April 2016

Vol. 43 No. 4

April

Cover Story

https://www.providermagazine.com/Issues/2016/April/Pages/Here-Come-The-Boomers.aspx

Here Come The Boomers

<div>As Norman Mailer tried to claw his way out of the crucible that was the 1968 Democratic Convention in Chicago, he bumped into the daughter of Eugene McCarthy, who was decidedly not thrilled to see Mailer scuttling away. </div> <div> </div> <div>Smiling into “the proud disapproval of her eyes,” Mailer considered a reply: “‘Dear Miss,’ he could have told her, ‘we will be fighting for 40 years.’”</div> <div> </div> <div>Mailer could be brilliant, and ludicrous, and sinister, and confounding, and clear-eyed—often all in the same paragraph. But, if anything, his insights here were eerily prescient, and yet strangely understated.</div> <div> </div> <div>As baby boomers like to remind people, they lived through America’s war in Vietnam, and the protests over it. They lived through the grand and noble marches and demonstrations for civil rights, and the horrid and horrifying race riots in America’s then-rotting cities. They lived through bras being burned on campus and Kitty Genovese being butchered while her neighbors (supposedly) clicked through their television dials.</div> <h2 class="ms-rteElement-H2">Grand, And Absurd</h2> <div>Most boomers, it is true, were mere spectators in the pageant of their own lives, but inasmuch as this country has divided itself, time and again, over what boomers came to call “identity politics,” it has been the result of an intra-generational argument spilling over into the country’s body politic. <br><br></div> <div>This is the generation, remember, whose members claim to get misty over Dr. King (but still voted for Richard Nixon). It’s a generation whose members still flash knowing grins whenever “Puff the Magic Dragon” plays (but gave 10 weeks of the Billboard Hot 100 chart to Debbie Boone). </div> <div><br>These controversies—some grand, some absurd—haven’t been resolved so much as they’ve faded into memory as new generations have risen. (Gay marriage and pot, for instance, have only become legal since the millenials—the kids and even grandkids of boomers—attained the franchise.) And there are those who argue that aging will actually be another front in boomers’ long culture wars (<a target="_blank" href="/archives/2016_Archives/Pages/0416/Reconciling-To-The-Aging-Process.aspx">see sidebar</a>). </div> <div><br>So, as the flower children fade with their own, long sunsets, the question is, will they take their culture wars into America’s long term care centers with them? <br></div> <h2 class="ms-rteElement-H2">Teach The Elders Well </h2> <div>“It’s a big challenge,” says Jodi Lyons, chief executive officer of Senior Sherpa, a group that helps elders adjust to their care (and their caregivers adjust to the elders). “The baby boomers are consumers. The prior generation used to accept the medical profession as being able to issue edicts. They said, ‘Thou shalt…’ and everyone did it. The boomers have gotten good at getting what they want, and not what people tell them to take.”<br><br></div> <div>Take, for instance, the matter of gay rights. A June 2015 poll by the Pew Research Center found that millennials and genXers overwhelmingly were okay with gay marriage, the silent generation (those born from the mid 1920s to early 1940s) were overwhelming opposed to gay marriage, and boomers were split almost exactly down the middle.</div> <div>Already, some gay rights activists are voicing concern that their elder brothers and sisters and being forced “back into the closet.”</div> <h2 class="ms-rteElement-H2">House Divided? </h2> <div>And, at least in the Medicaid context, administrators will in real time be admitting residents who may well have thrown rocks at each other during bus riots in their hot youth. <br><br></div> <div>So will boomers make care centers a house divided?<br><br></div> <div><img src="/Issues/2016/April/PublishingImages/LoveDave.jpg" alt="Love Dave" class="ms-rtePosition-2" style="margin:5px 15px;" />“It’s going to be interesting,” says Love Dave, administrator at Elmhurst Extended Care in Chicago’s western suburbs. “The next generation of adult children is going to be myself, and people like me. It’s going to be interesting to see how we’re going to handle it.”<br><br></div> <div>This isn’t just some boomer think-in, either. A whole bevy of recent studies has found that the most common abusers of elders in care centers is… other elders. Aggression is, of course, one of the many terrible offshoots of dementia. But just think of what might happen if a lifetime of angry protests, or heavy drug use (say), is added to advanced dementia.<br><br></div> <div>Boomers were the generation, remember, that famously made the personal, political. Or, as Mailer put it, “the last property of political property is ego.”<br><br></div> <div>Providers and provider advocates are already mapping out boomers’ egos and finding their fault lines—civil rights, sexual freedom, feminism, consumerism; they’re trying, as best they can, to make care centers earthquake-proof. </div> <h2 class="ms-rteElement-H2">Civil Rights</h2> <div>For many experts, the collisions aren’t just going to be intra-generational. <br><br></div> <div>“There is bound to be significant frustration when the boomers age and are cared for by a generation of workers who are unlike them,” says Clifton Porter II, senior vice president for government affairs at the American Health Care Association/National Center for Assisted Living, who worked his way up the ranks in the Deep South (and has the stories to prove it).<br><br></div> <div><img src="/Issues/2016/April/PublishingImages/ClifPorter.jpg" alt="Clif Porter" class="ms-rtePosition-1" style="margin:5px 15px;" />“Many boomers have had different lifetime events post WWII that younger staff, many new to the U.S. or from different racial backgrounds, did not experience in the same way.”<br><br></div> <div>Porter has thick skin and a broad back, so it’s hard to hurt his feelings with mere insults. Still, he spends a lot of time thinking about the paradoxes that boomers will bring to long term care. First, “person-centered care,” if it means anything at all, will have to mean that residents have a right to their own thoughts, feelings, and ideas—even ones that are offensive to others. But Porter says he can understand how a frontline worker—toiling, often thanklessly, for long hours—would not quite be in the mood for some (shall we say?) old-fashioned values.