continuum fall 2015

7162019 Continuum Fall 2015

httpslidepdfcomreaderfullcontinuum-fall-2015 115

Building for the Long Term

A publication for Wisconsinrsquos Long-Term Care Profession by

Fall

Including Budget Review Fall Session Preview Staffing Agency Workers

Donrsquot Assume You are Avoiding Employment Law Requirements and Risks How Data Influences Policy The Role of Analytics and Statistics

Wisconsinrsquos LTC Facilities Invest $1 Billion in TheirBuildings to Provide Modern Effective Therapy



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WelcomeMilestones

The Fall 2015 issue of Continuum is being released asa part of the 2015 WHCAWiCAL Fall Conventionand comes at the same time that our community ofproviders offers its best wishes in retirement to one ofour Associationrsquos long-standing champions

This summer WHCA Executive Director Thomas PMoore informed the WHCA Board of Directors of hisintention to retire in early 2016 Tom first aligned with WHCA (then known as the Wisconsin Nursing Home Association) in 1984 serving as its first in-house LegalCounsel He was appointed by the Board of Directorsto the Executive Director position in January 1986 when the Associationrsquos first Executive Director GeorgeF MacKenzie stepped down after 30 years of service

In his 32 years of service as Executive Director Tom hasadvanced and represented the interests of the Associationand its membership before the respective administrationsof 5 US Presidents and 5 state Governors

ldquoGiven the scope intensity of the unceasing changethe profession and membership have experienced overthe past thirty years my tenure as Executive Directorseems to have passed in the blink of any eyerdquo he saidin the announcement of his retirement ldquoHowever Irealize that successfully addressing the new and complexchallenges that loom on the horizon will require anenormous commitment of additional time and energythat is difficult to reconcile with the DOB that appearson my driverrsquos licensehellip Itrsquos a perfect and exciting timefor me personally and WHCAWiCAL professionallyto move onrdquo

WHCA Board President Mike Schanke offered thefollowing in the announcement of Tomrsquos retirementldquoThroughout his tenure as Executive Director Tomhas steered WHCA through many complicated

problems in the areas of reimbursement regulatory legislative affairsrdquo Schanke said ldquoTom has faithfand impartially represented the varied interests of profession these many years and I know I speak for entire membership in offering Tom our best wishehis retirementrdquo

In this issue of Continuum WHCAWiCAL offers readarticles on several topics of concern to our statersquos long-tecare providers The Cover Story in this issue highligthe significant investment that providers are making

ensure that our residents receive the best care possiIn Stakeholder Spotlight HealthCare Interactive C John Hobday offers insights into the origins of WHC WiCALrsquos new on-line dementia education partnerCapitol Connection we breakdown the 2015-17 SBudget signed into law over the summer and previthe upcoming fall floor period

In the other sections of the magazine the LTC LeLetter explains some of the potential legal implicatiof using a staffing agency a new column DDigest offers background on the use of data in public policymaking process and finally in ClinCorner WHCAWiCALrsquos on-line education partCE Solutions offers insight on the issue of influeimmunizations

As always thank you for taking the time to readContinu

Sincerely

John J Vander MeerManaging EditorContinuum

983158 983158 983158

Fall 2015



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ContentsFall 2015

6CAPITOL CONNECTIONBudget Review Fall Session PreviewState Budget Legislative Background for ProvidersFollowing weeks of state agency briefings and public hearings in mid-April the JoFinance Committee began its actions on the many fiscal and policy issues contained inbudget bill Capitol Connection provides detailed background on provisions passed law as a result of the budget and offers a preview of forthcoming issues in the 2015 floor period

DATA DIGESTHow Data Influences PolicyThe Role of Analytics and StatisticsData use in policy decision making has been growing with the advent of more sophisticated systems and programs However as data has proliferated it has also been important to unders

appropriate means to gather data accurately operationalize performance and understandproblems facing the people who report data In order to improve care and optimize performaskilled nursing and assisted living facilities need to become more data-driven

CLINICAL CORNER

2015-16 Influenza Immunization UpdatePending Legislation Risks and ResourcesThe flu season has arrived ndash have you gotte n your flu shot yet In long-ter m care organizatias well as acute care settings it is beneficial to increase vaccination efforts for your staff residents to assist in creating a herd immunity against the flu Flu isnrsquot just an inconvenienitrsquos a killer itrsquos estimated each year between 3000 up to 49000 people died due to associated deaths in the United States

