Thursday, November 13, 2008

Everytime a CNA becomes a NHA, an angel gets its wings

I very rarely talk about myself, but I am going to make an exception just this once. I got my administrator's license!!! I went through the process in Michigan, because if you are a RN you don't have to meet any other requirements besides passing the state and national licensure examinations. I probably won't be running a facility anytime soon as I got the license primarily for enhancing my ever-growing list of credentials and qualifications.

As far as that something special I promised, I am going to put up a NAB test that I constructed myself when I was studying. I found that I can learn and retain information better if I act as if I'm having to teach it, so a mock exam was in order. I don't recall any of the questions I made actually showing up on boards, but it should serve its purpose well and it will save you however much you might otherwise pay for a practice test (I've seen them go for $15 to $75 apiece). Look for it to come out either tomorrow or saturday.

Monday, November 10, 2008

Once again, slides are late

MDS inservices for both CNAs and LPNs is available at They are over a week late, so watch out for the good thing I have promised.

Sunday, October 26, 2008

All about IDR

There are two processes in place for challenging surveyor findings: formal appeals (which is used primarily for getting rid of civil monetary penalties) and informal dispute resolution. Informal dispute resolution is used primarily to get F tags taken off the record when the allegation of deficiencies doesn't actually represent an actual deficiency. It can also be used to challenge the scope and severity of quality of care deficiencies. It cannot used to challenge deficiencies on a follow up survey that have been cited on a previous survey, for scope and severity on F tags that do not fall within the quality of care domain OR represent an immediate jeopardy, to challenge remedies levied by the state or federal government, procedural violations on the part of the surveyors, or alleged inconsistency in the way that two different facilities were surveyed. In order for an IDR to be successful (and they rarely are -- less than 20% of the time), you have to either show that the alleged deficiency is not actually a violation (although the state survey agency may label this as a procedural violation and then disqualify your claim) or that there is documentation to support the facility's position that was not reviewed by the surveyor at the time.

Wednesday, October 15, 2008

NHA without AIT

If you want to become licensed as a nursing home administrator, almost all states require that you have a bachelor's degree and complete an administrator in training program, which is a 6 to 12 month preceptorship with an experienced administrator, all before you are allowed to take the state and national boards. There are two states that do not require an AIT for licensure, just a bachelor's degree OR licensure as a RN: Illinois and Michigan. A third state, Missouri, has relatively lax standards for licensure but they reserve the right to require an AIT if they think it is necessary.

Tuesday, October 7, 2008

Good news and bad news

Good news: This month's powerpoint slides are up at The topic this month is skin.
Bad news: Once again, I'm a week late getting them out. I promise to have next month's slides up by November 1, or I'll do something good to make up for it.

Tuesday, September 30, 2008

Life Safety Resource

While trolling the web, I came across a very interesting document -- a fire and life safety toolkit. It has everything you might possibly need to prepare for a LSC survey. It's available at:

Thursday, September 25, 2008

Another long term care blog! Yay!

A DON is blogging about her work at I really like her take on things; have a look sometime.

Tuesday, September 23, 2008

Wound care wisdom, part deux

Here are some quick tidbits on dressing types.
-Hydrogels are the way to go for wet-to-dry; they work well for most applications
-Hydrocolloids are not appropriate for acute care, but might be okay for nursing homes
-Acrylics only have to be changed every 7 days (can sometimes last even longer)
-Foams are best for shallow wounds on the extremities; don't use on the sacrum
-Aliginates are used for lots of drainage
-Hydrofibers absorb 3x more than aliginates
-Xenaderm is good for progressive stage I/II ulcers
-Betadine keeps necrotic tissue dry and is best for heels and toes

Monday, September 15, 2008

Wound care wisdom, part 1

-Juven is better than Boost or Ensure for residents with low albumin levels, and can be mixed with near anything, thus increasing compliance.
-Arterial ulcers need to be kept dry, preferably with Betadine.
-Venous incompetence with lymphedema: redness is most often reactive erythema and not infection, so don't give antibiotics.
-Betadine keeps necrotic tissue dry and is best for heels and toes.
-If there is a yellow ulcer, the red spots that are speckled throughout it are hair follicles and this indicates that it is a stage II.
-Heel ulcers are 100% preventable.

Friday, September 5, 2008

New Slides are Here

The September staff development slides are finally up at I apologize for taking so long to post them, and also for not writing any blog entries in a while. It's been a crazy month.

For the bathing slides, you need to also access this page to find out most of the information listed:

Friday, August 15, 2008

Book Review: The Principles of Health Care Administration

I've finally found a book on nursing home administration that I finally like. If you've seen my reviews on, you probably know that I absolutely loathe James E Allen's Nursing Home Administration. I was at a used book store in Nashville on monday and I found a copy of Winborn Davis's The Principles of Health Care Administration for only $5, which is great because it sells for $103 new -- I think that's just a bit too much. The book is divided into four chapters, one for each of the four NAB domains. It almost reads like a commentary on the State Operations Manual because most, if not all, of the F tags are discussed at length. The chapter on financial management needs more practical advice on how the business office should be run, but other than that I was thoroughally impressed. I think it would be the perfect AIT text or study guide for the NAB boards. Although it's out of print on amazon, it can still be ordered here for $98.50.

