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The Latest Wrinkle December 1, 2017
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Nursing Home Services – An Endurance Sport?


November 28 marked the implementation of SNF Mega Rule Phase 2 Requirements that have been operationalized just last week through a 703-page updated version of Appendix PP (see article below), the Interpretive Guidance. Congratulations to our members are in order, although the next few months may continue to be a bit rocky as new surveyor processes are also put into place.

LeadingAge had officially asked CMS for a delay of Phase 2 and Phase 3 implementation. There does seem to be some recognition that the number and intensity of the new requirements have been challenging for even the very best providers since CMS has delayed civil money penalties and other enforcement actions and has frozen the 5-Star ratings as well.

Members must remember however, that Michigan is awaiting federal approval for a Medicaid State Plan Amendment that increases provider taxes to support incentive payments for performance on quality measures. It will be important to ensure performance on the quality measures as well.

Standardization of clinical and other processes is considered to be one of the best ways to ensure performance, but it takes effort and time to effectively embed new policies and procedures solidly into practice. Members will need to be vigilant and continue to work even though the Phase 2 deadline has technically past.

Our collective missions are focused on our duty to serve, and as we move forward we can focus on that as the driver that will continue to move us forward.


Regional Meetings Held

During the month of November LeadingAge Michigan held four regional meetings throughout the state. Invited were LeadingAge Michigan members and business partners to hear the latest thoughts related to senior care and updates on the association. Over 100 participants were in attendance and 70 organizations were represented at the meetings.

Topics touched on advocacy and the upcoming gubernatorial election, the state budget, managed care, and Senior Care Resources. Also discussed were benefits of The Compliance Store and recent updates with Omnicare.

Attendees were invited to join LeadingAge Michigan in its celebrations of the association’s 50th anniversary over the coming year. In honor of that milestone members are asked to participate in a short survey seeking feedback on its programs and services. The survey can be found here.

Thanks are offered to the following members who graciously hosted these events:

Marycrest Campus - Karis Wilson Jones

Grand Traverse Pavilions - Kory Hansen

Vista Grand Villa - Cristine Morreale

Beacon Hill at Eastgate - Jeff Huegli and Sarah Johnson



Legislative


Proposed Federal Tax Reform Legislation Puts Seniors at Risk


This week, the US Senate took further steps to pass federal tax reform legislation that could result in major changes in healthcare. Senate Republicans may well pass their version of the Tax Cuts and Jobs Act as early as today (Friday). The House version looks much different however, but the House may well either simply pass the Senate version or negotiate changes.

Republican supporters state that economic growth will outpace the projected increases in the federal deficit. Doubling the personal exemption and simplification of the tax brackets are expected to ease tax burden on middle families according to supporters. Others have concerns that the legislation is expected to cause at least a $1 trillion to $1.5 trillion increase in the federal deficit and will put health care and other entitlement spending at risk.

With recent reports that Medicare margins for hospitals have dropped to -7% and are expected to go as low as -10% next year, there is concern about access and coverage for seniors in the near future as financial pressures continue to grow. SNF reimbursement changes slated for the next year also place members in challenging situations.

And importantly, both the House and Senate versions limit tax-exempt financing for not-for-profit organizations.


Advocacy


LeadingAge Michigan has been very busy advocating for the membership over the past year. Please find below some of the results of efforts.

Public Act 172 (CNA Reciprocity)

Public Act 172 of 2017 was signed into law, providing State oversight of Certified Nurse Aides (CNA) working in Michigan. This legislation would add Part 219 to the Public Health Code, which provides for the training and registration of nurse aides, nurse aide training programs and nurse aide trainers. In addition, this new law will provide for:

  • Assessing fees, implementing CNA reciprocity under certain circumstances, and investigations for abuse, neglect and misappropriation of property in health care settings.

  • Allowing employers to hire CNAs for up to four months while they are waiting to become registered.

  • Allows for the hiring of CNAs from bordering states who are in good standing and with active registration.

Administrative rules are being written in support of this new legislation and will be completed with the help of stakeholder groups. The effective date for this Act is February 19, 2018.