COVER STORYBuilding for the Long TermWisconsinrsquos LTC Facilities Invest Hundreds of Millions in InfrastructureOver the last five years Wisconsinrsquos skilled nursing and assisted living facilities have invenearly $1 billion in their buildings and campuses to provide residents with the best modand effective long-term care and rehab therapy services Todayrsquos LTC facilities provide athe amenities and cutting-edge therapy options that residents and their families have coto expect In Wisconsin a DHS study found that the over-85 population will increase percent between 2010 and 2040 As a result of this increasing need providers havefound ways to invest in their buildings despite the statersquos limited reimbursement

STAKEHOLDER SPOTLIGHTCARES Online Training and Alzheimerrsquos Association essentiALZ CertificatioPersonal Connection to Alzheimerrsquos Leads to Development of Online DementiaCare Training and Certification ProgramThe story is hardly unique A woman in her late-80s begins to decline with memory issstops some of her favorite activities like cooking sewing and gardening and eventually for

to eat or drink for days Her hygiene suffers she seems confused and uneasy at family evno longer recognizes some family members or neighbors and even becomes incontinent Tpersonal experience leads to creation of a celebrated online dementia care training program

LTC LEGAL LETTERStaffing Agency Workers Donrsquot Assume You are Avoiding EmploymLaw Requirements and RisksMany providers erroneously think that since temporary staffing workers are not their ldquodiemployeesrdquo they do not assume any employment or labor law responsibilities as to thindividuals Unfortunately this is not true as in some circumstances providers can be considldquojoint employersrdquo of temporary workers which may expose the provider to responsibitowards the contracted personnel What terms should you pay particular attention to

14

16

22

12

10

Continuum is published for the

Wisconsin Health Care Associationand the Wisconsin Center for

Assisted Living

131 W Wilson Street Suite 1001

Madison WI 53703

Phone 6082570125

Fax 6082570025wwwwhcawicalorg

Managing Editor

John J Vander Meer

Publisher

Dean Gille

Editor

Melissa Keller

Account Manager

Abbie McDowell

Creative Director

Sara Rice

Layout amp Design

David Cox

Published by

1155 Wilburn Road

Sun Prairie WI 53590

6088343400wwwbgsinccom

For more information in advertising inContinuum call 6082570125 or go to

wwwwhcawicalorgcontinuum

If you are planning on moving andwould wish to continue receiving

Continuum call 6082570125 and

inform WHCAWiCAL of your new

address

copy2015 Badger Graphic Systems

All rights reserved The contents of this

publication may not be reproduced byany means in whole or in part without

prior written consent of the publisher

PUBLISHED OCTOBER 2015

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Fall 2015INUUM | wwwwhcawicalorg



Budget ReviewFall Session PreviewState Budget Legislative Backgroundfor Providers

By Jim McGinn

Capitol Connection

In the Spring Issue of Continuum anoverview of Governor Scott Walkerrsquos

proposed 2015-17 biennial budgetbill Senate Bill 21 was provided inthe Capital Connection report

It may be helpful to review someof the issues and positions WHCA WiCAL advanced to the JointFinance Committee and theLegislature during its considerationof the biennial budget bill

In late March members of WHCA WiCAL met in Madison at ourLegislative Day program and werebriefed on the budget by WisconsinDepartment of Health ServicesSecretary Kitty Rhoades and AssemblySpeaker Robin Vos (R-Rochester)Following their presentations ourmembers met with their Legislatorsand expressed support for and concerns with the following issues

Although the Governorrsquosbudget included a significantcost-to-continue increasein Medicaid funding($657 million) it offeredno additional funding tosupport reimbursementincreases for nursing homesor other MedicaidFamily Careproviders

With respect to skillednursing facilities WHCA WiCAL requested supportfor restoration of the nursinghome bed tax ldquoskimrdquo ($15million all funds) and

support for $187 million(all funds) to address nursinghome resident acuity careneeds as identified by DHS

WHCAWiCAL requestedsupport for requiring MCOs

to ldquopass-thrurdquo some of theincrease in capitation rates toproviders who actually deliverthe needed care and servicesto enrollees and supportfor maintaining current lawpermitting consumers to selectldquoany willing providerrdquo for theirlong-term care services

Finally WHCAWiCALrecognized and supported theneed for extensive changes inthe statersquos current Family Caremodel but could not supportthe Governorrsquos dramaticchange without additionalinformation regarding thechange including how whenand by who those changes

would be structured andimplemented

Following weeks of state agencybriefings and public hearings in mid- April the Joint Finance Committeebegan its actions on the many fiscaland policy issues contained in thebudget bill Identified as ldquoexecutivesessionsrdquo committee membersreviewed Legislative Fiscal Bureaupapers prepared on specific subjectsdiscussed the papers asked questionsof staff and then voted to recommendpassage of the subject discussed

