License Assisted Living Director Course Handbook

Care Providers of Minnesota License Assisted Living Director Course Handbook

October 2021 Care Providers of Minnesota 7851 Metro Parkway, Suite 200 Bloomington, MN 55425 952-854-2844 800-462-0024 www.careproviders.org

Thank you to our Minnesota Experts Care Providers of Minnesota is indebted to the dedicated subject matter experts who shared their time, expertise, and insight to create Minnesota-specific modules for potential licensed assisted living directors. Without these dedicated experts, this course would not be possible.

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Doug Beardsley, LNHA, LALD, Vice President of Member Services, Care Providers of Minnesota

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Todd Bergstrom, Director of Research & Data Analysis, Care Providers of Minnesota

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Rebecca K. Coffin, Partner, Voigt, Rodè, Boxeth & Coffin, LLC

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Racey Gasior, MS, Lead Quality & Experience Specialist, Lifespark (Formerly Tealwood Senior Living)

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Linda Hall, MA, BSN, RN, CPHQ, Nurse Consultant, Advanced Health Institute (AHI)

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Cheryl Hennen, State Long-Term Care Ombudsman, Office of Ombudsman for Long-Term Care

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John L. Huhn, Vice President of Senior Living Operations, Community Living Solutions

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Monica Hunter, Senior Director of Business Development, Lifespark Senior Living (Formerly Tealwood Senior Living)

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Michelle R. Klegon, Attorney, Klegon Law Office, Ltd.

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Nicole Mattson, LHSE, SHRM-SCP, SPHR, MA, Vice President of Strategic Initiatives, Care Providers of Minnesota

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Michael Mireau, Public Health Architect, Assisted Living Physical Environment Supervisor, Engineering Services, Minnesota Department of Health

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Robert F. Rodè, Partner, Voigt, Rodè, Boxeth & Coffin, LLC

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Jill Schewe, LALD, Director of Assisted Living, Housing & Home Care, Care Providers of Minnesota

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Lindsay Schmidt, LALD, Director of Marketing & Hospitality, Dellwood Gardens Assisted Living and Memory Care

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Karolee Withers (formerly Alexander), RN, RAC-CT, Director of Clinical & Reimbursement Consulting, Pathway Health

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Mary Nell Zellner, LNHA, LSW, President/CEO, Zellner Senior Health Consulting, LLC

TABLE OF CONTENTS

MINNESOTA MODULES

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AGREEMENTS WITH OTHER HEALTHCARE PROVIDERS .............................................................. 7 EMERGENCY PREPAREDNESS ................................................................................................. 21 EMPLOYEE TRAINING ............................................................................................................ 39 FAMILY & RESIDENT COUNCILS .............................................................................................. 57 GROUNDS & CONTRACT MANAGEMENT ................................................................................ 63 INTERDISCIPLINARY TEAM (ROLE OF OTHER ASSISTED LIVING STAFF) ...................................... 93 LANDLORD-TENANT ............................................................................................................ 117 LONG-TERM CARE OMBUDSMAN ........................................................................................ 143 MARKETING & SALES BASICS ............................................................................................... 151 MENTAL HEALTH: OLDER ADULT MENTAL HEALTH BASICS .................................................... 163 MENTAL HEALTH: CRISIS PREVENTION & DE-ESCALATION ..................................................... 167 MENTAL HEALTH: PERSON-CENTERED CARE & COLLABORATION ........................................... 171 NURSING PRACTICE ............................................................................................................ 175 PAYMENT SOURCES ............................................................................................................ 205 PHYSICAL ENVIRONMENT REQUIREMENTS—DEMENTIA CARE ............................................... 259 QUALITY MANAGEMENT ..................................................................................................... 267 RESIDENT RIGHTS & ADDRESSING COMPLAINTS ................................................................... 275 SURVEY & ENFORCEMENT PROCESS ..................................................................................... 285 VULNERABLE ADULT PROTECTION ....................................................................................... 305

L ICENSED ASSISTED L IVING DIRECTOR

AGREEMENTS WITH OTHER HEALTHCARE PROVIDERS Mary Nell Zellner, LNHA, LSW, President/CEO Zellner Senior Health Consulting, LLC

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INTRODUCTIONS Mary Nell Zellner, LNHA, LSW, President/CEO Zellner Senior Health Consulting, LLC As owner and CEO of Zellner Senior Health Consulting, Ms. Zellner has 30+ years in the healthcare field as a clinician, health care administrator, regional director, vice president and senior vice president, lobbyist, and a consultant for the past 21 years. Ms. Zellner’s background has provided her education and practical experience in acute care continuum, long term care, sub-acute unit management, and assisted living settings. She has served on a variety of longterm committees in health care delivery and health reform. Ms. Zellner is a frequent presenter for state and national leadership venues on the topics of quality, turnaround, management and organizational system improvement.

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Zellner Senior Health Consulting Agreements with Other Healthcare Providers

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Minnesota Rule Requirements Services, 144G.70, Subd. 3 Temporary service plan. When a facility initiates services and the individualized assessment required in subdivision 2 has not been completed, the facility must complete a temporary plan and agreement with the resident for services.

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Contracts vs. Agreements

Definitions

Types of community relationships

Approaches

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Typical Types of Contractor Agreements Outside vendors and providers needed to assist your residents with a wide variety of medical and personal needs.

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Audiology RANGE OF SERVICES PROVIDED: 

Exams

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Updated Technology

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Replacement/Damage/Repairs

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Dental 

Resident/client needs

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Payor type consideration

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Availability of providers

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Home Care Providers TYPES OF SUPPLEMENTAL CARE DELIVERY: 

Family participation

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Changing resident needs

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Hospice Providers 

Collaboration with primary physician/provider

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Types of agencies and services

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Pharmacy KEY FACTORS FOR CONSIDERATION: 

Access for off hours delivery

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Drug reviews- medication contraindication

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Types of medication

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Over the counter items

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Podiatry EXAMPLES: 

Diabetic care

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Foot issues

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Prosthetics

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Mental Health Services 

Adjustments to placement

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Dementia

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Behavioral Modifications

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Education

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+ NUTRITION

Menus Special Dietary Needs 14

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+ THERAPY

Physical Occupational Speech 15

NAB – National Administrator Board 10.09 Ensure the planning, development, implementation/execution, monitoring, and evaluation of a rehabilitation program to maximize optimal level of functioning and independence for care recipients.

What does this mean?

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NAB – National Administrator Board 10.10 Ensure the planning, development, implementation/execution, monitoring, and evaluation of systems for coordination and oversight of contracted services.

What does this mean?

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Transportation 

State-wide research

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Availability

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Types of needs

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Timing

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Cost

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Access

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Transfer Agreements Hospital care- (E0025) Facilities are required to have policies and procedures which include pre-arranged transfer agreement, which may include written agreements or contracted arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

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Agreements Hospital care- (E0025), continued Memorandum of Understandings (MOUs) = The ability to demonstrate your compliance!

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+ WOUND SPECIALIST

WOCN–Wound Ostomy Continence Nursing CWS–Certified Wound Specialist 21

Consideration Factors 

Resident rights to use other providers (144G.52, Subd. 6)

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YOUR accountability to review and partner with resident choices

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Best Practices/Standard of Practice

What does this mean?

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DO’S & DON’TS

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Do… 

Be proactive

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Review all care range of services you plan to provide

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Think ahead- be proactive

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Do Not… 

Accept payment from providers for referrals

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Accept gifts or money for partnering (kickbacks)

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Threaten to end a resident contract when you can coordinate services

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SUMMARY POINTS

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L ICENSED ASSISTED L IVING DIRECTOR

EMERGENCY PREPAREDNESS IN MINNESOTA’S LICENSED ASSISTED LIVING FACILITIES Doug Beardsley, LNHA, LALD, Vice President of Member Services Care Providers of Minnesota Jill Schewe, LALD, Director of Assisted Living, Housing & Home Care Care Providers of Minnesota

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INTRODUCTIONS Doug Beardsley, LNHA, LALD, Vice President of Member Services Care Providers of Minnesota Doug Beardsley has been involved in the field of long-term care since 1982, when he became a nursing home administrator. Mr. Beardsley has a Bachelor of Science degree in healthcare administration from the University of Wisconsin–Eau Claire. His experience includes 20 years as a nursing home administrator, three years as a longterm acute care hospital CEO, manager of an in-house LTC pharmacy, and other long-term care related activities. Mr. Beardsley has been the vice president of member services with Care Providers of Minnesota since 2005, where he is responsible for the regulatory activities pertaining to nursing facilities, home care, housing with services, assisted living, and hospice.

Jill Schewe, LALD, Director of Assisted Living, Housing & Home Care Care Providers of Minnesota

Director of Assisted Living, Housing & Home Care, Care Providers of Minnesota Jill Schewe has worked in and with assisted living communities her entire career. As a former assisted living manager, her experience was in startup, management, and operations of several assisted living communities. In her current role, Jill works with assisted living providers on any topic they need help with to aid in their success, including licensing, policy, payment, and operational systems. She understands the needs of older adults and home- and community-based services alike. And most recently she obtained her Assisted Living Director license.

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CMS Appendix Z – Emergency Preparedness The primary requirement for emergency preparedness for Minnesota’s licensed assisted living facilities is to comply with a requirement that is only referenced in the assisted living rules: • The Centers for Medicare and Medicaid (CMS) State Operations Manual Appendix Z – Emergency Preparedness • This emergency preparedness requirement is also used as a requirement for hospitals, nursing homes, and many other health care providers.

• Appendix Z is over 100 pages long!

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The document shown here is a transmittal (notification) from CMS which contains the Appendix Z requirements.

Note - Appendix Z will not state it applies to assisted living – that was a MN decision put into the assisted living Rules!

Appendix Z can be found here: https://www.cms.gov/files/documen t/qso-21-15-all.pdf

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Emergency Preparedness • This course will not attempt to train the student on all the required elements of Appendix Z. • We will try to highlight the key elements that a Licensed Assisted Living Director would be responsible to plan, develop, implement, monitor, and evaluate in relation to an emergency preparedness plan.

• There are FOUR CORE ELEMENTS to an emergency preparedness plan that complies with Appendix Z.

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Four CORE COMPONENTS

Risk Assessment and Planning

Policies and Procedures

Emergency Preparedness Program

Communication Plan

Training and Testing

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Four CORE COMPONENTS

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Component #1: Risk Planning and Assessment • To be prepared for emergencies, the Licensed Assisted Living Director must first identify potential threats and hazards of concern.

• Once you predict the threats, you can then determine how much of an impact that threat will have on the assisted living building, people (staff and residents) and your business.

• You can then use that knowledge to prioritize and develop plans to mitigate the impact of such emergencies.

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Component #1: Risk Planning and Assessment • This risk planning and assessment is most commonly completed using a free excel based software tool called a: • HAZARD VULNERABILITY ANALYSIS (HVA) • HVAs should be conducted using multiple staff – not just the Licensed Assisted Living Director. Consider including your Clinical Nurse Supervisor and someone from Maintenance/Building.

• Sample HVAs are available for downloading from many sites on the internet.

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Addresses: • Probability of Events • Human, Property, and Business Impact • Level of Preparedness and Response CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

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Severe Thunderstorm Flood (external) Flood (internal) Winter Storm Tornado Seasonal Flu Pandemic Other Severe Weather Electrical Failure (Generator Works) Electrical Failure (Generator Failure) Water Failure Property Crime Landslide Wind HVAC Failure Building Compromise Sewer Failure (Main) Sewer Failure (Plumbing) Communication Failure Natural Gas Failure Other Commercial Utility Failure Transportation Failure

Transportation Failure Cyber Security Issues Mass Casualty Incident Hazmat Exposure Hazmat Spill Pharmaceutical Shortage Infectious Disease Pandemic Supply Chain Interruption Information Theft Sinkhole Hostage Violent Patient/Family Active Shooter Wandering Resident Surge of Residents Need to Evacuate (Fast Out) Need to Evacuate (Imminent) Access Control Breach Fire IT Outage

Addresses: • Natural Hazards • Technological Hazards • Human Hazards • Hazardous Materials

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Severe Thunderstorm Flood (external) Flood (internal) Winter Storm Tornado Seasonal Flu Pandemic Other Severe Weather Electrical Failure (Generator Works) Electrical Failure (Generator Failure) Water Failure Property Crime Landslide Wind HVAC Failure Building Compromise Sewer Failure (Main) Sewer Failure (Plumbing) Communication Failure Natural Gas Failure Other Commercial Utility Failure Transportation Failure

Transportation Failure Cyber Security Issues Mass Casualty Incident Hazmat Exposure Hazmat Spill Pharmaceutical Shortage Infectious Disease Pandemic Supply Chain Interruption Information Theft Sinkhole Hostage Violent Patient/Family Active Shooter Wandering Resident Surge of Residents Need to Evacuate (Fast Out) Need to Evacuate (Imminent) Access Control Breach Fire IT Outage

This list should be modified to your situation!

Is your facility next to a railroad? Add train derailment and spill.

Each sample HVA may have different hazards – modify them.

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Component #1: Risk Planning and Assessment • The HVA will then calculate your scores to help you prioritize those issues that are most likely to happen, will have a big impact, and you are least prepared for.

• You will then use this information to create your policies, procedures, and response plans.

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Component #2: Policies and Procedures • Appendix Z requires a LOT of specific policies and procedures related to an assisted living facility.

• A sample of required policies and procedures: • How will you provide for substance needs during an evacuation or shelter in place (food, water, medications, PPE, etc.)?

• How will you maintain temperature, lighting, sewage, and waste disposal in an emergency?

• How will you track staff, volunteers, and residents during an emergency?

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Component #2: Policies and Procedures • Continued sample of required policies and procedures: • Procedures for safe sheltering in place.

• Procedures for safe evacuation of the assisted living facility.

• How will you maintain medical documentation in an emergency?

• What arrangements (memorandums of understanding) do you have in place for moving residents if evacuation would be necessary? Do you have written arrangements to move your residents to an off-site location?

• How will you cooperate if an 1135 waiver is initiated by the Federal Government in a national or state emergency? Do you have a policy with required 1135 waiver contact information on it?

• How will you work with community resources in an emergency?

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Component #3: Communications Plan • The assisted living facility must have a communications plan that: • Identifies how you will share and access names and contact information for: • • • • • • • • • •

Staff Entities providing services under arrangement Resident’s physicians Other assisted living facilities or long-term care facilities Volunteers Family members and designated resident representatives Emergency Preparedness staff (local, regional, state, federal) Regulators Office of Ombudsman for LTC Other “sources of assistance”

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Component #3: Communications Plan • The assisted living facility must have a communications plan that: • Identifies how you will share and access medical documentation for residents in the assisted living, and share, if necessary, with other providers to maintain continuity of care.

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Component #3: Communications Plan • Many health care providers have, as part of their communications plan, an organized incident command system to organize communications and emergency response.

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Component #3: Communications Plan

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Component #4: Training and Testing • A big part of an emergency preparedness plan is training and testing.

1. Staff of the assisted living must be trained on your emergency preparedness plans: • Upon hire • Annually after that 2. Training must be documented, have demonstrated knowledge, and be based on the facilities risk assessment as well as the communication plan.

3. The assisted living facility must conduct drills and exercises to test the emergency plan to identify gaps and areas for improvement.

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Component #4: Training and Testing • Testing (drills and exercises) • On an annual basis, the assisted living must conduct at least two training exercises: 1. A full-scale exercise that is community-based. This may include local fire, EMS, hospitals, nursing homes, other assisted living facilities, etc. Full-Scare exercises are usually coordinated by Regional Health Care Preparedness Coordinators – but they need to know you want to be included in such drills!

2. A second full-scale exercise, or a facility-specific table-top drill.

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Minnesota’s Regional Health Care Preparedness Coordinators

Critical for arranging Full-Scale Community Wide exercises.

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Tabletop exercises are discussion-based sessions where team members meet in an informal, classroom setting to discuss their roles during an emergency and their responses to a particular emergency situation. A facilitator guides participants through a discussion of one or more scenarios.

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Component #4: Training and Testing • The assisted living facility must document these drills and participate in a debrief to identify what went well and not so well, and initiate changes to its emergency preparedness plans accordingly.

• Note – an actual emergency can replace a drill. (not something you want to shoot for!)

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Appendix Z The emergency preparedness program must be reviewed annually.

Risk Assessment and Planning

Policies and Procedures

Emergency Preparedness Program

Communication Plan

Training and Testing

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Assisted Living Rules and Statutes • In addition to requiring compliance with Appendix Z, Minnesota’s Assisted Living Statutes (MN 144G) and Rules (MN 4659) contain additional emergency preparedness requirements.

• Required Fire Drills • Portable Fire Extinguishers • Required Smoke Alarms • A Fire Safety and Evacuation Plan CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

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Assisted Living Rules and Statutes • Continued…

• Resident Emergency Training offered once per year • Assisted Living with Dementia Care buildings must be fully sprinkled by August 1, 2029 • Posted evacuation plans on each floor • Twice per year staff training on fire safety and evacuation

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Assisted Living Rules and Statutes • Continued…

• Missing Resident Policies and Procedures with quarterly review • Individual Abuse Prevention Plans for residents • HVA of the property for those with a dementia license • Awake staff on a memory care unit at all times

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AND THAT’S IT! 1. CMS Appendix Z 2. Certain MN Assisted Living Statutes (MN 144G) 3. Certain MN Assisted Living Rules (MN 4659) • Lots of planning • Lots of documentation • Lots of training

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As a future Licensed Assisted Living Director, your facility will need to be prepared for emergencies and disasters – they will occur. A resident may go missing, a snowstorm may block roads, a pandemic may exist.

Spending time developing and improving your response to emergencies will help with your business continuity as well as the health and safety of your staff and residents.

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L ICENSED ASSISTED L IVING DIRECTOR

ASSISTED LIVING EMPLOYMENT RELATED TRAINING Nicole M. Mattson, Vice President of Strategic Initiatives Care Providers of Minnesota Jill Schewe, LALD, Director of Assisted Living, Housing & Home Care Care Providers of Minnesota

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INTRODUCTIONS Nicole M. Mattson, Vice President of Strategic Initiatives Care Providers of Minnesota

Nicole Mattson is Vice President of Strategic Initiatives for Care Providers of Minnesota, where she focuses on Advocacy, Workforce and Quality. Nicole is a licensed nursing home administrator and a Health Services Executive candidate. She has a master’s degree in Human Resource Management from St.Mary’s University, and an undergrad from Metropolitan State University. She holds SPHR certification from the Human Resource Certification Institute and SHRM-SCP from the Society of Human Resource Management. She has over 25 years of experience in the senior care profession, in various capacities, most recently as an Administrator with Good Samaritan Society-Specialty Care Community. Nicole is a Senior Examiner for the AHCA Quality Award Program and is the Chairperson of the Hennepin Carver Workforce Development Board.

Jill Schewe, LALD, Director of Assisted Living, Housing & Home Care Care Providers of Minnesota

Director of Assisted Living, Housing & Home Care, Care Providers of Minnesota Jill Schewe has worked in and with assisted living communities her entire career. As a former assisted living manager, her experience was in startup, management, and operations of several assisted living communities. In her current role, Jill works with assisted living providers on any topic they need help with to aid in their success, including licensing, policy, payment, and operational systems. She understands the needs of older adults and home- and community-based services alike. And most recently she obtained her Assisted Living Director license.

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Care Providers of Minnesota Assisted Living Employment Related Training

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Content for this module: • We’re going to cover some of the staffing, orientation, training and human resource components of 144G Assisted Living Licensure and Assisted Living Rule 4659 • We’ll also cover some Minnesota specific employer laws • Federal laws pertaining to employment and general human resource practices will be covered elsewhere

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Pre-employment Screening

Statutes: • 364.021, • 144G.41 Subd. 2 & • 144G.60 Subd.1

• Minnesota Statute Consideration of Criminal Records https://www.revisor.mn.gov/statutes/cite/364.021 • So called “Ban the Box” law • Doesn’t prevent employers from considering an applicant’s criminal history.

• It’s a timing thing. Employers must wait until a job applicant has been selected for an interview, or a conditional offer of employment has been extended, before asking the applicant about their criminal record or conducting a criminal background record check.

• Does not remove your requirements under statute 144.057 to perform a DHS Background Study on all employees before they have access to residents/clients/tenants • A good practice to inform potential candidates that successful completion of a DHS Background Study is requirement of employment

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Background Studies

Statutes: • 144G.41 Subd. 2 (2) & • 144G.60 Subd. 1

• Must conduct a Minnesota Department of Human Services background study for all employees, volunteers and contractors • Using NETStudy 2.0 https://mn.gov/dhs/general-public/backgroundstudies/ • Must read and follow the information on the notifications received from DHS regarding status of the background study: • Background study on the individual has been completed and the individual may provide direct contact services for the agency for which the background study was completed or • More time is needed to complete the background study for the individual and the individual may provide direct contact services while the background study is being completed or • More time is needed to complete the background study for the individual and they must be supervised at all times. If constant direct supervision by another qualified individual is not possible, the person cannot work while the study is pending or • A notice stating that the individual is disqualified from any position allowing direct contact with or access to, people receiving services. Note – Individuals with this result cannot be employed.

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Employee Records

Statute: • 144G.42 Subd. 8

Must maintain an employee record that includes: • Evidence of current professional licensure, registration or certificate, if required • Records of all training and in-service education required and/or provided including record of competency testing as required • Current signed job description, which includes qualifications, responsibilities, and identification of supervisors, if any • Documentation of annual performance reviews that identify areas of improvement needed and training needs • For individuals providing Assisted Living services, verification that required health screenings for Tuberculosis (TB) have taken place and the dates of those screenings (keep medical information in a separate employee medical file) • Documentation of a competed criminal background study • Evidence that a reference check has been completed • Verification of completed orientation and annual training and competency testing as required

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Employee Records Other documents that may be included in an employee record include: • • • • • • • • • • • •

Completed employee application Resume (when provided) Proof of I-9 compliance Completed W-4 Verification that reference checks were completed prior to hire Record of annual training on A Workplace Accident and Injury Reduction (AWAIR) program Record of Minnesota Employee Right to Know Act (MERTKA) training upon hire Record of HIPAA training upon hire Record of Vulnerable adult prevention and reporting/ abuse and neglect prevention plan training Information regarding employee benefits provided or elected Other records deemed appropriate Proof that written notice was given to employee upon start of employment that contains information as required by MN Wage Theft Law

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Employee Records Other health related documents should be kept in a separate file:

Other things to remember with employee records:

• Employee injury records, including any exposure to bloodborne pathogens • Workers compensation records • Any other health screenings required by infection control programs established • Other applicable health records • Employee exposure and medical records should be maintained 30 years per https://www.osha.gov/lawsregs/regulations/standardnumber/191 0/1910.1020 with a few exceptions outlined in the rule

• Obligation to maintain confidentiality and security.

• Minnesota employers are required to provide employees with access to their personnel record upon written request. A current employee is entitled to review his or her personnel record once every six months. A former employee may either request to review his or her personnel file once a year or obtain a copy of his or her personnel file free of charge once a year for as long as the record is maintained • Records should be maintained for a minimum of 3 years 144G.42 Subd 8.

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Licensed AL Director (LALD)

Statute: • 144G.10

• Each facility to have and maintain a licensed or permitted Assisted Living Director from the Board of Executives for Long Term Services and Supports https://mn.gov/boards/nursing-home/ • Complete an approved training course and pass an examination approved by the board that is designed to test for competence and that includes assisted living facility laws in Minnesota.

• Assisted Living Director-in-Residence (ALDIR) ALDIR is designed to allow individuals who are currently serving as Director and do not qualify an opportunity to apply for licensure and complete their education and experience while working in an assisted living setting as a Director under supervision/mentorship for up to a year as they complete their licensure requirements.

• Assisted Living Director Frequently Asked Questions • ALD Flowchart/Application Guide

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Delegation and Supervision

Statute: • 144G.62

• A Registered Nurse (or other licensed health professional where appropriate) will determine what nursing services may be delegated to properly trained and competency tested unlicensed personnel.

• Only unlicensed personnel who are determined to be competent and possess the knowledge and skills consistent with the complexity of tasks being delegated will be permitted to perform such delegated tasks.

• If unlicensed personnel have not regularly performed the delegated home care task for a period of 24 consecutive months, the unlicensed personnel must demonstrate competency in the task to the registered nurse or appropriate licensed health professional.

• The Assisted Living facility will have a system in place to communicate up-to-date information to a RN regarding current available staff and their competencies.

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Delegation and Supervision

Statute: • 144G.62

Staff who provide delegated nursing or therapy tasks to residents will be supervised by an RN or appropriate licensed health professional where the services are being provided to verify that work is being performed competently and to identify problems and solutions related to the staff person’s ability perform the tasks. Supervision will include observation of the staff administering the medication or treatment and the interaction with resident.

• Direct supervision of staff performing delegated tasks must be provided within 30 calendar days after the date on which the individual begins working and first performs the delegated tasks for residents and thereafter as needed based on performance.

• This requirement also applies to staff that have not performed delegated tasks for one (1) year or longer.

• The supervision should be through the direct and indirect observation of the unlicensed personnel performing the services. The resident or resident’s responsible person may be interviewed to assure they are satisfied with the services they are receiving.

• It is the responsibility of the RN staff to ensure the supervision is done within the time frames outlined above and specified on the client’s service plan.

• Documentation of supervision activities will be retained in the employee’s record.

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Orientation All staff providing and supervising direct services must complete an orientation to Assisted Living facility licensing requirements and regulations before providing assisted living services to residents.

Statute: • 144G.63.

Rule: • 4659.019

• The materials and/or type of training (i.e. video, lecture, reading, etc.) will be documented for compliance.

• The orientation must contain the following topics: 1. An overview of the appropriate Assisted Living statutes and rules 2. An introduction and review of the facility's policies and procedures related to the provision of assisted living services by the individual staff person 3. Handling of emergencies and use of emergency services 4. Compliance with and reporting of the maltreatment of vulnerable adults under section 626.557 to the Minnesota Adult Abuse Reporting Center (MAARC) 5. The assisted living bill of rights and staff responsibilities related to ensuring the exercise and protection of those rights 6. Principles of person-centered planning and service delivery and how they apply to direct support services provided by the staff person

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Orientation 7. Handling of residents' complaints, reporting of complaints, and where to report complaints, including information on the Office of Health Facility Complaints 8. Consumer advocacy services of the Office of Ombudsman for Long-Term Care, Office of Ombudsman for Mental Health and Developmental Disabilities, Managed Care Ombudsman at the Department of Human Services, county-managed care advocates, or other relevant advocacy services 9. A review of the types of assisted living services the employee will be providing and the facility's category of licensure 10. The staff person's job description upon hire and whenever there is a change to the job description that changes the nature of the job or how the job is to be performed 11. The facility's organization chart and the roles of staff within the facility, and the services offered by the facility as identified in the uniform checklist disclosure of services 12. The identification of incidents of maltreatment as defined under Minnesota Statutes, section 626.5572, subdivision 15, including abuse, financial exploitation, and neglect, and an explanation that any act that constitutes maltreatment is prohibited.

Statute: • 144G.63.

Rule: • 4659.019

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Orientation

Statute: • 144G.61

In addition to the topics previously listed, orientation may also contain training on providing services to residents with hearing loss.

Any training on hearing loss provided under this subdivision must be high quality and research based, may include online training, and must include training on one or more of the following topics: 1.An explanation of age-related hearing loss and how it manifests itself, its prevalence, and the challenges it poses to communication 2.Health impacts related to untreated age-related hearing loss, such as increased incidence of dementia, falls, hospitalizations, isolation, and depression; or 3.Information about strategies and technology that may enhance communication and involvement, including communication strategies, assistive listening devices, hearing aids, visual and tactile alerting devices, communication access in real time, and closed captions.

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Statute: • 144G.61

Orientation • Staff providing assisted living services must be oriented specifically to each individual resident and the services to be provided. This orientation may be provided in person, orally, in writing, or electronically • All direct care staff and supervisors providing direct services must demonstrate an understanding of the training specified • Evidence of the completion of required orientation topics must be kept in the employee record of each staff person having completed the orientation.

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Dementia Care-AL Facilities

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Dementia Care-AL with Dementia Care licensed facilities

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Staff Competency Evaluation

Statute: • 144G.41 Subd. 2 (3) & • 144G.61 Subd. 2

Training and competency evaluations for all Unlicensed Personnel will include: 1. Documentation requirements for all services provided 2. Reports of changes in the resident's condition to the supervisor designated by the facility 3. Basic infection control, including blood-borne pathogens 4. Maintenance of a clean and safe environment 5. Appropriate and safe techniques in personal hygiene and grooming, including: 1. hair care and bathing 2. care of teeth, gums, and oral prosthetic devices 3. care and use of hearing aids 4. dressing and assisting with toileting 6. Training on the prevention of falls CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

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Staff Competency Evaluation

Statute: • 144G.41 Subd. 2 (3) & • 144G.61 Subd. 2

Topics continued:

7. Standby assistance techniques and how to perform them 8. Medication, exercise, and treatment reminders 9. Basic nutrition, meal preparation, food safety, and assistance with eating 10.Preparation of modified diets as ordered by a licensed health professional 11.Communication skills that include preserving the dignity of the resident and showing respect for the resident and the resident's preferences, cultural background, and family 12.awareness of confidentiality and privacy 13.Understanding appropriate boundaries between staff and residents and the resident's family 14.Procedures to use in handling various emergency situations 15.Awareness of commonly used health technology equipment and assistive devices.

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Staff Competency Evaluation

Statute: • 144G.41 Subd. 2 (3) & • 144G.61 Subd. 2

Additionally, training and competency evaluation for unlicensed personnel providing assisted living services must include: 1. Observing, reporting, and documenting resident status 2. Basic knowledge of body functioning and changes in body functioning, injuries, or other observed changes that must be reported to appropriate personnel 3. Reading and recording temperature, pulse, and respirations of the resident 4. Recognizing physical, emotional, cognitive, and developmental needs of the resident 5. Safe transfer techniques and ambulation 6. Range of motioning and positioning 7. Administering medications or treatments as required

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Staff Competency Evaluation Additional nursing tasks that could be delegated to unlicensed personnel that would require training and competency testing by a RN include (this list is not all inclusive): • Use of glucometers

• Splints

• TED stockings

• Urostomy care

• Foley catheter care and cleaning

• Thickened liquid preparation

• Peak lung capacity flow (asthma protocol)

• Use of alarms

• Oxygen Administration and Oxygen saturation levels (pulse oximeter)

• Leg braces

• Dressing Changes

• Protective boots, soft casts, and inflatable boots

• Nebulizers

• Exercises ordered by Physical Therapy

• Ace bandage application

• Wound care procedures

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Staff Competency Evaluation List continued: • Blood pressure checks

• Nasal Sprays

• Use of mechanical lifts

• Eye drops

• Catheter procedures

• Peak Flow meters

• C-PAP machines

• Insulin

• Lymphedema wraps

• PRN meds (pain, eye drops, nitro-stat, inhalers, etc.)

