Fighting the front from behind the lines

---

THE BUSINESS OF SENIOR CARE NOVEMBER/DECEMBER 2015

VOLUME 64, NUMBER 6

` RESIDENT SMOKING POLICIES ` VOLUNTEER PROGRAMS ` REVISITING MEMORY CARE VISITS VIS

Germ

warfare

Fighting the front from behind the lines

SCAN TO RENEW/ SUBSCRIBE

WWW.LTLMAGAZINE.COM A VENDOME PUBLICATION

How well does your EMR travel? For today’s higher-acuity LTPAC patients, a comprehensive EMR can mBLF the difference between a simple medication adjustment and
B
hospital readmission. 0VS
)FBMUI.&%9
7JTJPO¥ QMBUGPSN
QSPNPUFT
JOUFSEJTDJQMJOBSZ
DPPEJOBUJPO
BDSPTT
ZPVS
VOJRVF
DBSF
TFUUJOHT, allowing you to: • Improve clinical outcomes

• Strengthen relationships with referral networks and payers

• Maximize reimbursements

• 3FEVDF
QPUFOUJBMMZ
BWPJEBCMF
IPTQJUBMJ[BUJPOT

To learn how other organizations are TUSFBNMJOJOH
UIFJS
XPSLGMPX
QSPDFTTFT
and positioning themselves for a changing market, visit
www.HealthMEDX.com/ carecoordination.

XXXIFBMUINFEYDPN


]

$POOFDU
XJUI
VT
PO

TPDJBM
NFEJB
!)FBMUI.&%9

Flooring solutions that bring together beautiful design and established performance for senior living environments.

CONTENTS

/07&.#&3%&$&.#&3

ŭ
70-6.&

/6.#&3

ŭ
888-5-."(";*/&$0.

24 Cover Story

Departments

16 Germ Warfare

4

COMMUNITY

6

EDITORIAL

Battling infection is a never-ending fight in long-term care, requiring a team approach

BY PAMELA TABAR, EDITOR-IN-CHIEF

BY BETH THOMAS HERTZ

8

LEGAL LANDSCAPE BY ALAN C. HOROWITZ, RN, JD

Features 20 How to Attract Volunteers

32 Wide Beds

Whether paying back or paying it forward, volunteers are an invaluable asset to a longterm care community

Outfitting a facility with wider beds is a solution that can reduce falls and provide better sleep for residents

BY KRISTINA MORITZ

BY GUY FRAGALA, PHD, PE, CSP, CSPHP

12

BY LISA HOHLBEIN, RN, RAC-MT, CDP, CADDCT

14

Families that understand their loved ones’ dementia hold the key to quality visits BY DEBBIE SULLIVAN RESLOCK

BOARDROOM ONE-ON-ONE WITH… PETER SCHUNA

34 Powering Up for Power Outages An electrical interruption is more than an inconvenience in long-term care. It can be deadly

CARE MANAGEMENT BY DEBBIE SULLIVAN RESLOCK

40

24 Quality Memory Care Visits

MDS MONITOR

Advertising Section

BY STEVE WILDER, CHSP, STS

28 Reexamine Elopement Risk Assessment The answers to five questions can show if your wandering assessment is on target

36

RESIDENT CARE GUIDE

39

CLASSIFIEDS/ADVERTISER INDEX

BY CARL BLOOMFIELD, AAI; AND BETTE MCNEE, RN, NHA

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 bi-monthly 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. © 2015 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 Erin Beirne at 216-373-1217 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: http://www.submag.com/sub/nu 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.

#‘NOVEMBER/DECEMBER 2015

WWW.LTLMAGAZINE.COM

On your feet 24/7 Always on call Making sure no one is exposed to risk

Our job description’s a lot like yours. 0[[HRLZWHZZPVU[V^VYRPUHUPUK\Z[Y`YL]VS]PUNHYV\UKWLVWSL·[OH[HWWSPLZ [V\ZHZT\JOHZHU`VULLSZL0[»Z[OL]LY`[OPUN[OH[THRLZ\ZNVIL`VUK WHZZP]LPUZ\YHUJLJV]LYHNL·[VTHRPUNZ\YL`V\RLLW\W^P[OHJOHUNPUN LU]PYVUTLU[>OPSL^LJHU»[L_HJ[S`^HSRPU`V\YZOVLZ^LJHUILHU L_[LUZPVUVM`V\Y[LHT>L»SSMVJ\ZVU`V\YYPZRHUKÄUHUJPHSULLKZ· ZV`V\»YLMYLL[VMVJ\ZVU[OVZL^OVULLK`V\TVZ[

Actions Matter

NYHOHTJVJVT 

COMMUNITY

From our friends on Facebook “Ratings and rankings are helpful, but at times a mere snapshot. Take a tour... use your senses... look, listen. Talk to family and friends. And, consult a professional geriatric care manager.” – Comment on GAO’s review of the Nursing Home Compare system, ow.ly/TACIC

Welcome to our neighborhood! Join us in the digital world for daily updates and the chance to interact with your colleagues: Twitter @LongTermLiving; @Pamela_Tabar @SandiHoban; @Nicole_Stempak Facebook facebook.com/longtermliving LinkedIn group ow.ly/JZ2UI Sign up for our print or digital edition ow.ly/JZ2N6 Sign up for one or more of our weekly e-newsletters ow.ly/JZ2Bh

Hot on ltlmagazine.com High-dose flu shot reduces hospitalization for SNF residents: ow.ly/TAtCI Report: New regs are a bitter pill for LTC pharmacies: ow.ly/TAtPF

Calif. governor signs ‘right to die’ bill: ow.ly/TAu0K

“It amazes me that with most nursing programs, they do not require a geriatric rotation!! However, it’s a known fact our geriatric population continues to grow by leaps and bounds.” – Comments on Oklahoma’s new geriatric education program for SNF staffers, ow.ly/TAF70 “The key is not admitting clients who do not qualify for the facility. The Operations director must be brave enough to say no to marketing and corporate when they attempt to push the limit.” – Comment on a lawsuit alleging a facility failed to protect a resident from falls, ow.ly/TAD3V “This is kinda crappy. I am a big advocate for our folks, but the so-called minimum standards can be ‘violated’ repeatedly simply because someone was too busy to chart in real time when the doc was called, failed to put a date, or did not write ‘uses dentures’ on a care plan. The hundreds of standards have thousands and thousands of potential violations. Not all of those are abuse.” – Comment on an article discussing SNF citations and intake, ow.ly/TADsk

Pain management and dementia: ow.ly/TXWuw

Heard at AHCA/NCAL Have you heard?

INSTITUTE FOR THE Our editors are joining the ADVANCEMENT Institute for the Advancement OF SENIOR CARE of Senior Care (iASC) at its three Memory Care Forums in 2016. Join us and learn how administrative and clinical teams can work together to improve memory care delivery! Events will be held in Austin, Texas; Philadelphia and San Diego—Stay MEMORY tuned for dates. Check out the institute at www. CARE iAdvanceSeniorCare.com FORUM

Did you miss the AHCA/NCAL convention ? Here’s what attendees were tweeting about. @BlakefordVan: Very insightful session by Dr. @SusanGilster: “When your focus is serving others, everyone knows what to do!” @Providigm: Mary Ousley: “Hospitals hold the bundle. All roads lead to readmission and rehospitalization.”

Happy Holidays!

@Dayne_DuVall: Atrium Sr Living, Princeton Co-presenter @DeniseBScott has less than 1% #turnover rate! Now that’s #EmployeeEngagement

The editorial staff wishes you a happy and healthy holiday season!

@shawnachor: “The greatest competitive advantage in the modern workforce is a positive outlook.”

;‘8+5%30%2X/%1%30%2#N"O‘WWW.LTLMAGAZINE.COM

EDITORIAL

BY PAMELA TABAR, EDITOR-IN-CHIEF

Keep moving One of the greatest inspirations for living a healthy and happy seniorhood doesn’t come from a long-term care association, a state initiative or a federal aging agency. It comes from Dick Van Dyke, who turns 90 in December. His new book, Keep Moving: And Other Tips and Truths About Aging, is not about his legendary career on the stage and the silver screen. It’s his personal sharing about living as an older adult—including the importance of staying active, finding joy in creativity and purpose, embracing life’s curveballs and refusing to “act your age.” Rather than giving shallow advice such as “exercise and enjoy life,” Van Dyke dives deep into the crucial and often difficult tasks of senior connectedness, talking about the importance of making new friendships over the decades while maintaining current ones, forcing yourself to push beyond yesterday’s physical abilities and finding at least one thing to be happy about each day, even if it’s just a trip to a grocery store. “I don’t think about the way I am supposed to act at my age—or at any age,” he writes. “As far as I know, there is no manual for old age. There is no test you have to pass. There is no way you have to behave. There is no such thing as ‘age appropriate.’” In an interview this week with Canada’s CBC Radio’s “Q” host Shadrach Kabango, Van Dyke talked frankly about the realities of living into the 80s and beyond, including how attitude and ability can both help and counteract each other. Just because mobility may become an obstacle doesn’t mean seniors should stop trying, he notes. “Do whatever exercise you can, whenever you can,” he insists. Van Dyke’s connection between exercise and seniors’ physical/mental health is echoed by numerous scientific studies stressing the importance of exercise to the aging body and mind. He himself received a diagnosis of body-wide arthritis in his 40s—somber news for a professional dancer and actor—but he chose to use exercise as a way to prevent the condition from worsening. Fifty years later, “I still have arthritis and all the other conditions consummate with my age, but I just keep moving,” he said in the CBC Radio interview. “Keep the blood moving in your veins and your brain.” Over time, he told Kabango, “My motivations have changed. In my 30s, I exercised to look good. In my 50s, I exercised to stay fit. In my 70s, I did it to stay ambulatory. In my 80s, I did it to avoid assisted living. I think in my 90s, it’s just going to be complete defiance.” (Just a note to skilled nursing operators and caregivers: This is the new body of seniors you are inheriting soon, or may be among your census already. Are your activities programming and physical/occupational services keeping up with their own views of themselves and their aging process? How can you entice other residents to adopt similar attitudes?) What’s the hardest part about being his age? “Losing friends—So many of my contemporaries are gone,” VanDyke soberly told Kabango. “When you live into your 90s, you look back and see the roads not taken, and I don’t have anyone to talk to about it.” But, as he crosses into his 90s, he added, “I’m literally having a third life now, and I’m having more fun than I ever did.” And when it comes to the subject of death, Van Dyke keeps his famous humor in his message: “I know that at this time of life, you can cork off at any moment. But I really never think about it.” LTL

Vice President, LeadingAge Center for Aging Services Technologies (CAST)

Margaret P. Calkins, PhD, CAPS, EDAC President, I.D.E.A.S., Inc.

William V. Day President, St. Barnabas Health System

John F. Derr, RPh President, JD & Associates Enterprises

Tim Dressman Executive Director, St. Leonard Franciscan Community

P‘8+5%30%2X/%1%30%2#N"O‘WWW.LTLMAGAZINE.COM

Editor-in-Chief Pamela Tabar Managing Editor Sandra Hoban Associate Editor Nicole Stempak Associate Editor, Reader Engagement Megan Combs

DESIGN Creative Director Eric E. Collander

SALES National Sales Manager Shanel Butcher . #"Pd$Q$d"##Q‘ mP;Pd;"QdOQ#; e-mail [email protected] Directory Sales Erin Beirne [email protected] Ph: 216-373-1217 Traffic Manager Judi Zeng Please send IOs to adtraffi[email protected] All ad materials should be sent electronically to: https://vendome/sendmyadcom

ARTICLE REPRINTS      G m  m% 0  G [email protected] ‘Ph: 216-373-1217

CUSTOMER SERVICE www.ltlmagazine.com/page2/subscribe B  ]m dB ‘.CRRRdRQ$d$OPP

REUSE PERMISSION Copyright Clearance Center . SQRdQONdR;NN‘ mCSQRdP;PdRPNN d mC ]B ‘7 CBB

ONLINE www.ltlmagazine.com

ADMINISTRATION Chief Executive Officer Jane Butler President 3m 

Vice President, Finance Bill Newberry Vice President, Custom & Strategic Account Services Jennifer Turney Chief Marketing Officer Dan Melore

2015 EDITORIAL ADVISORY BOARD Majd Alwan, PhD

EDITORIAL

Charlotte Eliopoulos, RN, MPH, PhD Executive Director, American Association for Long Term Care Nursing

Leah Klusch, RN, BSN, FACHCA Executive Director, Alliance Training Center

Diane L. Krasner, PhD, RN, CWCN, CWS, MAPWCA, FAAN WOCN/Special Projects Nurse, Rest Haven

Robert N. Mayer, PhD President, Hulda B. and Maurice L. Rothschild Foundation

Judah L. Ronch, PhD Dean of and Professor at the Erickson School, University of Maryland

Director, Circulation Rachel Beneventi Director, Marketing Operations Kathryn Homenick

Choose Your Own: /ŶĨƌĂƐƚƌƵĐƚƵƌĞ

ĐĐĞƐƐ

ZĞƉŽƌƟŶŐ

EŽƟĮĐĂƟŽŶƐ

Make It Personal.

tŽƌŬŇŽǁ

ŶĂůLJƟĐƐ

/ŶƚĞŐƌĂƟŽŶ

A Complete EMR and AR/Billing System Tailored to and Controlled by YOU!

