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ENGAGED JOURNEY Got a whistleblower? Raising requirements for RN staffing When residents become financial victims



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Technology designed to make the great indoors even greater. Let’s go back a few hundred years. In the past, air circulated freely through gaps in walls, windows and doors. And while we’ve become better over the years at sealing interior environments, we’ve also sealed in everything, from aldehydes, to mold The bold and mildew and even innovation unpleasant odors.

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CONTENTS 4&15&.#&3t70-6.& /6.#&3












Design in living s g senior paces



22 Embracing QAPI: Part 6





26 Protect Residents from Financial Abuse BY TOM EALEY

28 How to Align Resources for Post-Acute Care Forging smart strategies for controlling costs can make post-acute companies into great referral partners BY JIM BOWE

30 OSHA’s Whistleblower Protections


Increas in nurs ing minimum ing hom RN hou rs es


The final steps of this series illustrates QAPI in action

At times, trusted resident representatives might not be so trustworthy. A facility has guidelines to follow

EDITORIA L Editor-inChief Pamela Senior Tabar Editor Lois A. Man

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What companies need to know about employee complaints to OSHA—and the laws that protect them BY STEVE WILDER, CHSP, STS

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Designing senior living spaces By Pamela Tabar, Editor-in-Chief


leven architecture and design experts, three editors, four conference planning team members and one (very long) day. I recently took part in a cross-curriculum committee that met in Baltimore with a sole task: to sort through all the presentations submitted for the 2015 Environments for Aging (EFA) Conference. The committee’s advanced degrees, certifications and credentials filled the room and spilled out the doorway—AIA, LEED AP, dementia design specialists, senior living consultants and PhD gerontologists. The annual EFA Conference is a literal mind-meld of the country’s leading architects, designers and land planners of senior living spaces. They are the experts who research, design, plan and build/renovate the campuses and communities in which providers work and deliver care every day. Although the conference began (back in 2009) primarily as an educational and networking forum for architects, designers and vendors of senior living’s physical environments, these days the conference has grown to embrace the crucial component of providers—owners, operators and caregivers—all of whom are themselves becoming increasingly involved in the renovation and construction decisions being planned at their senior care sites. More than 80 educational sessions had been submitted for consideration, and it was our group task to choose the very best 45 or so. The committee was in unanimous agreement about some submissions, while other proposals sparked vibrant debate. Every presentation was examined for its contribution to advancing knowledge, the depth of its material and its application in real life. In every case, it was a room-wide discussion and not just a “vote.” In every case, we asked, “Does this presentation truly raise the bar on the educational aspect of the conference?” The trends that emerged from the submitted presentations:

EDITORIAL Editor-in-Chief Pamela Tabar Senior Editor Lois A. Bowers Managing Editor Sandra Hoban Associate Editor, Reader Engagement Megan Combs ART Creative Director Eric E. Collander Art Director Rebecca DeNeau Senior Designer Suzanne Quintero SALES National Sales Manager Bill Rodman 1IPOFt'BY e-mail [email protected] Directory Sales Elana Ben-Tor [email protected] Ph: 216-373-1202 Traffic Manager Judi Zeng Please send IOs to [email protected] All ad materials should be sent electronically to: https://vendome/sendmyadcom ARTICLE REPRINTS 'PSSFQSJOUTBOEMJDFOTJOHQMFBTFDPOUBDU +JMM,BMFUIB 'PTUFS1SJOUJOHtPS  FYUtKJMML!GPTUFSQSJOUJOHDPN CUSTOMER SERVICE www.ltlmagazine.com/page2/subscribe MUMWFOEPNF!BETHJOGPt1I REUSE PERMISSION Copyright Clearance Center 1IPOFt'BY FNBJMJOGP!DPQZSJHIUDPNt8FCXXXDPQZSJHIUDPN ADMINISTRATION Chief Executive Officer Jane Butler

 t.FNPSZDBSF PGDPVSTF#VUJOTUFBEPGiMFUTCVJMEBOFXNFNPSZDBSFDFOUFS wUIJTZFBST submissions dive deeper (and more realistically) into the subjects of renovations and refurbs, as well as the ways in which facilities can incorporate the body of learning on dementiafriendly design across an entire campus instead of just a dedicated dementia wing.

President .BSL'SJFE

 t.PSFFEVDBUJPOBMJOGPPOUIFQSPKFDUQMBOOJOHQSPDFTT XJUIQSFTFOUBUJPOTUIBUBDLOPXMedge how providers are involving more of their team members in the process of repurposing sections of their senior care sites for new services.

Chief Content Officer Charlene Marietti

Vice President Ron Lowy Vice President, Finance Bill Newberry Vice President, Custom & Strategic Account Services Jennifer Turney Chief Marketing Officer Dan Melore Director, Digital Marketing Daniel P. Timoney Director, Circulation Rachel Beneventi

 t.BOZNPSFQSFTFOUBUJPOTUIBUJODMVEFUIFiUFBNTQFBLFSwQSFTFOUBUJPONPEFM JODMVEJOH an architect/designer and a provider as co-presenters. (In fact, as a committee, we chose to send several excellent proposals back to the submitters, asking them to include a provider in the presentation.)

Director, Production and Web Development ,BUISZO)PNFOJDL LONG-TERM LIVING MAGAZINE ONLINE: www.ltlmagazine.com

If your facility is in need of structural changes or renovations to enhance care delivery or to revamp your service lines, then April’s 2015 EFA Conference could be a “don’t-miss” learning opportunity for you. To learn more, visit our sister-publication at www.environmentsforaging.com.



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Increasing minimum RN hours in nursing homes Judi Kulus, NHA, RN, MAT, RAC-MT, C-NE


he “Put a Registered Nurse in the Nursing Home Act” (HR 5373) was introduced in Congress on July 31, 2014, to the House Committee on Ways and Means and the Committee on Energy and Commerce. While the name of the bill may seem a little awkward, the goals are not. HR 5373 would require that each Medicaidand/or Medicare-certified nursing home provide a registered nurse (RN) on duty 24 hours a day, seven days a week. Current federal law requires that each nursing home have at least one RN in the facility for eight hours a day, seven days a week. In some cases, facilities can apply for a waiver and can share an RN with one or more other facilities. Often the director of nursing functions as the RN on duty to meet the current requirements. This bill would expand these minimum staffing levels so that there would be a direct care–focused RN on duty 24 hours a day. Why is this so important? RNs are the only nursing personnel with the education and licensure to conduct headto-toe physical assessments, interviews and record reviews in order to draw conclusions about nursing diagnoses, appropriate nursing interventions and care planning; to continuously monitor and evaluate interventions; and, finally, to lead the healthcare team in providing care for each patient. RNs are also the nursing home staff members who work


directly with patients and with other medical professionals to develop plans of care that promote the patients’ highest level of health and well-being.1 The RN assessment function is especially critical when a patient has an acute episode or a flare-up of a chronic condition. When a patient experiences a decline in status during the evening or night shift and there is no RN in the facility, the assessment and coordination functions may suffer. While the licensed practical nurse (LPN) plays a critical role in caring for patients, according to most states’ nurse practice acts it is the

responsibility of the RN to assess and coordinate patient care. A number of staffing studies have shown that a higher level of RNs leads to higher quality of care for patients.2-4 A strong coalition of associations has joined together to support this initiative. One member organization that has done a lot of work on nursing home staffing issues is the National Consumer Voice for Quality Long Term Care. This summer, they rolled out a staffing campaign called Better Staffing: Key to Better Care. Their resources help consumers and providers alike be informed of the importance of staffing levels in nursing homes. For many months, representatives from member organizations of the Coalition of Geriatric Nursing Organizations (CGNO) have been working with Congress to propose this RN staffing bill, https://beta.congress.gov/bill/113thcongress/house-bill/5373. One CGNO member organization is the American Association of Nurse Assessment Coordination (AANAC). Diane Carter, president of AANAC, is thrilled to see this legislation move forward in Congress, stating, “With higher registerednurse staffing, patients have fewer pressure ulcers and urinary tract infections and catheterizations. They stay out of hospitals longer. Their care improves, but it costs less. And these homes get fewer serious deficiencies from state inspectors. This is one of the most significant pieces of nursing home legislation that could impact positive patient care outcomes since the introduction of OBRA ’87.” The Omnibus Budget Reconciliation Act of 1987 (OBRA ’87), mandated that nursing home staff provide care that helps patients attain and maintain their highest practical physical, mental and 888-5-."(";*/&$0.






psychosocial wellbeing. Nursing homes have come a long way in 20 years, but more work is needed. Under Carter’s direction, AANAC assessed Judi Kulus, NHA, RN, staffing data MAT, RAC-MT, C-NE from the OSCAR (Online Survey, Certification and Reporting) reports in 2012. Through this analysis it was discovered that only 1,777 nursing homes reported staffing fewer than four RNs per day. This was good news. Carter determined that only 11.4 percent of facilities fail to cross that critical threshold; filling the gap is not an insurmountable task. So what can you do to support this important initiative? Please contact your representatives and ask them to

contact Waverly Gordon in Rep. Jan Schakowsky’s office, (205) 225-2111 or [email protected], and sign on to this bill. Additionally, contact your senators and ask them to introduce this bill in the Senate. By supporting continuous direct-care RN staffing, they will ensure that some of America’s most vulnerable citizens have the care they deserve in nursing homes. With a groundswell of public support from patients, families, and nursing home staff, we can see this bill enacted. LTL Judi Kulus, NHA, RN, MAT, RAC-MT, C-NE, is Vice President of Curriculum Development for the American Association of Nurse Assessment Coordination (AANAC).