• AFO Brace

• Dialysis catheter dressing changes (and instructions for showering)

• Inhalers • Nebulizers

• Medication Patches • Medications via gastrostomy tube

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Staff Competency Evaluation

Statutes: • 144G.41 Subd. 1 (2) • 144G.61 Subd. 1

Other things to remember with competency evaluations • When appropriately specific to the client, the registered nurse or licensed health professional must document instructions for the delegated tasks in the client's record.

• Competency may be demonstrated via a written, oral, or practical test of the skill.

• A copy of all education, training, and competency testing shall be kept in each employee’s personnel file.

• Training and competency evaluations must be conducted by individuals with work experience and training in said areas. And training of unlicensed personnel will be conducted by a RN, or another instructor may provide the training in conjunction with a RN.

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Annual Training

Statute: • 144G.61 Subd.5

All staff that perform direct care services at will complete at least eight (8) hours of annual training for each 12 months of employment.

• A training record, kept in employee records, will be retained for each employee who performs direct services to track compliance with annual training requirements.

• Annual training may be obtained from the facility or another source and must include topics relevant to the provision of assisted living services.

• The following training elements MUST be included every 12 months to all staff who performs direct care services: 1. Training on reporting of maltreatment of vulnerable adults under section 626.557 2. Review of the assisted living bill of rights and staff responsibilities related to ensuring the exercise and protection of those rights 3. Review of infection control techniques used in the home and implementation of infection control standards including a review of hand washing techniques; the need for and use of protective gloves, gowns, and masks; appropriate disposal of contaminated materials and equipment, such as dressings, needles, syringes, and razor blades; disinfecting reusable equipment; disinfecting environmental surfaces; and reporting communicable diseases 4. Effective approaches to use to problem solve when working with a resident's challenging behaviors, and how to communicate with residents who have dementia, Alzheimer's disease, or related disorders 5. Review of the facility's policies and procedures relating to the provision of assisted living services and how to implement those policies and procedures 6. Principles of person-centered planning and service delivery and how they apply to direct support services provided by the staff person.

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Statute: • 144G.61 Subd.5

Annual Training • In addition to the topics previously listed, annual training may also contain training on providing services to residents with hearing loss. Any training on hearing loss provided under this subdivision must be high quality and research based, may include online training, and must include training on one or more of the following topics: 1.An explanation of age-related hearing loss and how it manifests itself, its prevalence, and challenges it poses to communication 2.Health impacts related to untreated age-related hearing loss, such as increased incidence of dementia, falls, hospitalizations, isolation, and depression 3.Information about strategies and technology that may enhance communication and involvement, including communication strategies, assistive listening devices, hearing aids, visual and tactile alerting devices, communication access in real time, and closed captions.

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Training Records

Rule: • 4659.0190 Subp.6

Facility must maintain record of all required staff training and competency that documents the following information for each competency evaluation, training, retraining, and orientation topic must include: 1. Facility name, location, and license number 2. Name of the training topic or training program 3. The training methodology, such as classroom style, web-based training, video, or oneto-one training 4. Date of the training and the competency evaluation, and the total amount of time of the training and competency evaluation 5. Name and title of the instructor and the instructor's signature, and the name and title of the competency evaluator, if different from the instructor, and the evaluator's signature with a statement attesting that the employee successfully completed the training and competency evaluation, and 6. Name and title of the staff person completing the training, and the staff person's signature with a statement attesting that the staff person successfully completed the training as described in the training documentation.

7. Documentation of the completed competency evaluation, training, retraining, or orientation will be provided to the employee at the time the evaluation or training is completed.

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Rule: • 4659.0190 Subp. 5

Portability of Training • Unlicensed personnel providing assisted living services who transfer from one licensed facility to another or who are newly hired by a licensed assisted living facility, may satisfy 144G.61 Subd 2 training requirements by providing written proof of previously completed training within the past 18 months.

• The accepting facility must complete a competency evaluation, conducted by a competency evaluator who has meet the assisted living license requirements.

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• Minnesota Wage Theft Prevention Act MN Statute 16C.285 Subd. 3 • Passed in 2019 Legislature passed the wage theft law to create additional protections for workers, including adding criminal penalties for employers that commit wage theft, which occurs when employers do not pay their workers what is owed them for the work they have performed.

MN Employer Laws

• All employers must provide each employee with a written notice at the start of their employment and keep a signed copy of the notice on file. The notice must contain required information about an employee's employment status and terms of employment. The notice must include a statement, in multiple languages, that informs employees they may request the notice be provided to them in another language. Employers may use the example notice or create their own.

• In Minneapolis, employers may have additional wage theft requirements under the city's Wage Theft Ordinance.

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MN Employer Laws • Pregnancy and Parenting Leave Employees may take up to 12 weeks of unpaid leave upon the birth or adoption of their child when: 1. they work for a company with 21 or more employees at one site; 2. they have been with the company for at least 12 months; and 3. they worked at least half time during the past 12 months. Could qualify for FMLA, runs concurrent, total leave not to exceed 12 weeks MN Statute 181.941 • Minnesota’s School Conference and Activities Leave law allows eligible employees up to 16 hours of unpaid leave from work to attend their child’s school conferences and activities each year and for each child MN Statute 181.9412 • Sick and Safe Leave Employers that allow employees to take time off for their own injury or illness must also allow the employee to take time off: to care for an ill or injured minor child, adult child, spouse, sibling, parent, mother-in-law, father-in-law, grandchild, grandparent or stepparent in the same manner the employer would allow an employee to use the leave for themselves OR For themselves or a relative (as listed above) to provide or receive assistance because of sexual assault, domestic abuse or stalking. This leave does is not required to be paid MN Statute 181.9413 • Pregnancy and Lactation Accommodation An employer must provide reasonable accommodations to an employee for health conditions related to pregnancy or childbirth if she so requests, with the advice of her licensed health care provider or certified doula, unless the employer demonstrates that the accommodation would impose an undue hardship on the operation of the employer's business MN Statute 181.9414. And nursing mothers must be provided reasonable break times-effective 1/1/2022.

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MN Employer Laws

• Wage Disclosure and Protection Act Every Minnesota employer must comply with the Wage Disclosure Protection law in the Women's Economic Security Act. Under this law, no employer can prohibit employees from disclosing their own wages MN Statute 181.172 • Employee Notice Law Minnesota labor standards law requires employers to provide each employee with a written notice detailing important terms of employment, including how much the employee will earn, when they will be paid and who owns the company they will be working for. See the rule for details on what items are required to be included on the notice.

• Youth employment restrictions on hours and scheduling. Remember that there are applicable rules for lifts usage for 16 & 17 year olds

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• The state minimum wage is higher than the federal minimum wage and there are some municipalities with minimum wage laws as well Minneapolis and St. Paul

MN Employer Laws

• Most employees and all direct care workers are entitled to overtime protections under Fair Labor Standards Act (FLSA), which would be overtime 40 per workweek (any fixed and regularly recurring period of 168 hours – seven consecutive 24-hour periods) at a rate not less than one and one-half times the regular rate of pay.

See the Department of Labor and Industry http://www.dli.mn.gov/business/employmentpractices for more information on employment practices in Minnesota

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Workplace Safety MNOSHA in addition to federal standards here are some Minnesota OSHA regulations: • A Workplace accident and injury reduction (AWAIR) program found in ALL manual 11.01-see required elements of how accidents and injury prevention will be handled. Minnesota Statutes 182.653, subd.

8; Minnesota Rules 5208.1500 • Employee Right-to-Know to identify hazardous substances, harmful physical agents and infectious agents that are present in the workplace and provide information and training to employees who are “routinely exposed” to those substances or agents. in ALL manual 11.03 Minnesota Rules Chapter 5206) CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

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Workplace Safety • Safe patient handling mechanical lifts in addition to federal rules pertaining to lifts, see the Minnesota safe patient handling requirements • Safety Committee (Minnesota Statutes 182.676) – The statute requires all employers with more than 25 employees to have a safety committee. The statute also requires employers with 25 or fewer employees to have a safety committee if they have either a lostworkday case incidence rate in the top 10% of all rates for employers in the same industry or with a workers' compensation premium classification rate in the top 25% of premium rates for all classes.

• MN OSHA Consultation can provide no cost assistance to help you improve safety for workers and compliance with state and federal OSHA regulations.

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• MN statute ch 176 • MN Workers Compensation

Workers Compensation

• A no-fault system • Employee does not need to prove negligence on the part of the employer to establish liability.

• employer cannot use negligence on the part of the employee as a defense to a claim.

• Provides benefits for work-related injuries or illnesses • Covers conditions caused or aggravated by employment activities • Benefits paid by the insurer (employer’s insurance company or by employer, if self-insured) • There is a 3-day waiting period before benefits kick in • Presumption of coverage for COVID-19 MN Statute 176.011 Subd. 15, which expires 12/31/2021 CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

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• MN Unemployment Employers Guide

Unemployment

• To be in compliance with Minnesota Unemployment Insurance Law, employers must do all of the following: • Register for an employer account • Display current version of the Unemployed?

• Maintain current account information • Submit Quarterly Wage Detail Report by due date • Submit payment by due date • Maintain complete records • Provide requested audit information • MN Unemployment Statute https://www.revisor.mn.gov/statutes/cite/268 • 2021 new legislation regarding COVID-19 related unemployment claims not being used in employer experience rating CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

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L ICENSED ASSISTED L IVING DIRECTOR

FAMILY AND RESIDENT COUNCILS 144G.41 SUBD. 5-6 Lindsay Schmidt, LALD, Director of marketing & hospitality Dellwood Gardens Assisted Living and Memory Care

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INTRODUCTIONS

Lindsay Schmidt, LALD, Director of marketing & hospitality Dellwood Gardens Assisted Living and Memory Care Lindsay is a brand and marketing strategist, who came to Dellwood Gardens Assisted Living and Memory Care after spending nearly a decade in the corporate communications and marketing field. She oversees marketing, sales, and outreach for the senior living community. Lindsay has a desire to share the Dellwood Gardens Story and assist in finding seniors the best fit for their care needs and living environment. “What drives me every day, is the little moments I get to spend with our residents. Chatting with them, learning from them, and knowing all of us here at Dellwood are making a difference in the lives of those we serve.”

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FAMILY AND RESIDENT COUNCILS 144G.41 SUBD. 5-6

LINDSAY SCHMIDT, LALD DIRECTOR OF MARKETING & HOSPITALITY DELLWOOD GARDENS ASSISTED LIVING AND MEMORY CARE, ST. PAUL

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OBJECTIVES Review the minimum Assisted Living requirements for Resident and Family councils.

1.

2.

I.

144G.41 Subd. 5. Resident councils

II.

144G.41 Subd. 6. Family councils

Understand and appreciate how the new law has officially empowered Assisted Living residents and their family members to lead their own resident councils.

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144G.41 SUBD. 5. RESIDENT COUNCILS

“The facility must provide a resident council with space and privacy for meetings, where doing so is reasonably achievable. Staff, visitors, and other guests may attend a resident council meeting only at the council’s invitation. The facility must designate a staff person who is approved by the resident council to be responsible for providing assistance and responding to written requests that result from meetings. The facility must consider the views of the resident council and must respond promptly to the grievances and recommendations of the council, but a facility is not required to implement as recommended every request of the council. The facility shall, with the approval of the resident council, take reasonably achievable steps to make residents aware of upcoming meetings in a timely manner.”

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144G.41 SUBD. 6. FAMILY COUNCILS

“The facility must provide a family council with space and privacy for meetings, where doing so is reasonably achievable. The facility must designate a staff person who is approved by the family council to be responsible for providing assistance and responding to written requests that result form meetings. The facility must consider the views of the family council and must respond promptly to the grievances and recommendations of the council, but a facility is not required to implement as recommended every request of the council. The facility shall, with the approval of the family council, take reasonably achievable steps to make residents and family members aware of upcoming meetings in a timely manner.”

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WHAT DOES THIS MEAN?  You MUST have a designated space for residents and families to meet.  The space MUST be private.  You MUST designate a staff person, approved by the councils to be responsible for assisting and responding to

requests.  The designated staff person MUST respond promptly to grievances and recommendations of the councils. 

This DOES NOT mean that you must implement every request made by the councils, but a response is required.

 You MUST with approval of the councils make residents and family members aware of upcoming meetings in a

timely manner.

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IDEAS ON HOW TO IMPLEMENT  Create an event to introduce the concept of a resident and family council.  Invite residents and family members to attend using your monthly newsletter, a memo, email or other platform

of communication commonly used in your community.  Inform them of the new law and inquire about their interest.  Designate a staff member representative to follow up with a resident representative and a family representative.  The staff member, resident representative and family representative can determine how to establish the councils,

structure the councils and create and recurring date/time/location to host meetings.  Decide on who will take on the role of communicating agenda, date, time, location to others.  Create a binder and document when meetings take place and topics for discussion. Include follow ups once

completed.

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FREQUENTLY ASKED QUESTIONS 

If we’ve never had a council, where do we begin?



If we have councils, does this change anything?





Invite residents and family members to gather, create an event, introduce the topic of resident and family councils.

Review how your councils are operating now. If you do not meet any of the requirements under the new law, implement those (i.e., Do you provide a private space? Do you have someone designated to follow up?)



Do our councils need to have a formal structure (President, Vice President, Secretary, etc.)?



Do we need to appoint leaders within the councils?





There is nothing in the statute stating how councils must be structured.

As an AL, you do not need to provide anything aside from space, however, it may benefit you to make recommendations to the councils and if the councils agree to allow you to help establish them, you can schedule a meeting with both councils to determine structure, meeting occurrence, process for written grievances/recommendations, etc.



Do we need to have meeting notes taken or document when councils meet?



What if no one is interested in starting a council?







There is nothing in the statute that states that you do. However, it’s not a bad idea to implement and track in the event of a survey.

That’s okay. Document that the concept was introduced, and the decision made. Reintroduce the concept every few months to see if any new residents or family members may want to start a resident and/or family council.

Do you create separate councils for IL, AL, MC? 

This is entirely up to your community. There is nothing in the law that requires they be separate.

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L ICENSED ASSISTED L IVING DIRECTOR

GROUNDS & CONTRACT MANAGEMENT John Huhn, LALD, LNHA, Vice President of Senior Living Operations Community Living Solutions, LLC

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INTRODUCTIONS John Huhn, LALD, LNHA, Vice President of Senior Living Operations Community Living Solutions, LLC John Huhn leads business development at Community Living Solutions, a professional planning, design, and construction services firm dedicated solely to serving the senior living industry. Over the past 30 years, he has operated and developed senior living communities as well as led a technology company solely serving senior living. He understands the challenges of operating a community and the impact small design details have on the lives of the staff and the residents they serve. His experience assures a balanced, sustainable outcome. John has a Bachelor of Science from the University of Wisconsin–River Falls and graduated from the University of MN, Center for Long-Term Care Administration Education.

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ASSISTED LIVING DIRECTOR GROUNDS & CONTRACT MANAGEMENT PRESENTED BY: JOHN HUHN, LALD, LNHA VICE PRESIDENT OF SENIOR LIVING OPERATIONS COMMUNITY LIVING SOLUTIONS, LLC

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AGENDA 1.

2.

3.

4.

5.

Introduction Rules and Codes to know Contracted Services – Considerations in‐house versus outsourcing Compliance matters related to provisions of contract services Specifics by Department A. Preventative and Routine Maintenance Programs B. Contract Services 6. Contracts – An operator's perspective on what’s important 7. Key Resources you should know

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ABOUT ME OPERATIONS • Project Manager • Corporate Director of Environmental Services • Licensed Nursing Home Administrator • C‐Suite ORGANIZATIONS SERVED • Walker Methodist • Volunteers of America‐ National Services EDUCATION • University of Wisconsin‐ River Falls, Bachelor of Science • University of Minnesota‐ Minneapolis, Center for Long Term Care Administration Education, Nursing Home Administrator Certification • University of Minnesota‐ Minneapolis, Carlson School of Management‐ Mini MBA Contact: 612.963.0889 / jhuhn@commmunitylivingsolutions.com

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WHAT I AM GOING TO COVER Domain: Environmental Services Description K08

Preventative and Routine Maintenance Programs for buildings, grounds, and equipment

K09

Contracted Services for mechanical, electrical, plumbing, laundry systems and IT

K10

Compliance matters related to provisions of contracted services

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RULES AND CODES Rule/Code

Description

Where to find

Federal NFPA Life Safety Code

www.nfpa.org

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Sprinkler

101

Occupancy Chapters‐ Residential Board and Care HealthCare (limited care)

OSHA

www.osha.gov

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RULES AND CODES Rule/Code

Description

Where to find

State 144G Effective August 1, 2021 • Assisted Living Facility • Assisted Living Facility‐ Dementia Care

https://www.revisor.mn.g ov/statutes/cite/144G

State Chapter of Fire Code, Chapter 7511

State Fire Code

https://www.revisor.mn.g ov/rules/7511/

Local Governing laws, regulations, standards, ordinances and codes

Varies by community

Local Government offices

https://www.revisor.mn.g ov/laws/2020/7/1/laws.6.

17.0#laws.6.17.0

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CONTRACTED SERVICES Definition: Outsourcing is the business practice of hiring a party outside a company to perform services or create goods that were traditionally performed in‐house by the company's own employees and staff.

Source: Investopedia

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CONTRACTED SERVICES Considerations when choosing between in‐house and outsourcing (contracted services): 1) Resources A. People B. Tools

2) Expertise of in‐house team 3) Available Funds

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CONTRACTED SERVICES Considerations when choosing between in‐house and outsourcing (contracted services): 4) Value of your team's time 5) Risks A. Legal B. Regulatory

6) Ability to stay relevant 7) Ability to manage contractors 11

CONTRACTED SERVICES Considerations when choosing between in‐house and outsourcing (contracted services): 8) Staff Morale 9) Can you legally do 10)Work related to “on‐boarding” contracted services personnel 11)Market Volatility 12

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CONTRACTED SERVICES Vetting Contractors Considerations 1. Implication of company policies 2. Competitive Process?

3. References 4. Key elements in decision making?

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COMPLIANCE MATTERS RELATED TO PROVISIONS OF CONTRACTED SERVICES *****In‐house or outsourced provider still responsible for meeting codes/rules**** 1) Provide Contractor copy of your Policy and Procedure(s) 2) Cite applicable codes 3) Qualifying contractors 4) Certificate of Insurance 5) Document, Document, Document‐ Tell them what you expect!!

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PREVENTATIVE AND ROUTINE MAINTENANCE PROGRAMS Maintain systems in a “continuous state of good repair and operation”

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DEPARTMENT SPECIFIC Preventative and Routine maintenance programs Management by “Wandering Around”

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MANAGEMENT BY “WANDERING AROUND” WHY? 1) Know the residents 2) Know the staff 3) Identify environmental risks 4) Safety and Security Risks

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MANAGEMENT BY “WANDERING AROUND” WHY? (cont.)

5) Overall cleanliness‐ odors, dirty walls, floors 6) Temperatures 7) General Upkeep

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PREVENTATIVE AND ROUTINE MAINTENANCE BASICS WHY? • Safety of residents, visitors, and staff • Marketing • Compliance/Regulations • Longevity of equipment

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PREVENTATIVE AND ROUTINE MAINTENANCE BASICS 1) Know the regulations 2) Know the manufacturer recommended maintenance schedule 3) Leverage Vendors 4) Leverage Peers 5) Leverage Technology 6) Document, Document, Document A. Software B. Paper 20

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DEPARTMENT SPECIFIC Preventative and Routine maintenance programs

LAUNDRY

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LAUNDRY SERVICES Preventative and Routine maintenance programs 1) Typically 2 areas of focus A. Central Laundry Rooms – Available for staff, residents, and family 1. Vent Cleaning – Quarterly 2. Routine maintenance after each load – lint filter 3. Include in Resident Handbook B. Resident unit laundry 1. Vent Cleaning – Annual 2. Routine maintenance 3. Include in Resident Handbook

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LAUNDRY SERVICES Contracted Services 1) Dryer Vent Cleaning A. Is there a code/rule? No B. Suggested frequency is quarterly.

NOTE: Frequency of cleaning varies by community specific variables C. Suggest Monthly Random check of dryer vents

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ELECTRICAL Preventative and Routine maintenance programs DO YOU HAVE AN EMERGENCY GENERATOR???

IF you have one, there are REGULATORY REQUIREMENTS. They include: A. Routine PM’s 1. Weekly 2. Monthly – 30 minute with load 3. Annual – Contracted Service REQUIRED A. Load tests requirements

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PLUMBING Preventative and Routine maintenance programs 1) Hot Water System 2) Drain cleaning 3) Grease Traps 4) Water Softener 5) Boilers – See HVAC

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PLUMBING Preventative and Routine maintenance programs 1) Hot Water System A. Daily 1. Routine water temps A. Random throughout community B. Special equipment‐Dish machines DOCUMENT, DOCUMENT, DOCUMENT

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PLUMBING Preventative and Routine maintenance programs 1) Hot Water System (continued) B. Weekly 1. Circulating Pumps 2. Flame

C. Monthly 1. Manual Pressure relief Valve

D. Annual‐ Consider Contractor Check up 27

PLUMBING Preventative and Routine maintenance programs 2) Drain cleaning 3) Grease Traps 4) Water Softener 5) Boilers‐ See HVAC

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MECHANICAL Preventative and Routine maintenance programs 1) Elevators – MUST USE CONTRACTED SERVICES A. Operational Considerations 1. At a minimum, how many elevators do you need to operate effectively and safely?

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MECHANICAL Preventative and Routine maintenance programs 1) Elevators (continued) B. Contract Considerations 1.

2.

3.

4.

Definition of Normal Business Hours What are their Holidays Overtime Rates Response times

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HVAC Preventative and Routine maintenance programs GENERAL COMMENTS 1. Keep Customers Happy A. Temperatures!!

2. Know your system A. Centralized B. De‐Centralized C. Hybrid 31

HVAC Preventative and Routine maintenance programs 3. Know your capabilities and License parameters 4. Impact of Covid‐19

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HVAC Preventative and Routine maintenance programs 5. Think of it like your home!

A. Do..

1. Filter changes 2. Condensing units

B. Check 1. Stagnant air

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HVAC Preventative and Routine maintenance programs 6. Typical HVAC system components to check A. B. C. D. E.

Heating source Pumps Filters/Screens (air, water systems) Condensing units Exhaust system

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HVAC Preventative and Routine maintenance programs 7. Typical PM schedule Daily (will vary by system)‐Hot Water Boiler Example: A. B. C. D. E.

Record Pressure Record Boiler Temp Record Flue Temp Ambient Temperature Date/Time Recorded

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HVAC Preventative and Routine maintenance programs 7. Typical PM schedule (continued) Weekly (will vary by system) A. Observe Flame Condition B. Observe Circulating pump operations

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HVAC Preventative and Routine maintenance programs 7. Typical PM schedule (continued) Monthly (will vary by system) A. Manual Relief Valve B. Review/Test the following: 1. Flame Detection Devices 2. Fail safe Devices 3. Operating controls 4. Refractory 5. Valves‐ Stop, Check, Drain 6. Linkages

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HVAC Preventative and Routine maintenance programs 7. Typical PM schedule (continued) Monthly (cont.)

C. Observe Gage Glass D. Check Combustion air‐ adequate?, Unobstructed?

E. Clean Condensing Units

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HVAC Preventative and Routine maintenance programs 7. Typical PM schedule (continued) Quarterly (will vary by system) A. Air Filters B. Strainers Seasonal (will vary by system) A. Check/Clean Condensate lines B. Clean Condensing units

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HVAC Preventative and Routine maintenance programs 8. Contracted Services A. Comprehensive Annual Check of System and related components

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RESIDENT UNIT TURNS Resident Unit Turns Thorough review of entire unit to assure: 1) Great first impression 2) Resident safety 3) Community standards are maintained

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RESIDENT UNIT TURNS Resident Unit Turns What’s on the list?

1) 2) 3) 4) 5) 6) 7) 8)

Interior finishes in state of good repair Appliances functional and safe Electrical and Plumbing devices all function Flooring Safety and Security Misc. Technology Comfort Unit cleaned/sanitized

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IT 1. Know your systems 2. Know what your customer expects 3. Infrastructure 1. Internet Service A. B.

Size Redundancy

2. Networks/WIFI A. Business B. Resident C. Public

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IT 4. Misc. Systems A. B. C. D.

Card Access Nurse Call Wander Management Security Systems

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IT 5. Policies and Procedures A. Back up for critical systems A.

Cloud vs on site?

B. WHEN power goes out/System Failure 1. Resident safety 2. Business interruption A. B. C. D. E. F.

Culinary Electronic Health Record Pharmacy Communication systems Heating and Cooling Security

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IT 5. Policies and Procedures (cont.)

C. Concierge/ Help Desk Services 1. Residents 2. Staff 3. Technology Specific Solutions

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IT 6. Contracted Services • Typically services are contracted out • Help Desk

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GROUNDS Considerations 1. Role in Marketing 2. Seasonal Requirements 3. Regulations 4. Policy and Procedures

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GROUNDS – ROLE IN MARKETING • First Impressions • Safety • Resident Satisfaction

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SEASONAL REQUIREMENTS 1. Pest control 2. Lawn and Landscape Services 3. Snow Removal

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SEASONAL REQUIREMENTS Preventative and Routine maintenance programs 1. Pest control – Typically Contracted Service A. Exterior 1. Perimeter

B. Interior 1.

2.

3.

4.

Kitchen Garage Storage Entrances

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SEASONAL REQUIREMENTS Preventative and Routine maintenance programs 2. Lawn and Landscape Services A. Contract vs in‐house B. Seasonal Service 1) Spring‐ clean up, parking lot sweeping, winter damage repair, fertilizer 2) Summer‐ Mow, weed, fertilize, flowers 3) Fall‐ Clean up, fertilizer, Winter prep 4) Winter‐ snow removal, ice control‐ A.

Snow removal separate contractor?

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SEASONAL REQUIREMENTS Preventative and Routine maintenance programs 3. Snow Removal A. First impressions B. Safety‐ 1. Resident 2. Staff

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SEASONAL REQUIREMENTS Preventative and Routine maintenance programs 3. Snow Removal (cont.)

C. In‐house vs contract D. Considerations when writing contract

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CONTRACT MANAGEMENT An operator’s perspective – I AM NOT AN ATTORNEY

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CONTRACT MANAGEMENT Where do I start – NOT AN ATTORNEY! 1. WHAT IS RISK TO ORGANIZATION 2. Do I need a contract?

3. Contract length 4. Performance issues and process to resolve 5. Cancellation clause‐ curing, without cause

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CONTRACT MANAGEMENT Where do I start – NOT AN ATTORNEY! 6. Mutual Indemnity In a mutual indemnification, both parties agree to compensate the other party for losses arising out of the agreement to the extent those losses are caused by the indemnifying party's breach of the contract. In a one‐way indemnification, only one party provides this indemnity in favor of the other party. Nolo.com

7. Price 8. Payment terms – upon receipt, net 10, net 30, discounts 9. Authority to sign

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RESOURCES 1) Law posted on Revisor’s website https://www.revisor.mn.gov/statutes/cite/144G https://www.revisor.mn.gov/laws/2020/7/1/laws.6.17.0#laws.6.17.0 2) MDH engineering https://www.health.healthcareengineering@state.mn.us https://www.health.state.mn.us/assistedliving 3) Care Providers of MN www.careproviders.org 4) John Huhn, LALD, LNHA, VP of Senior Living Services, Community Living Solutions Jhuhn@communitylivingsolutions.com

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DISCLAIMER 1) 2) 3)

Law passed in 2019 legislative session Presentation not all‐inclusive of law.

Codes and Regulations are revised frequently, so always refer to Revisor website for most current codes and regulations

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L ICENSED ASSISTED L IVING DIRECTOR

INTRODUCTION TO THE INTERDISCIPLINARY TEAM Karolee Withers (formerly Alexander), RN, RAC-CT, Director of Clinical & Reimbursement Consulting Pathway Health

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INTRODUCTIONS Karolee Withers (formerly Alexander), RN, RAC-CT, Director of Clinical & Reimbursement Consulting Pathway Health Ms. Withers has over 25 years of nursing leadership in long term care, including as a Director of Nursing Services and various MDS and Reimbursement positions. In these roles, she has established herself as an expert in the management of nursing operations, reimbursement systems and performance improvement. Ms. Withers is a strong proponent of resident centered care having established many programs and processes to bring about cultural changes to ensure the success of the programs. In her role as a Consultant, she has proven success with regulatory turn around, mentoring of Nursing management, revenue cycle management and quality.

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Objectives

Consulting | Talent | Training | Resources

Participants will: • Identify the roles of various healthcare providers in the Assisted Living setting.

• Develop a list of titles to collect contact information about at the Assisted Living.

• Describe potential healthcare resources to meet residents’ needs. © Pathway Health 2021

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It takes a team!

Consulting | Talent | Training | Resources

© Pathway Health 2021

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Healthcare Team Members

Consulting | Talent | Training | Resources

•

Assisted Living Director

•

Dietician/Nutritionist

•

Clinical Nurse Supervisor

•

Activities or Life Enrichment staff

•

Admissions

•

Physical Therapy

•

Staff Educator

•

Occupational Therapy

•

Social Worker

•

Speech Language Pathology

•

County Case Worker

•

Therapy assistants

•

Community MD or NP

•

Ombudsman

•

Pharmacist

© Pathway Health 2021

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Which IDT Members Do I Need?

Consulting | Talent | Training | Resources

Required by Statute:

Based on residents’ needs:

•

Assisted Living Director

•

Admissions

•

Clinical Nurse Supervisor

•

Social Worker

•

Community MD or NP

•

County Case Worker

•

Dietician/Nutritionist

•

Staff Educator

•

UnLicensed Personnel (ULP)

•

Activities or Life Enrichment staff

•

Essential Caregiver

•

Physical Therapy

•

Occupational Therapy

•

Speech Language Pathology

•

Therapy assistants © Pathway Health 2021

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Which IDT Members Do I Need?