<br><br></div> <div>“Staff in long term care have high turnover rates already. We’ve got significant work to do so that everyone respects the multi-generational, multi-ethnic backgrounds of employees and the patients in their care,” he says.</div> <h2 class="ms-rteElement-H2">‘Women’s Lib’</h2> <div>It’s not just racial baggage that boomers may carry with them. People can tell a lot about different boomers by whether they refer to “feminism” (and specialists will even refer to “second-” or “third-wave feminism”) or “women’s lib.”<br><br></div> <div>The point is, though, the boomers were the first generation to test whether a woman can really have it all. As the adult caregivers of their parents, boomers have already demonstrated that they may or may not have it all, but it won’t take much to convince them they’ve had enough, says Senior Sherpa’s Lyons.<br><br></div> <div>“In most cases, the women are the caregivers—on top of everything else,” she says. “It’s a career, it’s the kids, and it’s the parents.”<br><br></div> <div>Boomers were raised, or learned, to be vocal about their needs, Lyons says.<br><br></div> <div>“And I’m not sure the profession is prepared to deal with all these competing interests of family caregivers,” she says. </div> <h2 class="ms-rteElement-H2">Sex…</h2> <div>Boomers were the first generation, as the late, great Christopher Hitchens pointed out, who were able to separate sex from reproduction. But they’ve learned that free love ain’t free. <br><br></div> <div>According to SAGE, a nonprofit group that advocates on behalf of gay and lesbian elders, exactly half of new HIV/AIDS infections were among those 50 years and older. By the end of this decade, 70 percent of new infections will be 50 years or older. (Hoping to stem the tide, SAGE has embarked on an ambitious publicity campaign, reminding folks that “Age is Not a Condom.”)<br><br></div> <div>As ever, dementia makes things worse (as it is bound to do). Already, providers find themselves caught in the horns of dilemma as their residents express themselves sexually. Does anyone think these questions will get easier as boomers age into care centers?<br><br></div> <div>As it stands, many providers better hope so. A survey by the American Medical Directors Association last year found that only a quarter of care centers had anything like advanced training for staff on how to handle the tough questions of sexual intimacy among those with dementia. Nearly one-third offered no training at all. </div> <h2 class="ms-rteElement-H2">Drugs…</h2> <div>Medical marijuana is now legal in 23 states and the District of Columbia. (Every-day-use marijuana is legal, tout court, in Alaska, Washington, Oregon, Colorado, and the District of Columbia.) And there is growing evidence that once-notorious drugs, such as psilocybin (found in mushrooms), Ecstasy, and even LSD have healing powers. <br><br></div> <div>Yet federal laws are clear that 1.) These drugs are still very illegal; and 2.) Worse, from a provider’s perspective, no federal funds shall cover the use of illegal drugs. (That’s why, for instance, Colorado dispensaries have had to hire armed guards for their cash: No bank wants to run afoul of federal anti-drug laws.)<br><br></div> <div>The Obama administration has been, at best, ambivalent about the changing attitudes toward formerly anathematized drugs. But what if the next president has a clearer sense of purpose?</div> <h2 class="ms-rteElement-H2">… Rock ‘N’ Roll</h2> <div>Whether or not boomers have made great music, they’ve certainly made their feelings known. No one expects that to age well, either. <br><br></div> <div><img src="/Issues/2016/April/PublishingImages/RobinHillier.jpg" alt="Robin Hillier" class="ms-rtePosition-2" style="margin:5px 10px;" />“The biggest change long term care providers will face as the baby boomers take over our centers will be the involvement that they will demand with their care, and the strong opinions they will bring,” says Robin Hillier, an Ohio provider and secretary treasurer of the American Health Care Association.<br><br></div> <div>“Baby boomers will bring a lack of respect for authority and will not hesitate to question the advice of their physician or the team. They will be more vocal about the goals they want for their care and will have strong opinions regarding the interventions used. They are used to googling symptoms and diseases and will approach care planning with more information than did previous generations.”</div> <h2 class="ms-rteElement-H2">‘I Can’t Withhold Care’ </h2> <div>Over at Elmhurst Extended Care, administrator Dave is already seeing some of the first signs of conflict. <br><br></div> <div>“I had a resident with mild to moderate dementia,” he recalls. “We had to bring in family members to try to have a sit-down and say, ‘If you don’t want care by that group of people, that’s your right. But when it comes to making derogatory remarks, that’s unacceptable.’ That was a case of moderate dementia. It’s a lot harder in advanced cases.”<br><br></div> <div>Dave says he thinks such moments are outliers. Baby boomers, after all, tend to be better educated than their parents’ generation. Still, one of the evils of dementia is how it takes over someone’s mind, he adds. A caregiver simply doesn’t know what might come out of a resident’s mouth. </div> <div> </div> <div>“I can’t withhold care because of the era someone lived in,” he says. “My job is to make sure that residents are well taken care of.”</div> <div> </div> <div>Mailer was no boomer, but he identified with at least one segment of their number. Now, as that restless generation packs for its trip into what used to be called “rest homes,” there is no doubt that they will change everything around them. The question is, will it be for the better? </div> <div> </div> <div>“We may yet win,” Mailer wrote. “Heaven help us when we do.” </div> <div> </div> <div>Bill Myers is Provider’s senior editor. Email him at <a href="mailto:wmyers@providermagazine.com" target="_blank">wmyers@providermagazine.com</a>. Follow him on Twitter, </div> <div>@ProviderMyers.</div>

As baby boomers like to remind people, they lived through America’s war in Vietnam, and the protests over it. They lived through the grand and noble marches and demonstrations for civil rights, and the horrid and horrifying race riots in America’s then-rotting cities. So, as the flower children fade with their own, long sunsets, the question is, will they take their culture wars into America’s long term care centers with them?

