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The Latest Wrinkle June 16, 2017
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SNF Occupancy Trends

Last week, the National Investment Center for Seniors Housing and Care issued a report on occupancy trends in skilled nursing. Average occupancy over the past year was 82.9% nationally, and averaged 82.6% at the end of the first quarter of CY2017. Researchers expect to see trending slightly upward in the first quarter of each calendar year related to seasonal factors. For this first quarter, Medicaid was the primary payer for 65.2% of days, Medicare 13.7% for Medicare A, 6.7% for Medicare Advantage Plans, and 9.1% for Private Pay.

Occupancy trends have been declining for the past several years, with average occupancy in 2015 at 85.7% and 84.3% in 2016. Decreasing occupancy levels in Michigan will likely put pressure on facilities who cannot meet the 85% occupancy standard for administrative costs under Medicaid.

As the post-acute care system continues to evolve and respond to the changes driven by health care reform, we must proactively look at the needs for senior care in Michigan. Some believe the current SNF model is at risk and quality may only be able to be maintained when facilities are reduced in number, particularly pressured facilities.

Average Nursing Home Occupancy 2012-2017 (NIC)

As Michigan’s certificate of need process continues to evolve, it is important to consider comments by noted gerontologist David Grabowski. He was quoted as saying the CON process inhibits quality and does not allow the market forces to address poor quality facilities. With or without CON, fewer beds will ultimately be needed even as the senior demographic grows. Success may well depend on how well each facility is truly focused on patient centered care and outcomes.


MDHHS Budget Moves to the Governor

Last week during Conference Committee that was a lot of advocacy occurring around the MDHHS budget as it moved to Conference Committee. The primary areas of focus for LeadingAge Michigan related to sections of language, inserted in the revised Senate version of the budget since it original publication that would impact the Long Term Care Supports and Services community. Those sections were 1852, 1855 and 1857.

Section 1852 would have required DHHS to implement a pilot project in the specific counties in Michigan and require the transition of Home and Community Based waiver recipients into a LTCSS program administered by an Integrated Care Organization. If the section had been approved and ultimately signed by the Governor many LeadingAge Michigan members could have been significantly impacted. This section of the budget was removed.

Section 1855 remained in the budget and reads “From funds appropriated for the program of the all-inclusive care for the elderly (PACE), to the extent funding is available in the PACE line item and unused program slots are available, the department may do the following:

  1. Increase the number of slots for an already established local PACE program if the local program has provided appropriate documentation to the department indicating its ability to expand capacity to provide services to additional PACE clients.

  2. Suspend the 10 member per month individual PACE program enrollment increase cap in order to allow the unused and unobligated slots to be allocated to address the unmet demand for PACE services.”

Section 1857 remains in the budget and requires the state to explore implementation of managed for LTCSS by July 1, 2017. LeadingAge Michigan does not consider this language as onerous as it basically commemorates the spirit of what was captured in PA 107 a few years ago, so we will have to wait to see what plays out.

In summary, the MDHHS budget moves forward to the Governor with positive impact for the LeadingAge Michigan membership. However, please keep in mind the cautionary words Chris Priest, the Medicaid Director, told us at the Annual Conference that given the changing federal landscape MDHHS will be examining options as we move into the future.

SB 378 Passed out of Committee

After many months of discussion among providers of unlicensed assisted living facilities, regulators, attorneys and provider associations, Senator Marty Knollenberg (R) introduced SB 378 on May 16 to resolve concerns of unlicensed providers of senior services across Michigan.

On June 14, 2017, SB 378 received unanimous support from the members of the Senate Regulatory Reform Committee. In addition to modifying the definition of “home for the aged,” this bill would also allow the Department of Licensing and Regulatory Affairs (LARA) to make exemptions from licensure as a home for the aged, modifies how Criminal Background Checks are funded and amends certain provisions of the National Fire Protection Association standard. To review the most version passed by the subcommittee here.