Consulting | Talent | Training | Resources

For a Secured or Unsecured Dementia Unit •

Awake staff 24/7 – located in the same building, in an attached building, or on a contiguous campus with the facility in order to respond within a reasonable amount of time; – capable of communicating with residents; – capable of providing or summoning the appropriate assistance; and – capable of following directions

•

Staffing levels must be sufficient to meet the scheduled and unscheduled needs of residents. Staffing levels during nighttime hours shall be based on the sleep patterns and needs of residents.

•

In an emergency situation when trained staff are not available to provide services, the facility may assign staff who have not completed the required training. The particular emergency situation must be documented and must address: (1) the nature of the emergency; (2) how long the emergency lasted; and (3) the names and positions of staff that provided coverage. © Pathway Health 2021

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For Facility with Dementia Care

Consulting | Talent | Training | Resources

At least ten hours of the required annual continuing educational requirements relate to the care of individuals with dementia.

•

medical management of dementia,

•

creating and maintaining supportive and therapeutic environments for residents with dementia, and

•

transitioning and coordinating services for residents with dementia.

•

can demonstrate a basic understanding and ability to apply dementia training to the residents' emotional and unique health care needs using person-centered planning delivery.

•

These requirements are in addition to the licensing requirements for training. © Pathway Health 2021

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Assisted Living Director

Consulting | Talent | Training | Resources

"Assisted living director" means a person who administers, manages, supervises, or is in general administrative charge of an assisted living facility, whether or not the individual has an ownership interest in the facility, and whether or not the person's functions or duties are shared with one or more individuals and who is licensed by the Board of Executives for Long Term Services and Supports 2020 Minnesota Statutes 144G.08 Definitions https://www.revisor.mn.gov/statutes/cite/144G.08

© Pathway Health 2021

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Assisted Living Director

Consulting | Talent | Training | Resources

Typical responsibilities

•

Budget

•

•

Business Office

•

Human Resources

•

Regulatory Compliance

Oversee and manage non-clinical services – Maintenance – Admissions – Dietary – Activities/Life Enrichment – Transportation

© Pathway Health 2021

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Assisted Living Director

Consulting | Talent | Training | Resources

•

Approved training course and passed exam or

•

Is a licensed nursing home administrator and had knowledge of assisted living laws or

•

Has a higher degree in nursing, social work, mental health or other professional degree with training specific to management and regulatory compliance and has three years of supervisory, management or operational experience and higher education applicable to assisted living and has completed 1000 hrs. of executive in training program, or

•

Has managed housing with services for at least three years © Pathway Health 2021

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Clinical Nurse Supervisor

Consulting | Talent | Training | Resources

RN in Minnesota Assists with development of policies and procedures Assessment Care plan/Service plan Infection Prevention and Control Medication ordering, receiving, storage and administration Nursing staff education, training and competency Oversees personal care and nursing care delivery Establishes a structure for delegation of nursing tasks to ULP.

© Pathway Health 2021

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Clinical Nurse Supervisor

Consulting | Talent | Training | Resources

Responsible to ensure adequate staffing May select people for hire May be responsible for validating credentials, licenses, certifications, and background checks of healthcare staff working in the facility.

Oversees performance evaluations of staff Investigates concerns, accidents and complaints about care and services with the social worker. © Pathway Health 2021

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Clinical Nurse Supervisor

Consulting | Talent | Training | Resources

May be the RN readily available in person, by telephone or by other means to the staff at all times when staff is providing services.

May rotate “on-call” with another RN

© Pathway Health 2021

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Staff nurses

Consulting | Talent | Training | Resources

Licensed Practical Nurses and Registered Nurses as staff nurses.

• Complete assessments and update care plans and service plans • Provide direct nursing care • Oversee ULP care • Interface with MDs, NPs •

Take and process orders

© Pathway Health 2021

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UnLicensed Personnel

Consulting | Talent | Training | Resources

May or may not be a certified nursing assistant or home health aide • Provide direct care • Provide delegated and assigned care • May administer medications

© Pathway Health 2021

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Admissions/Marketing

Consulting | Talent | Training | Resources

•

Not a separate role in all facilities

•

Promotes the facility to the community and potential referral sources

•

Tours

•

Events

•

Initiates collection of information about new residents.

•

Works with Clinical Nurse Supervisor to confirm appropriate admissions.

© Pathway Health 2021

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Admissions/Marketing

Consulting | Talent | Training | Resources

May be part of the Director, Clinical Supervisor or Social Worker’s role in small organizations May be a central intake office of a campus or larger organization Not a required position

© Pathway Health 2021

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Social Worker

Consulting | Talent | Training | Resources

a) "Practice of social work" means working to maintain, restore, or improve behavioral, cognitive, emotional, mental, or social functioning of clients, in a manner that applies accepted professional social work knowledge, skills, and values, including the personin-environment perspective, by providing in person or through telephone, video conferencing, or electronic means one or more of the social work services. Social work services may address conditions that impair or limit behavioral, cognitive, emotional, mental, or social functioning. Such conditions include, but are not limited to, the following: abuse and neglect of children or vulnerable adults, addictions, developmental disorders, disabilities, discrimination, illness, injuries, poverty, and trauma. Practice of social work also means providing social work services in a position for which the educational basis is the individual's degree in social work.

Licensing Scope of Social Work https://www.revisor.mn.gov/statutes/cite/148E/pdf © Pathway Health 2021 19

Consulting | Talent | Training | Resources

Licensed social worker (LSW) may engage in social work practice except that a licensed social worker must not engage in clinical practice. Must obtain 100 hours of supervision.

Licensed graduate social worker (LGSW) may engage in social work practice except that a licensed graduate social worker must not engage in clinical practice except under the supervision of a licensed independent clinical social worker or an alternate supervisor. Must obtain 100 hours of supervision.

Licensed independent social worker (LISW)may engage in social work practice except that a licensed independent social worker must not engage in clinical practice except under the supervision of a licensed independent clinical social worker or an alternate supervisor.

Must obtain 100 hours of supervision.

Licensed independent clinical social worker (LICSW) may engage in social work practice, including clinical practice. May supervise other social workers. Must obtain 200 hours of supervision.

Licensing Scope of Social Work https://www.revisor.mn.gov/statutes/cite/148E/pdf © Pathway Health 2021 20

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Social Worker

Consulting | Talent | Training | Resources

• A licensed social worker in Minnesota • Provides medical social work services • Identifies community resources • Identifies financial resources and assists with applications • Coordinates with County Case Worker • Identifies and refers to other mental health resources • Assists with family support related to the resident © Pathway Health 2021

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Social Worker

Consulting | Talent | Training | Resources

May do marketing/admission function Can assist with guiding the resident or family for referrals Typically, the Grievance officer May investigate and/or report alleged mistreatment Resident advocate © Pathway Health 2021

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County Case Worker

Consulting | Talent | Training | Resources

Usually, a social worker Assists seniors in the community to find and apply for social or financial resources

© Pathway Health 2021

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Community MD or NP

Consulting | Talent | Training | Resources

• Residents have their own physician or clinic • Appointments and transportation are arranged by family or resident or facility.

• Nurses communicate about changes or needs, get medication and treatment orders updated as needed.

• Nurses process visit notes and orders after resident returns © Pathway Health 2021

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Designated Essential Caregiver

Consulting | Talent | Training | Resources

In Minnesota, a facility can develop and implement an Essential Caregiver program The resident can identify another person who will be given access to visit even when others are restricted.

• The EC functions as an advocate and social connection.

• May be tested for COVID-19 • Must wear appropriate PPE when necessary © Pathway Health 2021

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Pharmacist

Consulting | Talent | Training | Resources

• Residents may get meds from their own pharmacy or from a facility partner.

• Pharmacist can take a verbal order from the provider.

• Assist the facility with policies and procedures related to medications • May contract to provide consultation to the facility nursing staff and/or residents © Pathway Health 2021

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Dietician/Nutritionist

Consulting | Talent | Training | Resources

Licensed dietician or nutritionist Assist with menu preparation, including altered textures and consistencies Oversee kitchen for compliance with MN Food Code, and Rules.

Assist with policies and procedures related to food procurement, storage, preparation and serving. © Pathway Health 2021

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Activities or Life Enrichment staffConsulting

| Talent | Training | Resources

No qualification requirement Responsible to promote and initiate social opportunities for residents. in-house activities trips and outings entertainment © Pathway Health 2021

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Licensed Therapists

Consulting | Talent | Training | Resources

Can assist the facility with policy and procedure development • request and receive orders • providing treatment • documenting • current practice standards © Pathway Health 2021

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Physical Therapist

Consulting | Talent | Training | Resources

Licensed in Minnesota Diagnose and treat functional mobility conditions, injuries or disabilities and develop a treatment plan.

May conduct the treatment, prescribe exercises and/or prescribe adaptations to environment to support independence. © Pathway Health 2021

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Occupational Therapist

Consulting | Talent | Training | Resources

Licensed in Minnesota Assess functional independence in activities of daily living and develop a treatment plan.

May conduct treatment, prescribe exercises and/or prescribe adaptations to environment to support independence. © Pathway Health 2021

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Speech Language Pathologist

Consulting | Talent | Training | Resources

• Licensed in Minnesota • Assess, diagnose and treat speech, language, communication, cognition and swallowing disorders.

• May conduct treatment, prescribe exercises and/or prescribe adaptations to environment or diet to support independence. © Pathway Health 2021

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Therapy Treatment

Consulting | Talent | Training | Resources

Develop individual treatment/service plans •

Include in the service plan

•

Administered by therapist, therapy assistant, nurse, physician, or delegated to ULP. o

ULP specifically instructed in treatment interventions

o

Specified in writing

o

Communicated with ULP © Pathway Health 2021

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Therapy assistants

Consulting | Talent | Training | Resources

• All three licensed therapies can partner with an educated and certified assistant.

• In Minnesota, an assistant can provide direct treatment with supervision from the licensed therapist.

• PTA, OTA, STA

© Pathway Health 2021

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Ombudsman

Consulting | Talent | Training | Resources

“An Ombudsman is an independent consumer advocate who: •

Investigates complaints about the health, safety, welfare and rights of Minnesotans receiving long-term services and supports

•

Works to identify problems and resolve individual concerns

•

Provides information and help with long-term care services, consumer rights and regulations

•

Resolves disputes between consumers and providers about long-term care services

•

Works with providers to promote a culture in which people have and can make choices.”

Minnesota Department of Health Ombudsman for Long-Term Care https://mn.gov/dhs/people-we-serve/seniors/services/ombudsman/ © Pathway Health 2021

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Ombudsman

Consulting | Talent | Training | Resources

• Good resource for helping a disenfranchised, unhappy resident to feel supported.

• Will make unscheduled visits.

© Pathway Health 2021

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Let’s walk through move-in •

Family and resident contact the community for information and a tour

Consulting | Talent | Training | Resources

•

Admission/Marketing or Director or Social Worker

– Decide to move in

•

Provide financial information

•

Admission/Marketing or Director or Social Worker

•

Provide medical information

•

Clinical Supervisor

© Pathway Health 2021

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Move in Approved

Consulting | Talent | Training | Resources

Environmental

Make sure Unit is ready

Admissions/Director

Obtain payment

Clinical Supervisor

Gather medical information

© Pathway Health 2021

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Consulting | Talent | Training | Resources RN – Initial assessment and process orders

Therapy – Safety evaluation

Resident

Nutrition – Initial assessment

Life Enrichment – Initial assessment

Social Work – Initial assessment

© Pathway Health 2021

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Consulting | Talent | Training | Resources

•

Vital signs and weight

•

Communication abilities

•

Confirm medical history – pain, symptoms, COVID-19

•

Assess ADL needs – Identify adaptive equipment

•

Bowel & Bladder continence

•

Physical Exam

•

Fall Risk © Pathway Health 2021

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Consulting | Talent | Training | Resources

•

Gather information about interests, leisure preferences and usual social activities

•

Identify needs for assistance

•

Identify therapeutic interventions © Pathway Health 2021

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Consulting | Talent | Training | Resources

Assess psychosocial functioning Determine needs for community supports Determine needs for psychology or psychiatry Identify problem behaviors Identify vulnerabilities - safety

© Pathway Health 2021

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Consulting | Talent | Training | Resources

Assess nutritional health Identify preferences Identify needs for assistance Meals self-made, delivered or attend dining room

© Pathway Health 2021

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Consulting | Talent | Training | Resources

Assess in the new environment • PT – Mobility, transfers, use of walkers/canes, furniture configuration, flooring • OT - Use of bathroom, dressing, kitchen, ADLs, laundry, memory assessment • ST – Communication strategies • Potential treatment or exercise program © Pathway Health 2021

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Care Plan

Consulting | Talent | Training | Resources

Identify actual and potential problems Define goals and collaborate with the resident & family. Establish re-evaluation time frame Describe interventions provided by team members, the resident and the family Review with the resident & family © Pathway Health 2021

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Service Plan

Consulting | Talent | Training | Resources

Based on the resident’s needs and care plan Define services – specific interventions, frequency and length of time.

• Based on service package available and purchased • Review with the resident & family © Pathway Health 2021

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Consulting | Talent | Training | Resources

© Pathway Health 2021

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Disclaimer

Consulting | Talent | Training | Resources

“This presentation provided is copyrighted information of Pathway Health. Please note the presentation date on the title page in relation to the need to verify any new updates and resources that were listed in this presentation. This presentation is intended to be informational. The information does not constitute either legal or professional consultation. This presentation is not to be sold or reused without written authorization of Pathway Health.” © Pathway Health 2021

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L ICENSED ASSISTED L IVING DIRECTOR

APPLICATION OF LANDLORD-TENANT LAW TO ASSISTED LIVING PROVIDERS Michelle R. Klegon, Attorney Klegon Law Office, Ltd.

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INTRODUCTIONS Michelle R. Klegon, Attorney Klegon Law Office, Ltd. Michelle Klegon is an attorney at Klegon Law Office. She practices in the areas of health law and employment law and has been representing nursing facility, home care, housing and assisted living providers since 1991. Ms. Klegon advises nursing facility, home care and assisted living providers on survey and other regulatory matters and assists housing providers with fair housing issues, contract drafting and review, and conflict resolution. She also advises employers regarding discrimination issues, policy and procedure drafting, conflict resolution, and a variety of other employment law matters. Ms. Klegon regularly conducts provider trainings on all of these topics.

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Care Providers of Minnesota Assisted Living Director Licensing Course

Application of Landlord‐Tenant Law to Assisted Living Providers MICHELLE R. KLEGON KLEGON LAW OFFICE, LTD. (763) 546‐1109 MKLEGON@KLEGONLAW.COM

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What We’ll Be Talking About The assisted living laws and rules How landlord‐tenant law applies to assisted living facilities The eviction process and how it may be used by assisted living providers

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Assisted Living Laws & Rules

5

Laws vs. Rules: What’s the Difference?

Laws & rules work together Laws are passed by elected officials at the State Legislature ◦ At the federal level, Congress passes the laws

Rules are designed to supplement the laws ◦ Written by government agencies rather that the legislative body ◦ Very technical procedure

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Laws Impacting Assisted Living Providers Assisted living licensure law ◦ Became effective Aug. 1, 2021 ◦ Found at Minn. Stat. §144G.08 ‐ §144G.9999: https://www.revisor.mn.gov/statutes/cite/144G

Licensure of Assisted Living Directors ◦ Became effective July 1, 2020 ◦ Found at Minn. Stat. §144A.20, subd. 4: https://www.revisor.mn.gov/statutes/cite/144A.20

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Laws Impacting Assisted Living Providers Vulnerable Adults Act (MN Stat. §§626.557 through 626.5573): ◦ Reporting: https://www.revisor.mn.gov/statutes/cite/626.557 ◦ Definitions: https://www.revisor.mn.gov/statutes/cite/626.5572

Electronic monitoring law ◦ Became effective Jan. 1, 2020 ◦ Found at Minn. Stat. §144.6502: https://www.revisor.mn.gov/statutes/cite/144.6502

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Laws Impacting Assisted Living Providers MN landlord‐tenant law (MN Stat., Ch. 504B): https://www.revisor.mn.gov/statutes/cite/504B

Fair housing laws (federal & state): ◦ ◦ ◦ ◦

MN Human Rights Act: https://www.revisor.mn.gov/statutes/cite/363A Fair Housing Act Section 504 of the Rehabilitation Act Americans with Disabilities Act (Titles II & III)

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Laws Impacting Assisted Living Providers Nurse Practice Act (MN Stat. §§148.171 through 148.285): https://www.revisor.mn.gov/statutes/cite/148

Minnesota Government Data Practices Act (MN Stat., Ch. 13): https://www.revisor.mn.gov/statutes/cite/13

Health Insurance Portability and Accountability Act (“HIPAA”)(45 C.F.R., Parts 160, 162 and 164)

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Laws Impacting Assisted Living Providers Consumer Protection Laws ◦ Uniform Deceptive Trade Practices Act (MN Stat. §325D.43 through §325D.48) ◦ False Statement in Advertisement Act (MN Stat. §325F.67) ◦ Deceptive Acts Perpetrated Against Senior Citizens or Handicapped Persons (MN Stat. §325F.71) ◦ Disclosure of Special Care Status (MN Stat. §325F.72): https://www.revisor.mn.gov/statutes/cite/325F.72

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Rules Impacting Assisted Living Providers Assisted living rule ◦ Adopted by MN Dept. of Health on July 19, 2021 ◦ Found at Minn. Rules, Pt. 4659: https://www.revisor.mn.gov/rules

Assisted living director rule ◦ Adopted by Board of Executives for Long‐Term Services and Supports on April 5, 2021 ◦ Found at Minn. Rules, Pt. 6400: https://www.revisor.mn.gov/rules/6400

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Landlord‐Tenant Law

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Application of Landlord‐Tenant Law to AL Landlord‐tenant identified in assisted living law as applying to providers: https://www.revisor.mn.gov/statutes/cite/144G.11

General areas of landlord‐tenant addressed: ◦ ◦ ◦ ◦

When a lease is required Mandatory lease provisions Duties of landlord and tenant Eviction process

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Areas Addressed in §504B A Landlord with 12 or more residential units must have a written lease for each unit rented to a residential Tenant ◦ Must identify the specific unit to be occupied ◦ First page must identify the start date, the end date, and any pro‐rated rents

A Landlord must give each Tenant a copy of his or her written lease

A Landlord may obtain from a Tenant a signed and dated receipt of the written lease

15

Areas Addressed in §504B In the event of nonpayment, a Landlord may bring action against a Tenant to recover possession of the leased premises ◦ Address partial payment issues in lease

If a Tenant pays the rent due after the Landlord has initiated legal action, the Tenant may then be restored to possession of the leased premises Rent paid by a Tenant after the initiation of action by a Landlord must first be applied to the oldest balance claimed in the Complaint, unless the Court finds the claim for earlier rent has been waived

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Areas Addressed in §504B If the building in which the leased premises is deemed unfit for occupancy and such unfitness is not the Tenant's fault, the Tenant cannot be held liable for the payment of rent unless the same is expressly provided for in a written agreement with the Landlord

If a Tenant abandons or otherwise vacates the leased unit without providing the Landlord with at least three (3) days notice, the Tenant is guilty of a misdemeanor ◦ Applies in cold weather months only (Nov. 15th – Apr. 15th)

If a Tenant dies, either the Landlord or the personal representative of the Tenant’s estate may terminate the lease upon two (2) months written notice ◦ If lease is month‐to‐month, termination notice period would be 30 days to end on last day of month

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Areas Addressed in §504B Payment of Rent (Minn. Stat. §504B.118) ◦ Landlord must provide Tenant with receipt if Tenant pays rent with cash ◦ Provide at time of payment if paid in person ◦ Provide within three (3) business days if paid by mail

Recovery of Attorneys’ Fees (Minn. Stat. §504B.172) ◦ If a lease entitles Landlord to recover its attorneys’ fees when it wins a legal action, Tenant is entitled to recover his or her fees if he or she wins ◦ Type of action must be identified in lease agreement ◦ Tenant’s action must be of the same type as Landlord’s, under the same circumstances and to the same extent as specified in lease for Landlord

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Areas Addressed in §504B Applicant Screening Fee (Minn. Stat. §504B.173) ◦ ◦ ◦ ◦ ◦

Fee charged by landlord to cover costs of processing application for tenancy Limitations on Landlord Written disclosures required prior to Landlord accepting fee 14‐day notice requirement if application rejected Must return all or portion of fee in certain circumstances

Late Fees ◦ Must be agreed to in writing ◦ Limited to 8% of late payment

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Areas Addressed in §504B Separate Utility Billing (Minn. Stat. § 504B.215) ◦ Applies if utilities billed by Landlord separate from rent ◦ Must use predetermined formula and include in lease

Abandoned Property (Minn. Stat. § 504B.271) ◦ Landlord must hold property left behind by Tenant for 28 days ◦ Prior to sale, Landlord must provide 14‐day prior written notice of the sale by personal service in writing or send written notice by first‐class and certified mail ◦ If Landlord notifies Tenant by mail, the 14‐day period is deemed to start the day the notice is mailed in the U.S. mail

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Promises by Landlord The leased premises and all common areas are fit for the use intended by the parties The Landlord will keep the leased premises in reasonable repair during the term of the lease, unless the disrepair of the premises is caused by the Tenant The Landlord will make the premises reasonably energy efficient The Landlord will maintain the leased premises in compliance with applicable health and safety laws of the State of Minnesota

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Promises by Landlord & Tenant Neither party will: ◦ ◦ ◦ ◦

Unlawfully allow controlled substances on the leased premises Allow prostitution or prostitution‐related activity to occur on the premises or in the common areas Allow the unlawful use or possession of a firearm on the premises or in the common areas Allow stolen property or property obtained by robbery in the premises or in the common areas

The common area will not be used by the Landlord, the Tenant, or by any other person acting under the control of either party, to manufacture, sell, give away, barter, deliver, exchange, distribute, purchase or possess a controlled substance in violation of any criminal provision

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Promises by Landlord & Tenant Neither Landlord nor Tenant will commit an act of: ◦ Domestic abuse; ◦ Criminal sexual conduct; or ◦ Harassment against another tenant or authorized occupant

A breach of these promises by the Tenant voids the Tenant's right to possess the leased unit

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Right of Entry A Landlord may enter the premises rented by a Tenant only for a reasonable business purpose and only after making a good faith effort to give the Tenant reasonable notice under the circumstances of its intent to enter “Reasonable business purpose” includes: ◦ ◦ ◦ ◦ ◦ ◦ ◦

Showing the leased unit to a prospective buyer or Tenant Performing maintenance work Allowing government inspections Investigating a possible disturbance or lease violation Performing prearranged housekeeping work Determining whether the unit is occupied by someone without the legal right to possess Determining whether Tenant has vacated the unit

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Right of Entry Exceptions to Notice Requirement

◦ The Landlord reasonably suspects that immediate entry is necessary to prevent injury to persons or property ◦ Must relate to building maintenance, security or law enforcement

◦ The Landlord reasonably suspects that immediate entry is necessary to determine a Tenant's safety ◦ The Landlord reasonably suspects that immediate entry is necessary to comply with local ordinances regarding unlawful activity occurring within a Tenant's premises ◦ If the Landlord substantially violates this provision of the law, the Tenant may use a tenants’ remedy action to enforce Minnesota law

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Deposits & Fees

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Pre‐Lease Deposits (Minn. Stat. §504B.175) Payment given to Landlord from prospective tenant ◦ Lease not yet entered into ◦ Different than applicant screening fee ◦ Often used with buildings under construction

Deposit must be given pursuant to written agreement between Landlord and prospective tenant ◦ Identify circumstances under which deposit will be returned ◦ Deposit must be returned within 7 days of occurrence of identified “trigger” event

Upon move‐in, landlord must apply deposit to security deposit or rent Landlord can be liable for amount of deposit plus 50%

◦ Exclusive of any other available remedies for violation of law

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Security Deposits (Minn. Stat. §504B.178) Security deposits not required under landlord‐tenant law ◦ If Landlord chooses to collect security deposit, Landlord must follow law

Purpose of security deposit is to secure Tenant’s performance under lease agreement ◦ Not advance payment of rent ◦ Held by Landlord until end of lease term ◦ Earns interest at rate of 1% per year

By definition, security deposits are refundable ◦ Can’t call it something else to avoid returning deposit

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Security Deposits (Minn. Stat. §504B.178) Landlord must return proper amount of security deposit within 3 weeks of tenancy ending ◦ If building condemned, must be returned within 5 days of Tenant moving out

Landlord may withhold monies from the security deposit: ◦ To pay unpaid rent or other funds due to Landlord from Tenant pursuant to agreement ◦ To restore the leased premises to their original condition, ordinary wear and tear excepted

Landlord must provide Tenant with written statement identifying amounts withheld and reasons for same

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Community Fees Not identified in MN landlord‐tenant law

Can mean different things to different landlords ◦ ◦ ◦ ◦

Security deposit in disguise Supplement operations expenses Pay for special projects Tenant directed

Can help provider cash flow

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Community Fees Legal vs. practical: Will you be able to collect a community fee from tenants receiving public assistance?

Best practice: Be thoughtful when structuring a community fee ◦ Make sure it isn’t a security deposit with another name ◦ Segregate funds if used for special projects or tenant‐directed ◦ “Safest” community fee is one used for the benefit of the community

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Pet Deposits/Pet Fees Is it a deposit or a fee?

◦ Deposit implies refundable ◦ Fee implies one‐time, non‐refundable payment

If treated as additional security deposit, must follow MN security deposit law ◦ Return at end of lease term with 1% interest

MN landlord‐tenant law doesn’t address pet deposits or fees If HUD property, HUD limits amount of deposit

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Pet Deposits/Pet Fees Is it a pet, a service animal or an emotional support animal? ◦ Okay to charge deposit or fee for pet ◦ Not okay to charge deposit or fee for service or emotional support animal

Service and emotional support animals are allowed as reasonable accommodation ◦ Service animals must be trained as such (per ADA) ◦ Emotional support animals do not need to be trained

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Pet Deposits/Pet Fees Emotional support animals must be medically prescribed to treat an identified disability ◦ Prescriber must be able to speak to Tenant’s emotional and social needs ◦ There must be a relationship between the Tenant’s disability and the assistance the animal provides ◦ If no identified disability, no right to accommodation

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Eviction Actions

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Removal from Property General rules: ◦ No force allowed ◦ Peaceful recovery ◦ Physical removal by sheriff

Nonpayment and lease violations can be pursued simultaneously

Because of appeal rights in assisted living law, eviction proceedings will probably be rare

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Reasons to Pursue Eviction Noncompliant resident

Damage to building

Disruptive to other residents

Resident holds over after lease has ended

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Action to Recover (Minn. Stat. § 504B.291)

Rebuttable presumption rent has been paid if Tenant provides one or more copies of money orders or one or more original receipt stubs showing the purchase of money orders and: ◦ The total amount of the rent paid ◦ A date or dates approximately corresponding with the date rent was due ◦ In the case of copies of money orders, they are payable to Landlord

Landlord can rebut this presumption by producing a business record that shows Tenant has not paid rent Landlord can introduce other evidence to rebut this presumption

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Complaint The specific facts of the grounds for eviction Dates and times of alleged violations Specific lease provisions violated Names of persons allegedly living on the property Names of neighbors stating complaints and the precise nature of those complaints A copy of the lease

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Defenses Retaliation or penalty for enforcing rights under lease or under Federal or State Law Retaliation or penalty for Tenant’s good faith report to a governmental authority of the Landlord's violation of any health, safety, housing or building codes or ordinances The Landlord increased rent or decreased services offered as a penalty for any lawful act of the Tenant as described in 1 and 2 above There is a statutory presumption of retaliation if a notice to terminate a Tenant’s lease is served within 90 days of an event described in 1 and 2 above

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Court Process The Court must hear an eviction action within 7‐14 days from the date on which the Court issued its Summons The Landlord files the Complaint with the Court Administrator, along with a filing fee The Court Administrator prepares a Summons The Court Administrator forwards the Summons to the Landlord The Landlord must arrange to serve the defendant (Tenant) with the summons at least 7 days before the initial hearing ◦ Landlord can use either personal or substitute service

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Court Process The Tenant may answer the Complaint In most courts, the initial court hearing serves as an arraignment ◦ In Hennepin and Ramsey Counties, a referee presides over the arraignment

Only a principal or licensed attorney is allowed to appear in Housing Court unless Power of Authority is attached to the Complaint at the time of filing ◦ Generally, a corporation is required to be represented by an attorney in an eviction action

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Court Process If the defendant (Tenant) does not appear, the Court will find for the plaintiff (Landlord) and issue a Writ of Recovery and Order to Vacate

If the defendant (Tenant) appears and does not dispute the action, the Court will rule for the plaintiff (Landlord), but could delay the issuance of a Writ for 7 days

If the defendant (Tenant) appears and disputes the action, the Court usually schedules a trial for another day

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Court Process At trial, the Landlord has the burden of proving breach of contract and the Tenant may raise numerous defenses If the Tenant prevails, the Landlord may not evict the Tenant at that time ◦ Tenant may be able to have record expunged

If the Landlord prevails, the Court may:

◦ Immediately issue a Writ of Recovery and Order to Vacate; ◦ Issue a 24‐hour eviction notice; or ◦ Delay issuance of the Writ for up to seven days

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Court Process If the Landlord prevails, the Landlord must arrange for the sheriff or police to deliver the Writ of Recovery and Order to Vacate If the Tenant does not move, the Landlord must schedule the Tenant’s physical removal from the premises with the sheriff or police

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Court Process Either party may appeal within 15 days from the entry of judgment If a referee heard the case (Hennepin and Ramsey Counties), a party may seek a judge’s review of a decision recommended by the referee The Landlord is required to store the Tenant's property for up to 28 days ◦ Can store either on site or with a storage company

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Summary

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To Wrap Up . . . Regularly review both the assisted living law and rule, as well as the landlord‐ tenant law Become familiar with how the landlord‐tenant law applies to assisted living facilities Know what the eviction process is, as well as how and why it may be used in the assisted living setting

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g{tÇ~ lÉâ4 MICHELLE R. KLEGON KLEGON LAW OFFICE, LTD. (763) 546‐1109 MKLEGON@KLEGONLAW.COM

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L ICENSED ASSISTED L IVING DIRECTOR

ROLE OF LONG-TERM CARE OMBUDSMAN Cheryl Hennen, State Long-Term Care Ombudsman Office of Ombudsman for Long-Term Care

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INTRODUCTIONS Cheryl Hennen, State Long-Term Care Ombudsman Office of Ombudsman for Long-Term Care Cheryl Hennen is the State Ombudsman for the Office of Ombudsman for Long-Term Care. She has been employed as an Ombudsman since January of 2004. She has also served as a Certified Ombudsman Volunteer, Regional Ombudsman, Policy Specialist, and Deputy Ombudsman.