Break Free from Your Software! Same Trusted Vendor, Now with NEW Hosting Options! ŽŽ–Š‡„‡‡Ƥ–•‘ˆ–Š‡…Ž‘—†™‹–Š–Š‡ ‘’–‹‘‘ˆŠ‘•–‹‰Ž‘…ƒŽŽ›Ǥȋ‘•–͙͘‹›‘—”ˆƒ…‹Ž‹–›‘” ‘‹…”‘•‘ˆ–Ž‘—†™Ȁ†‹”‡…–ƒ†•‡…—”‡ƒ……‡••.)

ƒŽŽ1.800.464.9942‘†ƒ›ˆ‘”ƒ ‡‘•–”ƒ–‹‘Ǥ V‹•‹–www.american-data.com ˆ‘”‘”‡‹ˆ‘”ƒ–‹‘Ǥ

legal landscape

BY AL AN C. HOROWITZ, RN, JD

Resident smoking policies If residents light up, don’t get burned by your safety policies Too often residents in skilled nursing facilities (SNFs) have died or suffered serious burns as a result of a fire caused by cigarettes. The Centers for Medicare & Medicaid Services (CMS) clarified its position on smoking in nursing facilities in its 2011 Smoking Safety in Long Term Care Facilities memo (ow.ly/SD0Af), but cigarette smoking remains an issue at many facilities. Exploring the contours of the applicable regulations and strategies can help avoid negative outcomes.

Resident rights Approximately 15,400 SNFs participate in the Medicare and/or Medicaid program. As such, they are obligated to follow the federal regulations regarding SNFs. One of those regulations, 42 C.F.R. § 483.15(e), states that residents have the right to “receive services in the facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered.” However, a resident’s right to smoke cigarettes in a SNF is not unfettered, and facilities must ensure that residents who smoke are not at risk of harming themselves or others. Increasingly, SNFs have decided to become smoking-free environments. It is permissible for a SNF to not allow residents to smoke on its premises as long as that restriction was made clear prior to admission. If a SNF decides to prohibit resident smoking, it may not impose that restriction on residents who were admitted while the facility permitted smoking. For SNFs transitioning into smoking-free environments, prospective residents must be informed of the policy change during the preadmission process.

Case studies The two case studies below are very different, yet CMS determined that “immediate jeopardy” existed and imposed substantial civil money penalties in both. Both providers challenged CMS’ findings through the appeals process. In one case, the facility lost its appeals. In the other case, the Administrative Law Judge’s (ALJ) decision is pending. Case #1. In 2008, a 45-year-old resident was admitted to a SNF with prescriptions for several medications, including Ambien, Remeron, fentanyl, Percocet, amitriptyline and methadone. The side effects of these medications may impair thinking and/or cause drowsiness, fainting or dizziness. On the day of admission, the resident underwent a smoking safety screening. The screening results showed he was able to safely light a cigarette, hold a cigarette independently, use an ashtray appropriately, keep ashes from falling on himself and extinguish a cigarette. He was cognitively intact and had good decision-making R‘NOVEMBER/DECEMBER 2015

WWW.LTLMAGAZINE.COM

skills. The smoking screen indicated by a “no” response that the resident did not exhibit effects from medications including sedation, drowsiness or dizziness. If “yes” was answered to all of the questions on the smoking screen, the screener could determine whether the resident could smoke alone or with assistance. Alternatively, if any question was answered with a “no,” the screener was supposed to select a type of supervision while the resident smoked. Even though one answer was “no,” the screener indicated that the resident was “able to smoke independently.” There were no further assessments in spite of the medications’ potential side effects. A month later, a nurse’s progress note indicated the following: “When this nurse was leaving the facility to go home in evening it was noted by this writer that this Resident was sitting outside in front of the facility door sleeping with a lighted cigarette in his mouth. This writer took the cigarette out of his mouth & woke [resident] up. Counseled [resident] on smoking when he is sleepy & the danger that could happen with a lighted cigarette. [Resident] refused to go to bed.” No incident report was completed and no new assessments were done. Likewise, the facility did not address this incident in a care plan and didn’t implement any interventions to safeguard the resident. Approximately two weeks after the incident described above, a survey occurred. One of the surveyors noted the following: “[Resident 3] seen out front [with] a cigarette on lap. Hole burned in towel. Lighter on lap. Towel smoldering—smoke coming out of edges of hole glowing red.[Resident 3] asleep out front. Woke resident up. [Resident 3] poured water on it to extinguish.” Based on the survey findings, CMS imposed a civil money pen-

PUZZLED BY YOUR CABLE BILL?

SeniorTV Total Solution % Customized Property Line-ups % Community Message Channels % HD / DVR Solutions

seniortv.com

% Internet / Wi-Fi Solutions % Healthcare LED TVs % Commercial Grade TV Sales

800-890-7770

To access DIRECTV HD programming, HD Access fee and HD equipment are required. Number of HD channels varies by package. DIRECTV programming, pricing, terms and conditions subject to change at any time. Taxes not included. Receipt of DIRECTV programming subject to terms of DIRECTV Terms of Service for Institutions; copy provided with new customer information packet. ©2015 AT&T Intellectual Property. All rights reserved. AT&T, Globe logo and DIRECTV are registered trademarks of AT&T Intellectual Property and/or AT&T affiliated companies. All other marks are the property of their respective owners.

legal landscape

RESIDENT SMOKING POLICIES

alty and the facility appealed. At the hearing, the facility acknowledged that the resident was taking several medications that could have sedative effects. However, the SNF asserted that over time, the sedative effects are diminished and that the nurses used their judgment about whether the resident could smoke independently. The ALJ noted that there was no evidence that the facility assessed the resident to determine if the sedative effects of his medications were diminished. In affirming CMS’ determination of immediate jeopardy, the ALJ noted that the facility’s risk manager testified that “Resident 3 should not have been designated to smoke independently, because he had been found violating the smoking policy when he was found asleep with a lit cigarette in his mouth.” Further, no new assessments were done following the incident and no interventions were implemented. Case #2. At another SNF, a resident who was assessed as a safe smoker accidentally burned herself when attempting to light a cigarette. The resident had smoked independently for more than 40 years without any known problems and both her attending physician and facility staff documented that she could smoke independently. As a consequence of the burn, the facility immediately revised its

safe smoking policy. It now required that all resident smoking materials must be kept in a secure tackle box behind the nurse’s station. It trained its staff and resident smokers about the revised safe smoking policy. Residents could only smoke at a designated time and in a designated place—the front porch, which had a concrete floor, sprinklers and no hazardous materials. All smokers were required to wear fire-retardant smoker’s aprons while smoking. Signs were placed on all facility entry doors reminding people not to give residents cigarettes or smoking materials. During an unrelated survey seven months later, a surveyor asked a staff member why the facility had signs on doors admonishing visitors not to give cigarettes to residents. The staff member mentioned the prior incident. Proving that no good deed goes unpunished, the surveyors and CMS determined that immediate jeopardy had continuously existed for seven months and imposed a penalty of more than $700,000, even though no one had been harmed in the seven months since the initial incident. CMS alleged that having a fire extinguisher more than 75 feet from the front porch and using a cup of water as an ashtray (under staff supervision) to extinguish cigarette butts created immediate jeopardy. At the hearing, under cross-examination, the surveyors

Genius runs in the family.

Now available in eight models and six capacities (40 lbs. – 160 lbs.), Milnor’s rigid mount washer-extractors with the MilTouchTM control combine rugged construction with energy savings thanks to RinSave® water saver and ExactXtract® extraction optimizer*. This intuitive control features an informative touch screen display that allows you to select and/or modify pre-programmed formulas, based on your specific needs. The graphic run screen gives you unprecedented control and insight into your wash. The control’s USB port is there for you to move or back up formulas–saving you time. Milnor’s MilTouchTM control is flexible. It’s easy to navigate. Some even call it genius. Test drive the MilTouchTM control for yourself. Download the PC programmer at www.milnor.com/miltouchprogrammer. Contact an authorized Milnor distributor or call 504-712-7656 to find out more.

*

Available for 36021 V7Z, 36026 V7Z, 42026 V6Z, 42030 V6Z.

"N‘NOVEMBER/DECEMBER 2015

WWW.LTLMAGAZINE.COM

www.milnor.com/miltouch

/pellerinmilnor

could not explain how placing a cigarette butt in a cup of water by a safe smoker who was wearing a smoker’s apron and being supervised by staff could create a fire hazard. In this instance, the facility seems to have taken reasonable measures to ensure the safety of residents. The surveyors also conceded on cross-examination that many of the actions taken after the burning incident “exceeded the regulations.” This case is still pending.

smoke—as well as the nonsmokers and the facility. LTL 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. He can be reached at [email protected].

Recommendations for a safe smoking environment Using Case #2’s multiple and appropriate interventions as a model, the following recommendations should be considered: t
%FWFMPQ
BOE
JNQMFNFOU
BO
BQQSPQSJBUF
Safe Smoking Policy. t
1FSGPSN
BOE
EPDVNFOU
BQQSPQSJBUF
BTsessments for residents who want to smoke JODMVEF
JUFNT
TVDI
B
NBOVBM
EFYUFSJUZ
hand-eye coordination, safety awareness, DPHOJUJPO
FUD
UP
EFUFSNJOF
JG
B
SFTJEFOU
is capable of smoking independently or requires supervision. t
1FSJPEJDBMMZ
SFQFBU
UIF
BTTFTTNFOUT
FTpecially if there is a change in a resident’s condition or medications with sedative effects are initiated. t
)BWF
B
EFTJHOBUFE
TNPLJOH
BSFB t
1SPWJEF
BQQSPQSJBUF
BTIUSBZT t
/FWFS
QFSNJU
B
SFTJEFOU
UP
TNPLF
XIJMF
using oxygen. t
%P
OPU
BMMPX
TNPLJOH
JO
BOZ
BSFB
XIFSF
there are hazardous materials. t
)BWF
åSFSFUBSEBOU
TNPLFST
BQSPOT
BOE
B
fire blanket available in the smoking area. t
)BWF
B
åSF
FYUJOHVJTIFS
XJUIJO

GFFU
PG
the smoking area. t
*OTFSWJDF
BMM
TUBGG
BOE
SFTJEFOUT
PO
TBGF
smoking policies. t
&OTVSF
UIBU
SFTJEFOUT
XIP
DBOOPU
TBGFMZ
smoke independently are supervised while smoking. t
3FNPWF
TNPLJOH
NBUFSJBMT
BOE
MJHIUFST matches from residents who may be cognitively impaired or unsafe. t
$BSF
QMBO
BDDPSEJOHMZ
BOE
SFWJTF
BT
OFDFTsary. Skilled nursing facilities may or may not permit resident smoking. If they do, certain precautions such as those noted above must be undertaken to protect the residents who WWW.LTLMAGAZINE.COM

LONG-TERM LIVING‘""