2016-04-01T04:00:00Z

Quality;Caregiving;Management

New Regs Put Emphasis On Care Planning	https://www.providermagazine.com/Issues/2016/April/Pages/New-Regs-Put-Emphasis-On-Care-Planning.aspx	New Regs Put Emphasis On Care Planning	<div>A new rule proposed by the Centers for Medicare & Medicaid Services (CMS) would revise the requirements that long term care facilities must meet to participate in the Medicare and Medicaid programs. CMS 3260-P Reform of Requirements for Long-Term Care Facilities was published in the Federal Register last July. </div> <div> </div> <div>CMS contends that these changes are long overdue and are an important focus in achieving improvements in the quality of care being provided through federal programs.</div> <div> </div> <div>Although this rule is in its proposed stage, one of the over-arching themes is a focus on a comprehensive person-centered care planning process. At the foundation of the regulation is the right of residents and their representatives to be informed, involved, and in control of decisions involving care. </div> <h2 class="ms-rteElement-H2">What‘s The Buzz? This Isn’t New, Or Is It?</h2> <div>Comprehensive care planning has always been a core requirement in skilled nursing facility (SNF) regulations. Step back in time to October 1995 when Congress passed the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87), otherwise known as the Federal Nursing Home Reform Law, “to ensure good clinical practice by creating a regulatory framework that recognize[s] the importance of comprehensive assessment as the foundation for planning and delivering care to the nursing home residents.” <br><br></div> <div>That law gave CMS’ predecessor, the Health Care Financing Administration (HCFA), the authority to issue regulations to improve SNF patient care.<br><br></div> <div>By placing emphasis on assessing, planning, and providing individualized care, HCFA (read CMS) fostered a holistic approach to resident care and strengthened team communication based on data collected in the Minimum Data Set (MDS) 1.0.</div> <h2 class="ms-rteElement-H2">Many Revisions Later</h2> <div>Moving forward, since OBRA ’87, there have been many revisions to the MDS, with the most current Resident Assessment Instrument Manual 3.0 version 1.13 coming out in October 2015. However, then and now, the plan of care continues to be the first step in designing a course of action that uses residents’ individual strengths to move them toward specific goals.<br><br></div> <div>Based on data collected on the MDS, the interdisciplinary team would build the care plan for review with the resident and a “responsible party.” The current time frame would allow a facility up to 21 days to develop the comprehensive care plan for a newly admitted resident in the SNF.<br><br></div> <div>However, while it is believed that SNFs are developing a resident-specific plan of care much sooner than required, a February 2013 OIG report found that for 37 percent of the resident’s stay, facilities did not meet requirements for care planning (https://oig.hhs.gov/oei/reports/oei-02-09-00201.asp). Therefore, CMS is proposing to have SNFs develop an interim plan of care within the first 48 hours of admission.</div> <h2 class="ms-rteElement-H2">So, What’s Changed, What’s Happening? </h2> <div>Currently, there are two source documents that outline requirements: §483.20(k) for care planning and §483.20(l) for discharge planning. CMS proposes to relocate these to §483.21 and combine all of the new requirements for care planning in one location.<br><br></div> <div>This proposed revision to the regulation addresses the timing of the plan of care and who is to be involved in its development. The changes are meant to have a positive impact on the care facilities provide and, as a result, ensure that residents live with dignity, respect, and improved self-esteem and self-determination, while protecting their choices. The revisions are meant to support the residents’ involvement and control.<br><br></div> <div>The regulations place increased emphasis on the resident’s right to participate in the care planning process. Additionally, the changes identify individuals, or roles, termed “other appropriate staff,” to be included in the process whenever their role would benefit the specific needs of the resident.<br><br></div> <div>Other members that have been identified as required participants of the interdisciplinary team (IDT) include nurse assistants responsible for the resident’s care, members of the food and nutrition department, and social workers who provide a vital link between providing individualized quality of care and quality of life specific to each resident.</div> <div>In addition, CMS recognizes the support that certified health information technology can provide to increase easy and efficient communication in the development of comprehensive care plans. </div> <h2 class="ms-rteElement-H2">What Is CMS After?</h2> <div>The intent of the CMS proposed changes is to ensure the resident’s involvement, while aiming toward an increase in resident satisfaction and safety. SNFs will be required to complete a baseline interim plan of care within 48 hours of admission.<br><br></div> <div>The interim plan would outline interventions that would increase resident safety and mitigate adverse events, especially those more likely to occur soon after admission, such as weight loss, dehydration, behavioral issues, and fall and elopement risk, to name a few. Also during those first 48 hours, the care planning team would need to assess the resident’s potential for future discharge and transitions in care in order to attain the highest level of quality of life.</div> <div>Bottom line? The proposed revisions are intended to ensure that residents receive adequate information in a manner that they can understand and use to become an active partner in the care planning process and to advocate for their own health care needs throughout their stay and beyond.<br><br>To read more on the proposed rule, see Section II, H: Comprehensive Person-Centered Care Planning (pages 26-30), <a href="http://www.gpo.gov/fdsys/pkg/FR-2015-07-16/pdf/2015-17207.pdf" target="_blank">www.gpo.gov/fdsys/pkg/FR-2015-07-16/pdf/2015-17207.pdf</a>.</div> <div> </div> <div><em><img width="93" height="128" class="ms-rtePosition-1" alt="Paola DiNatale, RN" src="/Issues/2016/April/PublishingImages/caregiving_Paola.jpg" style="margin:5px 15px;" /></em></div> <div><em>Paola DiNatale, RN, MSN, NHA, is a senior health care specialist at PointRight. She has been with the company since 2005 as an expert in quality improvement services and clinical program development, continuing care retirement community and single SNF facility operations analysis, due diligence, long term care survey and certification process, assisted living operations improvement, and Medicare and Medicaid reimbursement. Her master’s degree is in nursing as a clinical nurse specialist in gerontology.</em></div>	A new rule proposed by the Centers for Medicare & Medicaid Services (CMS) would revise the requirements that long term care facilities must meet to participate in the Medicare and Medicaid programs.	2016-04-01T04:00:00Z	<img alt="" src="/Issues/2016/April/PublishingImages/caregiving_t.jpg" style="BORDER:0px solid;" />	Caregiving	Column