Ms. Hennen is responsible for the ongoing management and administration of the MN Office of Ombudsman for Long-Term Care established in Federal and State law, program of the MN Board on Aging.

Ms. Hennen joined the State of MN in 2001 working in the Disability Services Division. Her primary responsibilities involved policy development and implementation of long-term care waiver programs specifically serving individuals eligible for Medicaid receiving home and community waiver services. Prior to state government service Ms. Hennen worked in county government social services.

Ms. Hennen holds a degree in Human Services Administration from Metropolitan State University and studied Negotiation-Mediation at Mitchell Hamline School of Law

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Role of Long-Term Care Ombudsman Assisted Living Director Licensing Curriculum 2021

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Agenda: • History of the Ombudsman for Long-Term Care Program • Genesis of the Long-Term Care Ombudsman Program

• Provide Legal Authority • Older Americans Act • Federal Regulations • MN Statute

• Unique aspects of the Long-Term Care Ombudsman Program • Coordination and Collaboration Efforts

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Office of Ombudsman for Long-Term Care Mission Statement (OOLTC): To empower, educate, and advocate alongside Minnesotans who are receiving long-term care services and supports to ensure their rights are upheld.

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Legal Authority • The Older Americans Act (OAA) established the Ombudsman Program. Older Americans Act of 1965. Section 712 • 45 CFR Part 1321 and 1324 LTCO Program • MN Statute 256.9742 DUTIES AND POWERS OF THE OFFICE. • State Unit on Aging (Minnesota Board on Aging)

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The OAA requires Ombudsman programs to: • Identify, investigate, and resolve complaints made by or on behalf of residents; • Provide information to residents about Long-Term Care Services and Supports, • Ensure that residents have regular and timely access to ombudsman services; • Represent the interests of residents before governmental agencies and seek administrative, legal, and other remedies to protect residents; and • Analyze, comment on, and recommend changes in laws and regulations pertaining to the health, safety, welfare, and rights of residents.

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State Long-Term Care Ombudsman Rule (regulation) • The State Long-Term Care Ombudsman Programs rule was published in February 2015 and became effective on July 1, 2016.

• The Rule addresses: • Responsibilities of key staff in the program, including the SLTCO and representatives of the Office of the Ombudsman; • Responsibilities of the entities in which LTC Ombudsman programs are housed; • Criteria for establishing consistent, person-centered approaches to resolving complaints on behalf of residents; • Appropriate role of LTC Ombudsman programs in resolving abuse complaints; • Conflicts of interest: processes for identifying and remedying conflicts so that residents have access to effective, credible ombudsman services 8

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Mandated Reporter Responsibilities and investigating abuse complaints • The Ombudsman for Long-Term Care is required to identify, investigate, and resolve complaints that relate to action, inaction or decisions that may adversely affect the health, safety, welfare, or rights of the residents.

• Both the Older Americans Act and the Rule prohibit reporting of residentidentifying information without the resident’s consent. This precludes mandated reporting of suspected abuse which discloses such information.

• The Ombudsman program is not the official substantiator for abuse complaints on behalf of the state or other governmental entity.

• The complaint resolution function of the Ombudsman program requires a thorough investigation. The goal of the investigation is to resolve the complaint to the resident’s satisfaction.

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Unique Aspects: • The Long-Term Care Ombudsman Program has some mandates that are not typical of other program specified in the federal law.

Long-Term Care Ombudsman Program is unique within the aging network: • Office of the LTCO is a distinct entity, separately identifiable, headed by a State LTCO, responsible for a statewide program • Has more strict confidentiality requirements • Has specific conflict of interest provisions • Pursues administrative, legal, and other remedies on behalf of residents • Is protected from willful interference

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Support to Providers of Service: • Consultation to Facility staff • Ombudsmen provide staff with consultations on resident rights, long-term care services and supports , care, and many other long-term care subjects.

• In-Service Education • Ombudsmen train facility staff on topics such as the Ombudsman Program, residents’ rights, and abuse.

• Resident and Family Councils • Ombudsmen help residents and family members establish resident and family councils in long-term care settings. We participate in resident and family council meetings as speakers, observers, and resource persons.

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Coordination between Ombudsman Programs and other programs: • Older Americans Act : • CHAPTER 3—PROGRAMS FOR PREVENTION OF ELDER ABUSE, NEGLECT, AND EXPLOITATION • SEC. 721. PREVENTION OF ELDER ABUSE, NEGLECT, AND EXPLOITATION. • Eligibility for funding requires coordination between agencies to develop, strengthen, and carry out programs for the prevention, detection, assessment, and treatment of, intervention in, investigation of, and response to elder abuse, neglect, and exploitation,

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SLTCO coordination with other agencies include: • Protection and Advocacy programs, • Facility and long-term care provider licensure and certification programs, • Medicaid fraud and abuse services, including services provided by a State Medicaid fraud control unit, • Victim assistance programs, • Consumer protection and State and local law enforcement programs,

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Thank you Cheryl Hennen SLTCO MN Cheryl.Hennen@state.mn.us 651-431-2553

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L ICENSED ASSISTED L IVING DIRECTOR

MARKETING & SALES BASICS LALD

Monica Hunter, Senior Director of Business Development Lifespark Senior Living (Formerly Tealwood Senior Living)

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INTRODUCTIONS Monica Hunter, Senior Director of Business Development Lifespark Senior Living (Formerly Tealwood Senior Living) Monica Hunter began her career in marketing research with Millward Brown and moved into health care as an LPN for over 25 years. Having worked as a Division Director in both homecare and assisted living, a nurse in acute, post-acute, and long-term care, her blend of the clinical and business skill has been instrumental in the growth of diverse healthcare service lines, increased occupancy, and new property development. Monica is proud to lead a team of specialists in supporting sales and marketing efforts across over 30 communities and looks forward to the future growth already in process.

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Unlocking solutions for elders in need

Marketing & Sales Basics LALD 3

What is Marketing and Sales in Assisted Living?

Working Definitions Marketing is the promotion and education of your product or service directly to the consumer (Business to Consumer) or to a referring business (Business to Business). The goal being to generate prospects who need your service. There are countless ways to internally or externally market your community; however, nothing takes the place of excellent care and customer service.

Sales in assisted living is the process of working with a lead or lead source that has been generated through your marketing efforts. In the case of a direct prospect or consumer; it’s discovering their current situation, if you’re the best solution, and closing . If not, being a health care resource to get them pointed in the right direction. Never leave someone lost in the care continuum. In the case of a referring business or relationship, it’s being a trusted resource and responsive when they have a client in need.

You’ll find in both categories- Marketing and Sales- education, patience, and knowing health care is important to be an effective resource.

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Marketing and Sales Break Down We delineate between marketing and sales to help you determine what is or isn’t working in your strategy.

Sales

Marketing How people with obstacles find us.

How we help them find a solution.

We’ll talk more about these processes later in the presentation.

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What is your role as an LALD in Marketing and Sales?

As an administrator, your role is varied depending on the company you work for, their structure, and expectations. At the minimum, you’ll need to manage the marketing and sales team that report to you and at most, you’ll be expected to participate or drive the marketing and sales effort with help from upper-level management. In some smaller communities, you may have much of the responsibility.

No matter how it works out, it’s very important to know your community in detail.

Ultimately, the prospective resident and family will want to meet you and know you can be trusted to care for them or their loved ones.

The typical structure in assisted living supports 1 to 2 either Director of Marketing, Sales Consultant, Leasing Manager, Community Liaison, or other uniquely named role responsible for occupancy.

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Managing a department where you don’t have a background can feel uncomfortable.

Here are marketing and sales basics your director should be executing.

Managing your Marketing and Sales Team Top 10

1.

Collaborating with you and your team on a marketing plan. There should ALWAYS be a plan. Your organization will have a template with their minimum requirements or KPI’s (key performance indicators). You will want to take advantage of additional opportunities as they arise as well.

2.

The marketing plan should be evaluated monthly and updated quarterly with a deep dive at the end of the year.

3.

Because each department, especially nursing, plays a role in driving occupancy, discussion on prospects and move ins are critical in your daily stand up. This is a team initiative.

4.

Weekly touch base meeting with marketing and sales will keep things running smoothly. Staying connected with each team member individually can avoid issues later.

5.

Customer Relations Management software oversight and usage will help you know where you are, where you’ve been, and where you’re going in your business.

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Managing your Marketing and Sales Team (cont.)

6. The marketing and sales position can feel thankless and defeating at times. Staff can feel taxed and not want move ins; prospects, families, and referral sources can be very difficult and rude. Being a positive force and a leader that can lend an ear can mean the difference between success and failure in your director. Notice signs of frustration early.

7. Be prepared to step in. There will be busy times where tours will need to double up and you’ll need to be prepared for after hour walk-in tours. Your leadership team should be tour trained.

8. When you have availability , attend community networking events and meetings. The community at large will want to know who’s steering the ship. Your marketing director will appreciate it as well.

9. You are not expected to be the expert, however, if an initiative is not showing tangible results, ask questions.

10. Just as in nursing, wellness, and budget, data is your best friend in evaluating occupancy trends and advertising effectiveness. Your CRM will tell the story along with many other available dashboards.

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HM1

We noted the CRM and data dashboards as being important in tracking, evaluating, and predicting your business. Every business uses some form of tracking clients and senior living has become more sophisticated in this area. It’s a valuable tool in not only business management, but also making the client feel valued by having details of their situation at your fingertips.

Each CRM system may have different terminology but operate similarly.

Customer Relation Management (CRM) 9

CRM Mobile Most software systems have a mobile entry feature. Be sure to ask. This can save you and your team a lot of time when not at your desk

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Here are a few CRM and Automation dashboards with KPI’s. Key Performance Indicators.

A snapshot to performance

Marketing-number of people who find us- for example- Inquiries.

Sales- were we able to solve that person's problem and result in a tour and move in.

Do NOT be alarmed, this will all make sense when you get to use the system in your community.

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Internal Marketing Upbeat staff and a clean, well-organized community is the 1st step to happy residents.

Where there are happy residents, a great reputations follows!

Quality and timely caregiving is the backbone to our work in assisted living. If the residents are receiving good care, their families and friends will hear about it. Likewise, if the care is poor, they will also hear about it.

Resident referral bonuses are helpful for both the community and the resident. If a resident refers a friend, a financial bonus or rent concession is common.

Staff referral bonuses are also a great way to spread the word about your community, sometimes our staff are the best ambassadors.

It may seem external but showcasing the wonderful engagement of your community on social media (following company guidelines) is invaluable. You're sharing their experiences with their families.

Events can be internal and external 12

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External Marketing Outreach: Visiting and educating referral sources (Senior Center, Transitional Care Units, Churches, Clinics, Hospitals) Always have a message of value. Think of how what you do could be a help to your audience. Most referral sources are truly unaware of the scope of senior living.

Events: creative and engaging events on site or being a part of city events is important.

Professional Expos and Fairs Community Engagement: Joining or creating boards or initiatives to support the community.

Print: Local papers, magazines, direct mail, inserts Digital: Website, PPC, Online Display, Retargeting, Social Media, OTT non skippable commercials, Reputation Management, etc. Making sure your external reputation with Google and Social star ratings are high.

Social Media deserves its own line as you have control over posting in most cases. Yiu have an opportunity to encourage everyone you encounter to follow you page and you can pay to get targeted audiences to follow you at a minimal cost.

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Deceptive Marketing Practices We get used to ambiguous advertising in the general marketplace. There are rules; however, they are difficult to enforce and often the consumer pays the price. Thankfully, the State of Minnesota is focusing on fair business practices and transparency. Let’s start with the obvious. If you are not licensed to do it, don’t do it. https://www.revisor.mn.gov/statutes/cite/144G Take note of rule 144G.80 If you are an Administrator of a campus promoting dementia care as a unit or specific service line, be absolutely sure the community is dual licensed. There are additional requirements that need to be fulfilled and the licensed posted must state “Assisted Living with Dementia Care License”. There is a host of fines broken out per resident and the chance of license suspension if you advertise and claim to provide dementia care without this license.

This is a good lead in to the obvious. Do not advertise services you do not or cannot provide.

For example, you may have printed collateral stating you have concierge services, but due to staffing you can’t fulfill that service until you hire and train a replacement. State that clearly either by email or some form of provable communication. We realize you cannot reprint collateral for every staffing change or service disruption. The point is to be transparent as possible to manage client expectations and ethical practice.

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Deceptive Marketing Practices Offers can be very helpful in your marketing efforts, especially in a competitive market.

There are ways to be competitive and use offers to trigger a phone call or web submission. It is critical to be transparent. For example: If you are going to give a free month’s rent but not give that concession until the third month, you could state it two ways. 1. Third Month Rent Free or 2. A Free Month’s Rent *restrictions apply or *call for details. You are stating there are rules that go along with that offer.

I will restate this in a later slide and it’s purposeful. At the beginning of the COVID-19 vaccination distribution, there were communities promoting a vaccine if you moved there.

This was a time when vaccine scarcity was prevalent. The State and Federal Government made it very clear as should our own ethics, this is wrong and will be prosecuted. This is an example of what may come in the future with any other item of scarcity. You can offer free services, or items so long as they are not medications or tied to an overall community need or emergency.

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Sales Process Basics We’ve talked a lot about marketing and now we turn to sales. That part of the customer experience that put us in contact, by phone, email, or in person. This is where we get to build relationship and help people through their health care journey. We all went into health care because we wanted to help people. Our titles may be different from one another, but we all play an integral role in the care team approach.

When you receive an inquiry, answer as soon as possible. They are in some sort of crisis, or they wouldn’t have reached out. It’s difficult for some to admit they need help, so use a delicate approach while discovering their story. Discovery is the most important part of the sales process.

Ask questions but do not interrupt.

Do not judge their situation. Come from a spirit of assistance.

Find out who the decision makers are and be sure they tour virtually or otherwise. Repeat back what they’ve stated is the issue.

Don’t waste their time on things that don’t matter to them until you’ve solved their problem.

Utilize the platform your company provides for training. Think of it as a way to help your prospects more efficiently.

Be comfortable asking for a decision and deposit, if they are not ready, we haven’t solved the real problem or haven't identified the true decision maker.

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Sales Process (Cont.)

Whether they deposit or not, stay in contact and nurture that person and family. It was a scary decision to either commit or to just reach out at all. They will need encouragement and to know you care. Think of things that are personal to them with your follow up.

This is a business built on trust and relationship. We have to earn it.

Make sure the nursing assessment is completed as soon as possible to be sure the move is appropriate and by a nurse who is warm and friendly.

Sign contracts and move in paperwork ahead of time so the move is as peaceful and joyful as possible.

Be sure the team is educated to who is moving in and things that are special about that person to give a very personalized welcome.

Ensure the apartment, medications, and clinical data that is possible is gathered ahead of time.

A warm welcome sign on the door and treat in the apartment upon arrival can make all the difference 17

It’s so exciting to see …

THIS

GO TO THIS

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What about the Pandemic?

We learned a lot during the pandemic and the continued ebb and flow of it. You and your team will find solutions to challenges pandemic or not. Here are some of the solutions we used from a marketing and sales perspective. It is more important than ever to be prepared to serve people who need us.

-Utilized Zoom, FaceTime, Google Hangouts, whatever the client, referral agency, or networking group was comfortable using to communicate.

-Took personalized videos and picture folders for prospects and families.

-Drone tours of interior spaces to send the link to families. This gave a multi-dimensional look at the community.

-Met families outside or in parking lots to sign paperwork -Provided mobile devices for move ins that didn’t have them, ensuring they could communicate with family anytime they wanted.

-Created community channel to provide “group activities” via interactive TV. -Explained, in detail, all our sanitization techniques, and creative visitation spaces.

-Created centralized moving teams so we could still facilitate moves during the heat of the pandemic for those who needed a place to live.

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A Few Important Things to be Aware of…

It has been a temptation through the pandemic for some senior communities to try to leverage the vaccine as a sales tool. Do NOT ever do this. Leveraging life saving medication or treatments as a hook for a move in is unethical by any standard. Boosters may be coming the way of senior care, so be aware of this strategy, When using any images online, be sure they’ve been purchased, or you’ve been given written consent to use them. This goes for activity calendars ad newsletters that will be posted online. There are bots to search them out.

We all believe our communities give the best care because we work hard to attain that goal. Set realistic expectations when working with prospects and families. If you do not have the ability to care for someone as you should, do not accept. It will do your reputation more harm than good.

As you know being a part of this program, August 1st brought licensure to Minnesota. The changes related to marketing are primarily meal costs being pulled out of package pricing. This was to bring pricing transparency. This allows residents to choose to purchase meal packages separately. This could be problematic for memory care. We have not run across anyone who has chosen less than 3 meals for a memory care resident, but in theory, it could happen. Be prepared to speak to the need for socialization and nutrition across all care levels.

Be sure you’re trained to all contracts, processes per department, and emergency preparedness plans.

There have been minor adjustments to each department.

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YOU’RE ON YOUR WAY!

We are so happy you’re joining us on the journey to helping elders live their best life and families feel the relief and trust our profession instills.

Thank you for all you do!

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Older Adult Mental Health Basics Action Checklist Depression, anxiety and other mental illnesses are not a normal part of aging.

Anxiety is the most common mental illness.

80% of older adults who get treatment for depression get better. Make sure older adults get access to treatment.

It’s not about you The odd or aggressive actions you deal with are caused by an illness.

Ask for help when working with residents who seem to thrive on conflict or require constant attention for every need.

Try to find the unmet need triggering a behavior or call for attention.

Symptoms you believe are a signs of a mental illness may actually be caused by brain injuries, dementia or from medication side effects.

Report changes in a person’s sleeping, eating or participation in activities. These could be early signs of a treatable mental illness.

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Mental illness is not a part of normal aging

What is mental illness?

It affects our thinking, feeling and emotions. Makes it hard to function in our daily activities and to maintain relationships with others.

Anxiety

is the most common mental illness

1 in 5 adults has a mental illness in a given year

Almost half of all mental illnesses begin by age 14 and 75% by age 24 Older Adults with Depression Rarely say they’re sad

Aches, pains and feeling tired are often depression warning symptoms

80% who are diagnosed get better with treatment

Be sure the older adults you care for get a depression

screening

Source: NAMI Minnesota

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Geriatric Depression Scale (short form) Instructions:

Circle the answer that best describes how you felt over the past week.

1. Are you basically satisfied with your life?

yes

no

2. Have you dropped many of your activities and interests?

yes

no

3. Do you feel that your life is empty?

yes

no

4. Do you often get bored?

yes

no

5. Are you in good spirits most of the time?

yes

no

6. Are you afraid that something bad is going to happen to you?

yes

no

7. Do you feel happy most of the time?

yes

no

8. Do you often feel helpless?

yes

no

9. Do you prefer to stay at home, rather than going out and doing things?

yes

no

10. Do you feel that you have more problems with memory than most?

yes

no

11. Do you think it is wonderful to be alive now?

yes

no

12. Do you feel worthless the way you are now?

yes

no

13. Do you feel full of energy?

yes

no

14. Do you feel that your situation is hopeless?

yes

no

15. Do you think that most people are better off than you are?

yes

no

Total Score

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Tools

165

may be copied without permission

Geriatric Depression Scale (GDS) Scoring Instructions Instructions:

Score 1 point for each bolded answer. A score of 5 or more suggests depression.

1. Are you basically satisfied with your life?

yes

no

2. Have you dropped many of your activities and interests?

yes

no

3. Do you feel that your life is empty?

yes

no

4. Do you often get bored?

yes

no

5. Are you in good spirits most of the time?

yes

no

6. Are you afraid that something bad is going to happen to you?

yes

no

7. Do you feel happy most of the time?

yes

no

8. Do you often feel helpless?

yes

no

9. Do you prefer to stay at home, rather than going out and doing things?

yes

no

10. Do you feel that you have more problems with memory than most?

yes

no

11. Do you think it is wonderful to be alive now?

yes

no

12. Do you feel worthless the way you are now?

yes

no

13. Do you feel full of energy?

yes

no

14. Do you feel that your situation is hopeless?

yes

no

15. Do you think that most people are better off than yes you are?

no

A score of > 5 suggests depression

Total Score

Ref. Yes average: The use of Rating Depression Series in the Elderly, in Poon (ed.): Clinical Memory Assessment of Older Adults, American Psychological Association, 1986

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Tools

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may be copied without permission

Crisis Prevention / De-escalation Action Checklist Your response determines the outcome of every crisis event.

Learn the early warning signs – like uncontrolled swearing or confrontations involving the invasion of your personal space.

Develop a personal prevention plan that identifies a person’s triggers and calming strategies.

Avoid power struggles.

Understand the crisis lifecycle.

Use the Listen…Understand…Act to help de-escalate a crisis.

Use Active Listening Let the person vent Guide person to a safer place Ask others to leave the area Do not put hands on anyone Ask for help when working with residents who seem to thrive on conflict or require constant attention for every need.

Memorize the “Never say” words and then never say them!

Role play and review your prevention and deescalation responses with your colleagues or family caregivers.

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Use the 3-Step Process to De-escalate Crises

Listen: approach the person from the front so they can see you. Use active listening - repeat back what the person has said to let them know you have their full attention and respect.

Understand: don’t argue or be defensive.

Let the person vent. Don’t take insults or foul language personally. Choose your words carefully.

Act: guide the person to a safer place. Do not put hands on anyone. Ask others to leave the area. Ask for help.

Never say…

Calm down!

What's your problem?

Those are the rules!

I'm not going to tell you again!

Why can't you be reasonable?

You’ll just make matters worse!

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Your response determines the outcome in every mental health crisis

What are some crisis prevention tips?

1. Determine the level of stimulation and uncertainty a person can handle.

2. Understand early warning symptoms like verbal and physical aggression such as swearing, hitting, or yelling pacing or rocking.

3. Avoid power struggles – delay a treatment or care if a person resists.

4. Develop a personal prevention plan to help a person identify triggers.

5. Back away and ask for help when someone’s tone, volume and cadence increases.

Understand the Mental Health Crisis Life Cycle

169

Don’t miss opportunities to intervene sooner in Stages 1 and 2 to prevent a crisis.

Rev. 11/2018

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Person-centered Care Planning Action Checklist People respond best when they’re involved in making decisions about their lives.

Person-centered care puts the person at the center and understands every person is unique.

Person-centered care always involves the person and views the person as an equal.

Person-centered care focuses on a person’s strengths, not their weaknesses.

A person-centered care plan may include unique approaches to mealtimes, living environments and level of risk.

A person-centered care plan gets input from the whole care team.

Mental health experts are important partners in helping you develop person-centered care plans.

Psychologists, Psychiatrists and Mental Health Social Workers have special training to help you identify behavior triggers and strategies to reduce unhealthy actions.

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Person-centered care is a way of thinking and caring that sees the person as an equal partner in planning, delivering and monitoring their care.

Use the whole-person approach to develop your person-centered plan Helps identify:       

Coping skills Social connections Physical needs Intellectual functioning Spiritual connection Occupation satisfaction and interest Financial status

Ask mental health experts for help when:  When a person fails to respond to your initial care plan  When a person has complex mental illness symptoms  When you’re new to caring for someone living with a mental illness

Psychologists, psychiatrists and mental health social workers have special training to help you identify triggers and strategies to reduce unhealthy responses and actions.

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Sample Person-centered Care Plans

Sample #1

Sample #2

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L ICENSED ASSISTED L IVING DIRECTOR

MINNESOTA NURSING PRACTICE KEY CONCEPTS AND PRACTICAL APPLICATIONS

Karolee Withers (formerly Alexander), RN, RAC-CT, Director of Clinical & Reimbursement Consulting Pathway Health

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INTRODUCTIONS Karolee Withers (formerly Alexander), RN, RAC-CT, Director of Clinical & Reimbursement Consulting Pathway Health Ms. Withers has over 25 years of nursing leadership in long term care, including as a Director of Nursing Services and various MDS and Reimbursement positions. In these roles, she has established herself as an expert in the management of nursing operations, reimbursement systems and performance improvement. Ms. Withers is a strong proponent of resident centered care having established many programs and processes to bring about cultural changes to ensure the success of the programs. In her role as a Consultant, she has proven success with regulatory turn around, mentoring of Nursing management, revenue cycle management and quality.

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Minnesota Nursing Practice Key Concepts and Practical Applications

Consulting | Talent | Training | Resources 3

Objectives

Consulting | Talent | Training | Resources

Participants will: • Define the difference between LPN and RN practice in Minnesota.

• Describe the definitions of Delegation, Assignment and Supervision of nursing care.

• List the required training and competencies for unlicensed personnel in AL in Minnesota. © Pathway Health 2021

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Definition

Consulting | Talent | Training | Resources

“Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; facilitation of healing; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, groups, communities, and populations.”

American Nurse Association Scope of Practice https://www.nursingworld.org/practice-policy/scope-of-practice © Pathway Health 2021

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Consulting | Talent | Training | Resources

© Pathway Health 2021

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State Regulations

Consulting | Talent | Training | Resources

Each state has its own Practice Act Definitions of roles – Registered Nurse, Licensed Practical Nurse Scope of practice Reasons for reporting misconduct Potential disciplinary actions © Pathway Health 2021

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National Council of State Boards of Nursing (NCSBN)

Consulting | Talent | Training | Resources

NCSBN is a not-for-profit organization whose U.S. members include the nursing regulatory bodies in the 50 states, the District of Columbia and four U.S. territories

© Pathway Health 2021

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Minnesota Nurse Practice Act

Consulting | Talent | Training | Resources

https://mn.gov/boards/nursing/laws-and-rules/nurse-practice-act/

© Pathway Health 2021

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Definitions

Consulting | Talent | Training | Resources

"Assignment" means the designation of nursing tasks or activities to be performed by another nurse or unlicensed assistive person. (Subd. 3a.)

“Intervention" means any act or action, based upon clinical judgment and knowledge that a nurse performs to enhance the health outcome of a patient. (Subd. 7b.)

"Monitoring" means the periodic inspection by a registered nurse or licensed practical nurse of a delegated or assigned nursing task or activity and includes: (1) watching during the performance of the task or activity; (2) periodic checking and tracking of the progress of the task or activity being performed; (3) updating a supervisor on the progress or completion of the task or activity performed; and (4) contacting a supervisor as needed for direction and consultation.

(Subd. 8a.)

"Patient" means a recipient of nursing care, including an individual, family, group, or community. (Subd. 12a.)

"Supervision" means the guidance by a registered nurse in the accomplishment of a nursing task or activity.

Supervision consists of monitoring, as well as establishing, the initial direction, delegating, setting expectations, directing activities and courses of action, evaluating, and changing a course of action. (Subd. 23.)

"Unlicensed assistive personnel" (UAP) means any unlicensed person to whom nursing tasks or activities may be delegated or assigned, as approved by the board. (Subd. 24) Legal Scopes of Practice Minnesota Board of Nursing https://mn.gov/boards/assets/NPA_2013_Combined_Def_12-2020_tcm21-37252.pdf © Pathway Health 2021

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LPN

Consulting | Talent | Training | Resources

Subd. 14.Practice of practical nursing.

The "practice of practical nursing" means the performance, with or without compensation, of those services that incorporates caring for individual patients in all settings through nursing standards recognized by the board at the direction of a registered nurse, advanced practice registered nurse, or other licensed health care provider and includes, but is not limited to: (1) conducting a focused assessment of the health status of an individual patient through the collection and comparison of data to normal findings and the individual patient's current health status, and reporting changes and responses to interventions in an ongoing manner to a registered nurse or the appropriate licensed health care provider for delegated or assigned tasks or activities; (2) participating with other health care providers in the development and modification of a plan of care; (3) determining and implementing appropriate interventions within a nursing plan of care or when delegated or assigned by a registered nurse; (4) implementing interventions that are delegated, ordered, or prescribed by a licensed health care provider; (5) assigning nursing activities or tasks to other licensed practical nurses (LPNs); (6) assigning and monitoring nursing tasks or activities to unlicensed assistive personnel;

© Pathway Health 2021

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LPN

Consulting | Talent | Training | Resources

(7) providing safe and effective nursing care delivery; (8) promoting a safe and therapeutic environment; (9) advocating for the best interests of individual patients; (10) assisting in the evaluation of responses to interventions; (11) collaborating and communicating with other health care providers; (12) providing health care information to individual patients; (13) providing input into the development of policies and procedures; and (14) accountability for the quality of care delivered, recognizing the limits of knowledge and experience; addressing situations beyond the nurse's competency; and performing to the level of education, knowledge, and skill ordinarily expected of an individual who has completed an approved practical nursing education program described in section 148.211, subdivision 1.

© Pathway Health 2021

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LPN - Assessment

Consulting | Talent | Training | Resources

(1) conducting a focused assessment of the health status of an individual patient through the collection and comparison of data to normal findings and the individual patient's current health status, and reporting changes and responses to interventions in an ongoing manner to a registered nurse or the appropriate licensed health care provider for delegated or assigned tasks or activities; (10) assisting in the evaluation of responses to interventions; (11) collaborating and communicating with other health care providers;

STRATEGIES FOR LPN SUCCESS • Must have baseline for comparison • Parameters for notification are helpful to the LPN practice • Establish communication channels © Pathway Health 2021

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LPN – Care Plan

Consulting | Talent | Training | Resources

(2) participating with other health care providers in the development and modification of a plan of care; (3) determining and implementing appropriate interventions within a nursing plan of care or when delegated or assigned by a registered nurse; (4) implementing interventions that are delegated, ordered, or prescribed by a licensed health care provider;

STRATEGIES FOR LPN SUCCESS • Part of care plan development, not solely responsible • RN delegation and assignment

© Pathway Health 2021

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LPN - Assignment

Consulting | Talent | Training | Resources

(5) assigning nursing activities or tasks to other licensed practical nurses (LPNs); (6) assigning and monitoring nursing tasks or activities to unlicensed assistive personnel;

STRATEGIES FOR LPN SUCCESS • Can not delegate – can assign • Responsible to monitor assignments

© Pathway Health 2021

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LPN - Safety

Consulting | Talent | Training | Resources

(7) providing safe and effective nursing care delivery; (8) promoting a safe and therapeutic environment; (9) advocating for the best interests of individual patients; (13) providing input into the development of policies and procedures; and

STRATEGIES FOR LPN SUCCESS • Actively engaged in the care environment

© Pathway Health 2021

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LPN - Accountability

Consulting | Talent | Training | Resources

(14) accountability for the quality of care delivered, recognizing the limits of knowledge and experience; addressing situations beyond the nurse's competency; and performing to the level of education, knowledge, and skill ordinarily expected of an individual who has completed an approved practical nursing education program.