MDS MONITOR

BY LISA HOHLBEIN, RN, R AC-MT, CDP, CADDCT

CMS releases v1.13 of the RAI User’s Manual The newly released RAI includes ICD-10 coding information and other clarifications On Sept. 24, 2015, the Centers for MediConfusion about when to complete an Admission care & Medicaid Services (CMS) released assessment around a new certification date has Centers for Med icare & the MDS 3.0 RAI User’s Manual v1.13, generated questions in the past. CMS clarifies in Medicaid Service s with changes effective Oct.1, 2015. This chapter 2, p. 2-4 of the manual that if facility staff release includes the full manual, replacecomplete an Admission assessment prior to the ment pages and change tables for both. certification date, there is no need to do another The change tables do not include correcAdmission assessment after certification. Facility tions to minor formatting, punctuation staff will simply continue with the next expected Long-Term Car e or typographical errors as in past releasOBRA and/or PPS assessment—even though there Facility Residen t es. As a general note, few of the changes may be a sequencing error on the validation report. Assessment in this update are substantive; most Lastly, CMS gives us the gentle reminder that Instrument 3.0 User’s Manual relate to clarity of phrasing, updated Medicare cannot be billed for any care provided URLs and punctuation. As expected, prior to the certification date. Therefore, facility staff Version 1.13 the biggest change in the manual conmust use the certification date as day one of the covcerns the new ICD-10 coding system ered Part A stay when establishing the ARD for the October 2015 for diagnosis, mostly affecting section I Medicare Part A SNF PPS assessments. of the MDS. However, CMS also made Significant Change in Status and hospice a number of other clarifications throughout the The subject of completing a Significant Change in Status Assessmanual where guidance may have been confusing in the past. ment (SCSA) MDS for residents enrolling in and/or discontinuing Newly certified nursing homes hospice has been touchy. It may be slightly more complicated, as CMS has clarified a few points concerning completion of the CMS has made a small, but powerful, change in the language. MDS when a facility is becoming newly certified. Chapter 2, page Chapter 2, page 2-21 now reads, “A SCSA is required to be per2-4 of the RAI User’s Manual reminds us that the completion and formed when a terminally ill resident enrolls in a hospice prosubmission of OBRA and/or PPS assessments is a requirement gram (Medicare-certified or State-licensed hospice provider) or for all Medicare and/or Medicaid long-term care nursing homes. changes hospice providers and remains a resident at the nursing When a nursing facility is in the process of certification, OBRA home.” If a resident elects hospice, a SCSA must be completed and/or PPS assessments are still required to demonstrate comwithin 14 days of the hospice election date. However, if that same pliance with certification requirements. Since these assessments resident decides to change hospice providers, a new SCSA is rehave assessment reference dates (ARDs) prior to the certification quired. This is to ensure that the plan of care is coordinated bedate, CMS does not have the authority to receive them into QIES tween the hospice and nursing facility. ASAP, and so they should not be submitted to the QIES ASAP Change of Therapy OMRA system. The rules on when to complete a Change of Therapy (COT) The American Association of Nurse Assessment Coordination (AANAC) OMRA are plentiful and can send even the most astute brain into is a non-profit membership association that supports long-term care a spin. CMS clarified some of the language in chapter 2, page professionals nationwide in their efforts to provide quality care for nursing 2-52. First, in cases where the last day of the Medicare Part A home residents. AANAC keeps its memebers current on ever-changing benefit (the date used to code A2400C on the MDS) is prior to federal regulations, quality management and accurate reimbursement day seven of the COT observation period, then no COT OMRA is through a comprehensive website, online community, education and gold-standard certification programs. required. In other words, the decision is made that the resident We invite you to join our 14,500+ satisfied no longer meets the criteria for skilled services and the last covmembers by visiting us at aanac.org or ered day (A2400C) is prior to day seven. calling us at (800) 768-1880. Second, if the date listed in A2400C is on or after day seven "#‘NOVEMBER/DECEMBER 2015

WWW.LTLMAGAZINE.COM

The Real Cost of Falls of the COT observation period, then a COT OMRA is required if all other conditions are met. This might occur when a resident’s last day of Medicare is on day seven of the COT evaluation period and the resident continues care as a long-term resident. Third, CMS has given direction for cases where the date used to code A2400C is equal to the date used to code A2000—that is, where the discharge from Medicare Part A is the same day as the discharge from the nursing facility—and this date is on or prior to day seven of the

While the changes to the RAI this year were not colossal, nursing facility leaders must continue to adhere to the rules ensuring accuracy. COT observation period: in these cases, no COT OMRA is required. However, the COT OMRA may be combined with the Discharge assessment, if that is preferred.

Changes in Chapter 3 In section M, page M-5, the item M0210 Unhealed Pressure Ulcer(s) has been revised to further simplify coding decisions. It reads, “If a resident had a pressure ulcer that healed during the look-back period of the current assessment but there was no documented pressure ulcer on the prior assessment.” Since the language changed here, CMS deleted two coding tips in M0300A, for clarity. They were:

t
*G
B
SFTJEFOU
IBE
B
QSFTTVSF
VMDFS
PO
UIF
last assessment and it is now healed, complete Healed Pressure Ulcers item (M0900). t
*G
B
QSFTTVSF
VMDFS
IFBMFE
EVSJOH
UIF
look-back period, and was not present on prior assessment, code 0. These two coding tips no longer apply. In a change to section A, page A-32 (A2400), CMS has replaced the words “Generic Notice” with “Notice of Medicare Non-Coverage (NOMNC),” referring to the first step in the Expedited Review Process. In section I, CMS added guidance on page I-4 that says, “When a resident receives aftercare following a hospitalization, a V code is currently assigned in section I. Beginning October 1, 2015, aftercare codes will begin with a Z.” Keep in mind that when Z codes are used, another diagnosis for the related primary medical condition should be checked in items I0100–I7900 or entered in I8000. While the changes to the RAI this year were not colossal, nursing facility leaders must continue to adhere to the rules ensuring accuracy. As with every change, communicating and teaching the new information to appropriate staff members remains a top priority; it is everyone’s responsibility to ensure that the MDS accurately reflects all residents and the care provided to them. Healthy interdisciplinary teams with qualified and informed professionals are a must for quality resident care. LTL Lisa Hohlbein, RN, RAC-MT, CDP, CADDCT, is a Curriculum Development Specialist for the American Association of Nurse Assessment Coordination.

The CDC reports that documented falls in LTC are 100-200 per year per 100 beds and average costs per fall may exceed $17,000. Many falls go unreported. Add the demands of family members for an explanation plus staff injuries caused by inappropriate lifting and it is easy to understand why this topic often dominates Senior Staff conversations. The Fall Management policies of your facility will dictate when an intervention for patient safety is mandated. Clinically studied by a leading University Medical Center*, Carefoam chairs have been in use for over 12 years and will return your investment by preventing just one fall. All Carefoam chairs feature memory foam seating, are incontinence-proof and bacteriostatic, yet seem less like “geri chairs” and more like living room furniture.

To schedule an in-house presentation or arrange a trial evaluation, visit us at:

www.carefoam.com *Inventor B. et, al, Rush University Medical Center, Chicago IL. “Fall Preventive Initiatives in Dementia Care” DCC 2008: PS 24

WWW.LTLMAGAZINE.COM

LONG-TERM LIVING‘"$

care management

BY DEBBIE SULLIVAN RESLOCK

Managing anticoagulants What happens when a drug is helpful and dangerous? Medication management is back in the spotlight, this time for the protocols for anticoagulant treatments. According to the National Action Plan for Adverse Drug Event Prevention, anticoagulants are one of the three most commonly implicated drug classes in adverse drug events (ADEs). But whether it’s the recent ProPublica report highlighting the mismanagement of residents on warfarin or July’s memorandum from the Centers for Medicare & Medicaid Services (CMS) urging a heightened focus on medication monitoring, one thing is clear: Anticoagulant-related ADEs need to be reduced. “Warfarin does have a high potential for medication error,” says Joan Baird, PharmD, CGP, FASCP and Director of Education and Clinical Affairs with the American Society of Consultant Pharmacists. The drug interacts with many other medications and requires frequent lab work to monitor dosage and effectiveness, Baird says.

Understanding the risks

acuity skilled nursing facility in Briarwood, N.Y., began its own trial to reduce the time it takes to receive blood test results for INR (International Normalized Ratio for blood clotting time) levels and the time frame for adjusting a resident’s medication dose. Under the initiative, caregivers changed the way they collected blood samples, switching from a venous draw method to a pointof-care capillary finger stick. The new method allows for in-house analysis of blood samples instead of sending them to an outside blood lab. Speeding up the turnaround time means that the physician often is still in the building when the lab results return, allowing caregivers to get the physician’s response right away on any dosage changes, explains Peaches Smith-Grinion, RN, nurse educator at Silvercrest. When more of the team is available to look at the results and examine the resident, a better understanding of the overall condition is achieved, Smith-Grinion adds. “Since we’ve implemented the protocol, it’s only been positive feedback from both nurses and doctors alike.”

In a 2011 New England Journal of Medicine article, warfarin was implicated in about one-third of the ADE emergency hospitalizations among older adults. But does the age of the user increase the risk? “[An older adult] can have a slower metabolism, as well as less body fluid and muscle mass, and that can affect how the medications are metabolized,” Baird explains. “In general, it means that medications stay in the system longer than they would with a younger, more robust patient. But it’s important to remember that warfarin is a highly effective medication and responds well to the risk of stroke, AFib [atrial fibrillation] and other conditions. It may need more oversight because of the risks, but it can be a life saver.” The good news is the majority of ADEs are viewed as preventable with better medication management. Medication regimen reviews, which are federally mandated for skilled nursing facilities at least once every 30 days, can help. A consultant pharmacist can serve as a second set of eyes when looking at the whole health record of a resident. A consultant pharmacist’s assessment may include reviews of anticoagulant levels, lab work, physician orders and medication administration schedules. Such reviews also routinely check for drug redundancies, potential drug interactions and dosing concerns. “It’s also important to observe residents physically for their overall condition, including evidence of bruising or bleeding and assessing any possible interactions with other medications,” Baird says.

For a drug that’s characterized as both dangerous and lifesaving, the search for better warfarin management strategies will no doubt continue. Reviewing the CMS ADE trigger tool (ow.ly/TB0lE) can help facilities evaluate processes on obtaining and communicating lab results, educating caregivers and residents on risk factors and symptoms of bleeding, alerting staff when anticoagulants are being combined with other drugs that increase ADE risk and monitoring the resident’s dietary plan for foods that can adversely interact with anticoagulants. Newer medications are available now, but it’s unclear whether they’ll solve warfarin’s monitoring challenges. “There are new anticoagulant drugs which may be less likely to cause bleeding, but their data is still unfolding,” Baird says. “Per labeling, INR is not required, but there’s also no antidote at this time if there’s a problem with bleeding.” Baird cautions that news reports of safety issues with some nursing home residents taking anticoagulants aren’t representative of all facilities. Most facilities work hard and do a great job of monitoring medications and training their staff, she says. “But what’s always needed is strong, collaborative care with the entire team, including nurses, physicians and pharmacists.” LTL

Faster testing, faster care

Debbie Sullivan Reslock is a freelance writer in Evergreen, Colo.

Delays or errors in communicating test results can be a barrier to anticoagulant management. After researching the industry’s best practices, Silvercrest Center for Nursing and Rehabilitation, a high";‘NOVEMBER/DECEMBER 2015

WWW.LTLMAGAZINE.COM

Education matters

  * + %,#

               

! " # $ %% & ' $ #% ( "# $ )% "# 

      ! 

  "# $# %& % & #  ' 

 !(&$&  & 

% "   %  )& !               ! "   #          $ %! & '! ( ) *+, *  - .

 

 

  

 

COVER STORY

WWW.LTLMAGAZINE.COM ‘LONG-TERM LIVING‘"Q

COVER STORY Why now?

Create a monitoring program

Coordinate usage

Phenelle Segal, RN, CIC, president of Infection Control Consulting Services, a consulting firm offering expert infection prevention services to healthcare facilities including nursing homes, says she believes the Affordable Care Act is part of the reason this issue is coming to the forefront right now. “Across the continuum of care, beginning with acute care facilities, moving into ambulatory surgery and then targeting nursing homes, the Affordable Care Act has been instrumental in driving change in practice for the benefit of patient safety. A large component of the Affordable Care Act that attempts to improve patient safety has been in infection prevention,” she says. In March, the Obama administration released a national action plan to combat antibiotic-resistant bacteria, and the new CDC recommendations are a result of that plan. “The elderly are definitely at increased risk because they frequently get aspiration pneumonia and urinary tract infections which require antibiotic therapy. Frequent antibiotic therapy predisposes them to infections such as C.diff,” explains Segal.

Every nursing home, regardless of its size, needs to develop an antibiotic monitoring program that monitors the use and the misuse of antibiotics among residents, according to Segal. She suggests they start small when building these programs. “This is a huge undertaking and it needs to be tailored to the individual facility, taking into consideration the size, available resources and antibiotic usage. All facilities need to implement one or two steps at the beginning and then gradually add new strategies over time,” she explains.