Facility Purchasers Require A Lot Of Paperwork	https://www.providermagazine.com/Issues/2016/April/Pages/Facility-Purchasers-Require-A-Lot-Of-Paperwork-.aspx	Facility Purchasers Require A Lot Of Paperwork	<div>As activity from mergers and acquisitions (M&A) heats up, long term and post-acute care providers need to be aware of demands during the M&A process to ensure a smooth and successful transaction.</div> <div> </div> <div>It’s an incredible amount of detail work that needs to be completed in a very short period during the transaction courting period, whether it’s a divestiture or acquisition of another company. The documentation required by private equity firms spans tax, accounting, legal, compliance, regulatory, human resources, and environmental concerns, among others. </div> <div> </div> <div>Smaller operations being considered for M&A often struggle to provide that documentation, particularly in a timely manner. It’s common to find that a company doesn’t follow U.S. generally accepted accounting principles (GAAP), probably hasn’t done an audit, and figures aren’t easily accessible or even prepared in some cases. </div> <div> </div> <div>This organizing stage often delays the process because there simply aren’t enough hours in a day while staff focus on caring for residents.</div> <h2 class="ms-rteElement-H2">Analyze The Numbers</h2> <div>Private equity firms have recognized the immense growth opportunity as the health care profession consolidates. While firms are now more comfortable with the profession in general and the different forces involved—the government, for example, with Medicare and Medicaid—they’re still cautious when it comes to risk and require a clear picture of an organization’s financial health. <br><br></div> <div>In the accounting, tax, and financial world, companies often don’t do a deep dive to ascertain how and where they’re making money. It isn’t enough to know that the company is profitable by looking at numbers from month to month. It’s important to take data to the next level and understand what drives growth and cash flow and which segment, product, or service line is responsible for the profitable results. Companies often don’t realize their success is incumbent on one service line while other lines aren’t profitable.<br><br></div> <div>Finally, long term and post-acute care providers often underestimate the value of good governance, which consists of an annual audit and tax compliance. All of these items add up to additional enterprise value. </div> <h2 class="ms-rteElement-H2">Items To Prepare</h2> <div>It benefits companies being considered for M&A to be aware of, and prepared to provide, the unique documentation required during M&A. Companies should also be ready to discuss budget and a five-year projection prior to the due diligence process and meeting with a prospective buyer. <br><br></div> <div>The key financial metrics to prepare are:</div> <div><ul><li><strong>EBITDA.</strong> The metrics in a transaction focus on the economics of the business, in particular where the profit is coming from. Earnings before interest, taxes, depreciation, and amortization (EBITDA) serve as a proxy for cash flow from operation. A deep understanding of the recurring and sustainability of EBITDA and cash flows, which are often referred to as the quality of earnings, is required. </li></ul></div> <div><ul><li><strong>Profitability by segment. </strong>Separate profitability by each segment that the company operates in. This might include service line, procedure type, location, and customer or payer. In some cases, buyers will want to know the referral source—if it’s a hospital or doctor—and the volume of referrals. There’s a risk, for example, that a hospital may open its own service line and compromise the referral source. A good mix of referrals helps to spread the risk. </li></ul></div> <div><ul><li><strong>Accounts receivable. </strong>Prepare everything around accounts receivable, including days of sales outstanding and a zero balance analysis by payer class. Having the latter done periodically provides a closer look at collections over time, including potential shifts in payer mix. </li></ul></div> <div><ul><li><strong>Due diligence.</strong> It’s a trend to hire due diligence experts to perform a sell-side due diligence project on the company’s behalf if it is an owner-manager company contemplating a divestiture (selling). This process really prepares the company on the financial, accounting, and tax side by organizing what information is needed and what metrics will be analyzed. It arms the management team with answers to questions that might arise during the buy-side due diligence process, and ensures the organization is well prepared. In summary, it protects against erosion of enterprise value due to lack of preparedness.</li></ul></div> <h2 class="ms-rteElement-H2">Types Of Due Diligence</h2> <div>Prepare for a heavy level of scrutiny. The main types of due diligence a company should be prepared for cover all functional areas:</div> <div><ul><li><strong>Legal.</strong> Includes any outstanding lawsuits and legal agreements. </li></ul></div> <div><ul><li><strong>Financial.</strong> Includes bank statements, recent financial statements, and key operating metrics.</li></ul></div> <div><ul><li><strong>Tax.</strong> Includes audits and several years of tax return information.</li></ul></div> <div><ul><li><strong>Employees.</strong> Includes surveys, questionnaires, or walkthroughs to understand the responsibilities of employees on a daily basis.</li></ul></div> <div><ul><li><strong>Regulatory compliance.</strong> Includes electronic data transfer that is compliant with the Health Information Portability and Accountability Act, disease and case management ICD-10 coding, health care coding compliance (health care Minimum Data Set reporting and resource utilization group coding compliance for billing purposes), provider contract management, and recovery audit contractor audit compliance, among other measures. </li></ul></div> <div><ul><li><strong>Other areas.</strong> Includes environmental and real estate if the company owns it.</li></ul></div> <h2 class="ms-rteElement-H2">Switch To Generally Accepted Accounting Principles</h2> <div>Often for smaller companies, the books and accounts are kept on a cash basis for simplicity. It’s beneficial to go beyond having tax returns prepared and transition books and records to GAAP because an acquirer will want to see those financial statements. Buyers, particularly private equity firms, will typically measure enterprise value on a GAAP basis. Consider hiring a certified public acounting firm to get financial statements in line with GAAP. </div> <h2 class="ms-rteElement-H2">Realistic Approach</h2> <div>Sellers will need a village to get this process done in a timely manner—and that village consists of tax, accounting, and investment banking professionals.