STRATEGIES FOR LPN SUCCESS • Establish reasonable expectations • Provide RN resources

© Pathway Health 2021

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RN Scope of Practice

Consulting | Talent | Training | Resources

Subd. 15.Practice of professional nursing.

The "practice of professional nursing" means the performance, with or without compensation, of those services that incorporates caring for all patients in all settings through nursing standards recognized by the board and includes, but is not limited to: (1) providing a comprehensive assessment of the health status of a patient through the collection, analysis, and synthesis of data used to establish a health status baseline and plan of care, and address changes in a patient's condition; (2) collaborating with the health care team to develop and coordinate an integrated plan of care; (3) developing nursing interventions to be integrated with the plan of care; (4) implementing nursing care through the execution of independent nursing interventions; (5) implementing interventions that are delegated, ordered, or prescribed by a licensed health care provider; (6) delegating nursing tasks or assigning nursing activities to implement the plan of care; (7) providing safe and effective nursing care; (8) promoting a safe and therapeutic environment;

© Pathway Health 2021

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RN Scope of Practice

Consulting | Talent | Training | Resources

(9) advocating for the best interests of individual patients; (10) evaluating responses to interventions and the effectiveness of the plan of care; (11) collaborating and coordinating with other health care professionals in the management and implementation of care within and across care settings and communities; (12) providing health promotion, disease prevention, care coordination, and case finding; (13) designing and implementing teaching plans based on patient need, and evaluating their effectiveness; (14) participating in the development of health care policies, procedures, and systems; (15) managing, supervising, and evaluating the practice of nursing; (16) teaching the theory and practice of nursing; and (17) accountability for the quality of care delivered, recognizing the limits of knowledge and experience; addressing situations beyond the nurse's competency; and performing to the level of education, knowledge, and skill ordinarily expected of an individual who has completed an approved professional nursing education program as described in section 148.211, subdivision 1.

© Pathway Health 2021

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RN - Assessment (1)

Consulting | Talent | Training | Resources

providing a comprehensive assessment of the health status of a patient through the collection, analysis, and synthesis of data used to establish a health status baseline and plan of care, and address changes in a patient's condition;

STRATEGIES FOR RN SUCCESS Establish documentation tools that guide a consistent comprehensive assessment RN to document the baseline and initial plan of care RN to re-assess for changes in condition © Pathway Health 2021

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RN - Communication

Consulting | Talent | Training | Resources

(2) collaborating with the health care team to develop and coordinate an integrated plan of care; (11) collaborating and coordinating with other health care professionals in the management and implementation of care within and across care settings and communities; STRATEGIES FOR RN SUCCESS Responsible for integration with other disciplines Responsible for discharge planning and care management

© Pathway Health 2021

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RN – Care Planning

Consulting | Talent | Training | Resources

(3) developing nursing interventions to be integrated with the plan of care; (4) implementing nursing care through the execution of independent nursing interventions; (5) implementing interventions that are delegated, ordered, or prescribed by a licensed health care provider; (10) evaluating responses to interventions and the effectiveness of the plan of care; STRATEGIES FOR RN SUCCESS Establish nursing orders for nursing interventions RN responsible for periodic evaluation (and documentation) of the effectiveness of the care plan © Pathway Health 2021

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RN - Delegation

Consulting | Talent | Training | Resources

(6) delegating nursing tasks or assigning nursing activities to implement the plan of care; (15) managing, supervising, and evaluating the practice of nursing; (16) teaching the theory and practice of nursing; and

STRATEGIES FOR RN SUCCESS RN can delegate RN must teach nursing skills and evaluate staff performance

© Pathway Health 2021

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RN - Safety

Consulting | Talent | Training | Resources

(7) providing safe and effective nursing care; (8) promoting a safe and therapeutic environment; (9) advocating for the best interests of individual patients;

STRATEGIES FOR RN SUCCESS RN responsible for a safe environment and the overall safety and effectiveness of nursing care

© Pathway Health 2021

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RN – Health Promotion

Consulting | Talent | Training | Resources

(12) providing health promotion, disease prevention, care coordination, and case finding; (13) designing and implementing teaching plans based on patient need, and evaluating their effectiveness;

STRATEGIES FOR RN SUCCESS RN to develop education for residents RN to establish care coordination with other practitioners

© Pathway Health 2021

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RN - Accountability

Consulting | Talent | Training | Resources

(14) participating in the development of health care policies, procedures, and systems; (17) accountability for the quality of care delivered, recognizing the limits of knowledge and experience; addressing situations beyond the nurse's competency; and performing to the level of education, knowledge, and skill ordinarily expected of an individual who has completed an approved professional nursing education program as described in section 148.211, subdivision 1.

STRATEGIES FOR RN SUCCESS RN accountable for quality of car delivered by everyone under supervision and delegation RN accountable for practicing within the scope of license © Pathway Health 2021

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Delegation & Supervision

Consulting | Talent | Training | Resources

"Delegation" means the transfer of authority to another nurse or competent, unlicensed assistive person to perform a specific nursing task or activity in a specific situation. (Subd. 7a.)

"Supervision" means the guidance by a registered nurse in the accomplishment of a nursing task or activity. Supervision consists of monitoring, as well as establishing the initial direction, delegating, setting expectations, directing activities and courses of action, evaluating, and changing a course of action. (Subd. 23.)

Legal Scopes of Practice Minnesota Board of Nursing https://mn.gov/boards/assets/NPA_2013_Combined_Def_12-2020_tcm21-37252.pdf © Pathway Health 2021

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Delegation

Consulting | Talent | Training | Resources

NCSBN Delegation https://www.ncsbn.org/1625.htm

© Pathway Health 2021

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Delegation

Consulting | Talent | Training | Resources

“The delegation process is multifaceted. It begins with decisions made at the administrative level of the organization and extends to the staff responsible for delegating, overseeing the process, and performing the responsibilities.

It involves effective communication, empowering staff to make decisions based on their judgment and support from all levels of the health care setting.

The employer/nurse leader, individual licensed nurse, and delegatee all have specific responsibilities within the delegation process. (See Delegation Model below.)

It is crucial to understand that states/jurisdictions have different laws and rules/regulations about delegation, and it is the responsibility of all licensed nurses to know what is permitted in their state NPA, rules/regulations, and policies.”

NCSBN Delegation https://www.ncsbn.org/1625.htm

© Pathway Health 2021

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Delegation vs Assignment

Assignment

Delegation •

Perform a skill beyond usual practice and not usually performed

•

Delegatee has obtained additional education, training and validated competence to perform the care

•

Licensed nurse maintain overall responsibility for the delegated task

•

Cannot delegate nursing judgement, clinical reasoning or clinical decisionmaking

•

Consulting | Talent | Training | Resources

Must have the authority and be within the scope of practice to delegate

•

Performing routine care, activities and procedures that are within scope of practice

•

Actions are included in education of the staff member.

National Guidelines for Nursing Delegation https://www.ncsbn.org/NCSBN_Delegation_Guidelines.pdf

© Pathway Health 2021

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Nursing Assignment & Delegation in Assisted Living

Consulting | Talent | Training | Resources 31

LPNs assign

RN Delegates to

Consulting | Talent | Training | Resources

Other RNs LPNs ULPs

Other LPNs ULP

This document is for general informational purposes only.

It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. © Pathway Health Services, Inc. – All Rights Reserved – Copy with Permission Only 2021

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Assisted Living Services

Consulting | Talent | Training | Resources

Subd. 9.Assisted living services.

"Assisted living services" includes one or more of the following: (1) assisting with dressing, self-feeding, oral hygiene, hair care, grooming, toileting, and bathing; (2) providing standby assistance; (3) providing verbal or visual reminders to the resident to take regularly scheduled medication, which includes bringing the resident previously set up medication, medication in original containers, or liquid or food to accompany the medication; (4) providing verbal or visual reminders to the resident to perform regularly scheduled treatments and exercises; (5) preparing modified diets ordered by a licensed health professional;

© Pathway Health 2021

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Unlicensed Personnel in Assisted LivingConsulting

| Talent | Training | Resources

Subd. 4.Unlicensed personnel.

(a) Unlicensed personnel providing assisted living services must have: (1) successfully completed a training and competency evaluation appropriate to the services provided by the facility and the topics listed in section 144G.61, subdivision 2, paragraph (a); or (2) demonstrated competency by satisfactorily completing a written or oral test on the tasks the unlicensed personnel will perform and on the topics listed in section 144G.61, subdivision 2, paragraph (a); and successfully demonstrated competency on topics in section 144G.61, subdivision 2, paragraph (a), clauses (5), (7), and (8), by a practical skills test.

Unlicensed personnel who only provide assisted living services listed in section 144G.08, subdivision 9, clauses (1) to (5), shall not perform delegated nursing or therapy tasks. (b) Unlicensed personnel performing delegated nursing tasks in an assisted living facility must: (1) have successfully completed training and demonstrated competency by successfully completing a written or oral test of the topics in section 144G.61, subdivision 2, paragraphs (a) and (b), and a practical skills test on tasks listed in section 144G.61, subdivision 2, paragraphs (a), clauses (5) and (7), and (b), clauses (3), (5), (6), and (7), and all the delegated tasks they will perform; (2) satisfy the current requirements of Medicare for training or competency of home health aides or nursing assistants, as provided by Code of Federal Regulations, title 42, section 483 or 484.36; or (3) have, before April 19, 1993, completed a training course for nursing assistants that was approved by the commissioner. (c) Unlicensed personnel performing therapy or treatment tasks delegated or assigned by a licensed health professional must meet the requirements for delegated tasks in section 144G.62, subdivision 2, paragraph (a), and any other training or competency requirements within the licensed health professional's scope of practice relating to delegation or assignment of tasks to unlicensed personnel.

2020 Minnesota Statutes, Section 144G.60 https://www.revisor.mn.gov/statutes/cite/144G.60

© Pathway Health 2021

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Unlicensed Personnel in Assisted LivingConsulting

| Talent | Training | Resources

(b) Unlicensed personnel performing delegated nursing tasks in an assisted living facility must: (1) have successfully completed training and demonstrated competency by successfully completing a written or oral test of the topics in section 144G.61, subdivision 2, paragraphs (a) and (b), and a practical skills test on tasks listed in section 144G.61, subdivision 2, paragraphs (a), clauses (5) and (7), and (b), clauses (3), (5), (6), and (7), and all the delegated tasks they will perform; (2) satisfy the current requirements of Medicare for training or competency of home health aides or nursing assistants, as provided by Code of Federal Regulations, title 42, section 483 or 484.36; or (3) have, before April 19, 1993, completed a training course for nursing assistants that was approved by the commissioner. (c) Unlicensed personnel performing therapy or treatment tasks delegated or assigned by a licensed health professional must meet the requirements for delegated tasks in section 144G.62, subdivision 2, paragraph (a), and any other training or competency requirements within the licensed health professional's scope of practice relating to delegation or assignment of tasks to unlicensed personnel.

2020 Minnesota Statutes, Section 144G.60 https://www.revisor.mn.gov/statutes/cite/144G.60

© Pathway Health 2021

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AL Care Only

Consulting | Talent | Training | Resources

(5) appropriate and safe techniques in personal hygiene and grooming, including: (i) hair care and bathing; (ii) care of teeth, gums, and oral prosthetic devices; (iii) care and use of hearing aids; and (iv) dressing and assisting with toileting;

(7) standby assistance techniques and how to perform them; (8) medication, exercise, and treatment reminders; NO DELEGATED NURSING OR THERAPY TASKS

Training and Written or Oral Test, and Practical Skills Test OR Test and Practical skills test

2020 Minnesota Statutes, Section 144G.60 https://www.revisor.mn.gov/statutes/cite/144G.60

© Pathway Health 2021

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Consulting ULP Performing Delegated Nursing Tasks

•

Training and competency in all listed topics of 144G.61 subdivision 2 AND

•

Practical skills tests for :

| Talent | Training | Resources

(b)(3) reading and recording temperature, pulse, and respirations of the resident;

(a)(5) appropriate and safe techniques in personal hygiene and grooming, including: (i) hair care and bathing;

(b)(4) recognizing physical, emotional, cognitive, and developmental needs of the resident; (b)(5) safe transfer techniques and ambulation; (b)(6) range of motioning and positioning; and

(ii) care of teeth, gums, and oral prosthetic devices;

(b)(7) administering medications or treatments as required.

(iii) care and use of hearing aids; and

AND

(iv) dressing and assisting with toileting;

All delegated tasks

(a)(7) standby assistance techniques and how to perform them;

OR Be a certified Home Health Aide or Nursing Assistant OR Completed Nurse Aide course prior to 4/19/1993

2020 Minnesota Statutes, Section 144G.60 https://www.revisor.mn.gov/statutes/cite/144G.60

© Pathway Health 2021

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Minnesota AL Statutes – Delegation and Supervision

Consulting | Talent | Training | Resources

“144G.62 DELEGATION AND SUPERVISION. §Subd. 2.Delegation of assisted living services. (a) A registered nurse or licensed health professional may delegate tasks only to staff who are competent and possess the knowledge and skills consistent with the complexity of the tasks and according to the appropriate Minnesota practice act.

The assisted living facility must establish and implement a system to communicate upto-date information to the registered nurse or licensed health professional regarding the current available staff and their competency, so the registered nurse or licensed health professional has sufficient information to determine the appropriateness of delegating tasks to meet individual resident needs and preferences.” https://www.revisor.mn.gov/statutes/cite/144G.62 © Pathway Health 2021

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Minnesota AL Statutes – Delegation and Supervision

Consulting | Talent | Training | Resources

“144G.62 DELEGATION AND SUPERVISION. (b) When the registered nurse or licensed health professional delegates tasks to unlicensed personnel, that person must ensure that prior to the delegation the unlicensed personnel is trained in the proper methods to perform the tasks or procedures for each resident and is able to demonstrate the ability to competently follow the procedures and perform the tasks.

If an unlicensed personnel has not regularly performed the delegated assisted living task for a period of 24 consecutive months, the unlicensed personnel must demonstrate competency in the task to the registered nurse or appropriate licensed health professional. The registered nurse or licensed health professional must document instructions for the delegated tasks in the resident's record.” https://www.revisor.mn.gov/statutes/cite/144G.62 © Pathway Health 2021

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Minnesota AL Statutes – Delegation and Supervision

Consulting | Talent | Training | Resources

“144G.62 DELEGATION AND SUPERVISION. Subd. 3.Supervision of staff. (a) Staff who only provide assisted living services specified in section 144G.08, subdivision 9, clauses (1) to (5), must be supervised periodically where the services are being provided to verify that the work is being performed competently and to identify problems and solutions to address issues relating to the staff's ability to provide the services. The supervision of the unlicensed personnel must be done by staff of the facility having the authority, skills, and ability to provide the supervision of unlicensed personnel and who can implement changes as needed, and train staff.

(An RN) (b) Supervision includes direct observation of unlicensed personnel while the unlicensed personnel are providing the services and may also include indirect methods of gaining input such as gathering feedback from the resident. Supervisory review of staff must be provided at a frequency based on the staff person's competency and performance.”

https://www.revisor.mn.gov/statutes/cite/144G.62 © Pathway Health 2021

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Minnesota AL Statutes – Delegation and Supervision

Consulting | Talent | Training | Resources

“144G.62 DELEGATION AND SUPERVISION. Subd. 4.Supervision of staff providing delegated nursing or therapy tasks. (a) Staff who perform delegated nursing or therapy tasks must be supervised by an appropriate licensed health professional or a registered nurse according to the assisted living facility's policy where the services are being provided to verify that the work is being performed competently and to identify problems and solutions related to the staff person's ability to perform the tasks.

Supervision of staff performing medication or treatment administration shall be provided by a registered nurse or appropriate licensed health professional and must include observation of the staff administering the medication or treatment and the interaction with the resident.”

© Pathway Health 2021

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Minnesota AL Statutes – Delegation and Supervision

Consulting | Talent | Training | Resources

“144G.62 DELEGATION AND SUPERVISION. (b) The direct supervision of staff performing delegated tasks must be provided within 30 calendar days after the date on which the individual begins working for the facility and first performs the delegated tasks for residents and thereafter as needed based on performance. This requirement also applies to staff who have not performed delegated tasks for one year or longer.

Subd. 5.Documentation.

A facility must retain documentation of supervision activities in the personnel records.” © Pathway Health 2021

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What does this mean?

Consulting | Talent | Training | Resources 43

Strategies for Success

Consulting | Talent | Training | Resources

•

Nursing department job descriptions and tasks must reflect the scope of practice for the position.

•

Orientation for new ULP nursing staff should contain, at a minimum: o

hair care and bathing;

o

care of teeth, gums, and oral prosthetic devices;

o

care and use of hearing aids; and

o

dressing and assisting with toileting;

o

standby assistance techniques and how to perform them;

o

medication, exercise, and treatment reminders

© Pathway Health 2021

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Strategies for Success

Consulting | Talent | Training | Resources

• Make it easy to document education and competency checks. o Use evidence-based resources o Base competency observations on policies and procedures

• Establish staffing to respect scope of practice. © Pathway Health 2021

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Resources

Consulting | Talent | Training | Resources

Handouts: • Minnesota Nurse Practice Act • Blank competency check form Online Minnesota Nurse Practice Act https://mn.gov/boards/nursing/laws-and-rules/nursepractice-act/ © Pathway Health 2021

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Resources

Consulting | Talent | Training | Resources

Online •

Minnesota Nurse Practice Act

https://mn.gov/boards/nursing/laws-and-rules/nurse-practice-act/

• 2020 Minnesota Statutes Chapter 144G Assisted Living https://www.revisor.mn.gov/statutes/cite/144G • Minnesota Approved Nurse Aide Training Curriculums https://www.health.state.mn.us/facilities/providers/nursingassistant/curriculum.h tml © Pathway Health 2021

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Consulting | Talent | Training | Resources

© Pathway Health 2021

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Disclaimer

Consulting | Talent | Training | Resources

“This presentation provided is copyrighted information of Pathway Health. Please note the presentation date on the title page in relation to the need to verify any new updates and resources that were listed in this presentation. This presentation is intended to be informational. The information does not constitute either legal or professional consultation. This presentation is not to be sold or reused without written authorization of Pathway Health.” © Pathway Health 2021

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1210 Northland Drive Suite 120, Mendota Heights, MN 55120 Voice: 612-317-3000 | Fax: 651-688-1841 |TTY: 800-627-3529 Toll Free (MN, IA, ND, SD, WI): 888-234-2690 Email: nursing.board@state.mn.us Website: www.nursingboard.state.mn.us

Minnesota Board of Nursing Nurse Practice Act - Minnesota Statute Section 148.171 The Minnesota Nurse Practice Act was amended in 2013 to revise the definitions of professional and practical nursing. Definitions of the terms used within the scope of practice definitions are listed below, followed by the scope statements shown in a side-by-side format to assist in comparing and contrasting the respective scopes of practice. The subdivision numbers refer to the location of the terms within Minn.

Stat. sec. 148.171. These amendments became effective on August 1, 2013. The full text of the Nurse Practice Act is available on the website of the Office of the Revisor: https://www.revisor.mn.gov/statutes/?id=148.171%20 "Assignment" means the designation of nursing tasks or activities to be performed by another nurse or unlicensed assistive person. (Subd. 3a.)

"Delegation" means the transfer of authority to another nurse or competent, unlicensed assistive person to perform a specific nursing task or activity in a specific situation. (Subd. 7a.)

“Intervention" means any act or action, based upon clinical judgment and knowledge that a nurse performs to enhance the health outcome of a patient. (Subd. 7b.)

"Monitoring" means the periodic inspection by a registered nurse or licensed practical nurse of a delegated or assigned nursing task or activity and includes: (1) watching during the performance of the task or activity; (2) periodic checking and tracking of the progress of the task or activity being performed; (3) updating a supervisor on the progress or completion of the task or activity performed; and (4) contacting a supervisor as needed for direction and consultation. (Subd. 8a.)

"Patient" means a recipient of nursing care, including an individual, family, group, or community. (Subd.

12a.)

"Supervision" means the guidance by a registered nurse in the accomplishment of a nursing task or activity. Supervision consists of monitoring, as well as establishing, the initial direction, delegating, setting expectations, directing activities and courses of action, evaluating, and changing a course of action.

(Subd. 23.)

"Unlicensed assistive personnel" (UAP) means any unlicensed person to whom nursing tasks or activities may be delegated or assigned, as approved by the board. (Subd. 24)

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Minnesota Board of Nursing Nurse Practice Act - Minnesota Statute Section 148.171 Effective August 1, 2013 Practice of Practical and Professional Nursing LPN Scope of Practice Subd. 14. Practice of practical nursing. The "practice of practical nursing" means the performance, with or without compensation of those services that incorporates caring for individual patients in all settings through nursing standards recognized by the board at the direction of a registered nurse, advanced practice registered nurse, or other licensed health care provider and includes, but is not limited to: 1) conducting a focused assessment of the health status of an individual patient through the collection and comparison of data to normal findings and the individual patient's current health status, and reporting changes and responses to interventions in an ongoing manner to a registered nurse or the appropriate licensed health care provider for delegated or assigned tasks or activities; 2) participating with other health care providers in the development and modification of a plan of care; 3) determining and implementing appropriate interventions within a nursing plan of care or when delegated or assigned by a registered nurse; 4) implementing interventions that are delegated, ordered, or prescribed by a licensed health care provider; 5) assigning nursing activities or tasks to other licensed practical nurses (LPNs); 6) assigning and monitoring nursing tasks or activities to unlicensed assistive personnel; 7) providing safe and effective nursing care delivery; 8) promoting a safe and therapeutic environment; 9) advocating for the best interests of individual patients; 10) assisting in the evaluation of responses to interventions; 11) collaborating and communicating with other health care providers; 12) providing health care information to individual patients; 13) providing input into the development of policies and procedures; and 14) accountability for the quality of care delivered, recognizing the limits of knowledge and experience; addressing situations beyond the nurse's competency; and performing to the level of education, knowledge, and skill ordinarily expected of an individual who has completed an approved practical nursing education program described in section 148.211, subdivision 1.

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RN Scope of Practice Subd. 15. Practice of professional nursing. The "practice of professional nursing" means the performance, with or without compensation of those services that incorporates caring for all patients in all settings through nursing standards recognized by the board and includes, but is not limited to: 1) providing a comprehensive assessment of the health status of a patient through the collection, analysis, and synthesis of data used to establish a health status baseline and plan of care, and address changes in a patient's condition; 2) collaborating with the health care team to develop and coordinate an integrated plan of care; 3) developing nursing interventions to be integrated with the plan of care; 4) implementing nursing care through the execution of independent nursing interventions; 5) implementing interventions that are delegated, ordered, or prescribed by a licensed health care provider; 6) delegating nursing tasks or assigning nursing activities to implement the plan of care; 7) providing safe and effective nursing care; 8) promoting a safe and therapeutic environment; 9) advocating for the best interests of individual patients; 10) evaluating responses to interventions and the effectiveness of the plan of care; 11) collaborating and coordinating with other health care professionals in the management and implementation of care within and across care settings and communities; 12) providing health promotion, disease prevention, care coordination, and case finding; 13) designing and implementing teaching plans based on patient need, and evaluating their effectiveness; 14) participating in the development of health care policies, procedures, and systems; 15) managing, supervising, and evaluating the practice of nursing; 16) teaching the theory and practice of nursing; and 17) accountability for the quality of care delivered, recognizing the limits of knowledge and experience; addressing situations beyond the nurse's competency; and performing to the level of education, knowledge, and skill ordinarily expected of an individual who has completed an approved professional nursing education program as described in section 148.211, subdivision 1.

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Insert Facility Name

[Insert Title] Competency ______________________________

________________________

Print Employee Name

Date of Hire

Please insert a check (“√”) or “X” for each corresponding skill task under each evaluation type.

1 = Criteria Met

2 = Did not meet criteria

3 = Met criteria after instruction

Annual

Interim

Interim

Insert Type: 1. Return Demonstration, 2. Exam , or 3. Other (If Other – Specify)

Skill Task

Employee

1

2

3

1

2

3

1

2

3

Met competency Did not meet competency

Employee Signature Evaluator Signature Print Employee Signature Evaluator Signature Print Employee Signature Evaluator Signature Print Comment:

______________________________________________________________________________ ______________________________________________________________________________

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L ICENSED ASSISTED L IVING DIRECTOR

SHOW ME THE MONEY—PAYMENT SOURCES Todd Bergstrom, Director of Research & Data Analysis Care Providers of Minnesota

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INTRODUCTIONS Todd Bergstrom, Director of Research & Data Analysis Care Providers of Minnesota As Care Providers of Minnesota's Direc tor of Researc h and Data Analysis, Todd's duties fall into two general c ategories. First, he provides members with data, analysis, and other researc h items upon request. These requests may inc lude Medic aid and Medic are rate analysis, demographic information, c ompensation data, survey development and analysis etc . Sec ond, Todd supports the Association's legislative and administrative advoc ac y efforts through the researc h analysis of legislation and regulations that may impac t the membership. He has a BA in History and Politic al Sc ienc e from the University of Wisc onsin, Madison and an MA from the Humphrey Institute of Public Affairs at the University of Minnesota, Twin Cities Campus.

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Show Me the Money—Payment Sources

TODD BERGSTROM DIRECTOR OF RESEARCH AND DATA ANALYSIS

CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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Agenda Medicare Medicaid Health Plans Billing, Level of Care, MnCHOICES, and Other Policies

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Medicare W W W. M E D I C A R E . G O V/ W W W. N G S M E D I C A R E . C O M

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Medicare  65 and older or under 65 and disabled  Part A ◦ ◦ ◦ ◦

Inpatient care in hospitals Inpatient care in a skilled nursing facility (not custodial or long-term care) Hospice care services Home health care services

 Part B ◦ Medically-necessary services ◦ Preventive services

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Medicare  Part C ◦ ◦ ◦ ◦ ◦

Medicare Advantage Plan Covers Part A (Hospital Insurance) and Part B (Medical Insurance) coverage.

May offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs.

Most include Medicare prescription drug coverage (Part D).

Premium to enrollee varies

 Part D ◦ Voluntary with monthly premium ◦ Medicare Prescription Drug Plans or Medicare Advantage Plans

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Medicare Part A - Detail  Hospital stays, which includes a semi-private room, meals, general nursing, and miscellaneous hospital services and supplies.  Nursing home or skilled nursing facility stays must be related to diagnosis during a hospital stay. ◦ A nursing home or skilled nursing facility stay includes a semi-private room, meals, and rehabilitative and skilled nursing services and care. ◦ The coverage is limited to a maximum of 100 days in a benefit period. ◦ The first 20 days are paid in full, and the remaining 80 days will require a co-payment.

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Medicare Part A - Detail  Home health services include limited reasonable and only medically necessary part-time care and services such as skilled nursing care, physical or occupational therapy, home health aide service, speech language pathology, and medical social services. ◦ Also includes certain home-use medical equipment (wheelchairs, hospital beds, walkers, oxygen), and other medical supplies.

 Hospice care is for the terminally ill who have six months or less to live. Coverage includes pain relief and symptom control drugs, medical and support services, grief counseling, and other services.

CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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Medicaid or Medical Assistance HTTP://MN.GOV/DHS/ HTTP://WWW.HEALTH.STATE.MN.US/INDEX.HTML

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Medicaid or Medical Assistance •

Medical Assistance (MA) is Minnesota’s Medicaid program.

• • •

•

State and federal funds.

Minnesota Department of Human Services The federal Centers for Medicare and Medicaid Services (CMS)

Health care programs (Medical Assistance, Minnesota-Care) •

1.2 Million people on average enrolled per month in 2017

•

Application at local county human service offices.