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in the USA.



Rx for Parkinson’s: Patience and safe modifications By Tobi Schwartz-Cassell



aring for residents with Parkinson’s disease (PD) requires an understanding of the unique ways in which the disease affects their muscles and nervous system, as well as the critical importance of precise medication management. Most caregivers are familiar with the symptomatic “shakes,” but those with PD often have challenges in processing information and getting their bodies to obey movement commands, too. “We have one client who describes her symptoms as standing in a bucket of wet cement,” says Jane Geiger, director of marketing at Parkinson’s Specialty Care (PSC) of Golden Valley, Minn. PSC is a two-pronged program dedicated to the wellness and quality of life of their clients. Its professionally trained caregivers serve clients across six, six-unit assisted living residences. “We really stress patience,” Geiger says. “As the Parkinson’s progresses, it causes a slowness in movement and thought process. Many times you’ll ask someone with PD a question and it’ll take them a

Most caregivers are familiar with the symptomatic “shakes,” but those with PD often have challenges in processing information and getting their bodies to obey movement commands, too. WWW.LTLMAGAZINE.COM

long time to answer. It’s not that they’re confused, deaf or don’t understand you. It’s a slowness in processing and you can cause a lot of stress by hurrying them.” At every residence in the PSC system, “Medication management is huge,” Geiger stresses. “Parkinson’s medications have on and off periods. When the medication wears off, freezing, stiffness and rigidity come on really strong. You don’t have that one-hour window like you do with other medications. We have a 15-minute window. Otherwise, their symptoms can come on and it could ruin their whole day.” Balance is another challenge for PD patients says Geiger. “If they have problems with their stride it can cause retropulsion where they’re falling backward. So you don’t want to distract them because they’re focusing really hard on every step. If they freeze, put your foot in front of theirs and tell them to step over it. Just that command can get them going again.”

Although PD is classified as a movement disorder, communication and nutrition can also be severely affected. In terms of communicating, “You should always be in a well-lit room because as the communication partner, you want to be looking at mouth movement. You need to get cues from them and they should get cues from you,” says Mary Beth Mason-Baughman, PhD, CCC-SLP, associate professor of Communication Sciences and Disorders at Clarion University in Clarion, Pa. Most therapists use the LSVT (Lee Silverman Voice Treatments) system, pioneered by Lee Silverman, who created the LSVT LOUD and LSVT BIG training certification programs. “When those with PD are talking, they’re using the amount of force they’ve always used, and they think the volume is the same it’s always been,” says Mason-Baughman. “But those muscles aren’t working as well so they aren’t getting the same impact as they once did. The LSVT LOUD program gets them thinking about putting more effort into talking. They’ll feel like they’re yelling, but it’ll be a good normal volume.” Physical and occupational therapists are trained in LSVT BIG, a whole-body PD treatment system. Stephanie CombsMiller, PT, PhD, NCS, an associate professor and director of research at Krannert School of Physical Therapy at the University of Indianapolis, Ind., says, “Growing evidence shows that exercise, activity and any type of mobility can help manage the symptoms of PD. A neurologist I work with tells her patients that exercising is almost as important as taking their medicine. “In a long-term care situation, residents shouldn’t stay in bed or sit all day. They need to be as active as they’re able, in a t-0/(5&3.-*7*/(t

CARE MANAGEMENT safe way. I realize that staff has a lot of patients to care for, but if they can get them active and moving, that’s going to help preserve their mobility, plus they’re going to feel better, be more alert and aware, and it’s going to help boost their medications.”

8 ADDITIONAL TIPS 1. Limit distractions. “If I go into a resident’s room to have an exchange and the TV is on, I always ask, ‘is it okay if I turn the TV off? I promise to turn it back on when we’re done.’ I’ll close the door if someone is vacuuming the hall. They’re already putting effort into speaking, so try to make it easier for them,” Mason-Baughman says. 2. Encourage residents to simplify what they’re saying. 3. Have residents sit upright to eat. 4. Be respectful. “If residents are feeding themselves, ask if they want their food

cut up. If they do, cut the food in bitesized pieces,” Mason-Baughman says. 5. Encourage them to drink throughout their meal. “Always make sure they have lots of drinks available in case food gets stuck in their mouth or throat,” Mason-Baughman adds. “Have them take a drink after every bite rather than saving it until the end of their meal. If time runs out at lunch and they haven’t been drinking, they risk dehydration.” 6. Become familiar with their food preferences and eating habits. “I’m a person who doesn’t like my food to mingle, other people like to mix things up,” Mason-Baughman says. “Little things like that can make a big difference in a person’s quality of life.” 7. Form affinity groups. Residents with PD often seek support from each other, Combs-Miller notes. “People with similar states of the same disease

tend to lean on each other and develop cohesive groups. They build camaraderie because they’re experiencing similar problems. Staff members can help build these networks, even if it’s just to get them out of their rooms to play cards.” 8. Form movement groups. “Develop a video exercise program they can do together or take them on walks. We find they’re more likely to stick with it for a longer period of time if they’re doing it together,” says Combs-Miller. Proper training can provide better care and better quality of life for those with PD, Mason-Baughman says. “I want them to enjoy their apple pie for as long as they possibly can.” LTL Tobi Schwartz-Cassell is a freelance writer based in Cherry Hill, N.J.

Congratulations on Winning the National OPTIMA Award 2014 We are proud to be your partner in helping seniors to connect, contribute and lead healthier lives.

Connected Living Network – Cloud Technology Connected Living University – Life Long Learning Connected Living Consulting – Engagement For more information contact us at: www.connectedliving.com












What if dementia care was really about keeping residents connected and engaged every day, instead of about mourning the memories that are fading away? This year’s winner of the Long-Term Living OPTIMA Award has taken dementia care programming far beyond reminiscing, brain-games and once-aday-activities; focusing instead on challenging residents to learn

and interact with each other—all day, every day.





Joshua Freitas leads resident Mary in “chair dancing” during the musical exercise program.




Eleven residents, all with diagnoses of varying stages of dementia, sit around a long table, wearing food-handling gloves. The staff leaders (all CNAs) pull in a cart laden with fresh fruits, explaining that the group needs to help prepare the fruit salad for the big Hawaiian luau meal planned for later, as the culmination of “Hawaii Week.” The leaders pass out bananas while asking the residents: “What needs to happen first?” “Peel them,” one resident says. As the peels are set aside, the room fills with the fragrance of bananas, prompting some residents to pipe in with their memories of picnic banana sandwiches or eating banana cream pie. Using the (safely dull) table knives, one resident cuts thick banana chunks for the community bowl, while another resident labors over her microthin slices, constantly asking, “Is this OK?” Another resident chooses to eat the whole banana himself. Meanwhile, the leaders talk about the texture and smell of bananas and ask what kinds of desserts bananas can be used for. Monkeys somehow come into the conversation at one point, and that’s OK—because it’s the engagement that matters.

Residents are welcome to touch and play the music station instruments.

16 • SEPTEMBER 2014

Associate Margaret Kargbo gets resident Everett onto the dance floor for a polka.


his is just one of the many activities the residents at The Atrium at Drum Hill take part in every day. Drum Hill, North Chelmsford, Mass., is part of the Benchmark Senior Living chain, which encompasses 50 sites across Massachusetts, Connecticut, New Hampshire, Rhode Island, Vermont and Maine. Benchmark’s memory care programming asks residents to stretch their brains all day, every day. As an all-memory-care community, Drum Hill’s 50-bed residence has served as the advanced site for Benchmark’s dementia care programming, which began in 2012. The goal is to engage residents in meaningful activities that cross the spectrum of the brain’s processes—tapping into the intellectual, physical, social, emotional, spiritual and purposeful community interactive aspects of thought processing and communication (See “The six dimensions of engagement,” p. 18). Above all, it’s about resident participation. Instead of insisting that a question must produce a certain answer or a “correct” memory, the caregivers (called associates) focus on simply having a discussion that helps residents join in. They call it “quilting a conversation.” One resident’s distant memory could prompt another resident’s current-day thoughts, which could prompt yet another resident to talk about a particular event he enjoyed back in 1975. But it’s all actual, active, daily conversa-

tion—and it’s one of the most difficult things to get residents with dementia to do on a regular basis. Activity programming, once viewed as a single session or activity in a resident’s day, has become Benchmark’s whole purpose and vision. The logic behind it is that even as dementia progresses, residents can still continue to remain engaged people if they are given a forum that stimulates the social, emotional and intellectual parts of their minds on a constant basis. “It’s a myth that people with dementia can’t learn new things,” says Joshua Freitas, director of memory care innovation and services. “People think it’s puzzles and games that exercise the brain, but it’s really learning new things.” One of Benchmark’s resident “engagement boxes” is called “A Day at the Beach.” While interacting with the real-life materials in the box, residents can sink their fingers into a container of sand, rub suntan lotion on their arms and touch seashells while listening to the sounds of waves—a multiplex brain-wave orchestra that accesses multiple parts of the brain’s processes simultaneously. The box is both a process and an avenue, Freitas explains. The activity taps into various parts of the resident’s brain processes, including emotional responses, intellectual thoughts, old memories—and the formation of new ones. Freitas, who is certified by the Alzheimer’s Foundation of America as a demenWWW.LTLMAGAZINE.COM