Sunday, August 3, 2008

New nursing home blog is a new blog that shows a lot of promise. Check it out!

New Staff Development Slides Availble

This month's staff development slides are now available at The topics are "Feeding the Hard to Feed" and "Renal Failure".

Thursday, July 24, 2008

F314: Pressure Ulcers


The facility must prevent pressure ulcers and effectively treat those that are present.


Pressure ulcer prevention must be promoted. Existing pressure ulcers must be treated appropriately, and the development of additional pressure ulcers must be prevented as well.

Common Reasons for Citing F314:

The lack of documentation and monitoring is the most common reason this tag is cited. Other causes include the care plan not being individualized for the resident with a pressure ulcer, failure of the communication process between CNA and nurse regarding the development of pressure ulcers, the lack of dietary intervention, failure of the nurse to notify the physician, the lack of pressure relieving devices even if not ordered, wound care not being provided per physician order, the nurse’s failure to maintain clean or sterile technique as indicated, using a shearing motion while turning and repositioning the resident, and providing wound care without cleaning up incontinence beforehand.


With the lack of documentation being the biggest factor with this citation, frequent chart audits are essential. It is also essential that nurses providing wound care be observed for their compliance with physician orders and established guidelines. Some facilities have had great success by having weekly skin rounds, in which an interdisciplinary team (including at a minimum the skin or wound care coordinator, MDS coordinator, DON or ADON, and dietician) shadow the treatment nurse as wound care is provided. This team based approach provides the opportunity for all of the above-mentioned audits to be done in a timely and efficient manner. It is also necessary to have an effective system in place for addressing CNA-nurse communication.

Thursday, July 17, 2008

Reminder about restorative

If a resident is receiving two different forms of restorative nursing at least 6 days a week, they will RUG into RLA or RLB (depending on the ADL score). This can mean up to an extra $75 per day, which amounts to roughly an additional 2K/month - 24K/year.

Tuesday, July 8, 2008

Profiting from Private Duty

At the beginning of this month, the state of Tennessee enacted a new law that shifted a large portion of Medicaid's long term care designated funds from nursing homes to in home private duty care services. This has obviously caused nursing home providers a great deal of worry, a' la "We're gonna lose all our patients!" The new law is actually a blessing in disguise to nursing homes because it gives us a perfectly valid reason to expand our product lines. Having a nursing home to provide home care services is a winner. The biggest issue in private duty nursing is human resources (recruiting and retaining nurses and techs, credentialing, staffing, etc.). Nursing homes have been dealing with these same issues for years and have the tools to address them (although many choose not to use for whatever reason). Since most nursing homes have an existing CNA training program in place, training additional caregivers would not become a problem. Staff could (not should) be rotated in between private duty and nursing home divisions, and developing a PRN pool would be a little bit easier. Additionally, community relations could be maintained and/or improved, particularly in rural areas, and continuity of care could be taken to new heights.

Monday, June 30, 2008

New training slides

This month's free staff development powerpoint shows are now available at The topic is survey preparation.

Friday, June 27, 2008

The PHI books

Although this has been posted here before, I have had some requests to repost the links to two manuals available for free from the Paraprofessional Health Institute. They are:

Coaching Supervision

Peer Mentoring

4 Thoughts

I was in a most excellent training session with Dianne Harris earlier this week. Here are four little tidbits I picked up on:
1. Sliding scale insulin is no longer considered appropriate for the nursing home setting. I will do some research and write more about this later.
2. Nursing homes are an excellent place for BSN students to do nursing management/leadership clinicals. This is something you should consider doing, as it is a great recruiting tool for RNs.
3. When interviewing licensed nurses, be sure to ask some clinical questions to make sure that their level of competency is where you want it to be at. It is suggested that you ask these 3 questions, at a minimum: (a)What are the signs and symptoms of heart failure, (b)How would you recognize if someone was hypoglycemic, and (c)What would you do if someone was having a stroke in progress?
4. Post the list of emergency stock drugs by the phone, so the nurse doesn't take an order for a med that can't be administered right then. It will also save a nurse the time needed to retrieve the list from wherever it is usually kept, which also keeps her from looking incompetent in the doctor's eyes.

Monday, June 16, 2008

Thoughts on Nursing Home Reimbursement

There is no business case for quality in long term care. There certainly is in the hospital industry, where compliance with evidence based practice practices was shown in a Premier demonstration pilot to save 11K per CABG patient. The reason that nursing homes can't afford quality is the current reimbursement system. Under RUGs, we are financially rewarded for keeping residents sick and maintaining utilization of resources as high as possible. While this is good for the bottom line, it is no good to residents. Perhaps we could look at going back to capitation, a system in which a facility is paid X amount of dollars per month per resident, with the dollar amount being determined by the average cost of care for nursing homes in that region. While this may not be the best system for skilled residents, it is certainly feasible for residents receiving an ICF level of care. Nursing homes would then have an incentive to maintain quality standards, because poor resident outcomes would result in nursing homes having to absorb that cost (ie, there would not be additional payments for in-house acquired pressure ulcers or other preventable complications). Hospitals have a list of no-pay diagnoses, inpatient acquired complications that they are not allowed to bill for. Third party payers should demand the highest quality of care from nursing homes, just as they do from every other provider type.