<br><br></div> <div>Consult with a tax and accounting advisor before the acquisition process begins to give personnel enough time to prepare and organize. Having a tax advisor on the owner’s side is of benefit not only to help put forward the best tax structure in preparation for the transaction but also to help put the owner in a beneficial position if the buyer wants a different structure. In that scenario, the seller could potentially get compensated for a higher tax burden resulting from the proposed change, for example. <br><br></div> <div>Finally, hire an experienced investment banker. Owners often don’t want to make this investment, but it’s rare to see a situation where investment bankers don’t pay for themselves when considering the value they provide. If the owner pays $1 million for an investment banker, for example, the banker might get $5 million more in enterprise value—and that’s a great return. <br><br></div> <div>The best course of action is to get one’s financial house in order and have the required legal documents readily available in anticipation of an acquisition. Going through a transaction process is a huge distraction from day-to-day business. The goal is a short timeline to minimize distractions from the key business of providing care. </div> <div> </div> <div><em><img alt="Luc Arsenault" class="ms-rtePosition-1" src="/archives/2016_Archives/PublishingImages/0416/LucArsenault.jpg" style="margin:5px 15px;width:93px;height:128px;" />Luc Arsenault, a partner and national practice leader of Transaction Services at Moss Adams, has practiced public accounting since 1992. He specializes in transaction due diligence ranging in deal size from several million to $20 billion. He can be reached at (415) 677-8287 or luc.arsenault@mossadams.com. </em></div> <em><div> </div></em><div><span><span><em><br><br><br><br><br><br></em></span></span><span><span><span><span><em></em></span></span></span></span><em><img alt="Amy Runge" class="ms-rtePosition-2" src="/archives/2016_Archives/PublishingImages/0416/AmyRunge.jpg" style="margin:5px 10px;width:93px;height:128px;" /><br><br>Amy Runge, a partner and national practice leader of the Long-Term Care Practice at <br>Moss Adams, has more than 23 years of accounting experience </em><span><span><span><em></em></span></span></span><em>and manages audits of continuing care retirement communities, </em><span><span><span><span><span><em></em></span></span></span></span></span><em>skilled nursing centers, assisted living communities, and other health care organizations. She can be reached at (415) 677-8264 or amy.runge@mossadams.com.</em><span><em></em></span></div>	Private equity firms have recognized the immense growth opportunity as the health care profession consolidates. While firms are now more comfortable with the profession in general and the different forces involved—the government, for example, with Medicare and Medicaid—they’re still cautious when it comes to risk and require a clear picture of an organization’s financial health.	2016-04-01T04:00:00Z	<img alt="" src="/Issues/2016/April/PublishingImages/finance_t.jpg" style="BORDER:0px solid;" />	Finance;Management	Column
Pressure Ulcers Are Easy Pickings For Lawsuits	https://www.providermagazine.com/Issues/2016/April/Pages/Pressure-Ulcers-Are-Easy-Pickings-For-Lawsuits.aspx	Pressure Ulcers Are Easy Pickings For Lawsuits	<div>Nursing care centers, rehab centers, and hospitals are easy targets for litigation where patients develop pressure ulcers while under the facility’s care. This is true despite the fact that such patients often have multiple comorbidities that put them at risk for impaired skin integrity.</div> <div> </div> <div>Although the defense may view the ulcer as “unavoidable” based on the patient’s pre-existing condition, a savvy plaintiff’s attorney may argue that the patient was at an increased risk for developing a wound and, despite the facility’s knowledge of this, was not adequately cared for at the facility.</div> <h2 class="ms-rteElement-H2">Lawsuits Trigger Big Numbers</h2> <div>Lawsuits against skilled nursing and rehabilitation facilities seek damages for compensatory loss such as pain and suffering, increased cost of medical treatment, and wage loss. They may also seek punitive damages, which generally are awarded only for willful conduct that is deemed outrageous or egregious.<br><br></div> <div>Some of the more significant verdicts in pressure ulcer cases include:</div> <div><ul><li><span class="ms-rteForeColor-1">2015: </span>In the Estate of Cote case, an Arizona jury awarded the estate of an 86-year-old woman $16.7 million in punitive damages, and $2.5 million in compensatory damages, against the defendant skilled nursing center. The estate alleged the facility consciously disregarded procedures designed to prevent pressure ulcers and intentionally falsified medical records to cover it up.</li></ul></div> <div>The case was brought for wrongful death and elder abuse, alleging development of a pressure ulcer that ultimately became infected with methicillin-resistant Staphylococcus aureus, overmedication with pain medications, malnutrition, and multiple falls. Notably, the estate argued the skilled nursing center was on notice of problems because inspectors in 2011 found that sufficient steps were not in place to prevent bed sores. Following trial, a settlement for an undisclosed amount was reached.<br><br></div> <div><ul><li><span class="ms-rteForeColor-1">2011:</span> A New York jury awarded $5.4 million to a 58- year-old man in his lawsuit against the defendant hospital. The man developed a Stage IV pressure ulcer on his hip four days after admission to the hospital. </li></ul></div> <div>The man, diagnosed with obesity, hypertension, and in need of kidney dialysis, sustained additional pressure ulcers, including on the bilateral buttocks, had related infections, and was permanently confined to a wheelchair.<br><br></div> <div>Allegations included inadequate treatment and improper pressure-relieving surfaces. The verdict breakdown was $2.9 million for pain and suffering, $162,000 for future lost earnings (plaintiff was a kitchen designer), and $55,000 for loss of services to his spouse.<br><br></div> <div><ul><li><span class="ms-rteForeColor-1">2015:</span> A Missouri jury entered a verdict against a medical center and in favor of a 58 year old, awarding $883,000 for development of a Stage IV pressure ulcer on the coccyx following surgery. Allegations included failure to turn and reposition, failure to prevent the wound, and inadequate treatment. There was no award for lost wages.</li></ul></div> <div><ul><li><span class="ms-rteForeColor-1">2015:</span> An Arizona jury awarded the estate of a 63 year old with paraplegia $6.5 million (including $3.5 million in punitive damages) against a hospital where the man developed a pressure ulcer in his sacrum that progressed into Stage III, suffered malnutrition, and lost 45 pounds. The estate argued the pressure ulcer, which eventually became infected, placed him in an irreversible state of deterioration, even though the cause of death was complications of paraplegia. Punitive damages were awarded under the Arizona Adult Protective Services Act. The case is currently under appeal.