The next step is for facilities to coordinate using certain antibiotics for certain infections, Segal said. They can develop “bundles” that make sure the medications are used in a consistent manner. “The team needs to look at the dose, the duration and why they are using an antibiotic, so that they are not used in a way that encourages drug resistance to develop,” says Segal. “Urinary tract infections (UTIs) are a good example of a condition in which these steps can be effective, because they are a frequent cause of antibiotic misuse,” she says. “The key to treating or not treating a UTI lies in how the culture is done and how the test results are interpreted. Collection of urine for culture by the nursing staff and the microbiology lab plays a critical role,” she says. “A lot of residents develop asymptomatic bacteriuria—there are no symptoms consistent with bacteria in the urine.” Essentially, residents who are not exhibiting symptoms of a UTI should not even be cultured, however, if they are, treatment with antibiotics needs to be thought out carefully as asymptomatic bacteriuria results in a lot of unnecessary antibiotic use. A second problem related to the urinary tract occurs when a physician orders antibiotics prophylactically in residents who have urinary catheters in place. Although 85 percent of residents eventually become colonized, that does not mean they require treatment. “That is one of the biggest violations in antibiotic use,” she notes.

Antibiotic stewardship resources Each year, at least 2 million people in the U.S. are infected with drug-resistant bacteria. The CDC released new guidelines in September to help skilled nursing facilities take on proactive roles in curbing antibiotic resistance. “The Core Elements of Antibiotic Stewardship for Nursing Homes” provides a step-by-step process for senior care settings to create a program for tracking antibiotic uses and outcomes within the facility and for establishing a crossdepartmental stewardship team to promote effective protocols for using antibiotics and curbing drug-resistant microbes. Read the CDC guidelines at ow.ly/TlDuH The CDC’s Get Smart About Antibiotics program also collects educational resources for nursing home leaders to use for awareness training for staff and as educational materials for residents and families.

"R‘8+5%30%2X/%1%30%2#N"O‘WWW.LTLMAGAZINE.COM

Identify a core team One of the first steps nursing homes should take is identifying a core team of people who will be responsible for developing and implementing the antibiotic stewardship program. “It cannot be handed to one individual, as successful programs happen when teamwork is present,” says Segal. At a minimum, the team should include: t
"
QIZTJDJBO
DIBNQJPO t
"
QIBSNBDZ
DIBNQJPO t
"O
BENJOJTUSBUJWF
SFQSFTFOUBUJWF " t
"
OVSTJOH
SFQSFTFOUBUJWF
QSFGFSBCMZ
XJUI
" some experience in infection prevention t
"
NJDSPCJPMPHZ
FYQFSU
GSPN
UIF
MBCPSBUPSZ "

Examine the data Ex Th second step is to look at the healthThe car care-associated infection data for the fac facility to identify infections or colonized residents and the organisms that are assores ciated with the facility, particularly those cia that result in the use of antibiotics, and tha ex examine their multi-drug resistant organism patterns. “Do they have a problem with C. difficile infection, for example? wi Do they know their multi-drug resistant org organism rates, such as Methicillinres resistant Staphylococcus aureus (MRSA), Va Vancomycin-resistant enterococci (VRE), extended-spectrum beta-lactamases ex (ESBLs), and Carbapenem-resistant (E Enterobacteriaceae En (CRE),” she asks. “They ne to identify their areas of weakness need with wi respect to healthcare-associated infections inf that could possibly be associated soc with the misuse or overuse of antimicrobials.” an

Implementing physician education Probably the most important step that a facility can take when implementing an antibiotic monitoring or stewardship program is to educate all physicians and any midlevel providers. “This can be a big challenge because some prescribers are resistant to change,” Segal says. Getting all prescribers on board requires education. Providing them with all information related to the program is extremely important. A key factor in making that happen is having physician champion who is fully dedicated to the control of use of antimicrobials. “It’s really the physician champion who can get his or her peers onboard with the new policies,” she concludes. LTL Beth Thomas Hertz is a freelance writer in Akron, Ohio.

Dr. Smith’s® Zinc Oxide Adult Barrier Spray

improved quality of care in nursing home usage trial. Nursing Home Usage Study*:

After a 30-day nursing home usage study, caregivers indicated that Dr. Smith’s® Adult Barrier Spray improved the quality of care in their facility, and the vast majority preferred Dr. Smith’s method of application over their previous barrier cream or ointment.

Study Finding Highlights: A


57*+*7
&
3*<
2*9-4)
4+
&551.(&9.43
94
89&3)&7)


protocol of ointment/creams A

 
8&.)
7
"2.9-8
):19
&77.*7
"57&>
-&8
.2574;*)

the quality of care in their facility A


<4:1)
7*(422*3)
7
"2.9-8
):19
&77.*7
"57&> A

#-*7*
<*7*
34
.389&3(*8
4+
$#
47
49-*7
.3+*(9.43
):7.3,

the course of the study A

Comments received included that it was “easy to use,” “more convenient,” “saved time,” and “provided a no-mess alternative.”

Incorporating Dr. Smith’s Adult Barrier Spray into your protocol can: Provide a more efficient way to treat and prevent Incontinence Associated Dermatitis (IAD) Offer nursing staff a touch-free alternative that saves them time and is easy to clean up with brief changes Help eliminate risk of cross contamination Help eliminate product waste and save money

For External Use Only Conduct your own usage trial with Dr. Smith’s Adult Barrier Spray to improve quality of care in your facility. To request samples, order product, or obtain a copy of the complete trial study, contact us at:

AdultBarrierSpray.com

* This study and its data were provided by a third party. Data on file. Copyright © 2015 Mission Pharmacal Company. All Rights Reserved. Patent Pending. DSL-P155946-4

f e at u r e

HOW TO AT TR ACT VOLUNTEERS

How to attract

volunte vo v ol nte te #N‘8+5%30%2X/%1%30%2#N"O‘WWW.LTLMAGAZINE.COM

eerss e ee

HOW TO AT TR ACT VOLUNTEERS

f e at u r e

Unlock success by examining 3 assumptions BY KRISTINA MORITZ

T

he traditional relationship between volunteers and staff members at elder care communities has been a simple one: Volunteers motivated by altruism apply and then interact with residents out of the goodness of their hearts, and community staff members express gratitude for their service. If we examine the products of this accepted wisdom, however, we most often will find volunteer programs that are lackluster in almost every way. Outside of the buildings in which I work, I have never met an administrator who is truly excited about the current state of the volunteer program in his or her building. What I hear instead is frustration that he or she cannot find any volunteers and bafflement as to the reasons behind this phenomenon and what they can do to change it. The problem, I tell them, is not a lack of volunteers. Instead, the real problem is the aforementioned notion of volunteer/facility relations, which is governing their efforts and consistently producing disappointing results. As with anything, one must adopt a different approach to obtain different results, and for volunteer programming, doing so means re-examining three key assumptions.

Motivators for volunteering Certainly, the selfless desire to help others is one reason people volunteer, but it is an enormous mistake to assume that this is the only reason. Consider the example of one volunteer, Jen. Some time ago, I learned that a long-standing problem existed related to the state of residents’ clothing: missing buttons, small holes, tears and items that generally were in poor condition. I began looking for someone who might volunteer his or her seamstress skills and met Jen. She was a high WWW.LTLMAGAZINE.COM

LONG-TERM LIVING‘#"

f e at u r e

HOW TO AT TR ACT VOLUNTEERS

school senior preparing to apply to fashion school later that year. She did not have much volunteer experience to highlight on her application, but she was thrilled when she saw this opportunity to use her skills in fashion and tailoring to improve the lives of older adults. Jen started her volunteerism by creating clothing inventories for long-term residents. When she found an item in poor condition, she mended it, if possible. If mending was not possible, then Jen transformed into a personal shopper. She would sit with the resident; ask about color, fabric and design preferences; and then select a few possibilities from the local thrift store, letting the resident make the final decision on pieces to keep and returning the items that didn’t make the cut. For Jen’s college applications, the social services director and I wrote glowing letters of recommendation, highlighting how she had taken ownership of this pilot program

GET MORE. DONE. * IN TOTAL $ SAVINGS! UP TO

3,550

RDX SERIES

RM SERIES

DTR SERIES

CLS SERIES

CLP SERIES

SAVE BIG WHEN YOU BUY MOTOROLA TWO-WAY BUSINESS RADIOS. * BASED ON THE AVERAGE TOTAL VALUE OF THE MAXIMUM PURCHASE OF THE 60 RDX RADIOS *

ACT NOW - Limited Time Offer! For Full Details, Visit www.motorolasavings.com

Order at TechWholesale.com or Call 888-Walky-Talky MOTOROLA and the Stylized M Logo are registered trademarks of Motorola Trademark Holdings, LLC and are used under license © 2015 Motorola Solutions, Inc. All rights reserved.

##‘8+5%30%2X/%1%30%2#N"O‘WWW.LTLMAGAZINE.COM

Volunteers have specialized skills that they want to offer, and communities can amply reward them through references, professional contacts and experience. The role of a volunteer coordinator, then, is to efficiently and effectively match these parties. and used her expertise to improve the quality of life for residents. This unique pre-professional experience no doubt helped differentiate Jen’s application from the rest, and she is finishing her first year in a fashion merchandising program, on scholarship. Jen’s experience, and the experience of many others like her whom we have welcomed into our innovative programs, highlight the fact that volunteers want to do more than what traditionally has been asked of them. Altruism did not fuel Jen’s desire to volunteer; instead, she was motivated by the opportunity to use her specific skills in a way that would better position herself for acceptance into a competitive academic program. Serving seniors was a plus—and something she greatly enjoyed— but it was not what got her in the door.

Community value Volunteers have specialized skills that they want to share with communities, but how can communities adequately compensate those who share their expertise? As seen in the example of Jen, references are one way. Another way is simply by providing them professional experience. Consider that all nursing homes and rehabilitation centers consist of departments that represent professional areas slated to grow much faster than average over the next decade: nursing, social services, dietetics, physical and occupational therapy, and general health service administration. Viewed through this lens then, buildings have the opportunity to provide highly desirable professional experience to motivated volunteers, helping those volunteers gain

admission to dream colleges, win competitive internships or land job interviews in this difficult economy. Buildings are not simply passive receivers of volunteer services; they also have the potential to be incredibly valuable resources. Jacki was a reception volunteer pursuing a degree in healthcare administration. Knowing that the managerial departments are always busy, I asked Jacki whether she would be interested in volunteering in the business office. She said yes. Over time, this relationship evolved into a formal internship between Jacki and our community, which ultimately resulted in a part-time position for her as she finishes her degree. In this mutually beneficial relationship, we offered hands-on experience to further her career prospects after graduation as well as references and numerous professional contacts in her chosen industry. In return, we have gained countless hours of specialized administrative service to the community as well as an exceptional employee. Additionally, the residents indirectly benefited from this relationship by having administrative staff members who were freed up to focus on matters that require a high level of education and expertise.

Getting volunteers, communities together Volunteers have specialized skills that they want to offer, and communities can amply reward them through references, professional contacts and experience. The role of a volunteer coordinator, then, is to efficiently and effectively match these parties. The recruitment, training and orientation methods on which the majority of buildings

HOW TO AT TR ACT VOLUNTEERS

and coordinators rely, however, are relics in today’s fast-paced digital world. It is not efficient to have a stack of paper applications behind the front desk for potential volunteers who happen to wander into a building. Making occasional phone calls to nearby churches and schools to try to drum up volunteers is almost entirely ineffective; ask any activities professional, who has tried. Those methods have persisted for at least 40 years and, at best, produce only a trickle of volunteers through a building in any given year. We can see alternatives to those traditional approaches all around us. How do most people apply to college, look for a job, keep in touch with friends, pay bills, watch movies, listen to music, make travel plans and buy things? Online. Eighty-seven percent of all Americans use the Internet regularly, and among certain groups, that amount climbs to 97 percent, according to the Pew Internet Project. Virtually every sector of modern American life has embraced the efficiency and expanded reach that the Internet provide—except for the field of volunteer management. Realizing this, it is not surprising that traditional volunteer management approaches are failing in this digital age. The surprising fact is that so many communities still embrace an antiquated model. A digitized volunteer management approach can yield high returns without the need to sacrifice any quality control. Instead of leaving a stack of paper applications behind the front desk, email a link to a Google form that new volunteers can complete online. Most volunteers are used to filling out applications online, and Google will plug their answers into a time- and date-stamped spreadsheet that is automatically updated each time a new volunteer applies. Also, don’t exclusively rely on churches and schools to find volunteers. Use one of the many free online volunteer recruitment sites to advertise your volunteer opportunities: www.allforgood.org, www.volunteermatch.org and www.createthegood.org are good options. And instead of waiting to hold group orientation sessions for new volunteers, make online orientation videos that new

f e at u r e

volunteers can view at their convenience on their personal computers or mobile devices. Making short training videos specific to each position in your facility also will ensure that when new volunteers arrive, they already are well-educated and well-trained. Finally, follow up with new volunteers via email, text or phone to make sure they had a good experience. Implementing this digital approach to recruitment, orientation, training and followup can produce a flood of new volunteers and completely revolutionize the culture of a building.