Public Act 154 (POST)


Public Act 154 of 2017 was signed into law, establishing Physician Orders for Scope of Treatment (POST) as a legal tool / portable medical orders designed to help health care professionals honor the treatment decisions of a seriously ill individual, or an advocate or Court-appointed Guardian about the care they desire should there be a medical crisis in which the individual cannot express a decision. The effective date for this Act is February 6, 2018. The Department of Health and Human Services will be coordinating an advisory committee to create forms and promulgating rules as to its use.


Public Act 167 (HFA)


On November 13, 2017, Public Act 167 of 2017 was signed into law, modifying the rules for Homes for the Aged (HFA). The Act takes effect on February 11, 2018. Over the next few weeks, the Bureau of Community and Health Systems (BCHS) in collaboration with LeadingAge Michigan will be developing form(s) to facilitate requests for exemptions etc. Contact LeadingAge Michigan if you have any questions.

Across the Continuum


     

Deep Dive Demo – New Survey Process:
Take a closer look at tools and resources designed to help you successfully navigate the new survey process.
Tuesday, December 5th at 11 am EDT - To Register, click here.

Introductory Overview Demo:
See the variety of tools and resources available through The Compliance Store.
Tuesday, December 12th at 12 pm EDT - To register, click here.

Electronic Injury & Illness Reporting Compliance Deadline Extended by Two Weeks
In a final rule published in the Federal Register on November 24th, the Occupational Safety and Health Administration (OSHA) stated its intention to delay a proposed December 1, 2017 compliance date for the electronic submission of the 2016 Form300A report of injuries and illnesses until December 15, 2017.

The agency also stated its intention to issue further rulemaking to modify the 2016 final electronic reporting rule. The original compliance deadline had been applicable to LeadingAge members in the following categories:

  • Employers with 250 or more employees – The employer must submit electronically OSHA Forms 300, 300A and 301 annually.
  • 20 or more but less than 250 in certain identified industries – The employer must submit electronically OSHA Form 300A annually. Included in the list of identified industries are nursing care facilities (NAICS 6231), community care facilities for the elderly (NAICS 6233) and other residential care facilities (NAICS 6239).
  • Other employers who receive notification from OSHA to electronically submit their OSHA Forms 300, 300A and 301.


Home and Community Based Services


MDHHS Issues Medicaid Provider Manual Chapter for HCBS for Public Comment


The Michigan Department of Health and Human Services (MDHHS) recently issued a proposed policy for a new chapter in the Medicaid Provider Manual that addresses the requirements for the Home and Community Based Services (HCBS) Final Rule issued by CMS on January 16, 2014. The purpose of the policy is to ensure that providers of HCBS enrolled in the Michigan Medicaid program are in compliance with the federal requirements. The Final Rule and the associated new policy are applicable to both the MI Choice Waiver and the MI Health Link HCBS Waiver (Duals Demonstration), as well as the Habilitation Supports Waiver and the Managed Specialty Services & Supports Waiver for behavioral health services.

Within the HCBS policy is a section on the heightened scrutiny process. Heightened scrutiny provides opportunity for settings that might otherwise be determined non-compliant with the rule to be reviewed for potential participation in offering waiver services. LeadingAge Michigan will be reviewing the new proposed policy and offering comment.

This policy bulletin was issued concurrently for the 30-day public comment period and as final policy. Comments will be accepted until January 1, 2018, which is the effective date of the policy.


Skilled Nursing


Comprehensive Care for Joint Replacement


This week, CMS issued a final notice that cancelled the mandatory hip fracture and cardiac bundled payment models which were scheduled to begin in January 2018. The notice also implemented changes to the current Comprehensive Joint Replacement Model. CMS is reducing the number of mandatory geographic areas from 67 to 34.

For a technical fact sheet on the changes in this final rule and interim final rule with comment period, please click here.

For more information on the Comprehensive Care for Joint Replacement Model (CJR), please click here.

Flint, Saginaw, South Bend area (MI) Michigan are now voluntary areas and will only continue to utilize the CJR Model if they choose to again opt-in.


Medicaid Policy Changes


The Michigan Department of Health and Human Services, Medical Services Administration, has over the last few months issued policy bulletins pertinent to nursing home providers. While these changes were introduced in previous editions of The Latest Wrinkle, it is important that members refresh their understanding of how some of these policies will impact them in the coming days and months.