</li></ul></div> <div><ul><li><span class="ms-rteForeColor-1">2012:</span> A Philadelphia jury awarded $2.78 million (including $500,000 in punitive damages) in favor of the estate of an 89 year old and against the nursing care center. The nursing center allegedly failed to adequately monitor and treat a pressure sore on the 89-year-old decedent’s buttocks and lower back while he was a resident for less than eight months. Notably, the decedent was admitted to two different nursing centers, but the jury only awarded damages against the latter because there was no proximate cause.</li></ul></div> <div>The decedent had been admitted to the first nursing center after suffering a stroke that left him paralyzed, and he already had a Stage I or healing Stage II pressure ulcer before being transferred to the second nursing center. Allegations were that that the nursing center failed to adequately communicate with either the physicians or family members, failed to adequately monitor and turn the patient, and although staff members of the facility complained to superiors that it was chronically understaffed, the complaints went unanswered. <br></div> <div><ul><li><span class="ms-rteForeColor-1">2010:</span> A Philadelphia jury entered an award of $6 million against a nursing center and hospital in favor of the estate of a 73-year-old patient. The decedent was hospitalized for 15 days before being transferred to a nursing center, where he remained for two weeks. Allegations included failure to prevent a sacral ulcer and failure to appropriately treat the ulcer, which led to its progression. The award included $3.5 million in punitive damages against the nursing center and $1.5 million against the hospital.</li></ul></div> <div><ul><li><span class="ms-rteForeColor-1">2010:</span> A Camden, N.J., jury awarded the estate of a 62-year-old male $1.77 million where the plaintiff alleged the nurses at the defendant’s hospital failed to turn and reposition him during his three-day admission after his hip surgery, resulting in the development of decubitus ulcers. One of the ulcers was a Stage IV ulcer, which required skin grafting. The plaintiff alleged that he should have been turned every two hours, and he and his wife testified that they did not recall him being turned at all. </li></ul></div> <h2 class="ms-rteElement-H2">Recommendations For Facilities</h2> <div>Facilities should pay close attention to what may be called the “essentials” for a wound care program. The facility should employ a specific wound care policy detailing the responsibilities for each staff person involved in the process. Education of staff goes hand in hand with a good policy. Administration must educate staff about the contents of the policy and ensure that staff have a good grasp of what is required.<br><br></div> <div>The facility should regularly train and re-train staff on wound care, emphasizing the importance of complete and accurate documentation. Staff performance and patient outcomes should be monitored and evaluated on a scheduled and as-needed basis. Administration should pay careful attention to Centers for Medicare & Medicaid Services (CMS) survey results, quickly and effectively addressing any identified deficiencies and making changes to existing policies or protocols to prevent future issues. <br><br></div> <div>As noted above in the Estate of Cote case, survey results can serve as what is called “notice” in the law. This means that the facility is charged with knowledge of a problem.</div> <div><br>For example, if a facility is cited for inadequate wound care in a January 2015 CMS survey, a plaintiff who develops a wound at the facility in July 2015 may cite the survey as evidence that the facility knew there was a problem and failed to address it.</div> <div><br>Where a facility has knowledge of an issue and fails to address it, it may be faced with punitive damages. Therefore, facilities must pay careful attention to survey results and, in addition to correcting the issue in the short term, take action in the form of revised policies or protocols to address the issue in the long term.</div> <div> </div> <div>Missed Opportunities Complete and accurate documentation of wounds and wound care is essential. The failure to pay close attention to this area invites litigation. Electronic medical records provide an opportunity for facilities to document more thoroughly and accurately, but they may open up a facility to legal exposure where staff do not “check all the boxes.” </div> <div><br>Where there is an indication for a pressure relief mattress, check the box. Where there is a box for the potential for skin breakdown, check the box. Where there is a box for turning and repositioning every two hours, check the box.</div> <div>In other words, each time there is an opportunity to document the fact that preventative or treatment measures were followed, do so. The failure to do so for any of these items creates the impression that they were not done. This is prime fodder for a plaintiff’s attorney, who will use this lack of documentation to imply (and persuasively argue) the measures were not followed. </div> <div><br>Further, the failure of staff to know what they are supposed to document and when suggests that lower-level staff are not paying attention to skin care issues. </div> <div><br>As noted above, nurse assistants have the most contact and most chances to enforce the skin prevention and treatment measures. Assistants are charged with the responsibility to turn and reposition patients and to see patients on a daily basis.</div> <div><br>A facility must not only foster an environment for staff where they are cognizant and feel a sense of responsibility for providing skin care for their patients, but also an environment in which documentation corroborates the care being provided at the facility. </div> <h2 class="ms-rteElement-H2">It’s Not That The Care Isn’t Done</h2> <div>The hardest thing to advise clients is that, despite the fact that they have great employees and are providing excellent care, the documentation is just not there and, therefore, they have exposure. It is difficult, if not impossible, for nurse assistants to overcome the pressure during depositions when confronted with the fact that they did not specify that certain measures were in place.<br><br></div> <div>They will be faced with the question, “If it was there, why didn’t you mark it? Isn’t it because it was not in place?” This inevitably leads to an opportunity for the nurse assistant to throw the facility under the bus. Defensive testimony most often comes out during pressured questioning where an inadequacy is addressed on the part of the individual.<br><br></div> <div>The natural reaction for many is to deflect any responsibility onto the facility. The assistant may say in her deposition that she just simply does not have enough time to thoroughly complete the forms or that she is overburdened with too many patients. The center wants to, and needs to, avoid both of these situations.<br><br></div> <div>It is essential for staff to be educated as to the contents and selections available in the forms and to take the time to “check the box.” Undoubtedly, the wheelchair cushion is in place or the turning and repositioning schedule has been put into effect.<br><br></div> <div>However, the lack of documentation presents a difficult obstacle for clients that can be avoided with proper education of staff, follow-up seminars, continuous evaluations of staff competency and performance, and an environment emphasizing the importance of documentation.<br><br></div> <div>The old adage, “if it’s not documented, it didn’t happen,” rings true in the context of litigation. Check the box—and have no regrets. <br></div> <div> </div> <div><em>Jacqueline Genesio is an attorney with </em><em>Weber Gallagher in Philadelphia. She practices law in Pennsylvania, New Jersey, and Delaware. She can be reached at (215) 825-7214 or </em><a href="mailto:jgenesio@wglaw.com" target="_blank"><em>jgenesio</em><em>@wglaw.com</em></a><em>.</em></div>	Lawsuits against skilled nursing and rehabilitation facilities seek damages for compensatory loss such as pain and suffering, increased cost of medical treatment, and wage loss.	2016-04-01T04:00:00Z	<img alt="" src="/Issues/2016/April/PublishingImages/legal_t.jpg" style="BORDER:0px solid;" />	Legal	Legal Advisor