•

Most are enrolled in Health plans, and some to Fee for Service (FFS)

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Personal Care / Home Care Nursing 6.4%

Physicians 1.4% All Other Expenditures 12.7%

Outpatient Hospital 0.8% Nursing Facilities 7.6%

Brain Injury Waiver (BI) 0.7%

MnCHOICES 1.3%

Community Access for Disability Inclusion Waiver (CADI) 8.9%

Mental Health Services 1.3%

Community Alternative Care Waiver (CAC) 0.4%

State and Federal Medicaid Expenditures

by Category of Service for Minnesota (SFY 2020)

Day Training and Habilitation for ICF/DD Residents 0.1% Developmental Disabilities Waiver (DD) 11.5%

Elderly Waiver (EW) 3.5% Inpatient Hospital 2.7% Managed Care (HMO) 40.0% Intermediate Care Facilities for Persons with Developmental Disabilities 0.7% 12

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Nursing Facility Census in Minnesota 6.9 Million Fewer Paid Nursing Facility Days 12,000,000 10,023,405

10,000,000 8,000,000 6,000,000

4,852,359

4,684,476 4,000,000 2,069,858 2,000,000 760,164

976,178

905,067 187,414

0 Medicare

Other / Third Party 1991

Private Pay

Medicaid

2017

Source: 9-30-2017 DHS Annual Statistical and Cost Report of Nursing Facilities

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69% of Seniors Meeting Medical Assistance Nursing Facility Level of Care Will Stay in Community, Assisted Living by 2023 50,000

Medicaid Monthly Average Recipients

45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Nursing Facility

Elderly Waiver

November 2020 DHS Medicaid Forecast CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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Monthly Average Payments Source: DHS November 2020 Forecast

$9,000 $8,000 $7,000

$6,413

$6,000 $5,000 $4,000 $3,000 $2,000

$1,415

$1,000 $Nursing Facilities

Elderly Waiver

Intermediate Care Facilities for Persons with Developmental Disabilities

Day Training and Habilitation for ICF/DD Residents

2000

Developmental Disabilities Waiver (DD)

Community Access for Disability Inclusion Waiver (CADI)

Community Alternative Care Waiver (CAC)

Brain Injury Waiver (BI)

2020 15

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Annual State Share Payments Source: DHS November 2020 Forecast

$800,000,000 $700,000,000 $600,000,000 $500,000,000 $400,000,000 $300,000,000 $200,000,000 $100,000,000 $Nursing Facilities

Elderly Waiver

Intermediate Care Day Training and Facilities for Persons Habilitation for with Developmental ICF/DD Residents Disabilities

2000

Developmental Community Access Disabilities Waiver for Disability (DD) Inclusion Waiver (CADI)

Community Alternative Care Waiver (CAC)

Brain Injury Waiver (BI)

2020

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Estimated Net Additional Nursing Facility Costs Without The Elderly Waiver Program $1,400,000,000

If all EW clients were served in nursing facilities state costs would be over $600 million higher annually

$1,200,000,000 $1,000,000,000 $800,000,000 $600,000,000 $400,000,000 $200,000,000 $0

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Net Additional Expenditures if Elderly Waiver Clients Resided in Nursing Facilities Elderly Waiver (Actual State Share Spending) Nursing Facility (Actual State Share Spending)

Source: February 2018 DHS Medicaid Forecast

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Monthly Average Recipients Source: DHS November 2020 Forecast

100,000 90,000 80,000 Community Access for Disability Inclusion Waiver (CADI)

70,000 60,000

Developmental Disabilities Waiver (DD)

50,000 40,000 30,000

Elderly Waiver

20,000 Nursing Facilities

10,000 0

Nursing Facilities

Elderly Waiver

Intermediate Care Facilities for Persons with Developmental Disabilities

Day Training and Habilitation for ICF/DD Residents

Developmental Disabilities Waiver (DD)

Community Access for Disability Inclusion Waiver (CADI)

Community Alternative Care Waiver (CAC)

Brain Injury Waiver (BI)

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State Share of Annual Medicaid Spending by Program Minnesota (DHS November 2020 Forecast $2,500,000,000

$2,000,000,000

Community Access for Disability Inclusion Waiver (CADI)

$1,500,000,000

$1,000,000,000 Developmental Disabilities Waiver (DD) $500,000,000

Elderly Waiver Nursing Facilities

$1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Nursing Facilities Intermediate Care Facilities for Persons with Developmental Disabilities Developmental Disabilities Waiver (DD) Community Alternative Care Waiver (CAC)

Elderly Waiver Day Training and Habilitation for ICF/DD Residents Community Access for Disability Inclusion Waiver (CADI) Brain Injury Waiver (BI) 19

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Nursing Facility (NF) State/Federal funded program Must meet nursing facility level of care Minimum Data Set (MDS) used to determine 48 Medicaid and Private Pay Rates Payors include Medicaid, Private Pay, Medicare and Other/Third Party Rate Equalization New Medicaid Payment System on January 1, 2016 ◦ Value Based Reimbursement or VBR

New Medicare Payment System on October 1, 2019 ◦ Patient -Driven Payment Model (PDPM)

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Nursing Facility (NF) Cont.

Bed hold 30-Day enhanced rate for new admissions Surcharge Return to community PIPP QIIP Medicare Co-Insurance

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Elderly Waiver (EW) an alternative for a person age 65 years or older, who would otherwise require the level of care provided in a nursing facility.

Basic eligibility ◦ Age 65 years or older ◦ Chooses to receive community services instead of nursing facility services ◦ Eligible for Medical Assistance

Level of care determination Cost of care ◦ In aggregate, the average per person cost for persons in receipt of EW services cannot be greater than the average per person cost for persons in receipt of nursing facility services.

Source: Disability Services Program Manual (DSPM) CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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Elderly Waiver (EW) - Covered Services an alternative for a person age 65 years or older, who would otherwise require the level of care provided in a nursing facility.

24-hour customized living

Environmental accessibility adaptations

Adult day service bath

Extended home health aide

Adult day services, center-based and family-based

Extended personal care assistant

Adult foster care (family and corporate)

Extended private duty nursing (LPN and RN)

Caregiver assessment

Home-delivered meals

Caregiver training and education

Homemaker

Case management

Personal emergency response

Case management aide

Respite care (in home, out of home)

Chore service

Residential care services

Companion service

Specialized equipment and supplies

Consumer directed community supports

Transitional services

Customized living

Transportation

Source: Disability Services Program Manual (DSPM)

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Elderly Waiver – Customized Living and 24-Hour Customized Living  Currently: For services provided in residential, Housing with Services Setting (HWS) and Comprehensive Home Care License  Until July 31, 2021

 August 1, 2021: Assisted Living License  Exceptions

 Client-based payment  Amount paid for a client's services is determined by EW Customized Living Workbook ◦ ◦ ◦ ◦ ◦

Minnesota Long-Term Care Consultation Services Assessment Services and Units of Services authorized EW Customized Living Rate Limits or Caps EW-CL or 24-Hour EW-CL CL Component Rates

Source: Minnesota Department of Human Services

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Comprehensive Policy on Elderly Waiver (EW) Customized Living

https://www.careproviders.org/ members/2021/ EWDHSComprehensivePolicyResidentialServic es2016.pdf

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2017 Legislative Amendments: Required Provider Communication for the Elderly Waiver and Alternative Care Programs https://mn.gov/dhs/generalpublic/publications-formsresources/bulletins/

The goal of the legislative changes is to promote better communication and coordination. The changes include: •

EW and AC Adult Day providers, in addition to EW customized living (CL) providers, must now be given the opportunity to provide recommendations related to the person’s needs prior to a lead agency assessment.

•

The EW Residential Services Tool (RS Tool) completed for an individual must now be sent to the provider.

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Strategies Learn case mix system

Be specific about the services you are providing

◦ What do the case mix levels mean? ◦ How do the caps relate? ◦ Educate your staff

Review the services you are providing for the client

Understand your organization’s Elderly Waiver Client’s data ◦ This does require an upfront investment in time

Standardize and document each Elderly Waiver Client’s needs and care provided. Build around: ◦ Areas influencing case mix ◦ Services provided

A.Talk to direct care staff B. Observe care and services C. Review nurse notes!

D. What do your service agreements say?

E.What do your ADL flow sheets/care plans say you are doing?

Include any care planning around behavior.

Keep communication open between you and your staff

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Strategies Create collaborative relationship with assessors and case managers ◦ ◦ ◦ ◦

Meet with them Invite them to care conferences Inform them of hospitalizations, changes in needs and health, falls Notify changes in service, case mix?

Formalize processes for communication of client information to assessors and case managers

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Public Documents DHS Forms at: https://edocs.dhs.state.mn.us/

DHS-3428-ENG Minnesota Long-Term Care Consultation Services Assessment Form - English The 34-page document is found at: https://edocs.dhs.state.mn.us/lfserve r/Public/DHS-3428-ENG

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AC, BI, CADI, EW Case Mix Classification Worksheet DHS-3428B-ENG

https://edocs.dhs.state.mn.us/lfserver/P ublic/DHS-3428B-ENG

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AC, BI, CADI, EW Case Mix Classification Worksheet DHS-3428B-ENG https://edocs.dhs.state.mn.us/lfserv er/Public/DHS-3428B-ENG

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AC, BI, CADI, EW Case Mix Classification Worksheet DHS-3428B-ENG https://edocs.dhs.state.mn.us/lfserver/Pu blic/DHS-3428B-ENG

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AC, BI, CADI, EW Case Mix Classification Worksheet DHS-3428B-ENG https://edocs.dhs.state.mn.us/lfserver/Pu blic/DHS-3428B-ENG

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Elderly Waiver Residential Services https://mn.gov/dhs/partners-and-providers/policies-procedures/aging/elderly-waiver-residential-services/ The longstanding Excel-based workbook was retired.

DHS will not publish new versions of the workbook.

Starting September 1, 2020, The MN-IT system will reject Excel workbooks created on or after August 3, 2020.

DHS will continue to provide technical support for existing Excel workbooks as needed.

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Residential Services Plan is Sent to Providers

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Residential Services Plan is Sent to Providers

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Residential Services Plan is Sent to Providers

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Residential Services Plan is Sent to Providers

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EW-CL Workbook SCR Doc Input

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Services Authorized by EW-CL Workbook Homemaking ◦ Light housekeeping ◦ Heavy housekeeping ◦ Laundry - personal ◦ Laundry-linens ◦ Shopping Food Preparation - Individual Assistance w Meal Prep in Own Apartment Food Preparation and Service: Breakfast prep and serve, Lunch prep and serve, Supper prep and serve, Snack prep and serve Supportive Services: Making appts, Arrange Non-Medical Transportation, Money Mgt Socialization - Individual Non-Medical Transportation Mileage Personal Care ◦ Dressing ◦ Grooming ◦ Bathing ◦ Eating ◦ Continence Care ◦ Walking ◦ Assistance with Use of Wheelchair (Yes/No Dropdown) ◦ Transferring

◦ Positioning Other Delegated Health Services ◦ Med Administration or assistance with self-administration ◦ Verbal or Visual Medication Reminders ◦ Insulin Injections ◦ Therapeutic Exercises (Yes/No Dropdown) ◦ Delegated clinical monitoring (Yes/No Dropdown) ◦ Delegated nursing tasks (Yes/No Dropdown) Medication Mgt by Licensed Nurse ◦ Med Set Ups and Monitoring ◦ Insulin Draws Active Cognitive or Behavioral Support ◦ Wandering ◦ Orientation issues ◦ Anxiety ◦ Verbal aggression ◦ Physical aggression ◦ Repetitive behavior ◦ Agitation ◦ Self-injurious behavior ◦ Property destruction Personal Security - Is the Mechanism included in the CL Rate?

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EW-CL Workbook RS Rate Limits and Component Rates –Effective January 1, 2020 CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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EW-CL Workbook Individual RS Plan In order to be eligible for the higher 24-hour CL rate limit, the participant must have the following needs: • Cognitive or behavioral intervention; or • Clinical monitoring with special treatment; or • Staff assistance in toileting, positioning, or transferring (single dependency); or • Medication management and at least 50 hours of service per month and a dependency in at least three of the following activities of daily living (ADL’s): bathing; dressing; grooming; walking; or eating (when eating is scored as 3 or greater) “Fifty hours of service” means 50 hours of direct component services per month approved to be part of the 24-hour Customized living plan as determined by the assessor, case manager, or care coordinator and the waiver participant.

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EW-CL Workbook: Individual RS Plan – 24-hour CL LTC SD 46 Toileting How well can you manage using the toilet? Would you say that you: 00 • can use the toilet without help, including adjusting clothing? *01 • need some help to get to and on the toilet but don’t have “accidents”? *02 • have accidents sometimes, but not more than once a week? *03 • only have accidents at night? *04 • have accidents more than once a week? *05 • have bowel movements in your clothes more than once a week? *06 • wet your pants and have bowel movements in your clothes very often?

LTC SD 43 Transferring How well can you get in and out of a bed or chair? Would you say that you: 00 • can get in and out of a bed or chair without help of any kind?

01 • need somebody to be there to guide you but you can move in and out of a bed or chair? *02 • need one other person to help you? *03 • need two other people or a mechanical aid to help you? *04 • never get out of a bed or chair?

LTC SD 42 Bed Mobility (Positioning on DHS-3428C) How well can you manage sitting up or moving around in bed? Would you say that you: 00 • can move in bed without any help?

01 • need and get help sometimes to sit up? *02 • always need and get help to sit up? *03 • always need and get help to be turned or change positions?

LTC SD 66 How about your ability to take your own medication? Would you say that you: 01 need no help or supervision 05 don’t take medications 06 need medication setup only 07 need verbal or visual reminders only 08 need medication setups and reminders 09 need medication setups and administration

LTC SD 45 Behavior “Intervention” includes cues, redirection or behavior management/instruction.

00 • Behavior requires no intervention or no behaviors.

01 • Needs and receives occasional staff intervention in the form of cues because the person is anxious, irritable, lethargic or demanding. Person responds to cues.

“Occasional” is defined as less than 4 times per week. *02 • Needs and receives regular staff intervention in the form of redirection because the person has episodes of disorientation, hallucinates, wanders, is withdrawn or exhibits similar behaviors. Person may be resistive, but responds to redirection. “Regular” is defined as 4 or more times per week. *03 • Needs and receives behavior management and staff intervention because person exhibits disruptive behavior such as verbally abusing others, wandering into private areas, removing or destroying property, or acting in a sexually aggressive manner. Person may be resistant to redirection. *04 • Needs and receives behavior management and staff intervention because person is physically abusive to self and others. Person may physically resist redirection.

LTC SD 48 Clinical Monitoring: Clinical monitoring refers to a formal written plan that reflects the elements for clinical monitoring found in DHS 3428B – Case Mix Classification Worksheet.

00Less than once a day 01 1-2 shifts 02 All shifts PLUS Special Treatment (SD 47) LTC SD 51 Orientation Orientation is defined as the awareness of an individual to his/her present environment in relation to time, place and person. See H.7 and H.10 for memory/orientation information.

00 • Oriented.

01 • Minor forgetfulness.

02 • Partial or intermittent periods of disorientation.

03 • Totally disoriented; does not know time, place, identity.

04 • Comatose.

05 • Not determined.

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EW-CL Workbook: Individual RS Plan – Homemaking Light Housekeeping • Home Management/Homemaking and Support Services: $17.84 LTC SD 63 How well can you manage to do light housekeeping, like dusting or sweeping?

Would you say that you: 01 need no help or supervision 02 need some help or occasional supervision 03 need a lot of help or constant supervision 04 can’t do it at all

Heavy Housekeeping • Home Management/Homemaking and Support Services: $17.84 LTC SD 64 How well can you do heavy housekeeping? Heavy housekeeping includes activities like yard work, or emptying the garbage, but not including laundry. Would you say that you: 01 need no help or supervision 02 need some help or occasional supervision 03 need a lot of help or constant supervision 04 can’t do it at all

Laundry – Personal / Linens • Home Management/Homemaking and Support Services: $17.84 LTC SD 65 What about your ability to do your own laundry, including putting clothes in the washer or dryer, starting and stopping the machine, and drying the clothes? Would you say that you: 01 need no help or supervision 02 need some help or occasional supervision 03 need a lot of help or constant supervision 04 can’t do it at all

Shopping • Home Management/Homemaking and Support Services: $17.84 LTC SD 61 Now I would like to know about how you manage shopping for food and other things you need. Would you say that you: 01 need no help or supervision 02 need some help or occasional supervision 03 need a lot of help or constant supervision 04 can’t do it at all CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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EW-CL Workbook Individual RS Plan – Food Preparation

Individual Assistance w Meal Prep in Own Apartment • Home Management/Homemaking and Support Services: $17.84 LTC SD 62 How well are you able to prepare meals for yourself? Meals may include sandwiches, cooked meals and TV dinners. Would you say that you: 01 need no help or supervision 02 need some help or occasional supervision 03 need a lot of help or constant supervision 04 can’t do it at all

Breakfast, Lunch, Supper, and Snack – Prep and Serve • Home Management/Homemaking and Support Services: $17.84 LTC SD 62 How well are you able to prepare meals for yourself? Meals may include sandwiches, cooked meals and TV dinners. Would you say that you: 01 need no help or supervision 02 need some help or occasional supervision 03 need a lot of help or constant supervision 04 can’t do it at all • • • •

Breakfast: $3.4597 Lunch: $4.3166 Supper: $4.3166 Snack: $0.4284

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EW-CL Workbook Individual RS Plan – Supportive Services

Making Appts and Arrange Non-medical Transportation • Home Management/Homemaking and Support Services: $17.84 LTC SD 60 How well are you able to make a telephone call? Would you say that you: 01 need no help or supervision 02 need some help or occasional supervision 03 need a lot of help or constant supervision 04 can’t do it at all

Money Mgt. • Home Management/Homemaking and Support Services: $17.84 LTC SD 68 Now I want to know about your ability to handle your own money, like paying your bills, or balancing your checkbook. Would you say that you: 01 need no help or supervision 02 need some help or occasional supervision 03 need a lot of help or constant supervision 04 can’t do it at all

Socialization with given Ratio of Staff/Resident / Hourly Rate • • • •

Socialization 1 Staff to 2-5 Residents: $5.10 Socialization 1 Staff to 6 - 12 Residents: $1.99 Socialization 1 Staff to 13 - 20 Residents: $1.09 Socialization 1 Staff to over 20 Residents: $0.59

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EW-CL Workbook Individual RS Plan – Supportive Services

Non-medical Transportation and Mileage • Home Management/Homemaking and Support Services: $17.84 (Driver 1:1) • 1:1 Mileage: $0.5248 LTC SD 69 How well are you able to use public transportation or drive to places beyond walking distance? Would you say that you: 01 need no help or supervision 02 need some help or occasional supervision 03 need a lot of help or constant supervision 04 can’t do it at all

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EW-CL Workbook Individual RS Plan – Personal Care Dressing • Home Care Aide Services including Active Behavioral Support: $23.72 LTC SD 38 How well are you able to manage dressing? By dressing, we mean laying out the clothes and putting them on, including shoes, and fastening clothes. Would you say that you: 00 • can dress without help of any kind?

01 • need and get minimal supervision or reminding? *02 • need some help from another person to put your clothes on? *03 • cannot dress yourself and somebody dresses you? *04 • are never dressed?

Grooming • Home Care Aide Services including Active Behavioral Support: $23.72 LTC SD 39 Now I have some questions about how you manage with grooming activities like combing your hair, putting on makeup, shaving, and brushing your teeth. Would you say that you: 00 • can comb your hair, wash your face, shave or brush your teeth without help of any kind?

01 • need and get supervision or reminding or grooming activities? *02 • needs and get daily help from another person? *03 • are completely groomed by somebody else?

Bathing • Home Care Aide Services including Active Behavioral Support: $23.72 LTC SD 40 How well can you bathe or shower yourself? Bathing or showering by yourself means running the water, taking the bath or shower without any help, and washing all parts of the body, including your hair and face. Would you say that you: 00 • can bathe or shower without any help?

01 • need and get minimal supervision or reminding?

02 • need and get supervision only?

03 • need and get help getting in and out of the tub? *04 • need and get help washing and drying your body? *05 • cannot bathe or shower, need complete help?

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EW-CL Workbook Individual RS Plan – Personal Care Eating • Home Health Care Aide Services/Delegated Nursing Services: $27.04 LTC SD 41 How well can you manage eating by yourself? Eating by yourself means drinking and eating without help from anybody else, but you can use special utensils and straws. It also means cutting most foods on your own.

Would you say that you: 00 • can eat without help of any kind?

01 • need and get minimal reminding or supervision? *02 • need and get help in cutting food, buttering bread or arranging food? *03 • need and get some personal help with feeding or someone needs to be sure that you don’t choke? *04 • need to be fed completely or tube feeding or IV feeding?

Continence Care • Home Health Care Aide Services/Delegated Nursing Services: $27.04 LTC SD 46 How well can you manage using the toilet? (Using the toilet independently includes adjusting clothing, getting to and on the toilet, and cleaning one’s self. If reminders are needed to use the toilet this counts as some help. An individual who manages any type or level of incontinence independently is not considered dependent and MUST be scored using 00, independent in this activity.) Would you say that you: 00 • can use the toilet without help, including adjusting clothing? *01 • need some help to get to and on the toilet but don’t have “accidents”? *02 • have accidents sometimes, but not more than once a week? *03 • only have accidents at night? *04 • have accidents more than once a week? *05 • have bowel movements in your clothes more than once a week? *06 • wet your pants and have bowel movements in your clothes very often?

Walking • Home Care Aide Services including Active Behavioral Support: $23.72 LTC SD 44 How well are you able to walk around, either without any help or with a cane or walker, but not including a wheelchair? Would you say that you: 00 • walk without help of any kind?

01 • can walk with help of a cane, walker, crutch or push wheelchair? *02 • need and get help from one person to help you walk? *03 • need and get help from two people to help you walk? *04 • cannot walk at all?

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EW-CL Workbook Individual RS Plan – Personal Care Assistance with Use of Wheelchair - Wheeling • Home Care Aide Services including Active Behavioral Support: $23.72 Wheeling (not on LTC Assessment) 0 Does not use wheelchair, or receives no personal help wheeling.

1 Needs help negotiating doorways, elevators, ramps, locking or unlocking brakes.

2 Needs and receives total help with wheeling.

Transferring • Home Health Care Aide Services/Delegated Nursing Services: $27.04 LTC SD 43 How well can you get in and out of a bed or chair? Would you say that you: 00 • can get in and out of a bed or chair without help of any kind?

01 • need somebody to be there to guide you but you can move in and out of a bed or chair? *02 • need one other person to help you? *03 • need two other people or a mechanical aid to help you? *04 • never get out of a bed or chair?

Positioning • Home Health Care Aide Services/Delegated Nursing Services: $27.04 LTC SD 42 Bed Mobility (Positioning on DHS-3428C) How well can you manage sitting up or moving around in bed? Would you say that you: 00 • can move in bed without any help?

01 • need and get help sometimes to sit up? *02 • always need and get help to sit up? *03 • always need and get help to be turned or change positions?

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EW-CL Workbook Individual RS Plan – Other Delegated Health Services Med Administration or assistance with self-administration • Home Health Care Aide Services/Delegated Nursing Services: $27.04 LTC SD 66 How about your ability to take your own medication? Would you say that you: 01 need no help or supervision 05 don’t take medications 06 need medication setup only 07 need verbal or visual reminders only 08 need medication setups and reminders 09 need medication setups and administration

Verbal or Visual Medication reminders • Home Care Aide Services including Active Behavioral Support: $23.72 LTC SD 66 How about your ability to take your own medication? Would you say that you: 01 need no help or supervision 05 don’t take medications 06 need medication setup only 07 need verbal or visual reminders only 08 need medication setups and reminders 09 need medication setups and administration

Insulin Injections • Home Health Care Aide Services/Delegated Nursing Services: $27.04 LTC SD 67 Are you diabetic? If yes, how do you control your diabetes?

01 not diabetic 02 no insulin require; diet controlled only 03 oral medications 04 sliding scale insulin and oral medications 05 scheduled daily insulin 06 scheduled daily insulin plus daily sliding scale

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EW-CL Workbook Individual RS Plan – Other Delegated Health Services Delegating clinical monitoring • Home Health Care Aide Services/Delegated Nursing Services: $27.04 LTC SD 48 Clinical monitoring refers to a formal written plan that reflects the elements for clinical monitoring found in DHS 3428B – Case Mix Classification Worksheet.

00 Less than once a day 01 1-2 shifts 02 All shifts

Delegated nursing tasks • Home Health Care Aide Services/Delegated Nursing Services: $27.04 LTC SD 48 Clinical monitoring refers to a formal written plan that reflects the elements for clinical monitoring found in DHS 3428B – Case Mix Classification Worksheet.

00 Less than once a day 01 1-2 shifts 02 All shifts

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EW-CL Workbook Individual RS Plan – Medication Mgt by Licensed Nurse Med Administration or assistance with self-administration • Medication Setups by Licensed Nurse: $33.97 LTC SD 66 How about your ability to take your own medication? Would you say that you: 01 need no help or supervision 05 don’t take medications 06 need medication setup only 07 need verbal or visual reminders only 08 need medication setups and reminders 09 need medication setups and administration

Insulin Injections • Home Health Care Aide Services/Delegated Nursing Services: $27.04 LTC SD 67 Are you diabetic? If yes, how do you control your diabetes?

01 not diabetic 02 no insulin require; diet controlled only 03 oral medications 04 sliding scale insulin and oral medications 05 scheduled daily insulin 06 scheduled daily insulin plus daily sliding scale

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EW-CL Workbook Individual RS Plan – Active Cognitive and Behavioral Support Wandering and Orientation Issues • Home Care Aide Services including Active Behavioral Support: $23.72 LTC SD 51 Orientation is defined as the awareness of an individual to his/her present environment in relation to time, place and person. See H.7 and H.10 for memory/orientation information.

00 • Oriented.

01 • Minor forgetfulness.

02 • Partial or intermittent periods of disorientation.

03 • Totally disoriented; does not know time, place, identity.

04 • Comatose.

05 • Not determined.

Anxiety, Verbal aggression, Physical aggression, Repetitive behavior, Agitation, Selfinjurious behavior, and Property destruction Home Care Aide Services including Active Behavioral Support: $23.72 LTC SD 45 Behavior - “Intervention” includes cues, redirection or behavior management/instruction.

00 • Behavior requires no intervention or no behaviors.

01 • Needs and receives occasional staff intervention in the form of cues because the person is anxious, irritable, lethargic or demanding. Person responds to cues. “Occasional” is defined as less than 4 times per week. *02 • Needs and receives regular staff intervention in the form of redirection because the person has episodes of disorientation, hallucinates, wanders, is withdrawn or exhibits similar behaviors. Person may be resistive, but responds to redirection. “Regular” is defined as 4 or more times per week. *03 • Needs and receives behavior management and staff intervention because person exhibits disruptive behavior such as verbally abusing others, wandering into private areas, removing or destroying property, or acting in a sexually aggressive manner. Person may be resistant to redirection. *04 • Needs and receives behavior management and staff intervention because person is physically abusive to self and others. Person may physically resist redirection.

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EW-CL Workbook Individual RS Plan Rate Summary

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Resources

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Elderly Waiver 24-hour Customized Living Client Assessment Tracking (Excel)

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Elderly Waiver 24-hour Customized Living Client Assessment Tracking (Excel)

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Elderly Waiver 24-Hour Customized Living Assessment and Payment Tool

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Elderly Waiver 24-Hour Customized Living Assessment and Payment Tool Instructions Download and make sure to save the tool to your network.

Since the tool uses Microsoft Excel, you will want to save a copy for each client you assess.

To keep the workbook as simple as possible, it is designed only for 24-hour customized living clients.

The tool has three worksheets: ◦ Step 1 – Assessment ◦ Step 2 – Case Mix ◦ Step 3 – Services

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Elderly Waiver 24-Hour Customized Living Assessment and Payment Tool MINNESOTA LONG-TERM CARE CONSULTATION SERVICES ASSESSMENT FORM – QUESTIONS USED Dressing

Telephone Calling

Grooming

Shopping

Bathing

Meal Preparation

Eating

Light Housekeeping

Bed Mobility

Heavy Housekeeping

Transferring

Laundry

Walking

Money Management

Toileting

Transportation

Special Treatments

Insulin Dependency

Clinical Monitoring

Neurological Diagnosis

Behavior

Vent Dependent

Orientation

Medication

Self-Preservation

STEP 1 – ASSESSMENT

This worksheet contains the 28 questions from the Minnesota Long-Term Care Consultation Services Assessment Form that are used to either determine a client’s case mix classification or allow the case manager to authorize services.

For the tool to work properly, you must answer each question on Step 1.

A drop-down answer selection is used for each of the assessment questions.

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Elderly Waiver 24-Hour Customized Living Assessment and Payment Tool Step 1 – Assessment

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Elderly Waiver 24-Hour Customized Living Assessment and Payment Tool Step 2 – Case Mix

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Elderly Waiver 24-Hour Customized Living Assessment and Payment Tool Step 3 - Services This worksheet allows the user to determine the services that a client may need, the overall monthly payment for services, and whether a client is over their budget cap.

The user enters the minutes per day and hours per month for each service.

The worksheet uses the information entered in Step 1 to determine if the client qualifies for 24Hour CL as well as allow for services to be authorized (depending on the client’s assessment).

Services Authorized Homemaking ◦ Light housekeeping ◦ Heavy housekeeping ◦ Laundry - personal ◦ Laundry-linens ◦ Shopping Food Preparation - Individual Assistance w Meal Prep in Own Apartment Food Preparation and Service: Breakfast prep and serve, Lunch prep and serve, Supper prep and serve, Snack prep and serve Supportive Services: Making appts, Arrange Non-Medical Transportation, Money Mgt Socialization - Individual Non-Medical Transportation Mileage Personal Care ◦ Dressing ◦ Grooming ◦ Bathing ◦ Eating ◦ Continence Care ◦ Walking ◦ Assistance with Use of Wheelchair (Yes/No Dropdown) ◦ Transferring ◦ Positioning

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Other Delegated Health Services ◦ Med Administration or assistance with self-administration ◦ Verbal or Visual Medication Reminders ◦ Insulin Injections ◦ Therapeutic Exercises (Yes/No Dropdown) ◦ Delegated clinical monitoring (Yes/No Dropdown) ◦ Delegated nursing tasks (Yes/No Dropdown) Medication Mgt by Licensed Nurse ◦ Med Set Ups and Monitoring ◦ Insulin Draws Active Cognitive or Behavioral Support ◦ Wandering ◦ Orientation issues ◦ Anxiety ◦ Verbal aggression ◦ Physical aggression ◦ Repetitive behavior ◦ Agitation ◦ Self-injurious behavior ◦ Property destruction Personal Security - Is the Mechanism included in the CL Rate?

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Elderly Waiver 24-Hour Customized Living Assessment and Payment Tool Step 3 - Services Summary of Services 24-Hour EW-CL Over Limit!

Monthly Rates!

Scores used for service authorization

Enter Units of Service

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Elderly Waiver 24-Hour Customized Living Assessment and Payment Tool Step 3 - Services

Under Limit!

Additional Services

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Elderly Waiver 24-Hour Customized Living Assessment and Payment Tool Step 3 - Services

Additional Services

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Elderly Waiver Reform: Rate Methodology January 1, 2019 Rate Increase

Establish base wages for each service rate using blended positions from the annual labor market information from the Minnesota Department of Employment and Economic Development (DEED).

◦ 10% of a new payment rate methodology for identified rates will be blended with 90% of the June 30, 2017 rates.

◦ The Minneapolis-St. Paul-Bloomington, MN-WI MetroSA is the geographic area

EW Caps/Limits Increases Moved to January 1 Programs included: ◦ Elderly Waiver (EW) and EW Customized Living (CL), EW Foster Care ◦ Community Access for Disability Inclusion (CADI) Customized Living (CL) ◦ Alternative Care (AC) ◦ Essential Community Supports (ECS)

Apply the following factors to the base wages determined for each service rate above: ◦ A payroll taxes and benefits factor ◦ A general and administrative factor ◦ A program plan support factor which is 12.8 percent ◦ A registered nurse management and supervision or social worker supervision factor equal to 15 percent

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Elderly Waiver Reform: Assessments ELIGIBILITY AND ASSESSMENT TIMING EXTENDED FOR ELDERLY WAIVER CLIENTS

RE-ASSESSMENT REQUIREMENTS FOR ELDERLY WAIVER CLIENTS SPECIFIED

If an eligibility update is performed, the faceto-face assessment (Minnesota Long Term Care Consultation Services Assessment or reassessment), is good for 90-days, as opposed to 60, when determining program eligibility.