COVERSTORY tia care trainer, refuses to be called the “inventor” of Benchmark’s programming, citing the many progressive thinkers he has encountered during his studies as a music therapist and its dementia care applications. But his energy is contagious; he visits the Drum Hill community every week, and he knows every resident by name. Too many memory care programs ask residents only to recall the past, instead of focusing on what their brains are still capable of learning anew, Freitas says. “I want to push the standard in the industry, because it’s set too low.” Resident engagement can still be activated in many other parts of the brain, says Krystee Ryiz, Benchmark’s corporate director of programs and customer engagement. Indeed, the residents often participate in activities meant to serve others, the key “community purposeful engagement” part of the programming. Drum Hill’s residents have sewn cat beds and made homemade dog biscuits for the local animal shelters, while reading about animals and watching videos about the relationship between people and pets. No one cares if some of the kitty beds turn out too small—it’s the resident participation in the project—the activation of resident brains toward a meaningful task—that matters. “Benchmark’s program represents our memory care residents engaging in life, and

the heart represents the inner person before the disease,” Ryiz says. “The four components of our program are the routine daily calendar, the daily curriculum, the engagement boxes and our signature programs. So it’s all about engaging the residents to do something new every day.”

As Hawaiian music plays from a nearby CD player, the luau fruit-cutting group has moved on to kiwis. Holding the fuzzy green fruit, one resident says, “What, a Keedee?” “No, a KeeWee,” the leader replies. The resident, suspiciously shaking her head, says, “Well, I’ve never heard of that fruit before.” “It grows in New Zealand,” the leader explains. A few seconds later, another resident giggles and whispers to his tablemate, “I thought we were talking about Hawaii!”

Benchmark’s programming concept has its roots in the combination of Benchmark’s existing assisted living mantra and Freitas’ 2012 idea for a memory care reading series, built on topics that might be of interest to people aged 65 to 80. Residents could read a large-print booklet to learn more about Frank Sinatra, a famous painter or Mexican

Allison Zwaschka asks resident Biruta to suggest a song for the group to sing. WWW.LTLMAGAZINE.COM

cooking, either on their own or in a group with an associate leading a conversation (See “The reading series,” p. 18). “We thought we could relate Benchmark’s assisted living program of ‘Live Now, Live Well’ and apply that to memory care in a greater way,” Freitas says. “So we changed it to ‘Live Now, Live Engaged,’ since our memory care residents are coming with us to be engaged.” The programming concept took off like wildfire. Soon, caregivers and residents’ families had ideas for more booklet topics, which Freitas readily added to the series. As of August, more than 320 booklets fill the reading series portfolio, which, thanks to funding from the Benchmark corporate level, has recently been rolled out across the entire Benchmark chain. In the past four months, the programming concept has ballooned into the addition of engagement boxes and “journey stations” placed around the Drum Hill residence, each one focused on a specific topic (sports, childcare, music, gardening)—each meant to stimulate interaction with the touchable and readable items displayed. Each station serves as a leader-based lesson point for activities, but the exhibits remain in place for residents to interact with them on their own as well. Each station includes items that residents are encouraged to interact with, as well as a list of questions

Associate Margaret Kargbo (center) helps residents Claire and Tony roll the community’s hand towels. LONG-TERM LIVINGt


L: Associate Margaret Yeboah (center) and a small group of residents explore the pets engagement box. R: Benchmark has dozens of different boxes for residents to interact with.

The six dimensions of engagement Benchmark Senior Living’s residents get their brains, memories and current thoughts exercised daily using the “six dimensions” of engagement. Every Benchmark program, now gathered under the mantra of “Live Now, Live Engaged,” uses six dimensions to encourage interaction with residents using the brain’s different ways of processing information—intellectual, physical, emotional, spiritual, social and community purposeful. Benchmark’s approach acknowledges research that shows that daily routines and structured “exercise” of the various parts of the brain’s processes can create a more supportive environment for those with cognitive decline, while keeping the brain thinking and working longer—and while reducing outbreaks of antisocial behaviors. Each of the six dimensions is involved in Benchmark’s daily programming and activities. Benchmark uses daily encounters with “engagement boxes” filled with physical materials that can prompt conversations, as well as a vast reading series meant to prompt residents’ minds to learn something new every day. Here’s the real key: All residents are involved in the engagement sessions each day, regardless of their cognitive abilities. “Residents, despite their cognitive challenges, can explore new opportunities, sustain and develop new skills and abilities, and continue having new life experiences,” says Krystee Ryiz, Benchmark’s corporate director of programs and customer engagement. “We want to engage our families, too, which is why we made the engagement boxes and our signature programs to engage with the local community.” 18 • SEPTEMBER 2014

that are designed to trigger the brain to engage in specific processes. For example, the sports display offers not only memory and current thought-provoking questions but also offers the hands-on texture of a real basketball and the scent of a well-oiled baseball glove, while offering a region-

appropriate book about Fenway Park. Each resident experiences the engagement boxes and journey stations every day, regardless of their cognitive abilities. Benchmark captures very detailed histories of its memory care residents, which often leads to the creation of new boxes,

The reading series Benchmark Senior Living’s journey began with a small idea that grew into a massive file cabinet of material. The reading series, first piloted in 2012, began as a way to engage residents in learning about new subjects. The series included short booklets on topics such as the biography of a sports figure or the hallmarks of Spanish cuisine. Each booklet is intended to exercise residents’ minds, encouraging them to read and to learn something new each day. Along the way, Joshua Freitas, director of memory care innovation and services for Benchmark, noticed that some of the residents had a difficult time reading the booklets. Older adults naturally lose some ability to discern colors as they age, but chronic conditions such as diabetes, macular degeneration, glaucoma, Parkinson’s disease and Alzheimer’s also contribute to color deficit vision, notes the American Optometric Association. Freitas changed the font to a larger type, added a large, red “next page” prompt and changed the text’s main font color from black to green—one of the last colors lost amid the aging eyesight’s color spectrum. Benchmark welcomed new ideas for the reading series from staff, residents’ families and residents themselves—and the program quickly skyrocketed. As of August, the reading series tops more than 320 booklets, all of which have now been shared across Benchmark’s entire chain. Photo: Joshua Freitas


COVERSTORY based on site-specific resident hobbies and interests. Families also get in on the endeavor, as many find the engagement boxes to be a great icebreaker for family-visitation activities and conversation-starters, Freitas says. Parallel programming is key for all memory care residents, says Allison Zwaschka, CDP, Drum Hill’s program coordinator. The boxes and stations are woven into the fabric of the main topic for each week. This week’s focus on Hawaii includes several videos about the Hawaiian Islands, Hawaiian foods, the cultural significance of grass skirts and colorful leis and, of course, the island music underlying it all. “When families visit, they’re surprised to see their loved ones interacting,” Zwaschka says. “We hear, ‘My mom’s so isolated she’s never going to get involved in anything’ a lot. But our residents don’t spend much time in their rooms. A lot of our family visits turn into group activities and multigenerational activities.”

The fruit-cutting squad has gotten to the fresh strawberries, a fragrance-bursting memory trigger for the residents. “I remember picking strawberries as a girl,” one woman says. Another resident adds, “We ate most of them before we got home.” The leader uses this comment to involve others, asking, “Who else did this? Did you get in trouble when you got back home with no berries in your bucket?” Then always asking: “Think of another recipe with strawberries in it.”

Each CNA cares for the same six to eight residents daily and is involved in every part of their lives, including nutrition, exercise, activities and health needs. So each CNA has a unique viewpoint—and input—on how the programming is applied. Tweaking the timing of the programs can optimize residents’ abilities to participate, such as placing intellectual activities right after breakfast and sensory activities after lunch, explains Margaret Yeboah, who has been a Drum Hill associate for 13 years. Program placement also plays a key role in warding off “sundowning,” a period of WWW.LTLMAGAZINE.COM

Resident Mary (left) and a visiting friend team up on the activity.

Above: While others cut the fruit, Associate Lauren Metzler asks resident John to stir the bowl. Below: The project encourages residents to socialize while working on finger dexterity and mental focus.

COVERSTORY heightened confusion and agitation that can occur late in the day. The Benchmark programming vision has affected the CNAs, too—most of the associates have been with the organization for more than 10 years, a turnover rate far lower than the national average. Ryiz will be spending the next year gathering deeper data, analyzing how the programming has reached residents and determining how best to expand the new program across the Benchmark chain. Freitas will be busy training new associates in the memory care program, as certified by the Alzheimer’s Foundation. The eventual goal, he says, is to have single Benchmark associate/caregiver trained and certified. But at Benchmark’s Drum Hill site, associates and families have begun to weigh in with early data already: Residents who participate in the project have been 33 percent more communicative and participatory during just the past six months. Caregiver associates have reported a 78 percent decrease in “challenging behaviors” among residents after just 30 days of using the program, and families also have agreed (in a separate survey), reporting a 71 percent decrease in such behaviors. More than enough for Benchmark to know the program is on to something big in the future of memory care.