A new paradigm For too long, volunteer programs have languished as an afterthought in most facilities, thrown onto the plate of activities professionals who are too busy with their official duties to give much thought to innovative approaches to volunteer management. The result of this neglect is an unconsciously adopted assumption that volunteer programs are not capable of having a tremendous effect, simply because they have not done so in the past. In reality, hundreds of potential volunteers are waiting for the opportunity to donate not only time, but also their specialized skills and training. In return, they will be grateful for the experience, references and professional contacts they make. Technology presents multiple opportunities to connect these parties in effective, efficient and inexpensive ways. The accepted wisdom of how to manage a volunteer program in an elder care community is outdated, and incredible benefit may be gained by accepting a new paradigm in which volunteers are valuable resources for communities, communities are valuable resources for volunteers and technology brings them together. LTL

www.omnicare. .

Kristina Moritz is the part-time volunteer coordinator of five Denver-area Ensign Group buildings. She also recently launched Modus, a company that aims to help organizations improve and modernize their volunteer programs. She may be reached at kristina@ modusvpdm.com. WWW.LTLMAGAZINE.COM

LONG-TERM LIVING‘#$

f e at u r e

QUALIT Y MEMORY CARE VISITS

Quality

memory care visits Help families learn how to interact with residents with dementia BY DEBBIE SULLIVAN RESLOCK

hen it comes to improving the quality of visits between families and residents with dementia, a little education can go a long way. Many families struggle with feelings of guilt, anxiety and awkwardness when they visit loved ones with cognitive decline. Family members can feel frustrated by an inability to hold a “current time” conversation, the unexpected reactions to physical contact and the fact that their loved one may shift between recognizing them and viewing them as strangers. As memory care professionals know, current memory care best practice is to “meet residents with dementia wherever they are,” rather than forcing them to accept a current time or reality. But family members often need help adjusting to this new reality. Helping families build a new relationship with their loved one while letting go of an old one can help ease anxieties and improve the quality of visits.

Adjusting to the new reality Having a family member with dementia requires families to come to terms with an unusual type of loss, since their loved one is physically present but is different and distant—perhaps even unwelcoming. “It can be a real struggle for families to accept this new reality,” says Jodi DiRaimo, resident program director at the Lighthouse at Lincoln, a memory care community in Rhode Island. “It’s unfortunate, but not everyone in the family always gets to a level of acceptance.” She recommends sending resident photos or updates to families who may need extra help and encouraging them to come to support groups or family meetings. “They need to understand that she is still their Mom, but it’s a new relationship now. She can’t change, so they have to,” DiRaimo says. Caregivers play a key role in reminding families how important an ongoing relationship with their loved one is, even if the resident doesn’t remember who the visiting faces are, adds Amelia Schafer, vice president of programs for the Alzheimer’s Association of Colorado. “Even if [residents] can’t recall how they relate to you, the family can still bring great joy to their lives.” And, families also can help caregivers and activity directors interact more #;‘8+5%30%2X/%1%30%2#N"O‘ O‘ WWW.LT WWW.LTLMAGAZINE.COM T LMAG G AZ IN N E.COM

“Instead of bringing an old QUALIT Y MEMORY CARE VISITS f e at utor visit e and friend insisting the resident remember who she is, try telling a story about [that] friend when you were growing up and there may be something that triggers a memory.” – Amelia Schafer

productively with residents by providing unique insights into the personality of the resident before the disease. One of the best ways caregivers can assist families in their visits is to guide them to a conversational path that doesn’t include asking questions based on current time. Quizzing a person with dementia on what they had for lunch or who visited yesterday often results in frustration for everyone, explains Carmen Bowman, a long-term care educator in Brighton, Colo. Trying to force the resident to orient to a specific point in time is counterproductive and just doesn’t work, she says. Instead, caregivers should teach the family how to share conversation without worrying about what time frame the resident’s memory is in, DiRaimo advises. “Whether that moment is in 1920 or 1940 doesn’t matter because what’s important is to meet them wherever they are.” Helping families learn to “quilt a conversation” encourages them to let go of wanting specific answers and gives residents a chance to participate and engage instead, adds Joshua Freitas, reflections and engagement manager for LCB Senior Living, headquartered in Norwood, Mass., and author of The Dementia Concept (2015). Freitas recommends that families bring in #P‘8+5%30%2X/%1%30%2#N"O‘WWW.LTLMAGAZINE.COM

a magazine or book with pictures relating to something of interest to the loved one as a conversation starter, and then allow one memory to prompt another. Using storytelling instead of fact identification also can help the family engage with the resident, Shafer adds. “Instead of bringing an old friend to visit and insisting the resident remember who she is, try telling a story about [that] friend when you were growing up and there may be something that triggers a memory,” she says.

the same thing. And what a nice moment to sit by the fireplace with a hot chocolate and talk about whatever comes to mind.” Families and residents tend to feel an innate need to feel useful, Bowman adds, recalling a husband who volunteered to set up a nearby room for church services while visiting his resident wife—and then his wife started helping him. “And imagine the joy it could bring if the resident known for making the best cinnamon rolls ever could share that again with her family,” Bowman says. Sensory outreach is especially helpful for those with dementia, including reflection Visit variety is key For those with dementia, no conversational baskets filled with family photos, puzzles, personal recipes or whatever speaks to the method works every day. It’s important resident’s interests, DiRaimo adds. “We live to show families more than one way to in a sensory world, and the basket is filled connect, and it can help to vary the visit with tangible and tactile items. It can be setting, Bowman notes. “I watched a wife used to give families something to engage in come to visit her husband and they sat in with the resident,” she says. the exact same place where he sits every Many families fail to realize that not all day. And then neither spoke,” Bowman visits have to involve conversation. Back says. “We need to encourage our families rubs, massages, manicures and holding to engage and not just sit with their loved hands are all ideas for valuable family one and be sad.” interaction. Listening to music together also Even simply going outside can be a new is great because it doesn’t rely on memory opportunity to engage. “Putting on a coat, facts, Schafer says. “All they have to do is hat and mittens gives you the chance to enjoy it. And you never know; it can lead talk about the weather or what they may them to clapping, tapping their feet or even remember about past winters,” Bowman dancing together.” says. “When you come back in, you can do

f e at u r e

QUALIT Y MEMORY CARE VISITS

Planning for visits The care team can help families prepare for a visit, but it’s important first to understand what the family’s goal is, Schafer adds. “Some may not be looking for conversation but rather a chance to help take care of their loved one,” says Schafer. “If sundowning happens in the late afternoon and [the resident] gets agitated or upset, a visit from a family member could be comforting. And for most facilities, right before and after dinner is a busy time for staff, so they could also help the transition to the evening routine,” Schafer says. Remind families to leave their own day at the door when they come to visit, DiRaimo adds. “Dementia residents pick up on others’ emotions, and when families are positive, that helps evoke positive emotions for the residents.” Keeping the number of visitors to no more than two or three at a time and keeping the conversations simple work best, Freitas suggests. And always focus on what the residents can do, not on what they can’t, he urges. “Reminding families to introduce themselves helps take the stress away from residents if they don’t know who you are or why they should know you,” he adds. Keep it simple, he says, such as, “Hi mom, it’s Joshua just stopping by to see you.” Families should know it’s OK to bring the kids, and caregivers should be ready to help prepare younger visitors what to expect, Schafer says. “Children bring life into a community and can often be more understanding and accepting than adults.” When a visit ends, saying goodbye can also trigger behaviors or emotions for residents, Freitas cautions. It’s better to be positive by saying something like, “I enjoyed our visit and I hope you did too,” or “It’s time for you to eat dinner but I’ll see you tomorrow,” he adds. The timing of the goodbye also can be important, DiRaimo adds. “One great way to handle this is for one of the staff to tell the resident they need the resident’s help with something, so it gives the resident the chance to say goodbye first,” she says.

Encourage, encourage

cult to see their loved one like this, caregivers need to remind families how important their visits are to their loved ones, Schafer says. “Giving positive feedback helps them understand that it really does make a difference.” Bowman agrees, saying, “We always assume that those suffering from dementia

don’t know who we are, but perhaps instead we should assume that maybe they do, at least on some level.” LTL Debbie Sullivan Reslock is a freelance writer in Evergreen, Colo.

Pocket Sized Radio

Ne

w

Designed Specifically for Healthcare Facilities • • • • • •

Fro

m

Weighs only 3.9 ounces 1.5 Watts of transmit power 4 channels Long battery life Up to 5 mile range Two-year radio warranty

Actual Size

Two-Way Business Radios

Ask About the Special Healthcare Package

1-800-950-5005

Even when family members say it’s too diffiWWW.LTLMAGAZINE.COM ‘LONG-TERM LIVING‘#Q

f e at u r e

REEX AMINE ELOPEMENT RISK ASSESSMENT

REEXAMINE

ELOPEMENT RISK ASSESSMENT

5 steps to keeping residents safe from wandering

I

t is estimated that over 30 percent of nursing home residents and between 25 percent and 70 percent of community-dwelling older adults with dementia wander from their supervised healthcare settings at least once during their stay. Incidences of elopement have resulted in costly liability claims. One major insurance carrier reported an award of more than $500,000 for a single elopement claim in 2012. Healthcare providers have been cited and fined by regulators and litigated out of business as a result of elopement incidents. Providers implement countless interventions to mitigate the risk of elopement, ranging from painting murals on exit doors to building never-ending walking paths to buying bracelets for residents to wear that lock nearby doors and sound alarms. Although elopement prevention plans often include a variety of best practices, a provider’s approach could be significantly improved by having a comprehensive risk assessment program to identify residents who wander. Providers regularly use standard risk assessment tools, but many tools don’t identify key risk factors. You can tell if your elopement risk assessment program is missing the mark and could be working harder for your facility by asking yourself the following five questions.

#R‘8+5%30%2X/%1%30%2#N"O‘WWW.LTLMAGAZINE.COM

BY CARL BLOOMFIELD, A AI; AND BET TE MCNEE, RN, NHA

REEX AMINE ELOPEMENT RISK ASSESSMENT

f e at u r e

WWW.LTLMAGAZINE.COM ‘LONG-TERM LIVING‘#S

f e at u r e

REEX AMINE ELOPEMENT RISK ASSESSMENT

1. Are you taking “no previous episodes” at face value?

3. Is a red flag raised for residents who exhibit confusion?

Most elopement risk assessments ask about a resident’s previous history of elopement, wandering or “getting lost.” Since a resident who had previously lived alone may not share past episodes of getting lost, or residents who lived with caregivers may not recognize “wandering” as roaming in familiar settings, the response of “no previous episodes” will not accurately reflect the resident’s current risk for wandering behaviors. Improve standard assessment tools with the inclusion of probing interview questions such as: “Have you ever found yourself in a room and were unsure how you got there?” “Has Mom ever wandered away in a store while you were shopping?” “Does Dad roam about the house without completing a task?” These types of questions will help residents and their families respond more accurately about behaviors that put one at risk for wandering away from a supervised healthcare setting.

Since a resident’s cognitive status is also a key risk factor, standard elopement risk assessments delve into a resident’s diagnosis of dementia and memory changes. Residents who have not been diagnosed with dementia may not trigger the risk factor; however, they still may be at risk for wandering and elopement because of confusion, which can be a side effect of new medication or from a change in setting, routine or sleep pattern. While assessment tools can be updated to include these factors, more important is the regular observation and supervision of newly admitted residents. Episodes of wandering and elopement are likely to occur within the first 48 to 72 hours from move-in and are usually related to changes in setting, routine and sleep pattern. The Alzheimer’s Association estimates that nearly half of all elopements occur within the first days after admission. They recommend observation and supervision by moving new residents to rooms away from exits and closer to community areas.