For example on May 27 the FiscalBureau prepared Paper 362 an11-page memo that reviewed ldquoMAReimbursement for Nursing HomesrdquoThe paper briefly identified thecurrent reimbursement paymentsystem and noted the Governorrsquosbudget provided no increase infunding for MA reimbursement forskilled nursing facilities Fiscal Bureaustaff noted ldquothe continuing increase inthe acuity of nursing home residentshas played a significant role in thegrowth in nursing homes costsrdquo Accordingly the Committee voted toappropriate $76 million (all funds)to provide a 1 acuity increase toskilled nursing facilities in 2016-17the second year of the biennium

The Finance Committee continuedvoting on various provisions in thebudget bill through Memorial Daybut a month-long stalemate developedbetween the two Houses For several weeks the focus of concerns anddebate on the budget centeredon funding for the transportationbudget and possible delays in majorstate highway projects the statersquosprevailing wage law a new arenafor the Milwaukee Bucks and forseveral days on possible changes to Wisconsinrsquos open records laws Whilethe Milwaukee Bucks arena was notincluded in the final budget bill theremaining issues were resolved

On July 6 the Joint FinanceCommittee concluded its actionson the budget bill voting 12-4 (onparty-line vote) to recommend thebill for passage Shortly thereafter theSenate passed the measure 18-15 the Assembly concurred 52-46 and thebudget bill was presented to Governor Walker on July 10

Governor Scott Walker acted quicklyin signing Senate Bill 21 (2015 WI Act 55) the biennial budget billinto law In fact Governor Walker

Continued on

and duplicative department already regevaluates the labor rmethodology and recommend changes if nee

County-to-County NuFacility Bed TransfersGovernor vetoed ldquothis sbecause it is unneceCurrent law already spthe requirements that mmet for a transfer of licbeds However I am dirthe department to rcurrent procedures and pa plan to address any issue

arise from that reviewrdquo

FALL SESSION PREVIEW MAINSTINVESTMENTS FAMILY CARE HEAR

TASK FORCE ON ALZHEIMERrsquoS

While the biennial budget balways the most importantconsidered by the Legislamany significant issues remabe discussed and debated byLegislature this fall and winter

As all members are awareIndiana real estate devel

signed the budget on Sunday July12 and on Monday announced thathe was running for President of theUnited States in the RepublicanPresidential Primary

The Governorrsquos 48-page vetomessage provided a summary of theissues and vetoes he believed willcontinue to make ldquoWisconsin moreprosperous more independent andmore efficientrdquo With respect to the104 vetoes the Governor notedldquothese vetoes will reduce overallspending constrain earmarks allowthe executive branch to efficientlyperform its statutory duties andcorrect legislative errata These vetoesincrease the general fund balance by$445 million (GPR-state dollars)over the bienniumrdquo

Governor Walker stated the budget billhe signed preserves essential safety netprograms including Senior Care andMedicaid while implementing reformsto slow expenditure growth andmaintain essential health care servicesincreases Medicaid reimbursementfor nursing homes through an acuity

adjustment expands Family Carestatewide and improves the integrationof long-term care and acute andprimary care services

Specific vetoes included Family Care the Governor

vetoed ldquothe requirement thatthere be no less than 5 long-termcare regions because I objectto creating a fixed numberof regionshellipthe requirementfor a separate actuarial studyfor integrated health agenciessince state and federal lawrequire rates be actuariallysoundhellipand the requirementthe open enrollment periodcoincide with Medicarehellipthe department will set anopen enrollment period thatmakes sense for Wisconsinconsumersrdquo

Labor Region MethodologyStudy the Governorvetoed this ldquoprovision toeliminate the labor regionmethodology requirementsas these requirements areadministratively burdensome




Capitol Connection Continued

Falls) to simplify rules relatinmaintenance and use stanfor oxygen equipment in sknursing facilities WHCAWhave joined 28 other healthproviders in opposing Senate218Assembly Bill 312 introdby Senator Frank Lasee (R-Deand Representative JeThiesfeldt (R-Fond du Lac) wrelate to prohibiting health profrom requiring flu vaccinations

While other issues may suthe fall session of the WiscoLegislature is expected to be bu

under the long-term care programPrior to submitting any plan changesto the federal government theDepartment is required to submita concept plan to the Joint FinanceCommittee for review and approvalor disapproval no later than April 12016 On July 1 DHS is directed torelease its waiver request for publiccomment and submit the waiverrequest to the federal government onSeptember 30 2016 If the state planis approved and is consistent with theplan approved by the Joint FinanceCommittee DHS can implementchanges to Family Care If the waiveris not approved Family Care willcontinue as in effect on July 1 2015