Lead agency shall conduct a change-in-condition reassessment where the client’s condition has changed due to:

Eligibility update performed over the phone.

◦ ◦ ◦ ◦

A major health event, An emerging need or risk, Worsening health condition, or Cases where the current services do not meet the client's needs.

A change-in-condition reassessment may be initiated by the lead agency, the client or by a party on behalf of the client, or the provider of services.

The lead agency shall complete the change-incondition reassessment within 20 calendar days of the request.

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Elderly Waiver Reform: Information With the permission of the person being assessed or the person's designated or legal representative, to provide a copy of the provider's nursing assessment or written report outlining its recommendations regarding the client's care needs to the lead agency, in advance of the Minnesota Long Term Care Consultation Services Assessment or re-assessment. ◦ The lead agency conducting the assessment must notify the provider of the date by which this information is to be submitted.

EW-CL and adult day services providers that have provided a copy of the provider's nursing assessment or written report are to receive from the lead agency: ◦ The completed EW Workbook ◦ The final written Community Support Plan

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Essential Community Supports (ECS) The Essential Community Supports program may Services be available to you if you need services to live in the community and meet certain eligibility rules. Adult day service It is designed for people who do not need the level of care provided in a nursing home.

You may qualify for up to $452 a month for services and supports.

Required service coordination, limited to $600 annually (an additional $600 for service coordination to assist in transition planning is available one time).

Caregiver training and education Chore services Community living assistance Home-delivered meals Homemaker services Personal emergency response system Service coordination / case management

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ECS Services and Eligibility Are age 65 or older

Are age 21 or older

Are not eligible for Medical Assistance

Can benefit from one or more of these services

Are not or no longer are eligible for nursing facility level of care Live in your own home or apartment Meet financial eligibility criteria for the Alternative Care program Need one or more of these services to live in the community.

Live in your own home or apartment Lose your Medical Assistance eligibility at your 2015 annual assessment because of changes in the nursing facility level of care criteria Meet Alternative Care financial eligibility criteria No longer meet the nursing facility level of care criteria Previously received services in a nursing home or under the Alternative Care program or Brain Injury, Community Alternatives for Disabled Individuals or Elderly waiver programs. These programs are designed for people who need the level of care provided in a nursing home but choose to live at home

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ECS Settings and Providers Requirements Settings

Providers Requirements

Are not available to individuals in congregate settings that may include foster care, board and lodge or noncertified boarding care.

Are the same as those in the EW waiver.

Are available to individuals in Housing with Services settings that are apartments.

Uses the state rates for these services.

◦ Providers previously enrolled to deliver one of these services were auto-enrolled to serve folks in ECS under major program UN-EC

An apartment is a self-contained unit that includes living, sleeping, cooking, dining areas and bathroom.

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Housing Supports Formerly known as Group Residential Housing (GRH) Housing Supports (formerly Group Residential Housing (GRH)) ◦ State funded program that pays for room and board costs for low income adults ◦ Housing Supports pays for those living in places like adult foster care, board and lodging establishments, supervised living facilities, and providers who are registered housing with services ◦ Housing Supports is administered through DHS and delegated back to a “Lead Agency” who is usually the county or tribe ◦ Contracts for Housing Supports are obtained through the county or Lead Agency

Housing Supports ◦ Effective July 1, 2020, this base rate is $934 per month ◦ To receive a Housing Supports payment, a person must meet certain eligibility requirements. These requirements include: ◦ ◦ ◦ ◦

being aged, blind, or over age 18 and disabled there are income and asset maximums

◦ The Housing Supports rate is a payment directly to the provider of housing on behalf of the eligible person.

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Housing Supports Formerly known as Group Residential Housing (GRH) Rate 1: This is the base rate. Rate 1 is a payment directly to the provider of housing on behalf of the eligible person. ◦ Many types of settings enter into a GRH contract with their county including Adult Foster Care (Family and Corporate), Board and Lodging establishments, Non-certified Boarding Care homes, and Registered Housing with Services establishments.

Rate 2: Rate 2 is known as the Service Rate and can only be paid in specific types of settings. ◦ These are Board and Lodge with Special Services, specific supervised living facilities licensed by the Department of Health’s Environmental Health Division, or Boarding Care Homes that are not certified for Medicaid. The Board and Lodge with Special Services settings are registered under Minnesota Statute 157.17. New Board and Lodge with Special Services Homes cannot be added to the system unless a facility closes and a replacement is developed with an equivalent number of beds. ◦ Counties negotiate Rate 2 with providers and cannot exceed the maximum unless the county agrees to pay the amount over the maximum with county funds, or the Legislature has specifically authorized a higher rate for a facility. Counties contracting with facilities receiving Rate 2 combine it with Rate 1 to provide the total GRH payment. These facilities typically serve mentally ill or chemically dependent clients who are not eligible for a Medical Assistance waiver.

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Alternative Care (AC) Program for age 65 years and older who are at risk of nursing home placement and are not yet financially eligible for Medical Assistance.

Eligibility  Age 65 or older

Covered Services

 Chooses to receive home and community-based services instead of nursing facility services  Has no other payer for needed community-based services  Has income and assets to sustain no more than 135 days of nursing facility services

 The AC program covers the same services covered under the Elderly Waiver program with the exception of the services provided in out-of-home placements. In addition, the following services are covered under the Alternative Care Program:

 Meets a nursing facility level of care

◦ Case management conversion ◦ Discretionary services option ◦ Nutrition services

Source: Disability Services Program Manual (DSPM) CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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Alternative Care (AC) For age 65 years and older who are at risk of nursing home placement and are not yet financially eligible for Medical Assistance.

Covered Services The AC program covers the same services covered under the Elderly Waiver program with the exception of the services provided in out-of-home placements. In addition, the following services are covered under the Alternative Care Program: ◦ Case management conversion ◦ Discretionary services option ◦ Nutrition services Source: Disability Services Program Manual (DSPM) CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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Community Access for Disability Inclusion (CADI) Waiver an alternative for person who would otherwise require the level of care provided in a nursing facility.

Eligibility  A person must choose the CADI Waiver and meet all of the following criteria: ◦ ◦ ◦ ◦ ◦

Eligible for Medical Assistance (MA).

Certified disabled by Social Security or the State Medical Review Team (SMRT) process.

Under the age of 65 years at time of opening to the waiver.

Determined by the case manager/service coordinator to need nursing facility level of care.

Has an assessed need for supports and services over and above those available through the MA State plan.

 Meet the nursing facility level of care  Rate Setting in Customized Living

Source: Disability Services Program Manual (DSPM)

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Community Access for Disability Inclusion (CADI) Waiver an alternative for person who would otherwise require the level of care provided in a nursing facility.

Covered Services 24-Hour Emergency Assistance

Foster Care

Adult Companion Service

Home Delivered Meals

Adult Day Care/Adult Day Care Bath

Homemaker

Caregiver Living Expenses

Housing Access Coordination

Case Management

Independent Living Skills (ILS) Training

Case Management Aide

Prevocational Services

Chore Service Consumer Directed Community Supports (CDCS)

Residential Care Services

Customized Living

Respite

Customized Living 24 Hour

Specialized Supplies and Equipment

Environmental Accessibility Adaptations

Supported Employment Services

Extended Home Care Services

Transportation

Family Training and Counseling

Transitional Services

Source: Disability Services Program Manual (DSPM) CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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Community Alternative Care (CAC) Waiver CAC Waiver services may be provided in ◦ ◦ ◦ ◦ ◦

a person’s own home in his/her biological or adoptive family’s home in a relative’s home (sibling, aunt, grandparent, etc.) in a family foster care home or corporate foster care home.

If married, a person may receive CAC Waiver services while living at home with his or her spouse.

Source: Minnesota Department of Human Services

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Community Alternative Care (CAC) Waiver alternative to institutionalization for those who would otherwise require the level of care provided in a hospital.

Covered Services

CAC Waiver services may be provided in

Case Management Case Management Aide Consumer Directed Community Supports (CDCS) Environmental Accessibility Adaptations Extended Home Care Services Family Training and Counseling Foster Care Home Delivered Meals Homemaker Respite Specialized Supplies and Equipment Transportation Transitional Services

a person’s own home in his/her biological or adoptive family’s home in a relative’s home (sibling, aunt, grandparent, etc.) in a family foster care home or corporate foster care home.

If married, a person may receive CAC Waiver services while living at home with his or her spouse.

Source: Disability Services Program Manual (DSPM)

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Developmental Disability (DD) Waiver an alternative for a person who would require the level of care provided in an Intermediate Care Facility for Persons with Developmental Disabilities.

COVERED SERVICES 24-Hour Emergency Assistance Adult Day Care/Adult Day Care Bath Assistive Technology Caregiver Living Expenses Caregiver Training and Education Case Management Chore Service Consumer Directed Community Supports

(CDCS) Consumer Training and Education Crisis Respite Day Training and Habilitation Environmental Accessibility and Adaptations Extended Home Care Services Home Delivered Meals

Homemaker Housing Access Coordination Personal Support Prevocational Services Residential Habilitation (In-Home Family Support, Supported Living Services) Respite Specialist Services Supported Employment Services Transportation Transitional Services

Source: Disability Services Program Manual (DSPM)

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Brain Injury (BI) Waiver Home and community-based services necessary as an alternative to institutionalization that promote the optimal health, independence, safety and integration of a person and who would otherwise require the level of care provided in a specialized nursing facility or neurobehavioral hospital.

Eligibility A person must choose the BI Waiver and meet all of the following criteria: ◦ ◦ ◦ ◦ ◦ ◦

Eligible for Medical Assistance.

Certified disabled by Social Security or the State Medical Review Team (SMRT).

Under the age of 65 years at the time of opening to the waiver.

Level of care criteria: Nursing Facility (BI-NF) or Neurobehavioral Hospital (BI-NB) Have a completed BI Waiver Assessment and Eligibility Determination (DHS-3471 PDF) Diagnosed with one of the following documented primary or secondary diagnoses of brain injury or related neurological condition that resulted in significant cognitive and behavioral impairment: ◦ Acquired or Traumatic brain injury that is not congenital ◦ Degenerative or genetic disease where cognitive impairment is present, becomes symptomatic on or after the person’s 18th birthday and is not congenital ◦ Able to function at a level that allows participation in rehabilitation. ◦ Has an assessed need for supports and services over and above those available through the MA State plan. ◦ In need of a service that is only available through the BI Waiver or requires a higher level of service than is available through other waivers due to cognitive and behavior impairments.

Source: Disability Services Program Manual (DSPM) CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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Personal care assistance (reform continues) State/Federal Funded Program Personal care assistance services help a person with day-to-day activities in their home and community.

PCAs help people with activities of daily living, health-related procedures and tasks, observation and redirection of behaviors and instrumental activities of daily living for adults.

It is available to eligible people enrolled in a Minnesota Health Care Program.

Under considerable policy review and restructuring

Source: Minnesota Department of Human Services

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Adult Foster Care * Foster care / supported living corporate will be renamed community residential services

A licensed, living arrangement that provides food, lodging, supervision, and household services. ◦ They may also provide personal care and medication assistance. ◦ Adult foster care providers may be licensed to serve up to four adults or five adults if all foster care residents are age 55 or older, have no serious or persistent mental illness nor any developmental disability.

There are two types of adult foster care: ◦ Family Adult Foster Care is an adult foster care home licensed by the Minnesota Department of Human Services. It is the home of the license holder and the license holder is the primary caregiver. ◦ Non-Family Adult Foster Care (Corporate Adult Foster Care) is an adult foster care home licensed by the Minnesota Department of Human Services that does not meet the definition of Family Adult Foster Care because the license holder does not live in the home and is not the primary caregiver. Instead, trained and hired staff generally provide services.

Source: Minnesota Department of Human Services CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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Adult Foster Care (Continued) * Foster care / supported living corporate will be renamed community residential services Payment ◦ Costs for room and board are met with client income such as Social Security Income, Supplemental Security Income, or other supplemental income support such as Housing Supports (GRH). ◦ GRH is available to help recipients pay for room and board costs when living in a licensed or registered setting.

◦ The cost of adult foster care services (provision of supervision, assistance with personal care and medication) may be met with client income such as Social Security Income, Supplemental Security Income, and through other state and federal programs. ◦ In order to be paid for services from a waiver, the provider must have a contract with a county agency and be enrolled as a health care provider with the Minnesota Department of Human Services. ◦ County human service agencies set the rates for services provided to individuals who need public funding to help pay for services.

The amount of payment a provider receives to care for an individual varies based on the resident's service needs.

Source: Minnesota Department of Human Services CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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Google Search: Home and Community Based Services (HCBS) Waiver and Alternative Care (AC) Provider Enrollment

Provider Enrollment Minnesota Department of Human Services

https://www.dhs.state.mn.us/main/idcplg?

IdcService=GET_DYNAMIC_CONVER SION&RevisionSelectionMethod=LatestReleased&dDocName= id_017530

Minnesota Provider Screening and Enrollment (MPSE) portal or Fill Out and Submit Forms Source: Minnesota Department of Human Services CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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Managed Care and other issues 89

Minnesota Senior Health Options (MSHO) State/Federal funded program Voluntary Age 65 and Older Eligible for Medical Assistance Medicare Part A, B, and D Covers acute care, doctor visits, PCA, home health services, lab, dental, transportation, and: ◦ Elderly Waiver ◦ 180-day nursing facility liability

Source: Minnesota Department of Human Services

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Minnesota Senior Care (MSC) Plus State/Federal funded program Enrollment in MSC or MSC+ is mandatory.

MSC is being phased out as the State moves to MSC+.

MSC + is similar to MSHO, but does not include Medicare services and Part D Elderly Waiver 180-day nursing facility liability

Source: Minnesota Department of Human Services

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MSHO (All 87 counties)

MSC + (All 87 Counties)

Medicare Part A & B

Medicare Special Needs Plan (SNP)

Fee for Service or other non-coordinated plan.

Medicare Part D Drugs

SNP

Separate Free standing Medicare PDP

Remaining Medicaid Drugs

SNP

Medicaid MCO

Medicaid Basic Care

SNP

Medicaid MCO

Medicaid NF

SNP (180 days for new community enrollees) remainder FFS

MCO (180 days for new community enrollees) remainder FFS

Medicaid Elderly Waiver (EW)

SNP

Medicaid MCO

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MSC+ Case Management and MSHO Care Coordination ◦ Some MCOs are contracting with counties ◦ Some with care systems and community organizations ◦ Some are health plan care coordinators ◦ Some have a mix of care coordination options ◦ Members will get letter with name of new care coordinator

Source: Minnesota Department of Human Services

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Providers Plans are responsible for providing provider training.

Providers should carefully check MN-ITS (EVS) for eligibility and health plan coverage information.

MSHO/MSC+ enrollment is noted on MN-ITS but other Medicare or Part D plan enrollment is not tracked by DHS. MSHO will provide primary coverage for Medicare SNF days.

MSHO/MSC+ NF Liability will be 180 days for enrollees who enrolled when in the community.

Nursing homes and EW providers need to be prepared to bill health plans for more services.

Source: Minnesota Department of Human Services CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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Billing, Level of Care, MnCHOICES, and Other Policies 95

Billing!

Health Plans

• Fee for Service • • •

Screening Service Agreement MN-ITS

• MN–ITS — Registration

https://www.dhs.state.mn.us/ main/idcplg?

IdcService=GET_DYNAMIC_CONVE RSION&RevisionSelectionMethod=L atestReleased&dDocName=id_010 419

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Service Agreement  Document used to identify services, providers and payment information for a person receiving home care or waiver services.  Allows providers to bill for approved services and allows DHS to audit usage and payment data.  Long-term care and DD Waiver utilize the same Service Agreement DHS-3070 (PDF) to authorize services.  Service agreements are stored in MMIS.  Service agreements are waiver span and date sensitive.  Once a service agreement is entered into MMIS, MMIS generates notices to the case manager/service coordinator and to each provider listed on the service agreement.

Source: Minnesota Department of Human Services CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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MN-ITS and Help https://mn.gov/dhs/people-we-serve/adults/health-care/health-care-programs/contact-us/mhcp-help-desk.jsp

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Monthly to Daily Billing • •

Monthly and daily rate Effective July 1, 2016, Managed care organizations that don’t use MMIS will follow their own internal processes and procedures to ensure that service agreements are updated with the correct codes so that providers can bill accurately for their services.

CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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MN E-Connect https://mneconnect.healthec.com/ProdMNeConnectAdmin/mnehome.aspx CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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A single, comprehensive and integrated webbased assessment and support planning application for long-term services and supports in Minnesota.

MnCHOICES The new MnCHOICES assessment will replace current long-term care assessment processes and forms, including:

CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

Developmental disability screening Long-term care consultation assessment Personal care assistance assessment Private duty nursing assessment, included in future enhancement

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Background

Nursing Facility Level of Care (NF LOC)

Remember: To be on the EW, CADI, or AC waivers or in a nursing facility on Medicaid, a client must meet the standard for nursing facility level of care.

Put differently, one standard is used for all of these programs.

Implemented on January 1, 2015

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Nursing Facility Level of Care Criteria https://edocs.dhs.state.mn.us/lfserver/Public/DHS-7028-ENG

CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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Nursing Facility Level of Care Criteria https://edocs.dhs.state.mn.us/lfserver/Public/DHS-7028-ENG

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Resource

Link

DHS Manuals including Minnesota Health Care Programs Provider Manual

https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMeth od=LatestReleased&dDocName=Manuals

Billing for Elderly Waiver and Alternative Care (AC) Program

www.dhs.state.mn.us/main/id_056766

DHS Bulletins

https://mn.gov/dhs/general-public/publications-forms-resources/bulletins/

DHS eDocs and Forms

https://mn.gov/dhs/general-public/publications-forms-resources/edocs/

Community-Based Services Manual – Forms by Number

http://www.dhs.state.mn.us/main/id_018176

Medicare

https://www.medicare.gov/index.html

Resources CARE PROVIDERS OF MINNESOTA | LEADING MEMBERS TO EXCELLENCE | #CPMEDUCATES

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L ICENSED ASSISTED L IVING DIRECTOR

PHYSICAL ENVIRONMENT REQUIREMENTS – DEMENTIA CARE Michael Mireau, Public Health Architect, AL Physical Environment Supervisor Engineering Services, Minnesota Department of Health

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INTRODUCTIONS Michael Mireau, Public Health Architect, AL Physical Environment Supervisor Engineering Services, Minnesota Department of Health Michael Mireau was born, raised, and educated in Wisconsin. He holds a Master’s degree in Architecture and is a licensed architect in the State of Minnesota. Before joining the Minnesota Department of Health (MDH), Michael worked at numerous architecture firms in the private sector until his appointment as the first Public Health Architect at MDH. Michael has been promoted as the Supervisor of the Assisted Living Physical Environment team. He is married, has two daughters and they love biking, camping, and lots of beach time during the summer. In his free time, Michael also likes to run and meditate.

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OBJECTIVES • Understand the differences between an ALF and an ALFDC license • Understand the basic requirements for all AL facilities • Understand the minimum fire protection and physical environment requirements for all AL facilities • Understand the minimum design requirements for new facilities with 6 or more residents • Understand the different Life Safety Code requirements between ALF & ALFDC • Understand the additional minimum requirements for an ALFDC license

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ALF vs. ALFDC ALF – Assisted Living Facility

 Compliance with 144G.45 (*updates made in Dec. 2020 Special Session)

ALFDC – Assisted Living Facility with Dementia Care

 Compliance with 144G.45 & 144G.81 (*updates made in Dec. 2020 Special Session)

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BASIC REQUIREMENTS

ALL FACILITIES – 144G.45, SUBD. 1 • Public utilities (or approved systems) must be available and working • Accessible to fire department services and emergency medical services • Sufficient natural drainage and not subject to flooding • All-weather roads and walks must be provided within the lot lines to primary entrance • Location must include space for outdoor activities for residents

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FIRE PROTECTION & PHYSICAL ENVIRONMENT ALL FACILITIES – 144G.45, SUBD. 2 • Smoke alarms • Fire extinguishers • Fire drills • Physical environment maintained in a state of good repair • Existing construction, elements, or systems cannot be a hazard to life

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FIRE PROTECTION & PHYSICAL ENVIRONMENT ALL FACILITIES 144G.45, SUBD. 2 (CONT.)

Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: For dwellings or sleeping units, as defined in the State Fire Code: i.

provide smoke alarms in each room used for sleeping purposes;

ii. provide smoke alarms outside each separate sleeping area in the immediate vicinity of bedrooms; iii. provide smoke alarms on each story within a dwelling unit, including basements, but not including crawl spaces and unoccupied attics;

iv. where more than one smoke alarm is required within an individual dwelling unit or sleeping unit, interconnect all smoke alarms so that actuation of one alarm causes all alarms in the individual dwelling unit or sleeping unit to operate; and v. ensure the power supply for existing smoke alarms complies with the State Fire Code, except that newly introduced smoke alarms in existing buildings may be battery operated

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FIRE PROTECTION & PHYSICAL ENVIRONMENT ALL FACILITIES 144G.45, SUBD. 2 (CONT.)

• Fire safety and evacuation plans shall be readily available at all times within the facility.

• Residents who are capable of assisting in their own evacuation shall be trained on the proper actions to take in the event of a fire to include movement, evacuation, or relocation. The training shall be made available to residents at least once per year.

• Evacuation drills are required for employees twice per year, per shift, with at least one evacuation drill every other month. Evacuation of the residents is not required. Fire alarm system activation is not required to initiate the evacuation drill.

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FIRE PROTECTION & PHYSICAL ENVIRONMENT ALL FACILITIES 144G.45, SUBD. 2 (CONT.)

• The physical environment is kept in a continuous state of good repair and operation • Any existing elements that an authority having jurisdiction deems a distinct hazard to life must be corrected.

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MINIMUM DESIGN REQUIREMENTS 144G.45, SUBD. 4

For all new licenses or new construction with 6 or more residents: Applicable chapters of the 2018 edition of the Facility Guidelines Institute (FGI) “Guidelines for Design and Construction of Residential Health, Care and Support Facilities.”

• Part 1 – General • Part 2 – Common Elements • Part 4 – Specific Requirements for Assisted Living Facilities

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LIFE SAFETY CODE DIFFERENCES For all new ALF with 6+ residents – 144G.45, Subd. 5 • Chapter 32 – Residential Board and Care Occupancies, 2018 edition of the NFPA 101, Life Safety Code For all new ALFDC, no matter # of residents – 144G.81, Subd. 3 • Chapter 18 – Healthcare (Limited Care), 2018 edition of the NFPA 101, Life Safety Code

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ADDITIONAL ALFDC MINIMUM REQUIREMENTS 144G.81, SUBD. 1 & 2

• A hazard vulnerability assessment (HVA) or safety risk must be performed on and around the property. The hazards indicated on the assessment must be assessed and mitigated to protect the residents form harm; • Facility shall be protected throughout by an approved supervised automatic sprinkler system by August 1, 2029.

• Fire drills shall be conducted in accordance with 144G.45

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AL PHYSICAL ENVIRONMENT QUESTIONS? CONTACT: • Michael Mireau, 651-587-7790, michael.mireau@state.mn.us • MDH website where we will post all questions and answers that we receive (for consistency and clarity) https://www.health.state.mn.us/assistedliving

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144G QUALITY MANAGEMENT ACTIVITY Racey Gasior, Lead Quality & Experience Specialist Lifespark (Formerly Tealwood Senior Living)

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INTRODUCTIONS Racey Gasior, MS, Lead Quality & Experience Specialist Lifespark (Formerly Tealwood Senior Living) Racey holds a Bachelor's in Psychology and a Master’s degree in Human Services. She is a Licensed Assisted Living Director, holds a Senior Specialty Certificate in Exercise, is Chair of the Care Providers of Minnesota (CPM) Recognition Task Force and is also a Basic Life Support Instructor for the American Red Cross. She has worked with older adults for 14 years and has been in the Wellness industry since 2006. She is a member of the CPM Quality Committee, has been featured on the Quality Innovation Network, and coached at various CPM Bronze and Silver Workshops as she has completed six years with the AHCA/NCAL National Quality Awards Program as an Examiner/Team Lead.

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Learning Objectives 

Discuss the regulation changes from 144A to 144G



Dissect each portion of the new regulation



Offer basic quality techniques and suggestions on how to meet the regulation



Provide resources on where to search for Quality Tools

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144A.477 COMPLIANCE. Home Care & HCBS Subd. 2.Medicare-certified providers; equivalent requirements. 

For home care providers licensed to provide comprehensive home care services that are also certified for participation in Medicare as a home health agency under Code of Federal Regulations, title 42, part 484, the following state licensure regulations are considered equivalent to the federal requirements:



(1) quality management, section 144A.479, subdivision 3;

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144A.479 HOME CARE PROVIDER RESPONSIBILITIES; BUSINESS OPERATION. Subd. 3.Quality management.  The home care provider shall engage in quality management appropriate to the size of the home care provider and relevant to the type of services the home care provider provides. The quality management activity means evaluating the quality of care by periodically reviewing client services, complaints made, and other issues that have occurred and determining whether changes in services, staffing, or other procedures need to be made in order to ensure safe and competent services to clients. Documentation about quality management activity must be available for two years. Information about quality management must be available to the commissioner at the time of the survey, investigation, or renewal.

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Assisted Living Facility & Assisted Living Facility with Dementia Care 144G.42 BUSINESS OPERATIONS Subd. 2.Quality management. 

The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. "Quality management activity" means evaluating the quality of care by periodically reviewing resident services, complaints made, and other issues that have occurred and determining whether changes in services, staffing, or other procedures need to be made in order to ensure safe and competent services to residents. Documentation about quality management activity must be available for two years. Information about quality management must be available to the commissioner at the time of the survey, investigation, or renewal.

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Assisted Living Facility & Assisted Living Facility with Dementia Care 144G.42 BUSINESS OPERATIONS Subd. 2.Quality management.

5 Key Elements of Quality Management

“The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided.… 

1)

Design & Scope

2)

Governance & Leadership

Maintain a Quality Assurance and Performance Improvement (QAPI) or Quality Committee

3)

Feedback, Data Systems & Monitoring



Address “appropriate to facility size” by having all departments involved

4)

Performance Improvement Projects



Recommend standing meetings to create importance

5)

Systematic Analysis and Systemic Action

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Assisted Living Facility & Assisted Living Facility with Dementia Care 144G.42 BUSINESS OPERATIONS Address “relevant to the type of services provided” by creating a Quality Meeting Minutes Template with all key services provided, metrics, processes that the team feels are essential to facility success Examples

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Assisted Living Facility & Assisted Living Facility with Dementia Care 144G.42 BUSINESS OPERATIONS Subd. 2.Quality management. …"Quality management activity" means evaluating the quality of care by periodically reviewing resident services, complaints made, and other issues that have occurred and determining whether changes in services, staffing, or other procedures need to be made in order to ensure safe and competent services to residents.…

Addressing “Evaluating”

Addressing “Periodically”: with the Quality Committee meeting at minimum quarterly if not monthly

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Assisted Living Facility & Assisted Living Facility with Dementia Care 144G.42 BUSINESS OPERATIONS Also Addressing “determining whether changes in services, staffing, or other procedures need to be made in order to ensure safe and competent services to residents”

Prioritization Tool

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Assisted Living Facility & Assisted Living Facility with Dementia Care 144G.42 BUSINESS OPERATIONS  Common

Projects: Fall Prevention, Regulation/Survey Compliance, Pendant Response Times, Med Errors, Turnover, Census/Occupancy

 Choose

a Quality Improvement Model---



Very common is PDSA (Plan, Do, Study, Act)



Other examples: Total Quality Management (TQM), Rapid-Cycle Improvement (RCI)

 Form

a PIP team to address the area of opportunity and work through the chosen model of improvement (Great place to include front line staff!)

 Document

all efforts on a PIP Worksheet

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Assisted Living Facility & Assisted Living Facility with Dementia Care 144G.42 BUSINESS OPERATIONS Subd. 2.Quality management. …Documentation about quality management activity must be available for two years. Information about quality management must be available to the commissioner at the time of the survey, investigation, or renewal.”

Meeting Minutes Template & PIP Worksheets: Committee Member’s Names

Date/Time of Meeting Held

Attendance Tracking

Key Measures, Metrics & Processes (Target Areas or Areas of Opportunity) Data Trend

Trend Analysis

Actions Taken/Quality Improvement Model Steps

Who Responsible

Whether Actions Taken Need to be Adopted, Adapted or Abandoned

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RESOURCES:

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ASSISTED LIVING RESIDENT RIGHTS AND ADDRESSING COMPLAINTS Robert F. Rodè, Esq, Attorney/Partner Voigt, Rodè, Boxeth & Coffin, LLC Rebecca K. Coffin, Esq, Partner Voigt, Rodè, Boxeth & Coffin, LLC

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INTRODUCTIONS Robert F. Rodè, Esq, Attorney/Partner Voigt, Rodè, Boxeth & Coffin, LLC Robert Rodè is a partner with Voigt, Rodè, Boxeth & Coffin, LLC. Rob serves elder care providers including LTC, AL/HWS, home health, rehab, adult day, hospice and independent living and the licensed professionals in all settings. Rob works with clients on issues like regulatory compliance, surveys/appeals, OHFC, behaviors, discharges/evictions, contracts, dispute resolution, litigation, employment/labor, licensing and AR. Rob is a frequent speaker, certified arbitrator and a “Rising Star” among MN lawyers and a “Who’s Who” among health, business and employment law litigators.

Rebecca K. Coffin, Esq, Partner Voigt, Rodè, Boxeth & Coffin, LLC Rebecca K. Coffin is a Partner with the law firm of Voigt, Rodè, Boxeth & Coffin, practicing in health law including accounts receivable, regulatory compliance and HIPAA compliance. Ms. Coffin represents providers on nursing home and home care licensing including change of ownership. Ms. Coffin also practices in employment law and advises clients on a variety of employment and labor issues. She currently represents a number of nursing homes, home care agencies and assisted living providers.

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ASSISTED LIVING RESIDENT RIGHTS AND ADDRESSING COMPLAINTS CARE PROVIDERS OF MINNESOTA LICENSED ASSISTED LIVING DIRECTOR EDUCATION SERIES ROBERT RODÈ RRODE@VRB-LAW.COM REBECCA COFFIN RCOFFIN@VRB-LAW.COM

Voigt, Rodè, Boxeth & Coffin, LLC 651-209-6161

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OBJECTIVES: 1.