The Atrium at Drum Hill, North Chelmsford, Mass.

About the OPTIMA Award care and resident quality of life. The OPTIMA Award winner is selected

See additional coverage of Benchmark Senior Living’s award-winning program at www.ltlmagazine.com/EngagedJourney.

by a judging panel of experts from the long-term care industry using a


Healthcare Media, is involved in the judging process.




term care communities that enact proactive projects to enhance resident



Since 1996, the annual Long-Term Living OPTIMA Award has honored long-


Today, resident Bob chooses to settle down in the chair at Drum Hill’s “sports journey station,” reading through a recent copy of Sports Illustrated. He may be reminiscing about the World Series of 1942 or thinking about today’s Red Sox box scores or connecting his own personal experiences with the magazine’s pictures of a batter at the plate—but it all matters equally to his engaged brain.

L to R: Allison Zwaschka, Joshua Freitas, Krystee Ryiz


double-blind entry-judging process and adjudicated by a third-party award coordinator. No one from Long-Term Living or its parent company, Vendome

To see the list of previous OPTIMA Award winners, visit www.ltlmagazine.com/OPTIMA2014. t4&15&.#&3





n 1999, the Institute of Medicine Committee on Quality Health Care in America released a report called To Err is Human: Building a Safer Health System. This report concluded that individual accountability is necessary; however, the root of the problem with medical errors or unintentional patient/resident harm is not the healthcare professionals’ competency or good intentions. The committee’s approach was that the safety of care, defined as freedom from accidental injury, is the responsibility of the system of care, not just the individual providing the care. Imposing reporting requirements and holding people and organizations accountable provides data. They are component of patient/resident safety but do not by themselves make systems safer or processes more efficient. Patients/residents are safer in all care settings in which specific attention is given to ensuring that care processes are designed to prevent, recognize and quickly recover from events and errors before harm occurs. Well-designed systems of care that focus on establishing processes and procedures make it easy to perform a task correctly and more difficult to do it incorrectly. Hidden in errors and near misses is the

The collective synergy of a team is the most efficient fuel for moving a systematic problemsolving process forward. t4&15&.#&3

cause of the problem, interventions can be identified that will more effectively manage or eliminate it. Completing an RCA helps the NH team working to resolve the problem look STEP 11: GET TO deeper than the most obvious THE “ROOT” OF THE reasons for the problem or PROBLEM undesirable outcome. Root cause analysis (RCA) All of the 12 QAPI steps are is a process for intentionally symbiotic. The RCA process drilling down to the reasons aligns with other QAPI steps, why an adverse event occurred including Step 2: Develop a or nearly occurred. Nursing Deliberate Approach to Teamhomes (NHs) are challenged work. The collective synergy to reframe their thinking and Nell Griffin, LPN, EdM of a team is the most efficient break down silos to improve fuel for moving a systematic problemcare delivery. Healthcare quality is publisolving process forward. QAPI at a Glance cally reported on Medicare’s Nursing presents tools for two problem-solving Home Compare, “Business as usual” is not models, which are discussed in detail later. an option for NHs with quality-of-care For some PIP (Performance Improveissues. ment Project) teams, the basics of the As revealed in To Err is Human, susproblem statement are included in the PIP tainable high performance is a result of charter, established by the Steering Team/ processes designed with respect to staff Committee. The problem to be solved is weaknesses and strengths that support the part of the charter. System problem-solvintent to do no harm. Except for instances ing begins by defining the problem and of deliberate abuse, adverse healthcare crafting a problem statement. events or near misses are rarely attributed to a healthcare provider’s purposeful intent WHAT’S THE PROBLEM? to inflict harm. An RCA will identify the The problem statement indicates the causal factors that are the source of the issue(s) to be addressed by describing system problems resulting in an adverse the problem. It is concise, specific and event. measurable, specifying who and what is impacted. Input from the problem-solving ROOT CAUSE ANALYSIS team confirms mutual understanding of Quality Assurance Performance Improvethe issue. The Centers for Medicare & ment (QAPI) is a culture change process Medicaid Services (CMS) provided a tool and a fundamental requirement for both to help NHs with this process is Guidhigh- and low-performing facilities. QAPI ance for Performing Root Cause Analysis at a Glance, details how to get to the (RCA) with Performance Improvement “root” of the problem. An RCA describes Projects (go.cms.gov/Nhqapi). This tool a systematic process for identifying the breaks the RCA process into seven steps. contributing causes leading to an undesirThe guidance discusses how to craft the able outcome. Armed with the true root information needed to design, update and sustain an efficient process to make correct task completion easier.


©2014 MMIC Group, Inc.

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POLICYMATTERS Getting to the root of the problem is an essential part of QAPI. All quality improvement organizations can provide technical assistance for this process.

problem statement and includes a sample of an effective problem statement (see helpful hints in the first step). The bottom line of a good problem statement is that every member of the team agrees that the problem statement is effective for that team.

TOOLS TO ASSIST RCA The cause and effect diagram is a structured team process for identifying factors and causes for an event, problem or a near miss. CMS provides an online tool called “How to Use the Fishbone Tool for Root Cause Analysis.” The fishbone diagram (below) is useful for moderate to difficult problems a team has been tasked to solve. The more complex the problem, issue, event or near miss, the more difficult it can be to identify the true root causes. Recurring adverse outcomes indicate that more difficult, less obvious root causes are at the heart of the problem. Beginning with the problem statement at the head of the fishbone diagram, the team agrees on the major categories of causes for the problem. The common categories include equipment or supplies; environmental factors; rule or policy; and people or staff. Causal ideas are listed by the team under each category on the fishbone. Responses generated by the team from continuously asking “why?” will help it identify and address the root causes under each of the categories. Part of completing an RCA is planning for the t4&15&.#&3

time needed to complete it. The CMS online tool for this process, called “Five Whys Tool for Root Cause Analysis,” can be used to get to the root of a problem, which involves listing the contributing factors of an undesirable outcome and asking why. The team’s responses to each “why” question about a contributing factor has to be based on the actual facts of the problem to get to the true underlying causes. Five questions and answers is not a requirement of the process. Armed with the facts of the event, the team answers the “why” question until it agrees that the root cause has been discovered. Then members can validate by asking whether removing it will prevent a recurrence of the problem. If team members agree that the responses to the validating questions is no, then that is not a root cause. If the team agrees the answer to the validating question is yes, then the team can agree this is a root cause and decide on a corrective intervention. After the team decides on an intervention, a Plan Do Study Act (PDSA) cycle will allow them to implement tested solutions. Getting to the root of the problem is an essential part of QAPI. All quality improvement organizations (QIOs) can provide technical assistance for this process. The QIO serving Illinois and Iowa (www.telligenqio.org) offers webinars Equipment/Supplies

and resources, including a recorded webinar titled “Root Cause Analysis” on its website.

STEP 12: TAKE SYSTEMIC ACTION QAPI is data driven. The data available to NHs to drive their process improvements can come from many sources, but data is needed to make improvements in systems and processes. The 12th, and final, QAPI step is Take Systemic Action. Typically, NHs react to data. Currently, NHs review data and improve systems as the data indicate a change is needed. Complaints, surveys, lower quality measures compared with the nation, the state or other peers, or an NH’s own internal numbers for events such as falls or turnover, are examples of data that a facility steering team can use to drive system improvements. Data revealing events with negative outcomes, missed targets or near misses indicate that systemic improvements are needed and that the steering team should consider chartering a PIP team to uncover the reasons for the problem by conducting a root cause analysis. Before systemic action can be taken, the root cause has to be identified, as discussed above.

CORRECTING A ROOT CAUSE After identifying the root causes, sustainable corrective actions become the goal. Changes that correct the root cause are the most effective and the most sustainable improvements. Strong corrective actions are

Environmental Location, physical layout, visibility Building safety Problem statement

Standards or compliance with standards

Lack of ability, supervision, scheduling Communication

Document issues Rules/Policies/Procedures

Lack of knowledge, information

Scheduling Staff/People

Example of a fishbone diagram. 888-5-."(";*/&$0.

POLICYMATTERS While thinking of ways to deal with a problem, it is important to think of ways to prevent recurrences. those that involve physical changes, force functions or constraints, and simplify the process. Intermediate actions are those that are somewhat dependent on staff competencies and abilities with accompanying tools to support and assist. Intermediate actions such as decreasing workload, initiating checklists, executing enhanced documentation and communication processes and implementing enhanced or modified software are intended to and likely will improve existing processes. Weaker actions are those that rely on staff to remember training or policies. Weaker actions include double checks, warning labels or training and education only. These actions likely will enforce existing processes but may be more difficult to sustain. There may be times when each type of action is appropriate.