On November 15, 2017, policy bulletin MSA 17-33 was issued stating that effective December 15, 2017 MDHHS will no longer accept the Facility Admission Notice form MSA-2565-C to process facility admissions. Effective January 2, 2018, nursing homes, along with MI Choice waiver agencies and PACE organizations, will enter admissions/enrollments directly into the Community Health Automated Medicaid Processing System (CHAMPS) Discharges/disenrollments will also be entered directly into CHAMPS by the providers. Questions can be directed to ProviderSupport@michigan.gov.

Policy bulletin MSA 17-28 was issued on August 31, 2017 providing details of the Medicaid Quality Measure Initiative (QMI) that will provide additional reimbursement nursing home providers based on performance on the nursing home compare Quality Measures (QMs) and level of participation in the Medicaid program. This initiative is currently in the State Plan Amendment process with the Centers for Medicare and Medicaid Services (CMS) and will be in effect retroactive to October 1, 2017 once approval is received by the state. Implementation details are in the policy bulletin and additional information will be provided as it becomes available.


Teleconference on Enforcement Delays for Certain Phase 2 F-Tags


LeadingAge Michigan is acutely aware of how recent changes and notifications from CMS initiate additional questions and concerns. To assist, LeadingAge Michigan will be hosting a teleconference call to discuss the implications of the temporary moratorium for specific Phase 2 requirements, the freezing of the health inspections star ratings and the changes to the health inspection star rating methodology expected in early 2018. This teleconference will take place on December 14 at 2:00 p.m. To participate, please dial (888)392-4560 using the participant code of 73026#.

Just days prior to the effective date for Phase 2 F-tags, the Centers for Medicare & Medicaid Services (CMS) released S&C 18-04-NH which provided an 18-month moratorium on the imposition of civil money penalties (CMPs), discretionary denials of payment for new admissions (DPNAs) and discretionary termination where the remedy is based on a deficiency finding of one of eight specified Phase 2 F-tags. This 18-month moratorium period is intended to educate surveyors and providers to ensure they understand the health and safety expectations that will be evaluated through the new survey process. It is important to note, non-compliance with any one of the 8 Phase 2 F-tags will result in a written citation, however the only remedies to be imposed are Directed Plan of Correction (DPOC) and/or Directed In-Service training (DIST).

Please consider participating in this teleconference to discuss the ramifications of these changes.


State Operations Manual Revised Appendix PP


The Centers for Medicare & Medicaid Services (CMS) has released a final version of Appendix PP on November 22, 2017 which replaces the advance copy they published in June of this year.

Please note the following changes in the initial review of the transmittal:

  • F582 - The guidance regarding Medicare liability notices eliminated the five alternative denial letters consistent with the recently revised SNF Beneficiary Protection Review survey worksheet.
  • F686 - The reference suggesting a tissue tolerance test has been removed from the guidance regarding pressure ulcers as this was not a current standard of practice.
  • F760 - Crushed medications that are combined and given orally will not be considered medication errors unless there are instructions not to crush the medications.
  • F838 - CMS corrected inappropriate wording in the guidance that a facility must include its operating budget in the facility assessment as it is not part of the regulation.
  • F906 - CMS reinstated the emergency power regulation was designated as "reserved" in the advance copy. There were no changes to the regulation. However, the definition for life support systems was modified and a definition for essential electrical system was introduced in the guidance. References were updated to reflect the new K-Tag numbers.

Nurse Aide Training Program Prohibition Waiver and Appeal Modifications


The Centers for Medicare & Medicaid Services (CMS) has issued S&C: 18-02-NH, a bulletin providing clarification regarding existing statutory and regulatory authority regarding waivers and appeals of prohibited nursing aide training programs, effective immediately. Federal regulations permit, and in some cases require, Nurse Aide Training and Competency Evaluation Programs (NATCEP/CEP) be prohibited from approval for two years based on survey findings or waivers of minimum requirements for licensed nurse coverage. The memo has a helpful chart outlining the waiver and appeal authorities.