Digital Payroll Journal Deadline Drawing Near	https://www.providermagazine.com/Issues/2016/April/Pages/Digital-Payroll-Journal-Deadline-Drawing-Near.aspx	Digital Payroll Journal Deadline Drawing Near	A critical government deadline for electronic payroll records is approaching fast, and officials at the nation’s largest provider advocacy group are urging their members to get in front of things before it becomes a crisis. <br><br>During its March skilled nursing facility open door forum, the Centers for Medicare & Medicaid Services (CMS) updated providers on rules that will require them to submit their payroll records digitally by July 1, 2016. <br><br>The government opened its new system to “voluntary” submissions last October, and advocates at the American Health Care Association (AHCA) have been urging their members to register and test things out since the beginning of the year. Now, with the deadline just a few months away, a new sense of urgency has crept into AHCA’s voice. <br><br>“This is a complex and time-consuming system,” Lyn Bentley, AHCA’s vice president for quality and regulatory affairs, tells Provider. “It is essential that all nursing centers register now, during the voluntary submission period, so they will be in compliance with the mandatory requirement.” <br><br>Regulators at CMS see the new e-filing system as a way to drag the profession into the modern era. <br><br>“CMS has long identified staffing as one of the vital components of a nursing home’s ability to provide quality care,” the agency says on its website. “Over time, CMS has utilized staffing data for myriad purposes in an effort to more accurately and effectively gauge its impact on quality of care in nursing homes.”<br><br>For providers, there’s little margin of error here. Eighteen months ago, claims that they were “gaming” the government’s system specific to staffing led to sweeping Five-Star Quality Rating changes just a year ago. Among other things, advocates are worried that data compromised by filing mistakes would open the sector to further criticisms surrounding self-reported data.	The government opened its new system to “voluntary” submissions last October, and advocates at the American Health Care Association (AHCA) have been urging their members to register and test things out since the beginning of the year. Now, with the deadline just a few months away, a new sense of urgency has crept into AHCA’s voice.	2016-04-01T04:00:00Z	<img alt="" src="/Issues/2016/April/PublishingImages/news1_t.jpg" style="BORDER:0px solid;" />	Technology;Caregiving;Policy	Column
National Poll Finds Public Not Ready For Long Term Care	https://www.providermagazine.com/Issues/2016/April/Pages/National-Poll-Finds-Public-Not-Ready-For-Long-Term-Care.aspx	National Poll Finds Public Not Ready For Long Term Care	<p></p> <p>New research finds a majority of American voters are thinking about their retirement, but not about whether they will need long term care. The national survey, conducted by Morning Consult and commissioned by the National Center for Assisted Living (NCAL), signals a need to educate members of the public about this often-overlooked part of the health care system. <br></p> <p>More than three-quarters of Americans (76 percent) said they had thought a lot or some about their living situation in retirement, but only four in 10 (44 percent) thought they would need long term care. The federal government estimates that seven in 10 elderly Americans will need long term care at some point in their lives. <br></p> <p>Six in 10 respondents also said they did not currently have a power of attorney or an advance directive (also known as a living will) in place. One-third of Americans believe Medicare will cover most of their health care expenses in retirement, despite the fact that Medicare does not cover long term care services and supports. <br></p> <p>“We understand aging is not a topic many Americans want to think or talk about, but the reality is that many of us will need some aspect of long term care in the future,” says NCAL Executive Director Scott Tittle. “It’s important that Americans plan for their health care needs and communicate with loved ones about what they desire when that day comes.” <br></p> <p>When asked what they would prefer to do if they were no longer able to live on their own, respondents were mostly split between hiring an in-home caregiver (25 percent), moving in with a family member (28 percent), or moving into an assisted living community (28 percent).</p> <p>Three-quarters of Americans also have a favorable opinion of assisted living communities. When told about some of the services, specialties, and initiatives assisted living communities undertake, respondents’ favorability increased overwhelmingly.</p> <p>“Many would assume that all Americans want to stay in their home for the rest of their lives, but this research shows that some in fact want the option of residing in an assisted living community,” Tittle says. “They provide consumers a high-quality, low-cost long term care option.”</p> <p></p> <div style="text-align:center;"><img width="1674" height="996" src="/Issues/2016/April/PublishingImages/news_poll-01.jpg" alt="" style="margin:5px;width:569px;height:333px;" /><br></div> <div> </div> <p></p>	More than three-quarters of Americans (76 percent) said they had thought a lot or some about their living situation in retirement, but only four in 10 (44 percent) thought they would need long term care. The federal government estimates that seven in 10 elderly Americans will need long term care at some point in their lives.	2016-04-01T04:00:00Z	<img alt="" src="/Issues/2016/April/PublishingImages/news2_t.jpg" style="BORDER:0px solid;" />	Caregiving	Column