Across the Continuum

Compensation Study Deadline Extended - We Need Your Help!

LeadingAge Michigan, in collaboration with LeadingAge Ohio, is conducting a workforce compensation study facilitated by Towers Watson Data Services. This collaboration will help inform our advocacy efforts and provide you with valuable insight into the workforce challenges facing not for profit providers within our region of the country. In an effort to ensure maximum participation we have extended the deadline until June 23, 2017.

Click here to access the survey.

For questions on the survey contact Monica Bellinger-Lewis at Towers Watson, or (703) 258-7689.

Home and Community Based Services

Updates from the Federal Perspective

LeadingAge National reports that 29 states have received initial approval of their Statewide Transition Plan (STP) for compliance with the federal home and community-based services regulations. Michigan is yet to have its plan approved by the Centers for Medicare and Medicaid Services (CMS) although it has been submitted for review. STPs are approved when states have completed systemic assessments with outcomes, remediation strategies to address issues identified through the assessment are in place, and the strategies have been implemented.

CMS reports that states are developing “tiered standards” to implement this final rule that impacts how HCBS waivers are operated. While there are minimum standards that must be met in implementing the rule, some states have created STPs that impose more vigorous requirements. While Michigan operates multiple HCBS [1915(c) waivers], the STP currently applies to the MI Choice Home and Community Based Services waiver, the Habilitation Supports Waiver, and the Waiver Program for Children with Serious Emotional Disturbance because these waivers have amendments prior to the statewide implementation date for the new HCBS rule.

Because of the degree of difficulty in implementing the rule, CMS has extended the date for final implementation to March 17, 2022. STPs must be approved by March 19, 2017.

PACE and Coordinated Care

Peter Notarstefano, the Director of Home and Community Based Services (HCBS) for LeadingAge in Washington, recently reported that the Health Subcommittee of the House Ways and Means Committee held hearings on Medicare Advantage and Promoting Integrated and Coordinated Care for Medicare Beneficiaries. Testimony focused on Special Needs Plans (SNPs), the Program of All-Inclusive Care for the Elderly (PACE) and value-based insurance design models. The subcommittee is interested in finding ways to serve the high-cost, high-need individuals enrolled in Medicare. Individuals testifying before the committee included Cheryl Wilson - CEO of St. Paul’s Senior Services in San Diego - who spoke on behalf of PACE services.

Of note, A. Mark Fendrick, MD, Executive Director of the University of Michigan Center for Value-Based Insurance Design, spoke on value-based purchasing models.

On the Senate side, the Finance Committee passed a bill that would have significant impact on serving Medicare beneficiaries through Medicare Advantage SNPs by making them a permanent part of Medicare. SNPs are health plans that focus on serving specific populations of Medicare beneficiaries. There are three types of these plans: dual-eligible SNPs, chronic condition SNPs and institutional SNPs. Making SNPs a permanent part of Medicare if the bill were passed by Congress would demonstrate a strong commitment to serving high cost Medicare beneficiaries.

Skilled Nursing

A Collaboration around Compliance

LeadingAge Michigan and 19 of its members have begun a collaborative designed to assist members in the implementation of the SNF Mega Rule and the Emergency Preparedness final rule all scheduled for November of 2017. The Compliance Store, our collaborative partner has 30 years’ experience in area of compliance and supports the only web-based comprehensive regulatory and compliance resource for long-term care.

To learn more about this new collaborative and the many resources offered by The Compliance Store contact

Interpretative Guidance for the Emergency Preparedness Final Rule

The Centers for Medicare & Medicaid Services (CMS) has released a new Appendix Z of the State Operations Manual (SOM), which contains interpretive guidelines and survey procedures for the emergency preparedness final rule. Appendix Z applies to all 17 providers and suppliers included in the final rule. The compliance deadline for the new rule is Nov. 15, 2017.