Thursday, June 5, 2008

Free training slides

I am offering free powerpoint slides for staff development, available at New slides will be available by the first day of each month. Two different sets will be posted, one for CNAs and a second one for licensed nurses. This month's topics are abuse prevention and interpretation of laboratory tests. Enjoy.

Friday, May 30, 2008

Survey Paranoia

Some time ago I bought a bunch of nursing home books on ebay and came into possession of a mini-manual from one of the state nursing home associations (which will remain anonymous) on how to effectively manage surveys. Some of it was quite good, such as making sure that staff did not acknowledge guilt. This would be evidenced by a surveyor's statement on the 2567 (Statement of Deficiencies) that stated "The DON admitted that the CNA should have never done that", for instance. Some of it was bad, such as the suggested method for doing mock surveys that I will not go into here. And some of was disturbing. One particular chapter of this manual was devoted to keeping tabs on the surveyors. It actually stated that "an unobtrusive surveillance system to keep tabs on the essential". If that is not possible, the manual states, a staff member should be placed outside the door with walkie-talkie access to the administrator. Now before I go any further, I want to make it clear that this manual was about 15 years old, and would probably no longer be applicable because the state this came from currently utilizes a different type of survey protocol. But is goes to perfectly illustrate the industry's ridiculously paranoid attitude toward regulatory compliance. Interestingly enough, a expose that came out in 1997 ("Patients, Pain, and Politics") described similar behavior going back to the 1960's, when nursing home regulation was nothing compared to what it is today. Even when I worked the floor just a few years back this same attitude was the rigor de norm. Everyone sneaked around, talked in hushed tones, and tried to predict which resident would be interviewed next. As a consultant, I still see this behavior.

Nursing home surveys are nothing to be paranoid about, unless you're trying to hide your substantial noncompliance. Survey protocol is clearly spelled out in the State Operations Manual. It should be no mystery who gets interviewed, because the manual tells you. "But the surveyor's don't do things by the book!", I can hear someone cry. If they don't, then appeal it. That's what IDR and the appeals process is for. The reason that deficiencies happen is primarily because nobody knows the rules of the game called survey. As I cannot emphasize enough, TEACH YOUR STAFF THE STATE OPERATIONS MANUAL!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Of course this is a problem if you don't know it yourself. When a week long DON orientation attempts to cover everything about survey in 45 minutes, and the required text for virtually every AIT program in the country doesn't even mention the word 'survey', it's not entirely your fault. But if you haven't been taught it, you need to learn it for yourself. As anyone who has ever tried to read the watermelon book cover to cover can tell you (myself included), it's one hell of a boring book. Perhaps you could try this instead: Get the forms used in the quality indicator survey and do mock surveys through QAA committee with them. You will learn the rules as you go along because the contain the relevant F tags and the critical elements necessary for demonstrating compliance with them.

You can be paranoid about state if you want, but it's a waste of time and energy you probably don't have. If your facility is not survey ready when they walk in the door, there is only so much you can do to fix things while the surveyors aren't looking. Doing well on survey takes staff education and frequent mini mock surveys conducted over the course of the entire year. Waiting until you're already inside the window is uselsss.

Monday, May 26, 2008

RCA Tutorial

There is a great tutorial on how to do a root cause analysis here. It is from the National Center for Patient Safety at the VA, which has a lot of other wonderful resources too, such as fall prevention tools.

Tuesday, May 20, 2008

Free Abuse Prevention Training Resources

Get it here.

F281: Professional Standards of Quality Care


Services provided or arranged by the facility must meet professional standards of quality.


All services performed in the facility must conform to generally accepted standards of clinical practice. These standards may come from textbooks, current journals, position statements by such organizations as ADA, AMDA, ANA, etc., or clinical practice guidelines published by AHCPR.

Common Reasons for Citing F281:

Improper disposal of controlled substances

Failure to secure controlled substances

Leaving medications at bedside

Failure to assess for dehydration issues

Failure to carry out physician orders

Failing to add new interventions after a fall

No care plans or lack of care plan review for resident care issues

Not monitoring or assessing dialysis access site

Failing to date multidose vials when first opened

Pre-pouring of medications

Improper documentation of medication administration


Frequent education is necessary to make sure that nursing staff understand the standards to which they should be practicing under. Explanation of rationales is vital in this aspect. Working alongside nurses during medication passes is a useful technique for ensuring compliance with this tag and has the potential to improve staff morale if carried out in an appropriate manner. Having generic care plans available for frequently missed areas of care is another useful idea. Frequently missed areas include safe smoking, constipation, weight loss, hydration, fluid restriction, accident prevention and falls, skin breakdown, and hemodialysis.

Sunday, May 18, 2008

Free self study modules for CNAs

There is a collection of 16 self study modules here, designed for direct caregivers such as CNAs. Some of the topics include managing challenging behaviors 1 & 2, aspiration, dehydration, infection control, fall prevention, and documentation. It looks very promising and would make a great addition to any facility's staff development program, especially if you rely on self-study to help the aides meet their 12 hour continuing education requirement.