2. Do you have a real sense for activity patterns? Another risk factor that is often missed during an assessment is that of previous activity patterns. Activities that are often discouraged in a supervised healthcare setting—such as smoking or having an alcoholic beverage— are often not reported, but these behaviors do put a resident at an increased risk for elopement. The staff member responsible for performing a risk assessment needs to establish a rapport to elicit an accurate history. Another activity pattern that will put a resident at risk for elopement is the concern for or the absence of a pet, wildlife or even a garden. Residents who perceive themselves to be caretakers are at increased risk for elopement because of their desire to return to their obligations of caring for a pet, feeding birds or squirrels or even picking vegetables from the garden. Even if pet care is provided during the resident’s stay in the healthcare setting, the risk of elopement still exists.

$N‘8+5%30%2X/%1%30%2#N"O‘WWW.LTLMAGAZINE.COM

Episodes of wandering and elopement are likely to occur within the first 48 to 72 hours from move-in and are usually related to changes in setting, routine and sleep pattern.

great risk for falling—should still be assessed for risk of elopement. In addition, residents whose risk was assessed at move-in should be reevaluated often as they progress in their therapy regimen. Elopement from a long-term care setting can pose serious risks for compromised residents, and the provider can be held liable for harm or injury to the resident. Providers are challenged to accurately assess residents’ risk for elopement so that appropriate measures can be implemented. Since standard risk assessment tools may miss a key wandering or elopement risk factor, it is important that providers never underestimate their resi4. Are you listening closely to dents’ propensity to wander or elope. residents’ complaints? No previous history of wandering, no A resident who often says, “I want to go diagnosis of mental status change, the desire home” or “I need to get to work” may be to return to one’s own pursuits, inability assessed as being at risk for elopement. However, a short-term rehabilitation resident to walk or demonstrated compliance with therapy regimens are not guarantees against who expresses frustration with the duration of the rehabilitation stay is at greater risk for elopement. Improvements in assessment elopement despite the lack of verbalizations. tools and consideration of risks outside standard risk assessment tools are a provider’s A resident’s complaints about complying best approach for preventing elopement. LTL with plans for length of stay and discharge plans is a risk factor for elopement that may Carl Bloomfield, AAI, is a Vice be missed in standard assessments.

5. Do you assume immobile residents are not at risk? Finally, a resident’s inability to independently ambulate can inaccurately reflect a risk for elopement. Surprisingly, residents who require one or two people’s assistance to take just a few steps have mustered the ability to exit the healthcare setting without the knowledge of staff. Residents who can stand—regardless if standing puts them at

President and leader of the Health & Human Services Division at The Graham Company. He can be reached at cbloomfi[email protected] or (215) 701-5420. Bette McNee, RN, NHA, is a Clinical Risk Management Consultant in the Health & Human Services Division at The Graham Company. Contact her at [email protected] or (215) 701-5429.

You don’t have to go at it alone. In fact, you can join forces with 14,000 of your peers working in long-term care by trying the American Association of Nurse Assessment Coordination (AANAC) risk free for 30 days. AANAC is the network and resource for long-term care professionals where you can enhance your knowledge, excite your passion, and be a part of something greater than you could be alone.

Together, with AANAC, you can...

Learn. 5HFHLYHVLPSOLÀHG0'6XSGDWHVDQGWLPHO\ORQJWHUP FDUHQHZV1HHGLQVSLUDWLRQ")ROORZWKH&DUH&RQQHFWLRQ EORJZKHUHVWRULHVLQVSLUHFKDQJH

Grow. (QKDQFH\RXUNQRZOHGJHZLWKPDQ\SURIHVVLRQDO GHYHORSPHQWRSSRUWXQLWLHVLQFOXGLQJ5HVLGHQW $VVHVVPHQW&RRUGLQDWRU³&HUWLÀHG®5$&&7 DQG &HUWLÀHG1XUVH([HFXWLYH&1( FHUWLÀFDWLRQV 0HGLFDUHWUDLQLQJ0'6EDVLFVZHELQDUV DQGDQDQQXDOFRQIHUHQFH

Succeed. &RQQHFWDQGHQJDJHZLWKH[SHUWVDQGSHHUVLQD FROODERUDWLYHFRPPXQLW\VHWWLQJLQWKH $$1$&RQQHFWRQOLQHPHPEHUVRQO\ FRPPXQLW\OLVWVHUYZKHUH\RXFDQÀQG GRFXPHQWVDQGDVNRUUHSO\WRTXHVWLRQV

Find your support system and get on top of your game.

AANAC.org/FreeTrial

f e at u r e

QUALIT Y MEMORY CARE VISITS

WIDE Added inches, added safety C

linical staff at Baptist Homes Society’s Mt. Lebanon Campus in Pittsburgh, Pa., recognized that fall rates among the facility’s residents were not acceptable and some action was required. By researching available equipment solutions and committing to a significant investment to obtain new beds designed with features intended to reduce risk of falls for high-risk patients and facilitate egress to promote mobility, Baptist Homes has been successful in substantially reducing fall rates within its facility. Clinical staff understood the need to reduce falls and successfully presented its case to the organization’s chief executive officer, gaining top management’s full support. Since Baptist Homes did not have the necessary resources to immediately implement an effective solution strategy, its foundation sought and was able to obtain grants from its Auxiliary, the George H. Campbell, Lillian S. Campbell and Mary S. Campbell Foundation and Joerns RecoverCare, Inc., to address the fall risks.

Seeking solutions Clinical staff became aware of work presented in the literature that discussed how wider beds in healthcare settings could be effective in reducing fall-risk frequency to residents. Fall severity was also a consideration and bed vertical travel range was also an important factor considered. Beds needed to go low enough for resident safety and $#‘8+5%30%2X/%1%30%2#N"O‘WWW.LTLMAGAZINE.COM

high enough for easy resident egress and to allow for good caregiver posture when delivering in-bed care. In addition, other bed system design enhancements were reviewed such as ambulatory assist-enabling devices to facilitate bed egress and reduce demands on caregivers. New beds with these risk-reduction features were obtained in August 2013, for a 41-bed dementia unit whose residents were at high risk for falls. These new bed systems were wider than previous traditional healthcare beds and immediately determined to be more comfortable because of the additional width and upgraded mattresses. Beyond comfort, important features related to the upgraded mattress surfaces included firm mattress perimeters that provided stability for residents when standing from a sitting position and a viscoelastic foam top that envelops the body and redistributes pressure, important for wound prevention. The new bed frames were also equipped with side grip enablers to assist in resident transfers and in bed mobility. Having the side grip enablers is intended to facilitate bed egress for residents, promoting mobility thus reducing demands related to patient transfers on caregivers.

New beds improve fall rates Acquiring new beds does require an investment but they are an expense normally incurred to update and improve a facility. Because of the work clinical staff had done to

create top management support and grants the organization’s foundation was able to obtain the acquisition of new beds was not an obstacle. Providing the new beds with features to prevent falls and facilitate bed egress added little cost to the overall cost of the beds. The kit to achieve the wide bed feature was $225 per bed and the larger mattress required added approximately $50 to $60 per mattress. To add the deluxe ambulatory assist enabling device was about $195 per set per bed. Total cost per bed including all upgraded features was $2,235. In the 12-months prior to installation of the new beds there were 134 falls reported on the unit, equating to a fall rate of 8.95 falls per 1,000 resident days. In the 12 months following installation of the new beds, reported falls were reduced to 95, equating to a reduced fall rate of 6.35 falls per 1,000 resident days. This translates to a decrease of 39 falls for the first year postintervention, which was a 29% reduction in the annual reported fall rates. In addition to reduced fall rates, the number of severe injuries as a result of bed falls was also reduced. Prior to installation of the new beds there were two falls out of bed resulting in a severe injury to the resident. These injuries included a cervical neck fracture and a knee fracture. Since the new beds have been put in place there have been no severe injuries reported, related to falls from bed.

QUALIT Y MEMORY CARE VISITS

f e at u r e

BEDS Wide beds and wider mattresses can reduce falls

BY GUY FR AGAL A, PHD, PE, CSP, CSPHP

travel range, which provides a bed height conducive to standing, and with the position of the enablers it was easier for the resident to pivot off and stand from the bed.

If a wider surface can reduce risk and prevent a resident from falling out of bed, many potential negative outcomes might be As a result of the success reported on the deavoided. These negative outcomes include mentia unit, additional beds were obtained the pain, suffering and disability that resifor the short-term rehabilitation unit in dents might experience and the large finanSummary August 2014. In the two months following cial burden placed on the healthcare delivery Bed systems are very important to the installation of these new beds, falls in the system related to resident falls. process of delivering care in the long-term short-term rehabilitation unit were reduced Wider bed surface options are currently by 66 percent (from 12 falls to 4 falls) when care (LTC) environment and can have an available with little cost increase over availimpact on the safety and well-being of both compared to the same two-month period able traditional beds. The small additional residents and caregivers. Further investigaone year earlier. cost for wider bed systems can be a very tions are required, but this initial evidence prudent investment when considering the is suggesting that wider bed surfaces might Additional benefits be an effective intervention for reducing falls alternative costs which can result from a Although not a focus of this study, in addihigh number of resident falls. from bed in the LTC environment. tion to a reduction in the number of falls, In addition to surface width there are A laboratory study has provided evidence staff noted improvement in resident sleep that wider beds for LTC residents may reduce other important bed system features to patterns resulting in a better quality of life. risk of falls. This current case study, discussed consider including vertical travel distance No formal studies were performed on sleep and range, side-mount enablers and a good patterns and a study of sleep patterns related in this article, further adds to the evidence base demonstrating that wider, height-adjust- surface with pressure-relieving characteristo wider bed surfaces could be considered able beds might be effective in reducing both tics. Organizations should take the time and for future research. the frequency and severity of fall-related inju- make the effort to best match bed system Qualitative data was provided by night shift staff via daily reports that included how ries. The limitations of this current case study design and function to the needs of their resident population. Proper bed systems are recognized in that it is only one small the unit’s residents slept through the night. are very important for maintaining a high Some residents were able to control their bed study. However indications are consistent quality and safe environment for delivering function better since the new remote control with previous laboratory study evidence. It is important to have a well-thought-out care. LTL is user friendly and can be moved from the process for selecting beds for an LTC facility. inside of the bed to the outside the bed at Various disciplines within the facility, includ- Guy Fragala, PhD, PE, CSP, CSPHP, night for staff to access. The enablers on the has more than 40 years of ing representation from clinical, rehabilitaside of the bed with nonslip grips helped experience as an Occupational tion, risk management, engineering and with transfer and bed mobility restorative Safety and Health professional purchasing functions should be consulted. programs. Some residents were taught how and is currently the senior The knowledge from the perspective of these advisor for ergonomics at the to reposition themselves in bed and use the Patient Safety Center of Inquiry, different disciplines will contribute to good enablers to stand up when transferring. Tampa, Fla. decision making. The new beds are designed with a height

Expanding the replacement program

WWW.LTLMAGAZINE.COM ‘LONG-TERM LIVING‘$$

REEX AMINE ELOPEMENT RISK ASSESSMENT

I

n 2003, the northeastern United States experienced a widespread blackout that left approximately 45 million people across eight states without power. As a result, some communication and transportation systems were disrupted, some areas experienced loss of water pressure and most businesses were unable to operate until power was restored. Unfortunately, many long-term care (LTC) communities in the affected areas discovered their unpreparedness the hard way. Many healthcare providers found that the emergency preparedness plan that they had put so much faith in did not address all of the problems they actually encountered, so they had to “wing it.” As a result of their experiences, the industry has learned many lessons. Even a brief power outage can potentially impact multiple systems, including: t
)7"$ t
-JGFTVQQPSU
TZTUFNT
WFOtilators, dialysis equipment, monitors) t
8BUFS
EJTUSJCVUJPO t
'JSF
QVNQ
BOE
MJGF
TBGFUZ
systems t
$SJUJDBM
MJHIUJOH
TZTUFNT t
$MJOJDBM
*5
TZTUFNT
including electronic health records; electronic document exchange/file transfers an from the facility to and (dis (discharge summaries, care plan etc.); and pharmacy plans, orde access and CPOE order (elec (electronic medication orde orders). On of the critical lessons One learne from the 2003 blacklearned wa that power outages do out was not just occur on dayshift when everyone is at work and all of the “experts” ar are readily available. They happen on al all shifts, and usually at

the worst possible times. Therefore, preplanning is a critical part of being ready for an outage.

Prepare for the worst-case scenario It is important to make certain that your preparedness plan includes critical contact information for the electric utility company. Knowing where your facility is located on the power distribution network may be of value as well. Meet with the electric utility company before an outage happens. Emphasize the serious effects a power outage will have on your operations and on the care of your residents. Many times, LTC facilities are forgotten, while hospitals and urgent care facilities receive all the attention. Power outages are another strong argument for allowing all employees to carry cell phones. During a power outage, the facility’s phone system will likely be inoperable; however, cell service may continue to operate OPSNBMMZ
)BWJOH
DFMMVMBS
DPNNVOJDBUJPOT
capabilities will keep staff in contact with the outside world and may be a valuable tool in summoning any emergency assistance as needed.