On Wednesday Aug 2, 2017 from 9:30 to 10:30a, LeadingAge Michigan will be hosting a webinar to assist in your compliance preparation titled, “All-hazards Approach and Facility-based and Community-based Risk Assessment”. This webinar will provide instructions on how to do a “risk assessment” (e.g. HVA, All-hazard risk assessment) and what health and safety risks must be addressed in your population as you develop your emergency plan. Stay tuned for future announcements regarding registration.

New Water Management Policy and Procedure

On June 9, the Centers for Medicare and Medicaid Services (CMS) posted a Survey and Certification Letter that outlines the responsibilities of health care providers, including Medicare-certified Skilled Nursing Facilities (SNFs), to develop and implement water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.

CMS expects Medicare certified healthcare facilities to have an industry standard calling for the development and implementation of water management programs to reduce the risk of legionellosis. In 2016, the Centers for Disease Control and Prevention (CDC) and its partners developed a toolkit to facilitate implementation of this American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) Standard. Environmental, clinical, and epidemiologic considerations for healthcare facilities are described in this toolkit.

Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities:

Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.

Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.

Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.

Proposed Rule to Revise Arbitration Agreement Requirements

The Centers for Medicare & Medicaid Services (CMS) published proposed rule in the Federal Register on June 8, 2017 revising the requirements for the use of arbitration agreements in long-term care facilities. The proposed rule reverses the ban on pre-dispute binding arbitration agreements contained in the October 2016 Reform of Requirements of Long-Term Care Facilities Final Rule. For more information see the CMS website.

LeadingAge is reviewing the proposed rule, soliciting feedback from members and will submit comments. For more information see the CMS website.

Advance Beneficiary Notice of Non-Coverage

The Advance Beneficiary Notice of Non-Coverage (ABN), Form CMS-R-131and form instructions were recently slightly modified and approved by the Office of Management and Budget (OMB) for renewal. The effective date for use of this ABN form is 6/21/2017.

As a reminder, the ABN (Form CMS-R-131) is to be issued by providers and suppliers to Medicare (fee for service) beneficiaries in situations where Medicare payment is expected to be denied. Skilled nursing facilities (SNFs) must use the ABN for items/services expected to be denied under Medicare Part B only.

While there are no changes to the form itself, providers should take note of the newly incorporated expiration date on the form. In accordance with Section 504 of the Rehabilitation Act of 1973 (Section 504), the form has been revised to include language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed. Use this link to download the ABN. Guidelines for mandatory and voluntary use of the ABN are published in the Medicare Claims Processing Manual, Chapter 30, Section 50.

The Governor's Award of Excellence Is Back!

MPRO, as part of Lake Superior Quality Innovation Network (QIN), and Governor Rick Snyder have recently announced the return of the Governor's Award of Excellence. These awards recognize healthcare providers for their dedication to improving healthcare quality and patient safety in Michigan. To be eligible for the awards, participating providers will have to achieve, maintain and continually improve specific and rigorous milestones. The self-nomination period ends July 31, 2017. Category of awards and goals include the following:

Community – improving coordination of care and antibiotic stewardship
Home Health – improving heart health and increasing adult immunizations
Nursing homes – healthcare-acquired conditions, clostridium difficile

To view full award details, visit the MPRO website.

CMS' Annual QIO Program Progress Report

TLake Superior Quality Innovation Network (Lake Superior QIN),the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Michigan, Minnesota, and Wisconsin, is pleased to share the findings from the third year of the QIO Program's five-year performance period in the Centers for Medicare & Medicaid Services' (CMS') newly released 2016 QIO Program Progress Report.

The CMS progress report highlights how Lake Superior QIN is successfully supporting six practice transformation networks in its three-state region (under "Snapshots of Success") to help clinics implement comprehensive quality improvement strategies.