Review resident rights;

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Understand the importance of the role of family and legal decision makers in providing care and addressing concerns;

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Learn tips in when and how to work with the Ombudsman

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WHY ADDRESS ? CHALLENGES IN ASSISTED LIVING • New requirements (and expectations!) in assisted living settings • State (and Federal) focus on abuse and neglect (DOJ) • Staffing issues • Financial issues • Dementia care increasing – increases risks of allowing to age in place

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COMMUNICATION, RESIDENT RIGHTS AND SAFETY • Abuse prevention is what you do – however, bad things happen • Protection and safety of residents are the most important part of your job – keeping seniors safe • Customer service is critical for PR and confidence in your services – YOU WANT TO HEAR families • You wish to promote good faith reporting to stop any ongoing maltreatment • You want to prohibit poor employees from working with you and your residents

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ASSISTED LIVING RESIDENT RIGHTS • Resident notices required (Minn. Stat. Sec. 144G.90) • Information on how to make a complaint to MAARC, and the Ombudsman • Notice of dementia training • Notices of available assistance for health and supportive services

• Resident Bill of Rights • Must provide to all AL residents • Right to refuse treatment, participate in care planning, freedom from maltreatment, privacy • See Section 144G.91 for all requirements

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ASSISTED LIVING RESIDENT RIGHTS, CONT. • Retaliation Prohibited (Minn. Stat. Sec. 144G.92) • Residents may file complaint or grievance, obtain third-party advocacy assistance • No terminating contract, discrimination, restriction of rights in response to resident’s actions under statute

• Must provide Residents with consumer advocacy and legal services information in the AL contract • Electronic Monitoring Rights (Minn. Stat. Sec. 144.6502)

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COMPLAINTS: LISTEN AND RESPOND Look at CMS All Cause Harm Prevention App A for ideas and use for training staff (document for surveyor review for skilled nursing facilities) Policies and procedures – grievance policies,VA reporting In-house strategy for handling complaints - from residents and clients - from family - from staff Difference between a grievance and a VA issue Personal contact critical – supervision and audits

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RESIDENT DECISION MAKERS • Resident • Designated Representative • Attorney in Fact Under Power of Attorney (Financial) • Health Care Agent • Conservator • Guardian • All the other family members calling you??

• HIPAA considerations

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INVESTIGATION IS KEY…SO YOU KNOW WHAT TO SAY TO FAMILY: • Report to RN/LALD IMMEDIATELY • No choice – Investigate/Evaluate/CONCLUDE • Send employees home during investigation • Talk to all persons involved • Confidential and use two people • Document all – statements, and YOUR conclusions • Report back to staff and family

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DETERMINING WHETHER TO REPORT THE INCIDENT TO MAARC/OHFC Review the law and your VA policies EVERY TIME Minnesota Vulnerable Adult Act Minn. Stat. Sec. 626.557 Make your own conclusions: It WAS an accident, no abuse, etc. Document and retain if you decide NOT to report Inform staff reporter whether you reported and if not, why not

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VA REPORTING – DOES IT IMPACT ME AND SHOULD I TELL THE FAMILY? VA Report could result in state licensing orders, maltreatment determination, or both • Written request and conferences from licensing board (BELTSS, BON) • Separate responsibility (Mitigating factors) if employee is the perpetrator • Possible criminal charges and prosecution • Reputation of your facility • Let family know what is going on… before, during and after

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SET NEW EXPECTATIONS OF STAFF FOR RESIDENT CARE AND QUALITY • Name badges not enough – introduce over and over and over • Know the client/resident and personal interests of them and their family • Report: “Here is what I’ve done for you lately.”

• Ask about preferences • Re-evaluate at care conferences or when there is a change in condition

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LISTENING TIPS Active listening: completely focused, not thinking about your response. Let them VENT. Reflective listening: restate back what the family told you. Clarify if necessary, what you heard.

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Be present, attentive and focused

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Approach conversation as a collaborative experience

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Refrain from trying to figure things out while family is speaking

4.

Don’t take things personally

5.

Let go of attachments, agendas or outcome

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WHAT DOES THE OMBUDSMAN PROGRAM DO? • Advocates for residents of nursing homes, board and care homes, assisted living facilities, and other similar adult care facilities.

• Educate residents, their family, and facility staff about residents’ rights, good care practices, and similar long-term services and supports resources • Ensures residents have regular and timely access to ombudsman services • Provide technical support for the development of resident and family councils; • Represent resident interests before governmental agencies; and • Seek legal, administrative, and other remedies to protect residents.

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WORKING WITH THE OMBUDSMAN – FOCUS ON VALUE DRIVEN PRINCIPALS • Person- centered care is grounded in deinstitutionalizing services and individualizing care.

• Providers of service report that a true commitment to fundamental person-centered care improves the quality of care and quality of life for long-term care residents and the quality of work experience for staff.

• Put the person before the task.

• All people are entitled to self-determination, wherever they live.

• Empower staff, focus on responsibility, accountability and strong support.

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CASE SCENARIOS Resident refusing to eat or take medications Resident requests to only have certain staff care for her Son stealing money from incapacitated resident

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RESOURCES Office of Ombudsman for Long-Term Care P.O. Box 64971 St. Paul, MN 55164-097 Telephone: 651-431-2555 Office of the Ombudsman for Mental Health and Developmental Disabilities 121 7th Place East Suite 420 Metro Square Building St. Paul, Minnesota 55101-2117 Telephone: 651-757-1800

Minnesota Adult Abuse Reporting Center Telephone: 1-844-880-1574 Minnesota Disability Law Center 111 N Fifth St, Suite 100 Minneapolis MN 55403 Website: https://mylegalaid.org/our-work/disability-law Telephone: (612) 334-5970 Senior LinkAge Line at 1-800-333-2433

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THANK YOU!

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LICENSED ASSISTED LIVING SURVEY & ENFORCEMENT PROCESS Doug Beardsley, LNHA, LALD, Vice President of Member Services Care Providers of Minnesota

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INTRODUCTIONS

Doug Beardsley, LNHA, LALD, Vice President of Member Services Care Providers of Minnesota Doug Beardsley has been involved in the field of long-term care since 1982, when he became a nursing home administrator.Mr. Beardsley has a Bachelor of Science degree in healthcare administration from the University of Wisconsin–Eau Claire. His experience includes 20 years as a nursing home administrator, three years as a long-term acute care hospital CEO, manager of an inhouse LTC pharmacy, and other long-term care related activities. Mr. Beardsley has been the vice president of member services with Care Providers of Minnesota since 2005, where he is responsible for the regulatory activities pertaining to nursing facilities, home care, assisted living, and hospice.

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Opening Commentary • Surveys and enforcement are part of being regulated and licensed.

• Surveyors/Evaluators/Investigators want the same things providers want – safe and regulatory compliant assisted living facilities with satisfied staff and residents.

• A Licensed Assisted Living Director’s most important tool is to fully understand the regulations the licensed facility operates under. Knowledge of the requirements provides a path to the creation of systems that result in regulatory compliance.

• Think of surveys as your routine external consultant visit – use the information gained as a means to improve your assisted living facility.

CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

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The Minnesota Department of Health (MDH) is the exclusive state agency charged with the responsibility and duty of surveying and investigating Minnesota’s licensed assisted living facilities.

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Routine Surveys • An assisted living who receives a provisional license (meaning a brand-new provider) must have an initial survey within one year of the provisional license issue date.

• Once a full assisted living license is given (after a successful provisional licensee survey), licensed assisted living facilities will be surveyed at least once every two years.

• For all new licenses after a Change of Ownership (CHOW), the facility must be surveyed within six months after the new license is issued.

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Routine Surveys Reason for Survey Change of Ownership (CHOW)

Survey Deadline Within SIX Months after new license is issued

Provisional License

Within ONE Year after new license is issued

Full License

At least every TWO Years

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Routine Surveys • Although MDH has deadlines when surveys must be scheduled, all surveys are unannounced. You will not be notified in advance to schedule your survey!

• Once a surveyor enters the assisted living to conduct a survey, the survey must continue until concluded. Key staff missing due to vacations or illness will not result in a survey being “rescheduled”.

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Routine Surveys • Surveys are intended to determine compliance with: • 144G – Minnesota’s Assisted Living Statutes

• If dementia licensed, includes dementia specific requirements

• Chapter 4659 – Minnesota’s Assisted Living Rules

• Including CMS Appendix Z – Emergency Preparedness Requirements • If dementia licensed, includes dementia specific requirements

• Chapter 4626 – Minnesota Food Code • For new construction or any provisional license with six or more residents or substantial remodeling:

• NFPA Life Safety Code 101 – Residential Board and Care Occupancies Chapter • Facility Guidelines Institute “Guidelines for Design and Construction of Residential Health, Care and Support Facilities CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

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Routine Surveys • Surveys will generally be conducted by a State Evaluations Team:

• MDH Nurse evaluators/surveyors, & • MDH Health Care Engineers (who look at building and safety issues) • At times may have MDH Environmental Health to assist with MN Food Code review

• Surveys have traditionally lasted between 2-4 days. The length of time the survey takes and the number of evaluators on site depends on: • • • • • • •

Number of residents in the assisted living Number of residents receiving assisted living services in the assisted living Number of locations (if a campus setting) Intensity of health-related services provided by the assisted living Building size and design Scope of regulatory problems identified during the survey Preparedness of the assisted living provider!

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What does a survey generally look like?

Some on-site survey tasks may be conducted in a different order

Entrance Conference

Kitchen Inspection

Document Review (AL contract, Emergency Preparedness, etc.)

Complete Survey Process or Continue with Follow-up Surveys

Building Tour

Building Inspection

by Engineer

Review of Employee Files

Follow-up Survey

Observations of Residents and Staff

Interview Staff

Review of Resident Files

AL Implements Changes Based on Licensing Orders

Medication Administration Observation

Interview Residents

Exit Conference

Receive 2567 Survey Form Listing Correction Orders

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Entrance Conference • Like it or not, the entrance conference sets the tone of the survey.

• It will become apparent very quickly to the surveyor/evaluator whether you are prepared or not.

• You will be provided with a list of “things” to produce for the surveyor/evaluator, some are needed within one hour, others are needed within two hours, etc.

• If you are not prepared to efficiently produce these documents in a timely manner, it will not be a good start to the survey!

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Entrance Conference

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Entrance Conference

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Entrance Conference

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Entrance Conference

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Entrance Conference • Lesson #1…Know what the surveyors will be asking for. Have systems in place to produce them accurately and timely. Have a back-up person that also knows how to produce these items…you may not be there when they show up!

• Lesson #2…Have a survey readiness binder. Many of the materials can be prepared in advance or updated quickly. This makes everyone’s job easier!

• Lesson #3…Use the MDH survey forms to help be prepared and conduct selfaudits using the same tools the surveyors will use. Survey forms can be downloaded here: https://www.health.state.mn.us/facilities/regulation/assistedliving/survey.html CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

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MDH Survey Forms

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Exit Conference • At the conclusion of the onsite survey a surveyor will ask to speak with key staff – most likely the Licensed Assisted Living Director and the Clinical Nurse Supervisor. You are welcome to have others attend if time and space permits.

• The surveyor will provide a draft list of potential correction orders that are being considered as a result of the onsite survey This list could be expanded or shortened up upon review once the surveyor is offsite.

• You will have a short period of time to send in additional documentation if you disagree with any of these initial determinations, for example a form was missed. Once the final survey form is released, the only way to get a correction order changed is through a reconsideration (more on that later).

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2567 - Survey Results Form • A form used by the Federal government to survey certified health care facilities – it was never intended to be used by States for assisted living surveys.

• That being said, Minnesota currently uses the 2567 form to document correction orders resulting from assisted living surveys and investigations.

• Half of the form is left blank, as it is intended for the certified facility to enter their correction plan in the space and submit for approval. But assisted living facilities do not need to submit plans of correction so half of every page is just blank.

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2567 - Survey Results Form • Assisted living statutes require MDH to provide the 2567 form to the facility within 30 days after the survey exit.

• Providers should not just wait until they receive the survey results form; they should begin conducting root cause analysis and action improvement plans on the issues that were identified on the draft survey exit form as soon as the exit conference is concluded!

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2567 - Survey Results Form • The 2567 form provides the facility with the following information: • Lists a Scope and Level for each correction order • Identifies specific statute or rule where non-compliance was identified • Lists the requirement • Provides examples of deficient practice observed or identified • Provides a date/deadline where compliance is expected CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

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2567 – Level and Scope of Correction Orders • Each correction order is assigned both a Level and Scope designation: LEVEL

DESCRIPTION

Level 1

A violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety

Level 2

A violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death

Level 3

A violation that harmed a resident's health or safety, not including serious injury, impairment, or death, or a violation that has the potential to lead to serious injury, impairment, or death

Level 4

A violation that results in serious injury, impairment, or death

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2567 - Level and Scope of Correction Orders • Each correction order is assigned both a Level and Scope designation: SCOPE

DESCRIPTION

Isolated

When one or a limited number of residents are affected or one or a limited number of staff are involved, or the situation has occurred only occasionally

Pattern

When more than a limited number of residents are affected, more than a limited number of staff are involved, or the situation has occurred repeatedly but is not found to be pervasive

Widespread

When problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all of the residents

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2567 - Level and Scope of Correction Orders Level 4

J

K

L

Level 3

G

H

I

Level 2

D

E

F

Level 1

A

B

C

Isolated

Pattern

Widespread

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2567 – Fines Resulting from Surveys The Level assigned to each correction order will determine if a fine is to be assessed and how large that fine will be: • • • •

Level 1, no fines or enforcement Level 2, a fine of $500 per violation* Level 3, a fine of $3,000 per violation* Level 4, a fine of $5,000 per violation* *Plus any enforcement actions available in the enforcement statutes (144G.20)for widespread violations

For every Level 3 or Level 4 violation, MDH may issue an immediate fine CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

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Survey Exit Date Within 30 days MDH must send 2567 (correction orders)

Days indicated on 2567

Provider has XX days to correct identified correction orders Within 90 days

Within 15 days Provider has opportunity to request any reconsiderations after receipt of 2567

Within 60 days

Reconsideration must be Determined

MDH conducts follow-up survey for Level 3, Level 4, or widespread findings

PASS or FAIL Start all over if FAIL (fines may double each fail)

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What Happens Next?

• Each correction order will identify how long the facility has to implement corrective actions that will result in compliance. These could be as short as “immediate” and as long as 21 days.

• When all plans of correction have been implemented by the facility, the facility must notify MDH. In general, this will be the date where the facility was provided the longest time period to take corrective action.

• Your plans of correction do not need to be submitted to MDH, nor do they need to be “approved” by MDH.

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What Happens Next?

• Assisted living providers should try to determine the root cause of what caused the non-compliance – rarely is “retraining” sufficient to correct system problems.

• Plans of correction should address the immediate situations identified in the 2567, but also implement system improvements that will hold over time.

• By the correction order date, the assisted living facility must document what actions the facility implemented to comply with the correction order. MDH may ask for this documentation at the follow-up survey. Document what actions the facility implemented for each correction order received. The better the documentation, the quicker the follow-up survey will be.

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What Happens Next?

• Sometime between the longest date for correction given on the 2567 and 90 days after the survey exit date, MDH will come back to conduct a follow-up survey (sometimes referred to as a resurvey).

• Follow-up surveys are required to be conducted in person for any correction order issued at a Level 3 or 4. Lower level correction orders may be re-surveyed using phone, email, fax, etc. – but that decision is up to MDH, not the provider.

• The purpose of the follow-up survey is to determine if the facility has corrected deficient issues and systems identified during the survey.

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What Happens Next?

• Surveyors will determine if the actions taken for each correction order have satisfactorily met the regulatory requirements – or if continued noncompliance exists.

• While conducting follow-up surveys, evaluators/surveyors are able to cite additional correction orders based on their observations during the follow-up survey!

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What Happens Next?

• If everything looks “cleared” the survey cycle ends.

• If continued non-compliance is determined, or new correction orders are issued, the process continues.

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What if you disagree with a correction order?

• Request for a Reconsideration • Must be filed, in writing, within 15 calendar days of receipt of the 2567 form • Must be filed for each correction order the facility disagrees with

• Reconsiderations • An MDH staff member not affiliated with the survey will review the reconsideration request, including any additional information provided by the facility • The reconsideration can be done via phone, in writing, or in-person • MDH has 60 days to respond in writing regarding the reconsideration decision

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What if you disagree with a correction order?

• Reconsiderations can result in…

• No change to the correction order • Changes in accuracy of facts in the correction order • Change in accuracy of statute or rule referenced • Changes in Level or Scope of the correction order • Changes in fines assessed • Full removal of the correction order

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When surveys go bad…

• Initial surveys for provisional licenses where substantial noncompliance is determined can result in the facility not receiving an assisted living license.

• For established licenses, the following actions against a license are available to MDH: • • • • • •

Fines Conditions put on the licensed (conditional license) Immediate temporary suspension of license Suspension of license Refusal to renew license Revocation of license

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MDH Guide to the Assisted Living Survey Process

• MDH has published a five-page summary of the survey process. It can be found here: https://www.health.state.mn.us/faciliti es/regulation/assistedliving/docs/surve yforms/p5019.pdf

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But wait, there’s more!

• In addition to the initial (provisional or CHOW) and every-two-year surveys, assisted living facilities may be investigated for noncompliance as a result of: • Complaints of non-compliance received by the Office of Health Facility Complaints (OHFC) - also known as Rapid Response • Facility reported incidents made by the facility to the Minnesota Adult Abuse Reporting Center (MAARC) • Allegations of maltreatment (abuse, neglect, exploitation) received by MAARC or OHFC CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

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But wait, there’s more!

• Investigations are unannounced • Investigations tend to be more focused on issues surrounding the complaint • Investigators tend to be a bit more ”tight lipped” about what they are investigating • Investigations can result in full-blown surveys if warranted

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But wait, there’s more!

• These investigations can result in: • Correction orders for non-compliance with Assisted Living Statues and/or Rules • Substantiated findings of maltreatment under the Minnesota Vulnerable Adults Act • Maltreatment findings can be issued against the Licensed Assisted Living Facility, or • Maltreatment findings can be issued against individual staff employed (or previously employed) by the Licensed Assisted Living Facility, or • Both CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

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Closing Commentary • Surveys and enforcement are part of being regulated and licensed.

• Surveyors/Evaluators/Investigators want the same things providers want – safe and regulatory compliant assisted living facilities with satisfied staff and residents.

• A Licensed Assisted Living Director’s most important tool is to fully understand the regulations the licensed facility operates under. Knowledge of the requirements provides a path to the creation of systems that result in regulatory compliance.

• Think of surveys as your routine external consultant visit – use the information gained as a means to improve your assisted living facility.

CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

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L ICENSED ASSISTED L IVING DIRECTOR

VULNERABLE ADULT PROTECTION UNDER MINNESOTA STATUTES 626.557 Linda Hall, MA, BSN, RN, CPHQ, Nurse Consultant Advanced Health Institute (AHI)

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INTRODUCTIONS

Linda Hall, MA, BSN, RN, CPHQ, Nurse Consultant Advanced Health Institute (AHI) Linda brings over 40 years of diverse clinical and operational experience to AHI. As a certified professional in health care quality, she has applied her expertise in assisted living, long-term care, pharmaceutical, and managed care environments. With over ten years of experience in regulatory compliance leadership roles, Linda understands the impact that regulation has on providers and how to achieve compliance based on risk and quality management principles.

With a passion for holistic health, Linda obtained her master’s degree in Human Development. She also has practitioner training in Reiki, Healing Touch, Emotional Freedom Technique, and is a certified stress management instructor.

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Vulnerable Adult Protection Under Minnesota Statutes 626.557

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Objectives Define

Define abuse, neglect, and financial exploitation

resident rights for self-determination and Understand Understand decision-making

Apply

Apply mandated reporting requirements to vulnerable adult reporting responsibility

Identify

Identify organizational risks and risk mitigation strategies

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What’s In the News?

KARE 11 Investigates: Elder neglect alleged in locked down facilities (2020) Advocates: Staffing, medication issues core to Central Minnesota elder abuse investigations (SC Times, 2020) Minnesota clears giant backlog of elder abuse complaints (Star Tribune, 2018)

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Minnesota Vulnerable Adults Act

The Minnesota Vulnerable Adults Act of 1980 establishes requirements for reporting alleged maltreatment of vulnerable adults to government agencies, investigating maltreatment reports, and providing protective services to vulnerable adults.

The purpose of the act is to ensure that vulnerable adults are safe in their living environments and in the receipt of health care and supportive services. The act has been amended numerous times.

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Adult Abuse Reporting Center

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Until 2015 there were 150 county-based systems for reporting crimes against vulnerable adults when the Minnesota Legislature created a statewide hotline for people to report mistreatment of vulnerable adults.

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The Minnesota Adult Abuse Reporting Center (MAARC) is open 24 hours a day, seven days a week.

Minnesota Adult Abuse Reporting Center (844) 880-1574 https://tnt09.agileapps.dhs.state.mn.us/networking/sites/880862836/MAARC Advanced Health Institute 2021

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Adult Abuse Reporting Center

 https://tnt09.agileapps.dhs.state.mn.us/networking/sites/880862836/MAARC

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MAARC Responsibility 

Notify county social services if a vulnerable adult needs immediate adult protective services.

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Notify law enforcement of any report of suspected maltreatment in which there is reason to believe a crime has been committed.

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Refer reports of suspected maltreatment to the lead investigative agency for responding to the report, which may include county and adult protection or reports to state agencies such as the Minnesota Department of Health or the Minnesota Department of Human Services.

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Vulnerable Adult Definitions Maltreatment (626.5572, Subd. 15.) - "Maltreatment" means abuse as defined in subdivision 2, neglect as defined in subdivision 17, or financial exploitation as defined in subdivision 9.

Abuse (626.5572, Subd. 2.) - Actions that meet elements of a crime, regardless of whether there is a criminal proceeding or conviction. Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: physical abuse, sexual abuse, or emotional abuse.

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Vulnerable Adult Definitions Neglect (626.5572, Subd. 17.) - The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision necessary to maintain health, comfort, or safety. It is not the result of an accident or therapeutic conduct.

Financial Exploitation (626.5572, Subd. 9.) - Failure to use the financial resources of the vulnerable adult to provide food, clothing, shelter, health care, therapeutic conduct or supervision for the vulnerable adult, and the failure results or is likely to result in detriment to the vulnerable adult.

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Vulnerable Adult Definitions Accident (626.5572, Subd. 3.) - An unexpected event which could not have been prevented by exercise of due care while a vulnerable adult is receiving services from a facility and happens when the facility and the employee are compliant with the laws and rules relevant to the occurrence or event.

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Vulnerable Adult Definitions Therapeutic Conduct (626.5572, Subd. 20.) - The provision of health care or other personal care services done in good faith in the interests of the vulnerable adult by a facility, employee, or person providing services in a facility under the rights, privileges and responsibilities conferred by state license, certification, or registration.

Mandated Reporter (626.5572, Subd. 16.) - a professional or professional’s delegate while engaged in the care of vulnerable adults.

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Vulnerable Adult Definitions Self-Neglect [626.5572 Subd. 2(c)] - Occurs when a vulnerable adult does not meet needs for the food, shelter, clothing, healthcare or supervision necessary to maintain or attain his/her health (DHS).

This Photo by Unknown Author is licensed under CC BY-SA-NC

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Witnessed/Unwitnessed Injuries should be classified as an injury of unknown source when both of the following conditions are met: 

An incident is not observed, or the source of the injury could not be explained by the resident.

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An injury is suspicious due to the extent of the injury or the location of the injury or the number of injuries observed at one point in time or the incidence of injuries over time.

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Self-determination Versus Self-Neglect 

Everyone has the right to make personal choices – being in control of one’s life, a causal agent, acting versus being acted upon.

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When a person-centered approach is used, support and service planning is not driven by professional opinion. Instead, planning looks at services and supports in the context of what it takes for a person to have the life they want.

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Self-determination Versus Self-Neglect Everyone has the right to make personal choices – good or bad.

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Minnesota Bill of Rights for Assisted Living Residents 2. Refusal of care or services.

Residents have the right to refuse care or assisted living services and to be informed by the facility of the medical, health-related, or psychological consequences of refusing care or services.

7. Individual autonomy.

Residents have the right to individual autonomy, initiative, and independence in making life choices, including establishing a daily schedule and choosing with whom to interact.

People have the right to do wrong and must pay the consequences for their actions.

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Decision-Making Capacity The question is not whether we make good or bad choices, but rather whether we have the capacity to make a choice.

Capacity does not always equate to making a good decision.

It’s the ability to understand the possible consequences of our decision. It’s a slippery slope when we evaluate quality of decision a right or wrong.

Must protect/keep safe as a reason to take away decisionmaking right. Nothing is 100% safe! There are no guarantees!

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Decision-Making Capacity In general, when you assess the capacity of a person to make a particular decision, you are considering whether the person can do the following: 

Understand the facts involved in the decision.

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Know the main choices that exist.

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Weigh up the consequences of the choices.

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Understand how the consequences affect them.

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The Reality…

The reality is that we care for residents living with individual physical and psychological challenges, and complex family and social dynamics.

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Vulnerable Adult Reporting 

Report timing - 626.557, Subd. 3(a).

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Witnessed or unwitnessed.

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Explainable or unexplainable injury - 626.557, Subd.3(a).

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Reporting to law enforcement - 626.557, Subd. 3(2)(b).

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Verbal or physical aggression between residents 626.557, Subd. 3a(2).

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Self-abuse - 626.557, Subd. 3a(2).

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Vulnerable Adult Reporting

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Internal written policy and procedure - 626.557 Subd.4a.

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Facility or mandated individual reporter - 626.557 Subd. 4a.(b)(c)(d).

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Immunity protection - 626.557 Subd. 5(a).

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Falsified reporting - 626.557 Subd. 6.

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Failure to report - 626.557 Subd. 7.

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Questions to Consider 

Is a report required? Does the incident meet the definition of maltreatment?

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Do I have all the details of the incident to make an accurate determination?

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Would I be over-reporting based on fear?

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What does facility policy and procedure require?

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What does history reveal about similar incidents?

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How do I best minimize individual and facility risk?

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Reporting Goals 

Promote resident safety and right to be free from maltreatment.

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Comply with reporting requirements and timelines.

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Consistency in applying facility policy and procedure.

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Avoid onsite investigation where possible.

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Manage risk to the facility and individual.

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Reporting Timeline Statute at 626.5572, Subd. 10 - A report must be made ‘immediately,’ however, further states that immediately means as soon as possible but no longer than 24 hours from the time that initial knowledge that that incident occurred is received.

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Reporting Timeline If staff did not report to the facility administrator a reportable incident until days after the fact, should the facility still report?

YES! be transparent and tell your story in a timeline If appropriate, try to show how it was not clear until after the fact, that it was a reportable event.

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Agency Responsibilities 

Upon request of reporter, agency must notify the reporter that the report was received and provide information on an initial disposition of the report within 5 business day of report receipt.

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Provide disposition based on whether facility actions were in accordance with provider order, prescription, resident care plan, or directive.

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Agency Responsibilities 

Conclusion based on the facility’s compliance with related regulatory standards, adequacy of policy and procedures, facility training, supervision, and staffing levels.

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Disposition based on whether facility actions were in accordance with provider order, prescription, resident care plan, or directive.

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Whether facility or individual followed professional standards in exercising judgement.

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Agency Responsibilities 

Complete final disposition within 60 calendar days, or 

Notify the vulnerable adult or the guardian or health care agent, when known and are aware of the investigation.

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Facility where applicable.

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Provide reason for delay and projected completion date.

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Determination Findings Substantiated– a preponderance of evidence meets the definition of maltreatment  Not substantiated– a preponderance of evidence shows that the definition of maltreatment did not occur.  Inconclusive– there is not a preponderance of evidence to show that maltreatment did or did not occur. 

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Determination Appeal 

Maltreatment determinations may be appealed by an individual or facility by requesting administrative reconsideration.

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A request for reconsideration must be submitted in writing to the lead investigative agency within 15 calendar days after the parties in the case received notice of the agency’s final disposition. [Minn. Stat. § 626.557, subd. 9d, para. (a)]

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Abuse Prevention Plans Individual Abuse Prevention Plan 626.557, [Subd. 14] 

Assessment of a person’s susceptibility to abuse by other individuals, including other vulnerable adults.

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A person’s risk of abusing other vulnerable adults.

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Specific measures to be taken to minimize the risk of abuse to that person or other vulnerable adults (includes self-abuse).

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Abuse Prevention Plans Use action steps such as ‘Encourage the resident to remain in full view’, instead of ‘keep the resident in full view.’

We all know that we cannot assure the resident will remain in full view. Why set yourself up for a deficiency.

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Abuse Prevention Plans Why are these interventions problematic?

They are unattainable.

We all know that when caring for people we cannot consistently deliver the intervention as planned.

We are setting our facility up for a deficiency when we use these interventions.

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Abuse Prevention Plans

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Abuse Prevention Plans

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Abuse Prevention Plans Develop criteria to address when resident needs or family expectation exceed or staffing levels.

Offer to find alternative placement.

Know the regulations for when you can issue a 30-day notice and when you cannot.

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Risk Management Family interaction after an injury: A common complaints from suing families: 

No explanation as to why the injury happened.

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Lack of compassionate communication after an incident.

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If a resident requires hospitalization or passes away: 

No condolences

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Risk Management Strategy Strategies to Avoid Lawsuits: Provision of Care 

Timely resident assessment and medical intervention.

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Perform comprehensive incident investigations.

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Document investigation results.

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Identify interventions and document.

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Document efficacy of new interventions.

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Consider/implement additional interventions.

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Maintain an updated care plan and orient staff to plan.

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Risk Management Strategy A good medical record includes: 

Evidence of interventions and interactions.

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Made during the regular course of business.

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A record of communication with the family and doctor.

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An explanation of what care was given and why (and sometimes even how).

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Staff Training Include VA training upon hire and annually including: 

Overview of statute 626.557.

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Review of facility vulnerable adult policy and procedure including role-based responsibility for event documentation and internal reporting.

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Interactive group discussion using examples of reported events, associated actions, and outcomes.

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Competency evaluation.

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The Reality…

Bad things can and do happen…falls, bruises, wounds fractures, elopement, missing resident property, drug diversion, and even death.

It is how we manage through them that matters.

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Thank You! Linda Hall, MA, BSN, RN, CPHQ, Nurse Consultant Advanced Health Institute (AHI)

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