Tips to stay in operation Predetermining critical systems and functions is another key step. If portable generators are needed in an extended outage (or if the facility does not have its own backup generator), it is critical to know how the QPSUBCMF
QPXFS
XJMM
CF
QSJPSJUJ[FE
8IJDI
systems need access the most? Can generator use be rotated among systems? Portable gasoline-powered generators are valuable tools, but they have their limitations. Plan their use judiciously. 'PPE
TBGFUZ
JT
BOPUIFS
DSJUJDBM
DPODFSO
If the power is out for less than four hours, then the food in the refrigerator and freezer TIPVME
SFNBJO
TBGF
UP
DPOTVNF
8IJMF
UIF
power is out, keep refrigerator and freezer doors closed as much as possible to keep food cold for longer.

f e at u r e

If the power is out for more than four hours: t
*O
UIF
GSFF[FS
TFDUJPO
"
IBMGGVMM
GSFF[FS
will hold food safely for up to 24 hours. A full freezer will hold food safely for 48 hours. Do not open the freezer door if it can be avoided. t
*O
UIF
SFGSJHFSBUFE
TFDUJPO
1BDL
NJML
BOE
other dairy products, meat, fish, eggs, gravy and perishable leftovers into a cooler surrounded by ice. Inexpensive foam coolers are fine for this purpose. Use a food thermometer to check the temperature of the food once it is removed from the refrigerator. Throw away any food that has a temperature of more than 40 degrees 'BISFOIFJU Temperatures within the buildings are BOPUIFS
DSJUJDBM
DPODFSO
8JUI
UIF
MPTT
PG
power, temperatures may rise quickly in the summer and plummet quickly in the winter. In severe cases, emergency evacuations may be necessary. The facility’s preparedness plan should include the parameters that define a temperature-related evacuation decision.

Summary The ramifications of a power outage are far-reaching. Preparedness plans are usually written with the mind-set that the outage XJMM
CF
TIPSU
)PXFWFS
UIF
MPOHFS
BO
PVUBHF
lasts the more complications and risks will compound; so a worst-case scenario must be planned for as well. The well-prepared facility is one that has developed a comprehensive plan, provides ongoing training to its employees and regularly exercises its plan to ensure that it works properly and that all employees understand their roles in a power emergency. LTL Steve Wilder, CHSP, STS, is President and COO of Sorensen, Wilder & Associates (SWA), a healthcare safety and security consulting group based in Bourbonnais, IL. Contact him at (800) 568-2931 or at swilder@ swa4safety.com.

Advice on o how to weather short or long power interruptions

BY STEVE WILDER, CHSP, STS

WWW.LTLMAGAZINE.COM ‘LONG-TERM LIVING‘$O

RESIDENT CARE GUIDE

Welcome to our 11th annual Resident Care Guide. This targeted guide will direct you to an array of products and clinical resources used in resident care and provide you with easy access to further information about the items of interest to you. We hope you find it informative and useful to your entire staff.

Invacare Continuing Care Elyria, OH Contact: ICC Customer Service (800) 668-2337 Email: [email protected] Web: www.invacare-cc.com

Alliance Monitoring Technologies, LLC

BARIATRIC EQUIPMENT Barrier Free Lifts, Inc. Ocala, FL (800) 582-8732 Email: [email protected] Web: www.barrierfreelifts.com

BARRIERS/PROTECTANTS

MasterCare Patient Equipment Columbus, NE Contact: Bryan Johnson (402) 564-5867 Email: [email protected] Web: www.mastercarebath.com

DermaRite Industries LLC

PGS Medical

North Bergen, NJ Contact: Customer Service (800) 337-6296 Email: [email protected] Web: www.dermarite.com

Leicester, MA Contact: Phil Stiles (508) 892-1569 Email: [email protected] Web: www.pgsmedical.com

Mission Pharmacal San Antonio, TX Contact: Sean Schwartz, R.Ph. (215) 302-3688 Email: [email protected] Web: www.AdultBarrierSpray.com SEE OUR AD IN THIS ISSUE

SureHands Lift & Care Systems Pine Island, NY Contact: Joyce Moraczewski (800) 724-5305 Email: [email protected] Web: www.surehands.com

DIABETES SUPPLIES

BATHING EQUIPMENT/SUPPLIES Barrier Free Lifts, Inc. Ocala, FL (800) 582-8732 Email: [email protected] Web: www.barrierfreelifts.com

$P‘8+5%30%2X/%1%30%2#N"O‘WWW.LTLMAGAZINE.COM

FALL PREVENTION/PROTECTION

ARKRAY Minneapolis, MN Contact: Richard Slouffman (800) 818-8877 Email: [email protected] Web: www.arkrayusa.com

Wichita, KS Contact: Scott Tucker (316) 263-7775 Email: [email protected] Web: www.alliancemonitoring.com Alliance Monitoring Technologies, LLC has provided security and resident monitoring products to the Long-Term Healthcare Industry since 1994. Alliance specializes in resident monitoring systems that fit the changing needs of residents and facilities while working closely with administrators. The Alliance product line includes: t
"MM$BMM¥
8JSFMFTT
/VSTF
$BMM
4ZTUFN t
"MM$BMM¥
"DDFTT
$POUSPM
4ZTUFN t
"MM$BMM¥
8BOEFS
$POUSPM
4ZTUFN t
"MM$BMM¥
7JEFP
4FDVSJUZ
4ZTUFN
"U
"MMJBODF
i8FSF
BMXBZT
HMBE
ZPV
DBMMFEw

Personal Safety Corporation Hiawatha, IA Contact: Rhett Olson (800) 373-3307, ext. 265 Email: [email protected] Web: www.padalarm.com )
JHIFTU
2VBMJUZ-PXFTU
1SJDFT(VBSBOUFFE
Complete line of fall management products purchased by more than 7,000 nursing homes and IPTQJUBMT
JO
UIF
64
$BOBEB
BOE
&VSPQF
0SEFST
ship 100% complete within 24 hours if received by 
QN
$45
"MMNFUBM
NPOJUPSJOH
QBE
DPOOFDUing pins...no easily broken plastic parts as found PO
DPNQFUJUPST
DPOOFDUJOH
QJOT
/POJOWPJDFE
'3&&
TBNQMFT
GPS
DMJOJDBM
USJBMT
'3&&
i#SFBLJOH
ćF
'BMM
$ZDMFw
$&
QSPHSBN
'3&&
CBUUFSJFT
BOE
screwdriver included in each fall alarm package. /PX
PČFSJOH
UIF
JOEVTUSZT
ĕSTU
BOUJNJDSPCJBM
monitoring pads to assist in controlling facilJUZ
JOGFDUJPOT
3FEVDF
'BMMT
3FEVDF
*OGFDUJPOT
3FEVDF
$PTUT

Barrier Free Lifts, Inc.

RF Technologies, Inc. Brookfield, NJ Contact: Mark Gallant (800) 669-9946 Email: [email protected] Web: www.rft.com

HYDROTHERAPY EQUIPMENT/ SUPPLIES

Ocala, FL (800) 582-8732 Email: [email protected] Web: www.barrierfreelifts.com

Invacare Continuing Care Elyria, OH Contact: ICC Customer Service (800) 668-2337 Email: [email protected] Web: www.invacare-cc.com

Vancare, Inc. Aurora, NE (800) 694-4525 Email: [email protected] Web: www.vancare.com

MATTRESSES/BEDDING

Apollo Corporation Somerset, WI Contact: David Anderson (715) 247-5625 Email: [email protected] Web: www.apollobath.com

INTERACTIVE ENTERTAINMENT/ REHABILITATION

SureHands Lift & Care Systems Pine Island, NY Contact: Joyce Moraczewski (800) 724-5305 Email: [email protected] Web: www.surehands.com

Chestnut Ridge Foam, Inc.

Readers Theater Plays

Vancare, Inc.

Somersworth, NH Contact: Jerome Lang (603) 335-6905 Email: [email protected] Web: www.readersplays.com Readers Theater is a wonderful activity for seniors! The players do not have to memorize any of their lines, because they hold a copy of the script in front of them and read their lines. The actors can perform sitting down, or in a wheelchair. Scripts with large type can be used for the visually impaired. Costumes and props can be easily obtained at a second-hand store. Please visit our website ReadersPlays.com for more information!

Aurora, NE (800) 694-4525 Email: [email protected] Web: www.vancare.com

LIFTS, CEILING Barrier Free Lifts, Inc. Ocala, FL (800) 582-8732 Email: [email protected] Web: www.barrierfreelifts.com

Latrobe, PA Contact: Steve Rymarowicz (724) 537-9000, ext. 269 Email: [email protected] Web: www.chestnutridgefoam.com Assurance™ – the newest offering of resident care mattresses from Chestnut Ridge Foam! Our Assurance line was created with resident care in mind while conscious of many facility budgetary constraints. This high density, multi-layered foam mattress with soft heel padding, provides essential comfort along with necessary pressure reduction characteristics. With its blend of longevity and affordability, the Assurance eliminates a further search for improved mattress performance. Various models are available to support individual needs.

Invacare Continuing Care Elyria, OH Contact: ICC Customer Service (800) 668-2337 Email: [email protected] Web: www.invacare-cc.com

MEDICAL EQUIPMENT/SUPPLIES McKesson Medical-Surgical SureHands Lift & Care Systems Pine Island, NY Contact: Joyce Moraczewski (800) 724-5305 Email: [email protected] Web: www.surehands.com

Richmond, VA Contact: Patrice Boone (800) 745-0509 Email: [email protected] Web: www.mckesson.com/ltc

WWW.LTLMAGAZINE.COM ‘LONG-TERM LIVING‘$Q

RESIDENT CARE GUIDE

LIFTS

RESIDENT CARE GUIDE

NURSE CALL SYSTEMS

Systems Technologies Alliance Monitoring Technologies, LLC Wichita, KS Contact: Scott Tucker (316) 263-7775 Email: [email protected] Web: www.alliancemonitoring.com Alliance Monitoring Technologies, LLC has provided security and resident monitoring products to the Long-Term Healthcare Industry since 1994. Alliance specializes in resident monitoring systems that fit the changing needs of residents and facilities while working closely with administrators. The Alliance product line includes: t
"MM$BMM¥
8JSFMFTT
/VSTF
$BMM
4ZTUFN t
"MM$BMM¥
"DDFTT
$POUSPM
4ZTUFN t
"MM$BMM¥
8BOEFS
$POUSPM
4ZTUFN t
"MM$BMM¥
7JEFP
4FDVSJUZ
4ZTUFN
"U
"MMJBODF
i8FSF
BMXBZT
HMBE
ZPV
DBMMFEw

ESCO Technologies LLC Liberty Township, OH Contact: Lorie Orth (513) 823-2081 Email: [email protected] Web: www.esco-tech.net

Hayden, ID Contact: Linda Paris (888) 826-3394 Email: [email protected] Web: www.wirelessnursecall.com

NUTRITIONAL SUPPLEMENTS

Remedi SeniorCare Towson, MD Contact: Sue Hilger (443) 730-8969 Email: [email protected] Web: www.RemediRx.com 3
FNFEJ
4FOJPS$BSF
JT
B
MFBEJOH
QIBSNBDZ
JOnovator, servicing long-term care facilities and DPNNVOJUJFT
0VS
UFBN
PG
RVBMJĕFE
QSPGFTTJPOBMT
understands and meets your pharmacy needs. 8F
IBWF
SFEFGJOFE
NFEJDBUJPO
NBOBHFNFOU
XJUI
1BYJU‰BO
BVUPNBUFE
NFEJDBUJPO
EJTQFOTing system that delivers accuracy, efficiency and DMJOJDBM
TBGFUZ
USVF
&)3
JOUFHSBUJPO
BOE
DPNQMFUF
caregiver satisfaction.