MSHDA Board Approved 2017-2018 QAP Amendment

This June, the draft 2017-2018 Qualified Allocation Plan Amendment was approved by the Michigan State Housing Development Authority Board (MSHDA) and the Governor. The amendment was in response to recent fluctuations in the LIHTC (low income housing tax credit) equity markets that were prompting some necessary changes in the LIHTC Program to address recently awarded LIHTC projects not yet closed on their LIHTC equity and financing sources. The approval letter and final document are available on the "Qualified Allocation Plan" page of MSHDA's website.

DUNS Number Required on All Voucher Submissions

U.S. Department of Housing and Urban Development (HUD) recently announced plans to implement the requirement to include the Dun & Bradstreet’s (DB) Data Numbering System (DUNS) Numbers on all vouchers submitted to Tenant Rental Assistance Certification System (TRACS). Effective December 1, 2017, vouchers that do not contain an active DUNS number will generate a Tenant Rental Assistance Certification System (TRACS) fatal error and will not receive payment until corrected. Entities must register/update annually in SAM to maintain an active status to be eligible to receive financial assistance. HUD requires an active DUNS number in order to renew contracts covered by the notice, and the DUNS number needs to be renewed each year to stay active. Owners of Project-Based Rental Assistance Contracts or Section 202 or 811 Project Rental Assistance Contracts (PRACS) are required to obtain and maintain an active DUNS number for their project.

Here are some resources to help you if you need to check/renew your DUNS numbers:

DUNS numbers can be registered and renewed each year at this website.

A “Quick Start Guide for Updating/Renewing an Entity” that provides guidance for renewing your DUNS number in SAM can be found by clicking here.

The HUD memo can be seen here.

Additional Updates to HUD Handbook

TThree additional draft chapters of the “Multifamily Asset Management and Project Servicing” HUD Handbook 4350.1 have now been posted to the “Multifamily Policy Drafting Table” for a 30-day review period. This handbook serves as a resource for staff, industry partners, and owners and agents. Please use this link to access the following newly posted chapters:

Chapter 4.01 Combining Section 8 Contracts

Chapter 6.03 Interest Rate Reduction

Chapter 8.02 Partial Payment of Claims

HUD staff and partners are encouraged to review each chapter, complete the corresponding worksheet and submit feedback by July 24, 2017 to

Member Value

Hydration for Memory Care Residents

Did you know that by the time you’re 80 you have 15% less water than when you were 20? Elderly residents are generally at a higher risk for dehydration, and those with memory issues are at an even greater risk. Gordon Food Service, a Value First vendor, has provided some signs of dehydration and tips in how to keep Memory Care Residents hydrated. For the entire article click here.

For further information, or if you’d like to speak with a Gordon Food Representative, please contact Rob Ervin at (517) 449-1712 or

Education Center


Annual Leadership Institute
New Location
Crystal Mountain Resort & Spa

Save the Dates
August 16-18, 2017

Make your room reservation early to get your preferred room type. Our room block cut-off date is July 17.
Click Here for reservation information.

Additional conference information coming soon!

Medicare University
June 20-22 ~ 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.

For more information call 517 323-3687.

MDS RAC Certification Workshops

July 18-20 ~ Grand Rapids
September 19-21 ~ Mt. Pleasant

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.

Click Here for more information and to register.

Nurse Aide Train-the-Trainer
July 24 ~ Okemos
September 25 ~ Okemos
November 13 ~ Okemos

The Train-the-Trainer workshop is a program for registered nurses who are interested in becoming qualified instructors for Nurse Aide Training Programs with the State of Michigan. The workshop is designed to provide learners the components of a nurse aide training program, the basic Federal requirements for a nurse aide program.

Click Here 
for more information and to register.