The Quality Forum	https://www.providermagazine.com/Issues/2016/April/Pages/The-Quality-Forum.aspx	The Quality Forum	<p><br></p> <p>What I know about revisions to the standard survey comes from the October 2015 Government Accounting Office (GAO) report, “Nursing Home Quality: CMS Should Continue to Improve Data and Oversight” (GAO-16-33).<br></p> <p>GAO highlighted the following issues:<br>■ Trends of increased complaints, decreased deficiencies, increased staffing hours, and improved Quality Measures (QMs), although “data issues complicate the ability to assess trends in nursing home quality over time.”</p> <p>■ A decline in average number of deficiencies between 2005 and 2014, which “may indicate an improvement in quality, may also be attributed to inconsistencies in measurement.” <br></p> <p>A research study using early data about the Quality Indicator Survey (QIS) that one of my colleagues and I published was consistent with these findings.<br></p> <p>The study showed that when the process was implemented, QIS states became more similar on the number of deficiencies over the first couple years, but with an average of about two more deficiencies, particularly in areas related to quality of life (Lin, M., and Kramer, A. “The Quality Indicator Survey: Background, Implementation, and Widespread Change;” <em>Journal of Aging & Social Policy,</em> 25:10–29, 2013).<br></p> <p>However, over time, survey results improved in the QIS states consistent with improving quality based on the more explicit QIS compliance measurements. <br></p> <p>So over this nine-year period of the GAO report, we would expect to see declining deficiencies in QIS states, but improvements in other measures of quality such as QMs and staffing since these constructs are measured in the QIS process. <br></p> <p>GAO acknowledged the challenge of consistent measurement with two survey processes: “One reason these measurement inconsistencies occur is the use of both traditional paper-based surveys and QIS electronic surveys…” where “As of late 2014, 23 states used QIS surveys, 25 states used traditional, and three states used both.”<br></p> <p>To address the different survey methodologies, CMS officials told the Office of Inspector General (OIG): “…they plan to develop a hybrid model of the QIS and traditional surveys, with the long-term goal of moving all states to this hybrid model.”<br></p> <p>CMS also responded to GAO that it is “developing a plan for improving efficiency and effectiveness of the survey process, using data collected and input from stakeholders.” As stakeholders I urge you to provide constructive feedback to CMS on the QIS, traditional, and any new hybrid model. <br></p> <p>From my perspective, my hope is that a new hybrid survey process will maintain the objective approach of the QIS methodology, with random sample selection and standardized investigation protocols. I know from my experience of working with thousands of providers that incorporating the QIS methodology as part of their Quality Assurance and Performance Improvement program has helped them to improve compliance, and to provide improved resident-centered care.<br></p> <p>CMS officials, with whom I worked on QIS, believed that a more replicable process should result in more explicit measures and standards that providers could use in their QAPI programs, and ultimately improve quality and compliance. <br></p>	To address the different survey methodologies, CMS officials told the Office of Inspector General (OIG): “…they plan to develop a hybrid model of the QIS and traditional surveys, with the long-term goal of moving all states to this hybrid model.”	2016-04-01T04:00:00Z	<img alt="" src="/Issues/2016/PublishingImages/AndyKramer_2015.jpg" style="BORDER:0px solid;" />	Caregiving;Management	Column
What is CMS planning for the standard survey process, with both the traditional and QIS processes currently in use?	https://www.providermagazine.com/Issues/2016/April/Pages/What-is-CMS-planning.aspx	What is CMS planning for the standard survey process, with both the traditional and QIS processes currently in use?	What I know about revisions to the standard survey comes from the October 2015 Government Accounting Office (GAO) report, “Nursing Home Quality: CMS Should Continue to Improve Data and Oversight” (GAO-16-33).<br>GAO highlighted the following issues:<br><br>■ Trends of increased complaints, decreased deficiencies, increased staffing hours, and improved Quality Measures (QMs), although “data issues complicate the ability to assess trends in nursing home quality over time.”<br>■ A decline in average number of deficiencies between 2005 and 2014, which “may indicate an improvement in quality, may also be attributed to inconsistencies in measurement.” <br><br>A research study using early data about the Quality Indicator Survey (QIS) that one of my colleagues and I published was consistent with these findings.<br><br>The study showed that when the process was implemented, QIS states became more similar on the number of deficiencies over the first couple years, but with an average of about two more deficiencies, particularly in areas related to quality of life (Lin, M., and Kramer, A. “The Quality Indicator Survey: Background, Implementation, and Widespread Change;” Journal of Aging & Social Policy, 25:10–29, 2013).<br><br>However, over time, survey results improved in the QIS states consistent with improving quality based on the more explicit QIS compliance measurements. <br><br>So over this nine-year period of the GAO report, we would expect to see declining deficiencies in QIS states, but improvements in other measures of quality such as QMs and staffing since these constructs are measured in the QIS process. <br><br>GAO acknowledged the challenge of consistent measurement with two survey processes: “One reason these measurement inconsistencies occur is the use of both traditional paper-based surveys and QIS electronic surveys…” where “As of late 2014, 23 states used QIS surveys, 25 states used traditional, and three states used both.”<br><br>To address the different survey methodologies, CMS officials told the Office of Inspector General (OIG): “…they plan to develop a hybrid model of the QIS and traditional surveys, with the long-term goal of moving all states to this hybrid model.”<br><br>CMS also responded to GAO that it is “developing a plan for improving efficiency and effectiveness of the survey process, using data collected and input from stakeholders.” As stakeholders I urge you to provide constructive feedback to CMS on the QIS, traditional, and any new hybrid model. <br><br>From my perspective, my hope is that a new hybrid survey process will maintain the objective approach of the QIS methodology, with random sample selection and standardized investigation protocols. I know from my experience of working with thousands of providers that incorporating the QIS methodology as part of their Quality Assurance and Performance Improvement program has helped them to improve compliance, and to provide improved resident-centered care.<br><br>CMS officials, with whom I worked on QIS, believed that a more replicable process should result in more explicit measures and standards that providers could use in their QAPI programs, and ultimately improve quality and compliance.	Over a nine-year period of the GAO report, we would expect to see declining deficiencies in QIS states, but improvements in other measures of quality such as QMs and staffing since these constructs are measured in the QIS process.	2016-04-01T04:00:00Z	<img alt="" src="/Issues/2016/PublishingImages/AndyKramer_2015.jpg" style="BORDER:0px solid;" />	Quality	Column

April 2016

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