Fall 2016 OIG Report Identifies Abuse Issues


Last week, the Office of the Inspector General for the US Department of Health and Human Services issued its Semiannual Report to Congress. The report noted that as nursing home complaints rose by approximately 33% from 2011 to 2015, they continue to review individual states for their oversight and completion of investigations in alignment with the regulations.

The OIG alerted CMS in August that preliminary findings regarding identification and reporting of potential abuse or neglect may be troubling. At that time, they identified 134 Medicare beneficiaries whose injuries may have been the result of abuse or neglect that occurred between January 1, 2015 and December 31, 2016.

The OIG plans to continue to monitor state performance in ensuring that potential abuse and/or neglect events are reported and properly investigated by the designated agency.


Assisted Living


HFA Tuberculosis Screening Compliance Training


The Division of AFC/HFA and Camps has developed a HFA TB screening training tool to assist facilities with developing policies and procedures that are compliant with administrative rules 325.1922(7), 325.1923(2), 325.1923(3), and 325.1923(4).


Housing


HUD’s Draft Service Coordinator Guide


A more comprehensive guide for service coordinators in Multifamily Housing for the Elderly and Disabled and Quality Assurance professionals was recently posted online for a 30 day comment period. This 35 page document can be found here. The guide focuses on how to operate an effective service coordination program in HUD assisted multifamily housing programs. LeadingAge has drafted a lengthy response representing member beliefs. Use this link to view the collective responses.


Violence against Women Act (VAWA) - Multifamily Assisted Housing


HUD has created a VAWA web page for assisted housing owners, agents, industry professionals, and residents. The web page contains links to the following:

  • Violence Against Women Reauthorization Act of 2013;
  • HUD’s final VAWA rule;
  • Press release announcing the rule’s publication;
  • Multifamily Housing program notice H 2017-05, “Violence Against Women Act (VAWA) Reauthorization Act of 2013 – Additional Guidance for Multifamily Owners and Management Agents”;
  • July 26 and August 1, 2017 training webcasts on YouTube and associated PowerPoint slides;
  • A summary of industry Questions & Answers;
  • HUD VAWA Forms, and Additional survivor resources.

Member Value


Offer Employee Perks With Ease and at No Cost.


Most providers are challenged with attracting and retaining staff. Budget constraints often limit your ability to compete for employees drawn to other industries that are able to pay more or offer more comprehensive benefits. This is not a new problem, but one that is becoming increasingly more difficult, especially in a time of low unemployment.

Value First, your GPO offered through LeadingAge Michigan, now has a new Employee Perks program for members to offer their employees, that is both easy to use and at no cost. Through our national GPO partner, Vizient, employees will have access to more than 300,000 deals and specialty corporate rates on wireless service, rental cars, hotels, restaurants, movie tickets and more, all with the ease of a mobile app. The app can also show employees current deals at local restaurants and stores just by knowing their current location.

Member facilities only need to complete a form for Verizon and AT&T, to allow employees access to those contracts, then employees register on the app to start using the program. Click on the link to learn more.

Contact Rob Ervin at Rob@leadingagemi.org or (517) 449-1710 to learn more.

     

Member Update


UMRC Launched Growing to Serve Campaign


 

Lori Potter, David Herbel and John Thorhauer

 

 A VIP Groundbreaking Event at United Methodist Retirement Communities (UMRC) Chelsea Retirement Community campus on November 28 launched this faith-based organization’s largest construction project in its 110-year history and marked the kick-off of the UMRC Foundation’s Growing to Serve Campaign.

The Groundbreaking Event was held at UMRC’s historic Chelsea campus at the Towsley Village Memory Care Center. The UMRC Foundation’s $26 million comprehensive campaign will support UMRC’s three priority initiatives:

  • Capital projects, including:
    • Expansion and Renovation of Kresge Healthcare and Rehabilitation Center, creating private rooms and bathrooms for all residents, regardless of income level;
    • McMullen Wellness Center, featuring an indoor pool, walking track, and other fitness initiatives for residents;
  • Resident Services and Life Enrichment Activities for residents at Chelsea Retirement Community and Rivertown Assisted Living in Detroit; and

  • Benevolent Care Fund, the cornerstone of the UMRC Foundation which ensures that older adults have a safe, loving home at UMRC, even if they outlive their savings.