Certified INTERACT 4.0 Champion (CIC)
July 26 & 27 ~ Lansing

Why become a CIC?
This workshop is designed to train clinical leaders to serve as champion for implementing and sustaining the INTERACT 4.0 Quality Improvement Program (QIP) for their organization. As a clinical leader, you play an integral role in ensuring the delivery of quality care and reducing avoidable rehospitalizations. Becoming a Certified INTERACT Champion (CIC) emphasizes your commitment to ongoing quality improvement. During this 2-day interactive course, you will gain insight on strategies to improve the delivery of care, changes in condition, and how to prevent avoidable hospital transfers. Join our new Master Trainer, Betty Brunner with Pathway Health, as she provides an in-depth description of the INTERACT strategies, care processes, tools and other valuable resources. The CIC Master Teacher will share lessons learned that will allow you to be successful in implementing and sustaining INTERACT 4.0 for your organization. If you are interested in becoming certified, this training will also prepare you for the CIC Certification exam.

Click Here for more information and to register.

LEAN Leadership Concepts
Six Month Course ~ July through December
All Classes 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. This Lean course will provide an in-depth learning experience that includes an introduction and overview of Lean concepts, structured problem solving, sustainable process improvement techniques, Lean leadership, and how to become a learning organization. The course will conclude with each participant providing a report that focuses on their organization-specific project completed during the six Lean sessions.

  • Session 1 – July 25: Introduce Lean concepts and how they can be applied by healthcare leaders throughout the various continuum of care settings.
  • Session 2 – August 31: Explore some of the common tools used in Lean. It will lay the foundation for deeper study in subsequent sessions.
  • Session 3 – September 28: Addresses how to scientifically solve problems as a foundational skill for making lasting process improvement.
  • Session 4 – October 26: Teaches the concepts of Lean organization align, enable and improvement process. Leader Standardized Work as the engine for improvement. How to apply structured learning and problem solving.
  • Session 5 – November 16: Learn how to replace traditional leadership traits with Lean leadership traits. Identify personal traditional leadership behaviors and the corresponding, desired Lean leader behavior. Leverage Leader Standardized Work, shared in the previous session, to move from traditional to Lean leadership.
  • Session 6 – December 14: Share a problem solved in a succinct, scientific manner. Be able to articulate the connection of various components of Lean and why a systematic approach to improvement is required for culture change.

Save the Dates ~ more information and registration opening soon!

Building Better Working Relationships
August 23 ~ Central Michigan
August 29 ~ West Michigan
September 7 ~ Southeast Michigan

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!

Director of Nursing Services-Certified (DNS-CT) &
Administrator in Training Course

October 10-12 ~ Lansing

Gain the skills and knowledge you need to be the support your team needs. Be a more effective facility leader and champion for quality care with validation of knowledge in facility management, risk management, QAPI, survey readiness,survey management and enforcement, human resources, quality indicator surveys, MDS and Medicare processes, care management, essential business skills, conflict resolution and leadership strategies.

Take your skill set to the next level. This three-day workshop offers a specialized American Association of Directors of Nursing Services DNS-CT certification for nurses; as well as relevant content for nursing home administrators, vice presidents of clinical services, administrators in training and other long-term care professionals with facility management responsibilities.

Click Here for more information and to register.

Leadership Academy

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.

For more information ~ please contact the Association at 517-323-3687.

Modular Education Program for Activity Professionals (MEPAP) 
Second Edition Course

We are still accepting students for 2017!

Classes offered in Southeast and West.
Accelerated courses can be scheduled at your location!

The MEPAP course prepares the activity professional for all aspects of their role. The nationally approved course curriculum is designed to enhance the skills and knowledge required to properly facilitate the activity needs for all residents in aging services settings. The 18-day course offers 180 hours of instructor-led training and 180 hours of supervised practicum assignments. After successfully completing the course, individuals will be prepared for the National Certification Council for Activity Professionals (NCCAP) exam and certification application process.

For more information ~ please contact the Association at 517-323-3687.

Mark Your Calendars!

2017 Annual Leadership Institute
August 16-18, 2017 ~ Crystal Mountain Resort, Thompsonville

2017 National Annual Meeting & Expo
October 29 - November 1, 2017 ~New Orleans, LA
Michigan Night Out - Monday, October 30th - Napoleon House

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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