PERFORM A SYSTEMATIC REVIEW An objective of QAPI is to be proactive. Adverse events and near misses should always trigger a systematic review, but the goal is to have systems designed to decrease the probability of a negative outcome. The “Guidance for Performing Failure Mode and Effects Analysis with Performance Improvement Projects,” available on the CMS QAPI website, is a resource designed to support proactive systematic evaluation. The Failure Mode and Effects Analysis (FMEA) is a structured way NHs can identify and then address potential problems and their likely impact on the system before an adverse event occurs. The goal for any healthcare process is to meet each resident’s healthcare needs by delivering consistent, effective, highquality, cost-efficient, person-centered care to the right person at the right time. The WWW.LTLMAGAZINE.COM

FMEA tool is intended to help nursing homes achieve this goal. The FMEA tool can be used when evaluating a new process or system, or one that has existed for a while. It can be used by the Steering Team as well as within departments to guide the team through the following seven-step process. 1. Select a process to analyze. 2. Charter and select a team facilitator and team members. 3. Describe the process. 4. Identify what could go wrong during each step of the process. 5. Pick which problem to work on eliminating. 6. Design and implement changes to reduce or prevent problems. 7. Measure the success of process changes. To illustrate, few NHs have a systematic process to enhance the quality of residents’ sleep. Although rest and sleep are a major part of the treatment plan for a person with any condition, rest and sleep are rarely included in resident care plans or treatment plans. Because NH populations are comprised of people who often each have several comorbid conditions, improving resident sleep supports person-centered care. The Midwest Best (www.metastar.com) is a consortium of seven quality improvement organizations (QIOs). On May 6, this consortium sponsored a downloadable webinar titled “A Solution to Preventing Falls and Providing Quality Sleep.” Speaker Sue Ann Guilderman presented the Restorative Sleep Vitality Program. Included in the handouts is “The Restorative Sleep Vitality Program Checklist,” which identifies the top 10 sleep disturbances and interventions that can be implemented. Detailing the process to enhance a resident’s quality of sleep by addressing these sleep disturbances will involve every department and every system in the nursing home. The FMEA is a tool designed to allow NHs to be proactive and identify potential obstacles and barriers to the consistent successful practice of a process or procedure. By analyzing the impact of a NH’s current practices in every department on resident’s

sleep, the team will likely uncover improvement opportunities in the systems within each department. From the 5 Elements (see Step 3) to the 12 Action Steps, QAPI is anchored in system improvement. All the tools and resources are designed and intended to help NHs improve their systems. Process improvement must be a priority. It requires a change in how daily activities are viewed. Looking for improvement opportunities in every event, problem or process needs to be encouraged and practiced. Administrators, director of nursing, department heads and other leaders have a huge impact on the NH culture and staff’s overall mindset. QAPI is a culture change for many. Deciding to just deal with a situation or problem is not enough. While thinking of ways to deal with a problem, it is important to think of ways to prevent recurrences. Not allowing new ideas to die in isolation but taking them through the systematic improvement process is a radical change for many. All new ideas may not be feasible or usable. Proactive NHs create processes for considering and prioritizing new ideas since they are a fundamental component of system improvement.

FINAL THOUGHTS Urgency is built into the everyday work of NHs. The enemy many nursing homes identify is time. They can’t find the time to make improvements because they are busy dealing with the day to day issues. The solution is to allow the reactive and proactive activities to exist in the same moment. Instead of focusing only on dealing with an issue, simultaneously focus on dealing with the issue and on ways to prevent a recurrence. Make the reactive activity of dealing with the issue and the proactive activity of preventing the same or similar issue, equally important. The new mindset is not to get through it but to improve it. Change takes consistent effort. Choose to make system improvement a priority every day. LTL Nell Griffin, LPN, EdM, is a Healthcare Quality Improvement Facilitator, a certified TeamSTEPPS Master trainer and author. She can be reached at [email protected].





he federal Consumer Financial Protection Bureau (CFPB) recently published a guide for long-term care (LTC) and assisted living (AL) facilities Protecting Residents from Financial Exploitation that provides case studies and recommended actions when abuse is suspected. The CFPB was created by the federal government in the wake of the 2008 financial meltdown and has wide authority to deal with the financial abuse of American consumers. As the guide points out, a facility receiving federal funding is responsible to report “any reasonable suspicion of a crime,” including financial crimes. It also includes protection for employee whistleblowers. What the law does not specify is the duty and authority to investigate, that is, how much the facility must delve into resident financial and family matters. This guide certainly implies a significant duty to protect residents. Consult your legal counsel for the exact requirements in your state. When the possible abuse is being committed by a facility employee, there is a duty to discover and correct. But as the guide makes clear, much of the abuse is committed by family members and financial surrogates (next of kin, powersof-attorney [POAs] and guardians) over whom the facility has very little authority. This point matches the findings of a decade of my research into financial abuse of the elderly.

DEFINING THE PROBLEM The three major categories of abusers are listed as: t4&15&.#&3

t USVTUFEQFSTPOTëOBODJBMTVSSPHBUFT t TUSBOHFST BOE t GBDJMJUZQFSTPOOFM Facilities often are placed in the middle of family conflicts, some of which might center around financial matters. Getting into the middle of family battles is not a rewarding position, but at some point protecting the residents might require investigation and referral to authorities (be especially aware of state laws requiring referral to human services agencies). Facilities have no specific investigative powers, and interfering in family relationships has its own dangers. The facility is

charged with being aware and alert to the condition of the resident, but at the same time there can be problems with diving into the middle of family or financial relationships. Often the abuse is taking place far away from the facility, and often the abuse is carried out slowly over a period of time. Picking up the warning signs might be difficult, if not impossible. One of many questions for your attorney is, “What is our liability if we miss criminal activity by a trusted person or stranger?” Another is “if we make a report and it turns out not to be true, or cannot be proven, do we get sued for defamation?” 888-5-."(";*/&$0.

FINANCIALMATTERS COGNITIVE DISABILITIES The mental alertness and orientation of residents will vary from 100 percent functional to near 0 percent cognitive abilities, and while every one of the residents has some vulnerability to scams, the low-functioning residents may be especially vulnerable. Even the most alert and oriented resident in the building may have trouble comprehending complicated financial transactions. All of us who have ever explained health insurance to a family understand how confusing modern financial transactions can be. Is an appointed guardian a guarantee of financial integrity? Unfortunately, many jurisdictions are now wrestling with a sad reality: Most guardians are not being monitored. This situation allows some to misuse guardianship funds, so the answer is no. And persons holding financial powers of attorney get almost no scrutiny until somebody notices a problem. The administrative and nursing staff should be trained to be vigilant, particularly when asked to witness or notarize legal documents, such as POA forms and “deathbed wills.” Generally these requests should be refused by staff and referred to the administrator.

ACTION STEPS The CFPB offers an outline for facility action: t QSFWFOU t SFDPHOJ[F t SFDPSE BOE t SFQPSU Prevention is difficult because the facility has more responsibility than authority. The facility has a major duty to prevent theft and abuse by facility staff and its contractors, but family members and financial surrogates are difficult to monitor and control. And if a resident wants to give his/ her money to a church group, when is this genuine religion and when is it grand theft? Who wants to make that call? For example, the pastor and members of a church visit one of your residents WWW.LTLMAGAZINE.COM

frequently. Does your resident have the right to give all of her property and money to the church? If she is legally “competent” she may well be within her rights, but does this situation seem to take advantage of the resident and, therefore, bear the taint of abuse? If so, how does a facility prevent such conduct? Recognition is often difficult, but sometimes signs do appear. Administrators would seem to work under a “reasonable professional” assumption: If a trained and licensed administrator sees untoward conduct, then there should be recognition of abuse. Often the abuse comes on the radar in a more obvious way; the resident is unable to pay the facility bill. This situation allows the facility to contact family and financial surrogates and inquire about payment. If no answer is forthcoming, or multiple answers are forthcoming, more investigation is prudent. The CFPB guide lists many signs and symptoms and case studies, a review would be helpful for senior facility staff. Record whatever observations raised the alarm. Copy and safeguard any relevant documents, clinical notes and administrative records as appropriate. Reporting is the act of contacting the appropriate law enforcement agency; adult protective services; city police, sheriff or state police; and presenting your documentation. These are difficult issues, and the CFPB documents provide guidance while also creating an expectation of increased vigilance by the facility. LTL

Are you prepared to meet CMS established goals for reducing avoidable readmissions? Today’s increasingly regulated healthcare environment means more emphasis than ever before on lowering avoidable hospital readmission rates. As the leading geriatric pharmacy services provider, Omnicare Pharmacy successfully implements programs that can help you reduce avoidable re-hospitalizations and deliver positive resident health outcomes. To learn more about the tools and resources that Omnicare provides, visit www.omnicare. com/readmissions.

Tom Ealey has long-term care experience as a CPA (Ohio), management consultant and regulatory compliance expert and author. He is a professor of business administration at Alma College in Alma, Mich. Reach him at [email protected]. He is the author of Consumer Protection Series: Protecting Seniors from Financial Abuse, which is available as an Amazon.com e-book.

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

888-545-OMNI [email protected] omnicare.com ©2013 Omnicare




Editor’s note: This is the first report in a twopart series on post-acute care strategies and tactics.


very segment, every niche across the nation’s entire healthcare delivery system during the past several years has been inundated by an unprecedented wave of radical, disruptive transformation. With the emergence of risk-based, pay-forperformance reimbursement models such as accountable care organizations and bundled payments, clinically integrated care networks are rapidly spreading to answer the need for the seamless coordination of transitions between physicians, hospitals, rehab and skilled

Fundamentals driving clinically integrated care networks Clinically integrated care networks are rapidly spreading to enable seamless transitions between physicians, hospitals, rehab and skilled nursing providers, and community-based services. These risk-based, pay-for-performance reimbursement models have emerged: t Accountable care organizations. Typically pool 5,000 lives or more in a population health/wellness management model funded by an annual per capita fee that covers the costs of virtually all services across the care continuum. t Bundled payment. Providers bear risk under a flat rate structure that reimburses for entire episodes of care by dividing the fee among pertinent service providers across the care continuum.


nursing providers, and community-based services. The fragmented delivery systems predicated on the economics of volumedriven, fee-for-service procedures are giving way to a broader, holistic approach that uses clinical care pathways to comprehensively, cost-effectively manage entire episodes of care throughout multiple care delivery sites. So how does a post-acute care (PAC) operator take advantage of these seismic changes and get in the game?