POSITIONING DEVICES DermaRite Industries LLC North Bergen, NJ Contact: Customer Service (800) 337-6296 Email: [email protected] Web: www.dermarite.com DermaRite, well known for high-quality skin care and wound care products, now offers nutritional supplements to support “Healing from without BOE
XJUIJOw t
130)&"-¥
-JRVJE
1SPUFJO
4VQQMFNFOU
8PVOE
Recovery Formula t
130)&"-¥
$SJUJDBM
$BSF
-JRVJE
1SPUFJO
4VQQMFNFOU
"EWBODFE
8PVOE
3FDPWFSZ
'PSNVMB t
65*
)&"-¥
-JRVJE
$SBOCFSSZ
4VQQMFNFOU
o
)FMQT
1SPNPUF
6SJOBSZ
5SBDU
)FBMUI t

'*#&3
)&"-¥
-JRVJE
'JCFS
4VQQMFNFOU

DM Systems, Inc. Evanston, IL Contact: Don Moorhead (800) 254-5438 Email: [email protected] Web: www.heelift.com

OINTMENTS/LOTIONS SKIN CARE

Rauland-Borg Corporation Mount Prospect, IL Contact: Patrick Fitzgerald (847) 590-7100 Email: [email protected] Web: www.rauland.com

DermaRite Industries LLC North Bergen, NJ Contact: Customer Service (800) 337-6296 Email: [email protected] Web: www.dermarite.com

RF Technologies, Inc. Brookfield, WI Contact: Mark Gallant (800) 669-9946 Email: [email protected] Web: www.rft.com $R‘8+5%30%2X/%1%30%2#N"O‘WWW.LTLMAGAZINE.COM

DermaRite Industries LLC North Bergen, NJ Contact: Customer Service (800) 337-6296 Email: [email protected] Web: www.dermarite.com

Advertiser Index Advertiser

Apollo Corporation Somerset, WI Contact: David Anderson (715) 247-5625 Email: [email protected] Web: www.apollobath.com

Page

AANAC ........................................... 31

RF Technologies, Inc. Brookfield, WI Contact: Mark Gallant (800) 669-9946 Email: [email protected] Web: www.rft.com

WOUND DRESSINGS

American Data .................................. 7 Aretech, LLC................................... 15 CAREFOAM, Inc. ........................... 13 Direct Supply Inc. .....................CVR 4 Dr. Smith Adult Barrier Spray ......... 19

DermaRite Industries LLC North Bergen, NJ Contact: Customer Service (800) 337-6296 Email: [email protected] Web: www.dermarite.com

WANDER PREVENTION

Alliance Monitoring Technologies, LLC Wichita, KS Contact: Scott Tucker (316) 263-7775 Email: [email protected] Web: www.alliancemonitoring.com Alliance Monitoring Technologies, LLC has provided security and resident monitoring products to the Long-Term Healthcare Industry since 1994. Alliance specializes in resident monitoring systems that fit the changing needs of residents and facilities while working closely with administrators. The Alliance product line includes: t
"MM$BMM¥
8JSFMFTT
/VSTF
$BMM
4ZTUFN t
"MM$BMM¥
"DDFTT
$POUSPM
4ZTUFN t
"MM$BMM¥
8BOEFS
$POUSPM
4ZTUFN t
"MM$BMM¥
7JEFP
4FDVSJUZ
4ZTUFN
"U
"MMJBODF
i8FSF
BMXBZT
HMBE
ZPV
DBMMFEw

HealthMEDX .............................CVR 2 J+J Flooring Group........................... 1

DermaRite Industries LLC North Bergen, NJ Contact: Customer Service (800) 337-6296 Email: [email protected] Web: www.dermarite.com

JVC KENWOOD USA Corp. ........... 27 Life Systems ................................... 11 Newell Rubbermaid .......................... 5

WOUND THERAPY

Omnicare ........................................ 23

Anacapa Technologies, Inc.

Pellerin Milnor ............................... 10

San Dimas, CA Contact: Dorothy Delaney (800) 489-2591 Email: [email protected] Web: www.anacapa-tech.net

SeniorTV ........................................... 9 Tech Wholesale .............................. 22 The Graham Company ..................... 3

WOUND PREVENTION

DermaRite Industries LLC North Bergen, NJ Contact: Customer Service (800) 337-6296 Email: [email protected] Web: www.dermarite.com

WWW.LTLMAGAZINE.COM ‘LONG-TERM LIVING‘$S

RESIDENT CARE GUIDE

SOAPS/CLEANSERS/BODY WASHES

QA

BOARDROOM

&

One-on-one with… Peter Schuna Born in 1978, Peter Schuna, NHA, straddles the line between Generation X and Y. Schuna also has crossed the line from direct care staff to administrator to president and chief operating officer of Minnesota-based Pathway Health, a professional service organization. Long-Term Living’s Associate Editor Nicole Stempak caught up with Schuna to talk about his unique experiences as a young worker rising up through the ranks and developing the next generation of leaders.

What was your experience like as a young worker? A lot of the [staff], at least when I entered the workforce, was older, especially those that I directly managed. When I started having 12 direct reports, the closest was probably 10 years older than I am. There’s a lot of generational differences and questioning your own ability along with people questioning your ability was nerveracking. The biggest thing that was hard to wrap my head around and understand was the steep learning curve, especially as quickly as the industry changes. That probably gives a younger workforce today a little bit more of an advantage because you can’t rely so much on “This is the way it’s always been done.” The rules and regulations keep changing at such a rapid pace that you have to continue to change. So there’s probably some benefit for those that start today versus 15 years ago when I started.

What advice do you have for millennials entering the field? Find as many mentors as you possibly can and from different age groups if you can be so choosy. Spend time with them talking about what’s going on in the industry, learning from their experiences. Looking back, I feel very fortunate to have had a lot of very smart people around me. I had opportunities to take them out to lunch and pick their brains. Get involved in associations. Find people who are dealing with the same issues you’re dealing with so you can bounce ideas off and get information. I think one of the most important things for young leaders [to do] is reach out. It’s hard to be an administrator or director whether it’s home care or hospice or a skilled nursing facility because you don’t really have any peers to speak with. Everyone reports to you. You have the ultimate responsibility 24 hours a day, 7 days a week, 365 days a year. That responsibility never goes away. If you don’t have a peer to talk to, failure rate is pretty darn high. ;N‘NOVEMBER/DECEMBER 2015

WWW.LTLMAGAZINE.COM

How can long-term care organizations foster young talent? Give them time to grow into roles. I think there’s a big hole across the country of having assistant-type administrators. You have a better opportunity of figuring out if people are going to be successful as opposed to just tossing them in and hoping and praying when they’re the be-all and end-all leader. I think most companies probably wouldn’t just easily hand over the reins to $10 million in revenue to a 22-year-old without the appropriate structure and training. If you think about it that way, then you can back into what some of the training responsibilities or experiences are needed to have someone be successful. I think one of those is having an assistant administrator role in an organization, so you can have that No. 2 be more operationally focused and allow that administrator to really be the CEO of that organization.

What do millennials bring to the table? I think the biggest thing is an idea of how technology can truly be used to enhance long-term care or post-acute care in general. I think the balance there, again, is making sure that young leaders understand it’s a field that revolves around caring for people. It’s very intimate from the standpoint that you’re touching other individuals, or at least your staff is touching elders, in order to care for them. That’s a very vulnerable position to be in. If they know that, I think they have a great ability to figure out how technology can improve those interactions, those relationships and make the industry a lot better.

How do you see millennials leaving their mark? I think their time, their leadership fits in well with their sort of overarching “Who millenials are,” and that is having meaningful work and a more meaningful place and not just working because they have to. I think that’s the attempt and direction of being able to pay for better interactions and better care. If they haven’t already left their mark, they’ll be quickly leaving their mark partly because they’re forced to and because it’s in their age group’s DNA. LTL

Learn more online Read the complete interview with Peter Schuna at ow.ly/TXGUy.

United States Postal Service Statement of Ownership, Management, and Circulation Required by 39 USC 3685 1. 3. 4. 5. 6. 

 9. 10. 11. 13. 14. 15.

Publication Title: Long Term Living Filing Date: 10/19/2015 Issue Frequency: January/February, March/April, May/June, July/August, September/October, November/December Number of Issues Published Annually:6 Annual Subscription Price: 0 &RPSOHWH0DLOLQJ$GGUHVVRI.QRZQ2I¿FHRI3XEOLFDWLRQ(Not printer): Vendome Group LLC., 216 East 45th St, 6th Fl, New York, New York, NY 10017 Contact Person: Rachel Beneventi Telephone: 212-812-4674 &RPSOHWH0DLOLQJ$GGUHVVRI+HDGTXDUWHUVRU*HQHUDO%XVLQHVV2I¿FHRI3XEOLVKHU(Not printer) Vendome Group LLC., 216 East 45th St, 6th Fl, New York, New York, NY 10017 Full Names and Complete Mailing Addresses of Publisher, Editor, and Managing Editor: Editor: Pamela Tabar, Vendome Group LLC., The Caxton Building, 812 Huron Rd., Suite #450, Cleveland, OH., 44115; Managing Editor: Sandra Hoban, Vendome Group LLC., The Caxton Building, 812 Huron Rd., Suite #450, Cleveland, OH., 44115. Owner Full Name: Vendome Group LLC, 216 East 45th St, 6th Fl, New York, New York, NY 10017 Known Bondholders, Mortgagees, and Other Security Holders Owning or Holding 1 Percent or More of Total Amount of Bonds, Mortgages, or Other Securities: None Publication Title: Long Term Living Issue Date for Circulation Data Below: September/October 2015 Extent and Nature of Circulation Average No. Copies Each No. Copies of Single Issue Issue During Preceding 12 Months

a. Total Number of Copies (Net press run) 32,295 b. Legitimate paid and/or Requested Distribution (By Mail and Outside of the Mail)

Published Nearest to Filing Date

33,060

(1) Outside County Paid/Requested Mail Subscriptions stated on PS Form 3541.(Include direct written request from recipient, telemarketing and Internet requests from recipient, paid subscriptions including nominal rate subscriptions, employer requests, advertiser’s proof copies, and exchange copies.) 27,001 26,770 (2) In County Paid/Requested Mail Subscriptions stated on PS Form 3541. (Include direct written request from recipient, telemarketing and Internet requests from recipient, paid subscriptions including nominal rate subscriptions, employer requests, advertiser’s proof copies, and exchange copies.) (3) Sales Through Dealers and Carriers, Street Vendors, Counter Sales, and Other Paid or Requested Distribution Outside USPS® 10 16 (4) Requested Copies Distributed by Other Mail Classes Through the USPS (e.g. First-Class Mail®) c. Total Paid and/or Requested Circulation (Sum of 15b (1), (2), (3), and (4)) 27,011 26,786 d. Nonrequested Distribution (by Mail and Outside the Mail) (1) Outside County Nonrequested Copies Stated on PS Form 3541 (include Sample copies, Requests Over 3 years old, Requests induced by a Premium, Bulk Sales and Requests including Association Requests, Names obtained from Business Directories, Lists and other sources) 4,134 4,655 (2) In-County Nonrequested Copies Stated on PS Form 3541 (include Sample copies, Requests Over 3 years old, Requests induced by a Premium, Bulk Sales and Requests including Association Requests, Names obtained from Business Directories, Lists and other sources) (3) Nonrequested Copies Distributed Through the USPS by Other Classes of Mail (e.g. First-Class Mail, Nonrequestor Copies mailed in excess of 10% Limit mailed at Standard Mail) or Package Services Rates)

16. 17.

(4) Nonrequested Copies Distributed Outside the Mail (Include Pickup Stands, Trade Shows, Showrooms and Other Sources) 814 1,520 e. Total Nonrequested Distribution (Sum of 15d (1), (2), and (3)) 4,948 6,175 f. Total Distribution (Sum of 15c and e) 31,959 32,961 g. Copies not Distributed 336 99 h. Total (Sum of 15f and g) 32,295 33,060 i. Percent Paid and/or Requested Circulation (15c divided by f times 100) 84.5 81.3 Publication of Statement of Ownership for a Requester Publication is required and will be printed in the November 2015 issue of this publication. Signature and Title of Editor, Publisher, Business Manager, or Owner Date Mark Fried, Vice President 10/19/15

I certify that all information furnished on this form is true and complete. I understand that anyone who furnishes false or misleading LQIRUPDWLRQRQWKLVIRUPRUZKRRPLWVPDWHULDORULQIRUPDWLRQUHTXHVWHGRQWKHIRUPPD\EHVXEMHFWWRFULPLQDOVDQFWLRQVLQFOXGLQJ¿QHVDQG imprisonment) and/or civil sanctions (including civil penalties).

30 YEARS OF HELPING YOU FOCUS ON WHAT MATTERS MOST.

Learn more about the many ways Direct Supply can Help You Build, Equip and Run better Senior Living communities at DirectSupply.com. © 2015 Direct Supply, Inc. All rights reserved.