014

careful that they’re documenting accurately and completely.

What new data are available for LTC leaders?

In Program for Evaluating Payment Patterns Electronic Reports, or PEPPERs, CMS takes segments of a facility’s billing records, analyzes them and compares with others in the state; with others in the payment jurisdiction, which is the Medicare audit contractor; and with the national averages. An operations person will see a very interesting picture of how a facility’s platform for Part A Medicare billing is similar or different demographically. But only half of the facilities in the United States have accessed their PEPPERs, according to CMS. That surprises me; the PEPPERs are very connected to the fraud prevention system and some of the audits, so I would think that facility managers and owners would be anxious to see their PEPPERs. The first set of PEPPERs was mailed to the facilities, but now they’re electronically transferred through the website. Initially, when you go on that website, you have to set up an account for the building, but it’s not difficult to do. And then those statistics are sent only to your building.

How have recent industry changes affected LTC operations? SNFs are part of the healthcare continuum and must open the lines of communication with acute care and home care providers so that all have a good understanding of the services rendered and have good transitions of care and documentation flow. Rehospitalizations are extremely expensive and can be very damaging to elders. The rehospitalization piece will be

the piece that CMS can specifically follow and penalize. CMS is being punitive right now with hospitals, and in another year or so, it’s going to be punitive with our industry, with payment being affected by a facility’s rehospitalization rate. It could be very damaging to a facility’s reputation and ability to operate in the community.

What can those in LTC do to prepare? It’s very important that we give clinicians the time and the tools to stay up to date so they don’t make mistakes. In addition to the other topics I mentioned, two new focuses on the regulatory side right now are on how we deliver care to residents with dementia and MDS accuracy. Surveyors in some states are reviewing the record during the visit and testing to see whether the MDS is a true representation of the condition of the resident during that specific time period. We’ve not had that scrutiny from the surveyors before. So clinicians, social workers and activities and dietary professionals need to look at the various ways they document to make sure that when an assessment document goes in, it’s an accurate representation of the resident’s status and care.

And what about philosophy? Person-centered care, individualized programs and communication are really important right now. We’re constantly looking to improve the personalization and individualization of care so that care delivery is appropriate and singularly effective for each person. As clinicians and operational professionals, we must strive to treat the individual, and no matter what his or her circumstances are, appreciate how the elder is perceiving care delivery and also think about the type of services necessary to deal with special needs. LTL WWW.LTLMAGAZINE.COM

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