Thursday, May 15, 2008

Training your CNAs

In the vast majority of nursing homes, CNAs are taught from the immensely popular How To Be a Nurse Assistant. Published by the American Healthcare Association, it is one of their best sellers (right after their reprint of the CMS State Operations Manual). Irregardless of how good the book is, nurse aides quickly find it to be useless in the real world. Despite all of the skills taught in the book, it doesn’t adequately cover the three things that the average CNA spends 90% of their time doing: skin care (turning, positioning, changing, bathing), providing assistance with eating, and dealing with psychosocial issues.

It is no secret that training programs for nurse aides are not only irrelevant to what really goes on, but are also of an inadequately short length. Whatever notion you may have to the contrary, the CNA is not an unskilled worker. Although some of the physical tasks probably would be considered menial, that is not the point here. As Lori Porter pointed out in her autobiographical Everything I Learned in Life...I Learned in Long Term Care, a nurse aide has the power to either promote a resident’s physical, mental, and psychosocial well-being, or completely destroy it and take that individual’s last shred of dignity away from them.

Either we forget (or simply have never realized) the enormous power we have entrusted to these folks – power that oftentimes goes unchecked. If we are to fulfill our legal obligations as nurses and/or administrators to maintain the health and welfare of our residents, it is simply incomprehensible to think that we would delegate this enormous task to unskilled workers. Thus we must transform the workforce, which can be achieved in one of two ways.

The first way is to change the way that CNA classes are conducted. Consider lengthening the course from two weeks to three weeks. The current practice is to have the students spend a week in class, then a week on the floor. What I suggest is that you combine class time with floor time. After three days or so in the classroom dealing with non-clinical topics, slowly introduce the students to the residents. Let them know what is going on with them from a medical and from a psychosocial standpoint so that they can truly see in action the conditions they are learning about. Have the students spend time on the floor during its busiest times, and then during the lulls have them to return to the classroom to talk about clinical issues. Don’t be limited by the textbook – allow the student’s minds to go above and beyond the norm. It seems that every nursing home wants well trained staff but they don’t want to put forth any effort to achieve that dream.

Although some corporate owners and administrators may balk at this approach, citing increased costs, it is actually a worthwhile investment. It is common knowledge that the vast majority of CNAs quit soon after being hired so it is prudent to keep a proverbial safety net under them for an extended period of time. With this paradigm in place, the students will have a supporting framework when things get rough. During the latter part of the second week or the early part of third would be an excellent time to begin peer mentoring.

Tuesday, May 13, 2008

Happy Nursing Home Week!!

I would like to just take a moment to wish everyone a happy national nursing home week. Thank you for all that you do. As nursing home providers, you take care of those who can't take care of themselves, despite being ridiculously overworked, underpaid, and sorely underappreciated. Thank you.

Saturday, May 10, 2008

Acuity Based Staffing

Sometimes staffing is based on resident acuity levels. This is usually calculated by averaging the RUG scores. However, this causes a big problem: Higher acuity levels don't necessarily mean that more CNA care is required, just more skilled nursing and/or rehab. CNA staffing should be based on average ADL scores. Doing so will eliminate complaints that you are being unfair about making assignments (ie, "on the ICF wing we've got 12 patients each that are all total care and Susie on skilled only has 8 patients that don't need a mother flipping thing").

Friday, May 2, 2008

F309: Quality of Care


Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care.


It is the nursing home’s responsibility to make sure that residents either get better or stay the same (within the resident’s right to refuse treatment), within the limits of the resident’s medical condition and/or the normal effects of aging.

Common Reasons for Citing F309:

The most common reason this tag is cited is for failure to reposition. For example, a resident is observed sitting in the same position for 3 hours, even though they are care planned to be repositioned every 2 hours. Another common reason for this tag is missing lab work. Other reasons that have been used to justify this citation include failing to properly manage pain, noting that residents are not wearing TED hose that has been care planned, failure to protect fragile skin, and lack of foot pedals when their use is obviously necessary. F309 is a sort of catchall citation and is frequently cross referenced to other tags.


Because of the vague nature of F309, it is often difficult to adequately plan for this. Missing lab work can be oftentimes be prevented by requiring nurses to maintain a log of lab work or having all labs being coordinated through just one individual, usually a RN supervisor or administrative nurse. Issues with repositioning can be handled by educating and monitoring staff on its importance. Some facilities have attempted to tackle persistent repositioning problems by keeping underpads in three different colors and requiring direct care staff to change the existing pad to one of another color every two hours. The resident will be repositioned in the process of the pad change, and it becomes rather easy to monitor staff compliance by just checking to see what color the pad is. The other issues can be addressed by frequently walking around and observing how residents are cared for.

Tuesday, April 29, 2008

Culture change on the cheap

CMS and the Pioneer Network had a culture change conference earlier this month and now the presentations are online at The most interesting one is "Low Cost Practical Solutions", which has some very good ideas on how to make things better with a minimum of both money and effort. Take a look.