DATA-DRIVEN METRICS The key to forging partnerships is developing data-driven metrics that track outcomes to validate a PAC operator’s qualifications and measure its ongoing performance. At the same time, PAC organizations also must analyze Medicare-related trends at their referring hospitals to identify opportunities for performance improvement that their acute care counterparts may have overlooked. By drilling into the performance data from the PAC operator and the analysis of hospital Medicare trends, both groups can jointly move forward to develop partnership strategies to improve outcomes, increase efficiency, reduce costs and enhance throughput/ access. The ability to consistently track and analyze a wide range of outcome and performance metrics in post-acute care depends, in large part, on software and information technology capabilities. Ongoing data input from a multidisciplinary team is crucial. Basic PAC quality indicators address pressure ulcers, urinary tract infections, weight loss, falls, fractures, decline in activities of daily living and restraints. The Medicare Nursing Home Compare five-star ratings also are a routine point of reference.

For short-term, post-acute rehab stays, each admission should be categorized according to payer source, admission and discharge dates, length of stay, diagnosis category and site of relocation following the rehab stay. Discharge data are required to gauge whether transitions from post-acute care back to the community have been successful. Measuring rehab functional gains outcomes, along with rehab therapy performance, is critical. And members of the clinically integrated care networks will monitor the PAC clients’ satisfaction scores. Timely length-of-stay transitions are a focal point under the pay-for-performance paradigm. To determine whether a provider is efficiently managing length of stays and following the clinical care pathway program, individuals should be classified according to diagnosis category to provide more specific medical profile breakouts. These categories may include: t QPTUTVSHFSZSFDVQFSBUJPO t PSUIPQFEJDSFDPWFSZ t GSBDUVSFT t TUSPLF t DBSEJBDSFIBCJMJUBUJPO t QVMNPOBSZSFIBCJMJUBUJPO t DPNQMFYXPVOEDBSF t QBMMJBUJWFDBSF t PODPMPHZBOE t NFEJDBMMZDPNQMFY

HOSPITAL UTILIZATION Controlling hospital utilization is paramount to successfully participating in a partnership. Doing so requires a continuous evaluation of historic emergency department admission trends to identify condition/rea888-5-."(";*/&$0.

FINANCEMATTERS son, date and shift, and length of PAC stay prior to hospital admission. By following early intervention programs that identify individuals at risk for hospital admission, action plans can be implemented to head off transfers. Efforts can include the use of protocols such as the INTERACT (Interventions to Reduce Acute Care Transfers) tool, which is a framework for the early identification, assessment, intervention, documentation and communication of changes in a resident’s condition. The Medicare Hospital Readmission Reduction Program, which penalizes hospitals for greater-than-expected 30-day readmission rates, has become an extremely highprofile concern. Hospitals and networks are closely tracking the ability of PAC operators to manage readmissions. Conditions currently targeted for hospital readmission payment penalties are acute myocardial infarction, heart failure and

pneumonia. This group of conditions will be expanded in fiscal year 2015 to include chronic obstructive pulmonary disease, coronary artery bypass, angioplasty and other vascular conditions. Care coordination, PAC utilization and readmissions will draw more oversight next year, when Medicare’s value-based purchasing program incorporates a spending-perbeneficiary measure in its reimbursement formula for hospitals. Hospitals will be assigned efficiency scores for each major diagnosis category, considering costs for the three days before admission, the length of the inpatient stay and the 30 days following discharge. This change will put the spotlight directly on the costs and efficiency of post-acute care, which when delivered in the same market often has significant payment variances within an episode of care while delivering services to people of similar health status. LTL

Keys to successful partnerships Post-acute care organizations and hospitals should aim for success in the following: t t t t t t t t t


Jim Bowe is principal of GlenAire HealthCare, LLC, in Bloomfield Hills, Mich. GlenAire works to realign the continuum of care with an emphasis on rewarding quality outcomes and cost-efficient operations through developing, expanding and repositioning post-acute care and senior living operations. Contact him at (248) 904-6766 or [email protected].

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OSHA’s whistleblower protections You can’t retaliate against a suspected whistleblower, but here’s what you can do BY STEVE WILDER, CHSP, STS


ave you ever had an employee get upset about something in the workplace and call the Occupational Safety and Health Administration (OSHA) in an attempt to cause a problem for you? You receive that dreaded letter in the mail bringing the “anonymous” complaint to your attention, and you have to spend time and money to respond. What’s even worse is that you know who the employee is, but you can’t do anything about it. Or at least you’d better not. One of my favorite holiday movies has been and will forever remain the 1989 classic “Christmas Vacation,” with the beloved Griswold family. Who doesn’t love Clark Griswold and Cousin Eddie? In one scene near the end, Clark is upset with his boss over not receiving a bonus, and he uses quite a few select adjectives to describe him. I believe Clark refers to his boss as a “cheap, lying, no-good, rotten, four-flushing, low-life, snake-licking, dirt-eating, inbred, overstuffed, ignorant, blood-sucking, dog-kissing, brainless,

Whether you know the employee who called OSHA or you just suspect a particular person, more than 20 federal laws protect employees from whistleblower retaliation.


hopeless, heartless, fat-a**, bug-eyed, stiff-legged, spotty-lipped, worm-headed sack of monkey dung”—and I may have deleted a couple of words. That is how we typically feel when we know that an employee has called OSHA. We are angry, disappointed and upset that a worker would be so callous as to try to cause problems for us. And often, right or wrong, some employers react with vengeance. The OSHA Whistleblower Protection Programs (www.whistleblowers.gov) are designed to protect employees from retaliation if they call OSHA when they believe an unsafe condition exists in the workplace. OSHA defines retaliation as any form of firing or laying off, blacklisting, demoting, denying of overtime or promotion, disciplining, denying of benefits, failing to hire or rehire, intimidating, making threats, reassigning affecting prospects for promotion, or reducing

pay or hours. Whether you know the employee who called OSHA or you just suspect a particular person, more than 20 federal laws protect employees from whistleblower retaliation.

NONCOMPLIANCE COSTS YOU The costs associated with a whistleblower case can be astounding. Consider a recent Iowa case in which a worker’s employment was terminated after the employee raised repeated concerns to the company’s owner about new procedures being implemented. The employee rightfully refused to perform his job in an unsafe manner, potentially causing serious injury to the worker, co-workers or the public. He filed a complaint, and the company subsequently was ordered to reinstate the driver to his former position with all pay, benefits and rights, in addition to paying back wages of $23,203 plus interest. OSHA ordered the


I see what others don’t. With my RAC-CT, it’s elementary. As a leader in your facility, you know just how powerful it is to have an individual with the RAC-CT® credential as an integral part of your interdisciplinary team. When your staff has a strong foundation of assessment and coding knowledge, they are able to detect the small documentation inconsistencies that affect care, reduce reimbursement, and put your facility under increased scrutiny from government auditors.

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company to pay $50,000 in compensatory damages and $50,000 in punitive damages as well as “reasonable” attorney’s fees. In her ruling, Marcia Drumm, acting regional administrator for the OSHA office in Kansas City, Mo., stated: “An employer does not have the right to retaliate against employees who report work-related injuries or safety concerns. OSHA is committed to protecting all workers from retaliation for exercising basic worker rights.” Although this case does not involve long-term care per se, the message remains loud and clear, and it is being applied across all industry lines: You cannot retaliate against an employee just

because he or she exercised the right to demand a safe work environment.

RX FOR SUCCESS? I wish I could give you a prescription to prevent upset employees from calling OSHA and filing frivolous complaints. If there is any light in the tunnel, it is that OSHA realizes that employees will do undertake such actions, and the agency usually will consider it when it accepts a complaint. But even then, OSHA takes each complaint seriously and will initiate some form of an investigation, even if only by paper trail. One closing thought: You never know how or when a complaint could happen. The simplest way to be prepared is to

keep your safety management program up to date and be able to prove that employee safety and health in your workplace is not just a phrase that is thrown around but something that is practiced on every shift every day. LTL Steve Wilder, CHSP, STS, is president and CEO of Sorensen, Wilder & Associates (SWA), a healthcare safety and security consulting group based in Bourbonnais, Ill. He is the co-author of the book The Essentials of Aggression Management in Healthcare: From Talkdown to Takedown. He can be reached at (800) 568-2931 or at swilder@ swa4safety.com.

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INTRODUCTION Welcome to Long-Term Living’s Special Purchasing Guide devoted exclusively to Facility/Operations. Similar in format to our annual Buyers Guide, this targeted guide will direct you to an array of products and services to help keep your facility up to date and running smoothly. This guide will provide you with easy access to further information about the items of interest to you. We hope you find it informative and useful to you and your staff. To access our Online Buyers Guide, please visit http://directory.ltlmagazine. com.