UMRC Foundation President Wendy Brightman also announced an anonymous gift of $1.5 million at the Groundbreaking Event that will match dollar for dollar any gifts specifically for these capital projects. “On behalf of the UMRC Foundation, I am honored to receive this gift that will transform care for the older adults we serve and help us reach our fundraising goal.”

Support for UMRC is personal for the families and residents alike, all of whom spoke eloquently of fondness for the organization and dedication to their mission.


Education Center


2018 Call for Presentations
Join us in celebrating our 50th Anniversary by sharing your knowledge and experience.

Help shape educational sessions at LeadingAge Michigan's 50th Annual Conference or other future programs in 2018. Support the aging services industry by submitting a presentation proposal. If selected as a speaker, you will gain visibility in the long term care industry and contribute to the advancement of aging services healthcare professionals. Submission deadline is December 15th.

Click Here to begin the online submission process.


 Leadership Academy 2018

The academy is designed to equip new and emerging leaders with the essential insights, knowledge, and skills to directly improve leadership effectiveness.

The academy integrates adaptive and technical learning for a comprehensive training experience. We will focus on what it takes to be a successful and effective leader in today's workplace; specifically within the aging services industry. Each class will provide unique, thought-provoking, opportunities for dialogue with aging services coaches, mentors, and executives. The academy will cultivate your leadership excellence, develop your leadership potential, and assist you in making a positive impact within your organization.

We encourage applicants from various positions, disciplines, experience, industry knowledge, and companies of different sizes to ensure a vibrant exchange of ideas and discussion. The academy is for high-potential professionals who want to learn to become better managers and leaders.

Click Here for the 2018 Academy Brochure 


Nurse Aide Train-the-Trainer
January 24: Adult Learning Principles
January 25: How to Become a Qualified Instructor and Build a Program
Both workshops will be held in Okemos

Workshops will also be held March 22-23, May 3-4, August 9-10, September 13-14 and November 15-16.

Due to new State of Michigan requirements, LeadingAge Michigan will now be offering two Nurse Aide Train-The-Trainer Workshops. One full day training will be the Nurse Aide Train-The-Trainer: Adult Learning Principles. The second training will be the Nurse Aide Train-The-Trainer: How to Become a Qualified Instructor and Build a Program. The adult learning principles workshop is not required by the State but will meet one of the State of Michigan's requirements to become a qualified instructor. The how to become an instructor and build a program workshop provides a lot of valuable information but completing this workshop is not required by the State of Michigan.

Anyone who would like to learn how to teach adults or build a nurse aide training program is welcome to attend the workshops. If you are a registered nurse who would like to become a qualified nurse aide instructor, we strongly suggest you review the Nurse Aide Trainer Application before attending the workshop to make sure you meet the State of Michigan's trainer requirements.

Completing the LeadingAge Michigan Nurse Aide Train-The-Trainer Workshops does not guarantee a participant will meet the requirements as a Qualified Instructor of Nurse Aide Training Programs with the State of Michigan.

Click Here for more information.


MDS RAC Certification Workshops 2018
March 13-15 ~ Novi
September 18-20 ~ Mt. Pleasant
November 6-8 ~ Grand Rapids

Did you know you can become RAC Certified in just three days?

LeadingAge Michigan, in partnership with the American Association of Nurse Assessment Coordination (AANAC), is pleased to offer the highly esteemed Resident Assessment Coordinator-Certified (RAC-CT) a certification program for long-term care professionals. This workshop is designed to increase knowledge of clinical assessment and care planning, completion of the MDS, and the regulations surrounding the RAI/MDS process. Earning the RAC-CT designation gives you the credentials to prove your assessment expertise; making you an invaluable asset for your facility, your residents, and the long-term care profession.

Save the Dates! More information and registration coming soon.