Sunday, April 27, 2008

Focus on the money part deux

There are quite a few nursing homes that like to limit supplies in a well-intended effort to contain costs. This practice is pound foolish and penny stupid. Not only does it decrease employee morale and directly affect resident care in a negative way, but it is a waste of time and energy that most administrators don't have to begin with. Assuming that with volume discounts, an incontinence brief will run you anywhere from about 30 to 50 cents each. Limiting how many briefs can be used per day will save you a dollar, maybe a buck fifty, per day per resident. Maximizing the RUG score by educating CNAs on their part and by ensuring that MDS nurses are credentialed will increase your revenue by a minimum of several dollars per day per resident. I'm not in any way saying you should try to defraud third party payors, but you should go to great lengths to make sure that your assessments are as accurate as possible. In short, go after the many big fish instead of concentrating on the few small fish that are out there in the sea of finance.

Wednesday, April 23, 2008

Preparing for LSC inspection
is the form that surveyors use to ensure compliance with the Life Safety Code. Perhaps you could find it useful when preparing for inspections.

Thursday, April 17, 2008

3 thoughts about employee behavior

1. 90+% of the time, folks do the best they know how under the given circumstances
2. There are four primary goals of behavior: Power, revenge, attention, and display of inadequacy
3. has "Coaching Supervision" pdf files for free (Normally $99 through AHCA)

Tuesday, April 15, 2008

Nursing Homes: Focus on the Bottom Line!!!

You may be thoroughly convinced otherwise, but I think that nursing homes don't think enough about making money. Reimbursement is typically something that only the front office and the administrator are concerned about, but I would encourage you to get every single member of your staff in a money mindset. Teach them how nursing home finance works. Make sure that CNAs understand (I mean *really* understand) how the ADL and restorative documentation that they are responsible for raise the RUG levels. It is imperative that everyone in the facility appreciate the MDS. Insist that anyone who so much as breathes on the MDS gets certified so that they know what they are doing. Have an inservice for the licensed nurses on what they have to chart for skilled residents, and why. Conduct an open-house meeting as you are preparing the annual budget. Share your projections with all staff and get their feedback. By getting everyone in a money mindset, not only are you helping the facility but you are helping them. Although unconventional, it is empowerment at its best, because everyone can see that they are making a difference in the one thing that seems to matter most to corporate owners -- making a profit.

Wednesday, April 9, 2008

Free videos for staff development

I've found some really good videos online on how to do nursing stuff, and of course they're free. They would make an excellent tool for a cash-strapped staff development office.

Thursday, April 3, 2008

Book Review: Quality Management Integration in Long Term Care

I was initially quite excited to get this book and it came with the full blessing of AHCA. After reading it, though, I am rather disappointed. I was expecting a book that actually explained practical applications of quality improvement in nursing homes, and this book was not that at all. It is a discourse explaining the need for quality improvement along with a very broad based overview of some statistical tools. It is not at all practical and seems to be geared more for students in a college-based NHA training program. I am not as enthusiastic about interviewing residents, staff, and families about quality as the authors, mainly because I feel that most folks in the nursing home are petrified of retribution and will tend to give answers that they think administration wants to hear. One bright spot of the book, however, is chapter 4, "Internal Critical Issues", which discusses barriers to quality improvement. Overall, the only truly good thing about the book is that it doesn't reference Allen's opus magnum which I detest. Although I commend the authors for being one of the very few to write a book on such an vital topic, I really have a hard time recommending it. A better QI text is "Quality and Performance Improvement in Healthcare", published by AHIMA, because it is extremely practical and does talk about long term care at length.

Monday, March 31, 2008

How to know when you have acheived quality

AAHASA has put together a series of questions that are asked in order to determine how focused a nursing facility is on quality. Although designed for consumers, it is also a useful tool for using internally. Take a look sometime.

Saturday, March 29, 2008

Are you a nursing home nazi?

I read an interesting discussion on the forums called "Rounds, Falls, and Skin issues". What caught my eye is this:

"On another note, this same study revealed another "secret." In war days in the concentration camps the prisoners were subjected to various types of torture. Among these was that they were awakened every 2 hours during the night and forced to stay awake for about 10 minutes and then allowed to go back to sleep. This severely disturbed their sleep patterns and thus, made them clumsy and confused during the day due to lack of proper REM sleep. Hmmm, is this what we are doing to our elderly? Is this part of the reason for so many falls and inappropriate behaviors?"

Does the way your facility take care of residents actually cause more harm than good? This is something to really think about.

Wednesday, March 26, 2008

A most powerful excerpt from "Everything I Learned in Life...I Learned in Long Term Care" by Lori Porter

"At that minute, I knew there was nowhere else a high school dropout could go and have that much power and influence...You see, we have the power to make an old person feel special, beautiful, worthwhile, needed, wanted, respected, revered, admired, and productive, but we also have the power to strip them of their every dignity. That power should come with a warning, and we should all be reminded of it everyday. None of us fully appreciate or comprehend the power of our own influence."
Although this book has been out for some time, I just got the chance to read it last night and I was really touched by it. I especially appreciate the above-mentioned quote so much that I plan on printing up a copy and sticking it in front of my desk just to remind me how much power I really do have working in long term care. I think you should print off a copy too, and make sure that no one in your nursing home forgets that power either.