CJMW Architecture Winston-Salem, NC Contact: Alan Moore (336) 724-1503 E-mail: [email protected] Web: www.cjmw.com

Kaba Access and Data Systems Americas Winston Salem, NC Contact: Dale Mathias (800) 849-8324 E-mail: [email protected] Web: www.kaba-adsamericas.com

Earl Swensson Associates, Inc.

Access Control, Suite/Office Security ...34 Architects ............................................34 Artwork................................................35

additions, or a complete repositioning—we strive to improve the quality of life of our ever-growing senior population.


Beds, Electric .......................................35

Nashville, TN Contact: Sandy Dickerson (615) 329-9445 E-mail: [email protected] Web: www.esarch.com

Buses ..................................................35 Cabinets/Casegoods ............................35 Carts, Housekeeping/Linen ..................35 Chairs, Dining ......................................36 Chairs, Lounge Area .............................36 Cleaning Supplies ................................36

Levi + Wong Design Associates, Inc.

Disinfectant, Sporicidal ........................36 Dressers/Chests/Armoires ...................36 Dryers .................................................36 Fabrics, Healthcare ..............................36 Floorcoverings, Resilient ......................37 Flooring ...............................................37 Furniture, Interior .................................37 Insurance.............................................37 Insurance, Assisted Living ....................37 Interior Designers ................................37 Kitchenettes ........................................37 Lenders ...............................................38 Lighting Fixtures/Supplies ....................38 Risk Management/Regulatory Compliance Documentation ............................38 Tables, Dining/Activity ..........................38 Upholstered Furniture ..........................38 Upholstery ...........................................38 Vans, Wheelchair-Accessible ................38 Washers ..............................................38


Photo credit: Jad Ryherd Photography

Concord, MA Contact: Thomas Levi, AIA (978) 371-1945 E-mail: [email protected] Web: www.lwda.com Levi + Wong Design is recognized for our outstanding healing and resident-centered designs, which are hallmarked by thoughtful responsiveness to patients, families, staff and communities. Levi + Wong Design is a multi-disciplinary design firm offering architecture, landscape architecture, interior design and planning services to Senior Living/Senior Care, Dementia, Long-Term Care, Acute, Rehabilitation and Corporate clients. Our client retention and excellent relationships with regulatory agencies is evidence of our reputation, commitment to service, responsibility, innovative problem solving and our ability to seamlessly integrate the entire project into a cohesive whole.

AG Architecture Wauwatosa, WI Contact: Gene Guszkowski, AIA (414) 431-3131 E-mail: [email protected] Web: www.agarch.com Senior living is experiencing an unprecedented shift due to a rapidly changing economy and marketplace. If you are planning to reposition your organization, work with visionary professionals who understand the history of the industry with an eye toward the future. AG Architecture continues a 45-year commitment to innovative senior living design. Master planning, new construction,

Rice Fergus Miller Bremerton, WA Contact: Mike Miller (360) 377-8773 E-mail: [email protected] Web: www.rfmarch.com 888-5-."(";*/&$0.

RLPS Architects Lancaster, PA Contact: Kathleen Goff (717) 560-9501 E-mail: [email protected] Web: www.rlps.com

SFCS Architects Roanoke, VA Contact: Tye Campbell, PE (540) 344-6664 E-mail: [email protected] Web: www.sfcs.com

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Studio E.L. Healthcare Emeryville, CA Contact: Kristen Jones (510) 740-6987 E-mail: [email protected] Web: www.studioel.com

Chino, CA Contact: TJ Matijevich (888) 993-5032 E-mail: [email protected] Web: www.starcraftbussales.com


TWM Architects + Planners San Rafael, CA Contact: Derek Dutton (415) 472-5770, ext. 39 E-mail: [email protected] Web: www.twmarchitects.com


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


Conover, NC Contact: Boyd Barnhardt (828) 328-5600 E-mail: [email protected] Web: www.legacyfurnitureseniorliving.com


ARCH Framing & Design St. Louis, MO Contact: Paul Burton (866) 945-6621 E-mail: [email protected] Web: www.archframing.com Artwork and Mirrors, Free Design Service, Art Consultants with 30+ Years of Experience in Senior Living, Assisted Living and Memory Care, Rehab Care. Evidence-Based Design Certification! We offer Complimentary Design Service together with beautiful artwork to create healing and soothing environments. We work with you and your budget to save you time and to help you create the environment you need. We ship from our own production facility and install anywhere.

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R&B Wire Products Santa Ana, CA Contact: Frank Rowe (800) 634-0555 E-mail: [email protected] Web: www.rbwire.com

Tecni-Quip Carts

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Seguin, TX Contact: J. Reilly (800) 826-1245 E-mail: [email protected] Web: www.tqind.com

Kankakee, IL Contact: Bob Anderson (800) 933-2412 E-mail: [email protected] Web: www.midwesttransit.com As the largest volume distributor of buses in WWW.LTLMAGAZINE.COM



America, we offer a huge selection of vans and buses ranging in capacities from 4 to 45. If we don’t have what you want in stock, we have an experienced sales team that can help you design a bus that meets your specific requirements. NO MONEY DOWN LEASE options are available, as well as loans with competitive finance rates, to help you meet your budget requirements. We are ready to serve you! When you think of bus, think of us!




Triple S Legacy Furniture Senior Living Conover, NC Contact: Boyd Barnhardt (828) 328-5600 E-mail: [email protected] Web: www.legacyfurnitureseniorliving.com

North Billerica, MA Contact: James Keough (800) 323-2251 E-mail: [email protected] Web: www.triple-s.com Triple S is a national distribution services and logistics company that provides facility maintenance solutions to the healthcare, education, commercial, retail, industrial and government markets through a network of local MemberDealers and regional distribution centers. For more information, please visit www.triple-s.com.

Continental Girbau Inc. Oshkosh, WI Contact: Joel Jorgensen (800) 256-1073 E-mail: [email protected] Web: www.continentalgirbau.com


Legacy Furniture Senior Living Conover, NC Contact: Boyd Barnhardt (828) 328-5600 E-mail: [email protected] Web: www.legacyfurnitureseniorliving.com


Triple S North Billerica, MA Contact: James Keough (800) 323-2251 E-mail: [email protected] Web: www.triple-s.com Triple S is a national distribution services and logistics company that provides facility maintenance solutions to the healthcare, education, commercial, retail, industrial and government markets through a network of local MemberDealers and regional distribution centers. For more information, please visit www.triple-s.com.

Inwood, NY Contact: Dan Goldman (516) 371-4400 E-mail: [email protected] Web: www.laundrylux.com Never purchase laundry equipment again. Pay only for what you use! t/FXMBVOESZFRVJQNFOUXJUIOPDBQJUBMFYQFOTF t/PMPOHUFSNDPOUSBDUPSDPNNJUNFOU t)VHFTBWJOHTPODIFNJDBMT XBUFS BOEFOFSHZ t-JGFUJNF1BSUT8BSSBOUZ t-JGFUJNF4FSWJDF8BSSBOUZ t4VQFSJPSRVBMJUZBOEMPOHFSMJOFOMJGF Introducing PLUS—Professional Laundry Utility Service—the revolutionary new innovation GSPN-BVOESZMVY"/%yGPSIPTQJUBMT OVSTJOH homes and other healthcare facilities—PLUS is reimbursable by Medicare according to CMS cost reporting forms.

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DRESSERS/CHESTS/ARMOIRES Pro-Link, Inc. Canton, MA Contact: Russ Seybold (800) 745-4657 E-mail: [email protected] Web: www.prolinkhq.com/ltc Pro-Link offers high quality cleaning products and solutions that help deliver consistently cleaner facilities at lower total costs. Pro-Link’s offering for LTC facilities includes a range of products that clean better, improve infections control efforts and reduce overall costs. We also offer tools such as building audits, infection control checklists and cleaning procedures for LTC environments to deliver a cleaner/healthier facility, better survey scores and a reduction in housekeeping costs.


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

St. Joseph, MI Contact: Steve Hietpas (800) 662-3587 E-mail: [email protected] Web: www.maytagcommerciallaundry.com

FABRICS, HEALTHCARE Bruin Plastics Co., Inc. Glendale, RI Contact: Steve Angelone (401) 568-3081 E-mail: [email protected] Web: www.bruinplastics.com


Emigsville, PA Contact: Leslie Haddad (717) 764-1192 E-mail: [email protected] Web: www.herculite.com


Hill Devine Design & Purchasing


nora systems, Inc. Salem, NH Contact: Customer Service (800) 332-6672 E-mail: [email protected] Web: www.nora.com/us

Grabill, IN Contact: Wieland Sales (260) 627-3686 E-mail: [email protected] Web: www.wielandhealthcare.com Wieland is all about innovation. Our furniture is a reflection of our commitment to providing a product of genuine value. We’re all about recovery, too. Our passion is to design and build furniture that accommodates the changing tastes and needs of our customers. We look beyond durability to renewability. Patient outcomes can improve when inflectional control, family caregiver and safety needs are met. Wieland fearlessly addresses these challenges to continue to transform healthcare environments.

Portland, OR Contact: TR Hill (503) 722-9141 E-mail: [email protected] Web: www.hilldevine.com Check us out on Facebook!