LEAN Leadership Concepts
March 6: Lean Overview
April 17: Lean Problem Solving
June 12: Lean Deep Dive

All three workshops will be held in Lansing

Lean is a system for making improvement that can be applied to any aging services provider. Leaders and staff members performing the same process day after day can become blind to the inherent problems with that process. Using a Lean approach will aid in the identification of problems and provide the necessary tools to make sustainable process improvements. Many organizations solve problems by jumping to solutions before thoroughly understanding what problem they are trying to solve and/or not fully understanding the root cause of the problem. As a result, the solutions typically don’t work or are unsustainable. Most of the time it is impossible to know if the solution worked because results were not measured. Lean is often thought of as a tool for the frontline worker. In reality, the most effective Lean organizations start with leadership modeling the right behaviors which facilitate the desired culture of improvement. Using Lean leadership concepts will allow you to become a learning organization with a methodical system for process improvement and measured results.

Save the Dates! More information and registration coming soon.


Building Better Working Relationships
March 29 ~ Lansing

As shown by Daniel Goleman's research, it is Emotional Intelligence (EQ) that makes and keeps someone employed. He has found that IQ takes second position to EQ in determining outstanding job performance because it is the human talents and qualities that makes and keeps one employed.  When an organization has employees with higher EQ they will interact with leadership, management, co-workers, residents/patients and families more effectively. All participants will complete an online Everything DiSC Workplace Personal Profile which will be reviewed and assessed during the training. This valuable assessment tool will be included in the cost of the training. Join us to learn more about your personal EQ, how to adapt your style to be more effective with others and how to build better working relationships.

Save the Dates! 
More information and registration coming soon.


QAPI Certified Professional (QCP) Prep Workshop
April 25-26 ~ Lansing

An effective QAPI process and program will take you beyond compliance and enable your facility to truly transform the care you provide residents. Increase your knowledge by attending a two-day QAPI education workshop that will help you prepare for the comprehensive QCP certification exam.

To implement quality assurance and process improvement (QAPI) strategies in long-term care effectively, you need strong nurse leadership. To achieve that leadership, follow the QAPI principles taught in this course to help you fulfill your mission to provide the best possible care and quality of life for your resident.

Save the Dates! More information and registration coming soon.


Medicare University
July 31-August 2 ~ Lansing

Become the Medicare leader in your facility with this comprehensive three day workshop. This in-depth program will help you manage the reimbursement system, navigate audits, avoid risky practices, and stop drowning in confusing and ever-changing regulations.

Authored by the foremost experts in Medicare, this workshop will:

  • Increase your understanding the Medicare benefits, eligibility, and the difference between Part A, B, C and D;
  • Share the concepts of SNF skilled services, payment structures, and consolidated billing;
  • Define the qualifications and requirements for both Part A and B therapy;
  • Explain the Medicare claim review and provider appeal processes;
  • Allow you to gain confidence in the documentation process;
  • Assist you complying with billing requirements; and
  • Provide an understanding of the principles of the Beneficiary Notification Initiative.

Save the Dates! More information and registration coming soon.


Director of Nursing Services-Certified (DNS-CT) Prep Workshop
October 16-18 ~ Lansing

Take your leadership and management talents to the next level with a preparatory workshop for AADNS’s Director of Nursing Services—Certified (DNS-CT) certification. Earning this credential validates your expertise, gives you the advantage among your peers, and helps you improve quality, communication, and resident care throughout your facility.

The DNS-CT credential from AADNS shows that you have the leadership and management skills and knowledge to excel as a DON. Certification indicates that you have met nationally recognized standards of expertise for directors of nursing services in long-term care, that you are up-to-date with the rules and regulations, and that you can lead and nurture your team.

This three-day workshop will complement your nursing expertise with leadership and management skills. Workshops are taught by individuals who go through rigorous requirements to become Master Teachers and who are experts in the field.

Save the Dates! More information and registration coming soon.


Mark Your Calendars!

2018 Annual Conference & Trade Show
Join us for our 50th Anniversary Celebration!

May 20-23, 2018 ~ Suburban Collection Showplace, Novi

2018 Annual Leadership Institute
August 22-24, 2018 ~ Mission Point Resort, Mackinac Island


Thank You Content Contributors!


201 N Washington Square, Suite 920
Lansing, MI 48933
Phone: 517-323-3687
Fax: 517-323-4569

Our Mission: To advance the mission of our members to enhance the lives of seniors.
Our Vision: To become the voice of aging services in Michigan.

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