Tuesday, March 25, 2008

2 things to think about doing

(1) Require all employees to initiate a conversation before touching a resident or doing something clinical to them
(2) Recruit volunteers to come in and write down the stories of resident's lives that they dictate to the volunteers. Share these stories with staff so they realize that the resident is a person with a rich, vibrant history and not just some inanimate object to feed, change, and bathe.

Wednesday, March 19, 2008

Occupational Hazards in LTC

OSHA has an interactive nursing home set up at where you can learn pretty much everything there is to know about occupational hazards in the long term care setting.

An interesting nursing home blog

Barbara Mitenberger has created an excellent blog at It focuses on the legal aspects of nursing home administration and is highly informative. Thanks Barbara!

Tuesday, March 18, 2008


Depending on who you ask, anywhere from 1/3 to 1/2 of nursing homes are cited with a F371 tag in a year. F371 requires that kitchens be clean and sanitary. One way to verify that the conditions of F371 are being met is to have the dietary manager to conduct a weekly audit. The easiest way to do this is to make a list of all potential violations and have the manager to circle them as they occur. The possible violations are:











(This means foods that are animal derived and/or high in protein)

















Saturday, March 15, 2008

Lectures on Pain Management

IPro has a set of 6 mp3 files on pain management in nursing homes at It's a good resource for audio learners.

Friday, March 7, 2008

SPIRIT: A rapid QI program that stays on the floor

Beth Israel Deaconess Medical Center in Boston has recently launched a new semi-informal QI initiative called SPIRIT: Solutions Promoting Improvement Respect Integrity & Teamwork. I'm feeling a bit lazy right now so I'm just going to link to its description on their CEO's blog here. Nursing homes seem to never do anything innovative, so the next best thing is to steal ideas (steal? I really mean borrow ideas) and adapt them to the long term setting. One thing that really impresses me about the SPIRIT initiative is that it strives to empower employees to answer these 3 questions with a "resounding YES!":

"Am I treated with dignity and respect by everyone I encounter, regardless of role or rank in the organization?

Am I given the knowledge, tools and support that I need in order to make a contribution to my organization and that adds meaning to my life?

Did somebody notice I did it, i.e., am I recognized for my contributio

Can every single employee in your nursing home, administrator on down to the lowliest part-time laundry aide, answer these questions in the affirmative?

Monday, March 3, 2008

Quality Indicator Surveys

The surveyor's manual for the quality indicator survey program can be found at Under "Tab 9", you can find the phase II critical elements. These forms serve as a sort of "how to survey nursing homes for dummies". They tell exactly what to ask residents and staff, exactly what type of documentation needs to found in the chart, what needs to be observed, and which F tags should be cited and under which conditions. It seems that this could be a great tool for your facility's QA committee, as they would be able to take care of quality issues while preparing for surveys at the same time.

Friday, February 22, 2008

Lessons in Quality Management

Here are some ideas I picked up from chapter 7 (Quality Management in Military Medicine) of Chip Caldwell's Handbook of Managing Change in Health Care:
1. "Throwing money at a problem usually only makes it worse"
2. Crisis management is bad. It is used to demonstrate that something is getting done. It causes processes to break down and for people to make shortcuts in order to save time. "Quick productivity takes precedence over quality".
3. "The fear or inability to say no in an organization is enormously destructive to any QM initiative. It immediately creates distrust and stifles productive feedback. Employees are fearful of being fired. Exposing any weakness or faults labels the employee as a troublemaker. Employees are then very distrustful of any management scheme that talks about empowerment. If they don't see empowerment or trust in action, they will correctly decide that it doesn't really exist. If their evaluations are based on the quantity of work performed, process improvement will be seen as a waste of time. Their view is, 'Why spend the time required to fix processes?' For them, management's over-focus on short-term tasks or projects give visible (but false) evidence that real work is being done."

I find this last item particularly true. It is interesting that this comes from a chapter about quality in military medicine, as I once heard someone say that calling CNAs the 'front line' makes it sound as if we are fighting a war. Perhaps we are.

Thursday, February 21, 2008

Employee vs Patient Centered Healthcare

Hospital Impact blog had a post on this recently. What are your thoughts on this delicate balance?

Saturday, February 16, 2008

Why nursing homes have poor quality

I was thinking about this last night and realized something quite obvious. JCAHO, the organization that accredits virtually every hospital in this county, has established standards for hospitals to go by. These standards are considered optimally achievable outcomes -- what a facility should aspire to be. CMS standards, the ones that nursing homes are required to comply with, are minimum standards -- the absolute bare minimum you can do to get by with. Literally every single nursing home I have worked with has regarded the CMS minimum standards as optimal achievable outcomes. The prevailing thought in the long term care industry is that a deficiency free survey is something you should aspire to. The problem with this thinking is that a deficiency free survey only means that you are providing a minimally acceptable level of care. Facilities must truly desire to go above the minimum standards, which requires blowing up the box and getting the hell away from the status quo. Unfortunately this is too scary for most providers and corporate owners. Nursing homes have the worlds worst case of "we have never done it this way before" that anyone has ever seen.

Tuesday, February 12, 2008

Medication Regimen Review Resource

If your facility's QA committee needs some help with medication regimen reviews, there is a course page from the University of Washington School of Pharmacy here that you will find useful. There are a number of course handouts that address things like breakdown of drug delivery systems (ie, how things can and do go wrong), classification of med errors, how to actually do a drug regimen review, Beers criteria, drug delivery systems in nursing homes, and lots of stuff on the law.