Invacare Interior Design St. Louis, MO Contact: Jacki Zumsteg (800) 347-5440 E-mail: [email protected] Web: www.invacareinteriordesign.com


Shannon Specialty Floors, Inc. Milwaukee, WI Contact: Kevin Shannon (800) 522-9166 E-mail: [email protected] Web: www.shannonspecialtyfloors.com At Shannon Specialty Floors, our job is helping you. We’re the source for dependable, durable and beautiful commercial resilient flooring, delivered with uncompromising quality and service. Since 1921, that’s been more than our mission...it’s been our promise—one you can always rely on. When your reputation is on the line, we deliver for you

West Des Moines, IA Contact: Deb Bozikowski (262) 689-4630 E-mail: [email protected] Web: www.guideone.com

INSURANCE, ASSISTED LIVING Sapphire Blue Chicago, IL Contact: Nancy McMahon (312) 784-6007 E-mail: [email protected] Web: www.sapphireblueuw.com


DesignPoint, Inc. Contact: Les McCoy, IIDA (610) 807-9670 E-mail: [email protected] Web: www.designpoint-interiors.com


Merlino Design Partnership, Inc. Gulph Mills, PA Contact: Bruce Hurowitz (610) 313-9550 E-mail: [email protected] Web: www.merlinodesign.com

RLPS Interiors Lancaster, PA Contact: Kathleen Goff (717) 560-9501 E-mail: [email protected] Web: www.rlpsinteriors.com


MicroFridge/Danby Foxboro, MA Contact: Mary Clupper (941) 359-0757 E-mail: [email protected] Web: www.microfridge.com LONG-TERM LIVINGt


Herculite Products, Inc.


LENDERS Ventas, Inc. Chicago, IL Contact: Raymond Lewis (312) 660-3732 E-mail: [email protected] Web: www.ventasreit.com

LIGHTING FIXTURES/SUPPLIES Eaton’s Cooper Lighting Business Peachtree City, GA Contact: Tom Lane (770) 486-4800 E-mail: [email protected] Web: www.cooperlighting.com

day, GLOBALcare produces products specifically designed to promote correct body positioning and alignment for an enhanced level of wellness, while meeting the quality standards and demands of today’s hospitals, long-term care facilities, assisted living environments, clinics and more.

Electrolux Laundry Equipment

UPHOLSTERY The Mitchell Group Niles, IL Contact: Ann Brunett (847) 647-7300 E-mail: [email protected] Web: www.mitchellfauxleathers.com



Maytag Commercial Laundry

MED-PASS, Inc. Dayton, OH Contact: Valerie Crider-Hill (800) 438-8884 E-mail: [email protected] Web: www.med-pass.com

Starcraft Bus Sales Chino, CA Contact: TJ Matijevich (888) 993-5032 E-mail: [email protected] Web: www.starcraftbussales.com


Maple Grove, MN Contact: Customer Service (800) 328-2580 E-mail: [email protected] Web: www.spacetables.com


St. Joseph, MI Contact: Steve Hietpas (800) 662-3587 E-mail: [email protected] Web: www.maytagcommerciallaundry.com

Milnor Laundry Systems


Inwood, NY Contact: Dan Goldman (516) 371-4400 E-mail: [email protected] Web: www.laundrylux.com Never purchase laundry equipment again. Pay only for what you use! t/FXMBVOESZFRVJQNFOUXJUIOPDBQJUBMFYQFOTF t/PMPOHUFSNDPOUSBDUPSDPNNJUNFOU t)VHFTBWJOHTPODIFNJDBMT XBUFS BOEFOFSHZ t-JGFUJNF1BSUT8BSSBOUZ t-JGFUJNF4FSWJDF8BSSBOUZ t4VQFSJPSRVBMJUZBOEMPOHFSMJOFOMJGF Introducing PLUS—Professional Laundry Utility Service—the revolutionary new innovation GSPN-BVOESZMVY"/%yGPSIPTQJUBMT OVSTJOH homes and other healthcare facilities—PLUS is reimbursable by Medicare according to CMS cost reporting forms.

Kenner, LA Contact: Marketing and Sales (800) 469-8780 E-mail: [email protected] Web: www.milnor.com See our ad in this issue

Continental Girbau Inc. Oshkosh, WI Contact: Joel Jorgensen (800) 256-1073 E-mail: [email protected] Web: www.continentalgirbau.com

GLOBALcare Marlton, NJ Contact: Ed Miles (800) 220-1900 E-mail: [email protected] Web: www.thinkglobalcare.com GLOBALcare is a prime source provider of furniture for hospitals and long-term care facilities. Since it was established in 1985, our GLOBALcare division has successfully grown to meet the demands of our aging population. Tot4&15&.#&3









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Advertiser Index Advertiser

Page #

AANAC ........................................................................................31 American Data ..............................................................................7 Antron ..........................................................................................5 Betco Corporation ..................................................................CVR 2 Carstens ...............................................................................10, 29 Connected Living ........................................................................12

t %PXOMPBE1%'TXJUINPSF detailed product/service information

Direct Supply Inc....................................................................CVR 4 Healthcare Signs....................................................................CVR 3 MMIC (Regional) .........................................................................23 Omnicare ....................................................................................27 Patcraft Commercial Carpet ..........................................................1 Pellerin Milnor.............................................................................32 Response Care Inc ......................................................................33 Rubbermaid Commercial Products ..............................................13

http://directory. ltlmagazine.com

Sherwin-Williams..........................................................................3 Tech Wholesale ...........................................................................39 VANCARE, Inc................................................................................9 This index is provided as a reader service. The publisher does not assume any liability for errors or omissions.



the boardroom

One-on-one with… Robert (Robb) White F or most prospective long-term care (LTC) residents, culinary offerings can be the deciding factor on moving to the community. The Goodman Group has no worries in that department, with Chef Robert (Robb) White, CEC, CCA, AAC, national director of culinary operations, for the organization’s multistate LTC communities. White is a recent recipient of the American Culinary Federation’s 2014 “Cutting-Edge Award.” He is a member of the American Academy of Chefs and the Escoffier Society. Across his 30 years of culinary experience, he has worked in the hospitality industry, corporate food service, country clubs and culinary education. Long-Term Living Managing Editor Sandra Hoban recently spoke to him about his transition from hospitality industry to healthcare. To read the entire interview, visit www.ltlmagazine.com/robertwhite.

How did you become interested in LTC foodservice as a career? I’ve worked in most aspects of the culinary industry—chef; executive chef, culinary administrator, evaluator and educator. As dean of culinary at the Culinary Institute of Michigan, I saw many students deciding to use their skills and knowledge in the growing healthcare industry. Seniors’ preferences and attitudes toward food enable me to be creative and incorporate some aspects of my experience from the hospitality side.

What does your role entail? The Goodman Group has a total of 33 LTC properties in nine states. I’m based at The Goodman Group’s Chaska, Minn., headquarters but travel frequently to consult, educate and work with the chefs and dining directors at the various locations. tSEPTEMBER 2014

Food preferences vary throughout the region as does the availability of some food items. My role diverse, ranging from menu consultation and recipe development to instructing staff on how to operate and maintain a new piece of equipment.

What part of your is most satisfying? This job rolls everything I love into one package—hands-on time in the kitchen, administrative obligations—basically, anything I can do to help and support our culinary staff. Because food ranks high for residents, the dining experience has to be exemplary. I have a great team of chefs and dietary managers to work with. Our main focus is to create menus based on nutritional content, presentation, flavor, texture and variety. Right now, we are introducing residents to vegetarian and vegan options.

Why take the culinary approach? Culinary encompasses all food. We want to switch from the whole dietary aspect of food and present a restaurant appeal. To change the mindset, we need to present food in another light. I began this process by switching menus out from institutional meals to very fresh, very local and organic food offerings. Many of our communities have resident gardens, and that produce is used in our kitchens. Each community purchases local, in-season organic food through our vendor network, local growers and farmers. Healthful, source-procured food is not a fad; it’s an actual mentality switch. Our Food for Life program is about giving residents healthy food choices. If residents want meatloaf, we take that recipe, dissect it, tweak it and serve the

residents the dishes they desire, but as a healthier and flavorful option.

Can the culinary focus be adapted for residents on special diets? Everyone “eats with their eyes,” so the plate has to be appealing. On modified diets, along with flavor, we like to keep the food’s texture. For someone on a special diet who was used to chewing and swallowing food, it can be difficult to adapt. We try to keep the dish as close to the real thing as possible to encourage eating and enjoyment.

What has been the most significant achievement of your program? Our company’s life enrichment program is a collaborative effort designed to improve or advance the residents’ lives on mental, physical and spiritual levels. All the various programs are tied together. Our Food for Life program gives residents healthy food choices, which can make them stronger and improve or preserve fitness. If someone has a poor appetite or is in pain, for example, aromatherapy can be used alternative therapy to combat pain and restore the appetite. Dining is an experience. All the senses are involved: The food must not only smell and taste good; it must be beautifully plated and served on well-appointed tables. Music is part of the experience, too.

What advice can you offer to improve dining programs? Don’t be afraid to try. Leadership needs to be committed. Buy organic. Offer fresh fruits and vegetables and make things from scratch. Those things make a difference. Commit to doing what’s best; it might not be the most cost-effective way, but it’s our commitment to our residents. LTL WWW.LTLMAGAZINE.COM


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