Monday, February 11, 2008

Great new MDS site

I found a great MDS site this morning, run by the state of Missouri's MDS help desk. Check it out here.

Handwashing, Semmelweis, and Quality Improvement

Did you know that the best way to prevent infections is to wash your hands frequently? Apparently the only people who didn't know this worked in nursing homes. There was an article in this month's AHCA Provider about this suprisingly new concept that was just recently discovered about, what, 100 years ago by Semmelweis. Ironically, the so-called "Semmelweis Reflex" is an outright dismissal of any information that is radically out of sync with the status quo. Kind of like introducing *real* quality improvement to nursing homes (by real, I mean the prospective, quantatative kind that actually gets results, not some half-arsed PDSA crap). If you need proof that this truly non-existant, take a look here.

Monday, February 4, 2008

Testing interviewees for honesty

Check out this idea from Service Untitled, "Find More Honest Employees". There might be some legal issues with this, as the author warns, but it is an interesting way to test prospective employees for honesty. I would certainly appreciate knowing who might and might not wind up being a thief.

Food for thought on suggestion boxes

I was killing time at a used book store on saturday and bought a cheap copy of Nuts!, a book on how Southwest Airlines is driven by innovation. There was a blurb on suggestion boxes that I would like to share here: "One of our managers mentioned to me that he wanted to put up a suggestion box. I responded by saying, 'Sure--why don't you put up a suggestion box right here on this wall and then admit that you are a failure as a manager?' Our theory is, is you have to put up a box so people can write down their ideas and toss them in, it means that you are not doing what you are supposed to be doing. you are supposed to be setting your people up to be winners. To do that, you should be there listening to them and available to them in person, not via a suggestion box...I think that most people employed here know that they can call any one of our vice presidents on the telephone and get heard, almost immediately." The book then goes on to say that at Southwest, managers are expected to spend a minimum of 1/3 of their time walking around. That's exactly what the NHA and DON need to do.

Thursday, January 31, 2008

Something to do during stand-up

During the daily stand-up meeting (a.k.a. department head), assign each person to go 2 or 3 tasks in the facility that will only take 5-7 minutes total to complete. Tasks could include returning an empty oxygen tank to the tank holder out back, cleaning up a messy sink area, helping a CNA with rounds, or getting a resident a cup of coffee. Put each task on a card and have each person draw a couple. Everybody participates -- no exceptions. This will do a lot for improving staff morale.

If Nordstrom ran your nursing home

Nordstrom's is a chain of upscale department stores famous for their customer service. They only have one rule for employees: "Use your best judgment". Let's play a quick game of what-if and imagine Nordstrom being hired to run a nursing home (this is just the ICF wing; Disney can run the skilled hall). Residents would be able to participate in the activities of their choosing, and it wouldn't just be groups like church and bingo. Nurses wouldn't have superfluous charting, aides wouldn't be assigned useless tasks like putting ice in water pitchers that everyone knows are never drank out of. Aides would pretty much run the place, in fact, and nobody would have a problem with it. There would be fewer med passes. Administration would never be in the office, and all the meetings would be condensed into one. There would be hot coffee and fruit for visitors to enjoy, and of course the residents would be partaking as well. Mutual cooperation between everyone would foster a genuine element of customer service, with customers being all stakeholders and not just visitors and residents. But now it's time to return to reality. What can you do today to bring the nursing home just a little bit closer to Nordstrom's?

Monday, January 28, 2008

Following up with new employees

You need to meet with new employees either 30 or 90 days after they are hired. You still need to meet with them informally on a regular basis before this point in time, however. This needs to be a quick little 5 or 10 minute sit-down meeting where you work on these 4 vital questions:
1. Now that you've been here for a while, how do we compare to what we claimed to be when we hired you?
2. What are we doing that's good? Who here has been helpful to you?
3. At the last place you worked, what were they doing that we could do here to make things better?
4. Is there anything here you don't like? What can we do to make things better?
After this meeting, continue to meet with your staff. If the employee has any answers to ideas 3 or 4 that deserve recognition or reward, make sure they get it.

Saturday, January 26, 2008

Random thoughts on customer service

Nursing homes typically give a horrible initial impression, simply because, well, that's just how they are. How can you fix it? I'm not talking about what to get rid of (except for the a-hole staff), but rather what can you add. How can you make your staff more friendly? What can you do to foster relationships between families and staff? How can your on-hold messages be changed so that callers get to hear something other than really bad advertising for the facility? Honestly, who cares about the bingo schedule? Get some ideas from other industries at

Friday, January 25, 2008

Yesterday's MDS 3.0 Conference Call

I didn't have a chance to listen in on the MDS 3.0 open door forum yesterday; I was urgently called out of town to deal with a pressing issue during the same time as the conference call. However, the topics that were discussed were posted online at
You can check out the results of the pilot projects and validation studies, which are now finished.

Tuesday, January 22, 2008

Open Letter to CEOs
is one management consultant's advice to all corporate executives. Although not directly applicable to nursing homes, or even healthcare, a lot of the same principles still apply, like, "If you want to see things change immediately, stop being an asshole". Check it out and apply it today.

MDS 3.0 Special Open Door Forum

CMS is having an open door forum at their Baltimore office on Thursday to allow providers to give their 2 cents worth on MDS 3.0. However, it will be presented as a teleconference as well, since there were more people interested in participating than there were seats. You can register at the CMS website. If you don't want to, or can't, take the call, check back here on Thursday afternoon and I'll post the highlights. Otherwise, you can download an audio recording of the teleconference after January 30 at

Sunday, January 20, 2008

Thanks to the Tennessee State Veterans Home, Murfressboro

Recently, I've had the opportunity to observe operations at the Tennessee State Veteran's Home in Murfressboro. Initially, I expected the worst. TSVH has gotten loads of bad press in the media, as they had 8 immediate jeopardies on their last survey. However, I was pleasantly suprised to find out that the facility was actually one of the best I have ever been in. I would especially like to commend the staff on the North Wing, which is the secure dementia unit. Robin Ronewicz, Gail Fish, and Annah Jones are truly exceptional staff members, and Diane Williams is one of the best house supervisors I have ever had the pleasure to meet. I would again like to express to them my thanks for the great work they do. I sent the administrator of the nursing home a short email expressing my kudos, and the staff couldn't believe that somebody would actually publically thank them as it had never happened before. I would like to present everybody out there with two pieces of advice: (1) Thank your staff, thank them often, because you have absolutely no idea how underappreciated they feel, and (2) Bad survey results don't necessarily mean that a facility is bad. Judge a nursing home by how compassionate and caring the nurses and techs are.

Friday, January 18, 2008

Random recognition

Starting today, send an employee a thank-you card to their house. In it, say something along the lines of, "On behalf of the residents and your co-workers, I would like to thank you for the hard work you do. It is really appreciated, much more so than you can ever know." Have the administrator and the person's department head to sign it. Everybody should get one at random at least once during the year.

Thursday, January 17, 2008

CMS SNF Open Door Forum Conference Call -- 1/17/08

CMS has an open door forum conference call for nursing homes once a month, where providers have the opportunity to give feedback on proposed changes to CMS law and policies, as well as get general questions on billing and survey issues answered. Here is a highlight of today's call for those of you who didn't chance to listen in.
1. After May 23, 2008 do not use the old legacy codes with your NPI # when submitting claims.
2. Due to a computer glitch that some of the fiscal intermediaries had, if you had denials on a no-pay bill at the end of the fiscal year, don't split it but instead resubmit.
3. AAPC offers CEUs to certified coders who complete any webinar or course sponsered by CMS or a carrier.
4. MDS 2.0 has had revisions as follows: (Chap. 3)I2J, I3, K2A, K3, L1E, M4, M4G, M5E, (App B).
5. MDS 3.0 will have a conference in Baltimore on January 24; it will also be presented via conference call at the same time. They will discuss the draft version and how the pilots went.
6. MACs (Medicare Modernization Act Contractors) will replace FIs and carriers. Meridian Services, Trailblazer, Wisconsin Physician Services, Highmark, and Palmetto have been awarded contracts for regions 3, 4, 5, 12, and 1, respectively. MACs for regions 2, 7, and 13 have not yet been awarded.
7. The therapy cap still remains at $1810/yr, but Congress is allowing the exception process to continue out through July 31, 2008.
8. Next Open Door Forum conference call will be on February 28, from 2-3 EST.

Monday, January 14, 2008

7 Questions to Ask Nurses

The next time you're out making walking rounds, ask a nurse these 7 questions on patient safety:
1. Have there been any near-misses that nearly resulted in resident harm?
2. Have there been any incidents recently where a resident was harmed?
3. What things do you think will cause another resident to be harmed?
4. What can we do to prevent the next adverse event?
5. Can you think of a way the system here doesn't work?
6. What specifically can administration do to make the work you do safer?
7. What are we doing that works?

Website for QI in LTC
has some really nice QI stuff. The website's title is "Problem-Oriented Best Practices". Topics include ethics, geriatric syndromes, nutrition, organization and administration, medication prescribing practices, and preventive practices. Good stuff!

Friday, January 11, 2008

5 ideas on communication

Here are some simple things you can do to improve communication in your facility:
1. Ask the employees what is going great on their unit
2. Bring an employee to the daily stand-up (also known as department head meeting), introduce them, and spotlight their successes
3. Let the residents know how good you know the direct care staff is -- be specific
4. When you speak at staff meetings, base everything around a story. If you need to talk about the importance of fall prevention, for instance, begin with the story of a resident who suffered undesirable consequences as the result of a preventable fall.
5. Have a communication board on each unit. Each week, have a white piece of paper titled, "What's Happening This Week". Keep it factual, short, and sweet. To quote Quint Studer from page 224 of Hardwiring Excellence, "We learned that employees define quality communication in terms of quick wins on what they really need to know about. Newsletters that feature executives in suits just don't do it."

Tuesday, January 1, 2008

Free CNA videos online has free training videos for CNAs on the survey process. is a online video based CNA course. This is a great resource for new CNA classes or for staff development.