FALL FLOOR PERIODRecently Speaker Vos announcedthe creation of a Speakerrsquos TaskForce on Alzheimerrsquos and Dementia According to the Speakerrsquos pressrelease ldquoroughly 53 million

Americans have Alzheimerrsquos disease with two-thirds of those being women Itrsquos reportedly the sixthleading cause of death in the countryand the only one in the top ten thatcanrsquot be prevented slowed or cured With the increasing population ofolder adults and increasing cost ofcare this task force will determine ways to ensure future quality of care while bending the cost curve of long-term care downward The task forcemembers also will look to improveand promote community-basedresources and raise awareness as wellas address legal issues and determinepossible state participation intreatment and researchrdquo

Finally WHCAWiCAL willcontinue to support Senate Bill160Assembly Bill 242 introducedby Senator Sheila Harsdorf(R-River Falls) and RepresentativeKathy Bernier (R-Chippewa

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Because when you get more from your distributoryou can make more of an impact on your residentsrsquowell-being

Care In response DHS scheduled 8public hearings in September to discussFamily Care The Department is alsorequired to include in its quarterlyMedicaid report (September 30 andDecember 30 2015) to the JointFinance Committee progress reportson the development of proposedchanges to Family Care

Over the next 6 to 8 months DHS isrequired to work on a waiver requestto submit to the Federal governmentexpanding Family Care statewide Ifapproved DHS is required to makeFamily Care available statewideby January 1 2017 or later ifdetermined by DHS The requestis required to include coverageof both long-term care and acutecare services including Medicarefunded services allowed by thefederal government from integratedhealth agencies (IHAs) and to makeavailable consumer-directed options

Mainstreet Investments was seekingintroduction of an amendment to thebudget bill that would allow a specialexemptioncarve out from Chapter150 relating to the statewide nursingfacility bed limit and the moratoriumon constructing new skilled nursingfacilities It has long been the law andpolicy of Wisconsin that transfers ofskilled nursing facilities beds are verylimited and the construction of anew facility is limited to the owner ofthe licensed facility or the sale of alllicensed beds to a new owner subjectto the approval of DHS MainstreetInvestments approached membersof the Joint Finance Committeeseeking to c onstruct 26 ldquotransitionalcarerdquo 100-bed facilities promotingsomething different from a nursinghome but licensed as a nursing homeunder Chapter 50 and DHS 132

While an amendment was notconsidered it is clear Mainstreet

will continue its efforts to constructldquotransitional carerdquo facilities (nursinghomes) in Wisconsin since similarefforts are being undertaken inseveral other states

FAMILY CARE REDESIGN

In his budget Governor Walkerproposed sweeping changes to theFamily Care Program includingIRIS and the Aging and DisabilityResource Centers The Joint FinanceCommittee deleted all of the statutorychanges recommended by theGovernor but approved a number ofchanges to the program which wereapproved by the Legislature

Since most citizens were surprised bythe Governorrsquos recommended changesto Family Care the Legislature directedthe Department of Health Services(DHS) to consult with Family Carestakeholders and hold no less than 2public hearings on changes to Family

James McGinn

is WHCA WiCALrsquos Directoof GovernmentRelations He canbe reached at jimwhcawical




How Data Influences PolicyThe Role of Analytics and Statistics

By Kate Van Camp

Data use in policy decisionmaking has been growing with

the advent of more sophisticated datasystems and programs As these newtechnologies have been developedagencies have been calling on long-term care facilities to collect andanalyze data to evaluate performanceof health care entities to better informdecision making at the macro levelHowever as data has proliferated ithas also been important to understandappropriate means to gather dataaccurately operationalize performanceand understand the problems facingthe people who report data While theintent of data-driven policy decisionsare clear it is often the execution ofthis model that brings complexity andnuance to understanding performanceand description

In the past policy changes in healthcare settings may have been drivenby innovative ideas or simply hearsayfrom others but it was hard toquantify the effectiveness of thosechanges In order to improve careand optimize performance skillednursing and assisted living facilitiesneed to become more data-drivenPart of the task of modern day datacollection is that there is a lot of it

Smart phones capture what apps we buy wersquore asked for feedbackon shopping websites like Amazoncom and we receive surveys fromour credit card and cable companies With all of the data passing arounditrsquos imperative to not only collectmeaningful data but also to do soin a time-efficient manner Manyorganizations already have the datathey need but lack the foundationalpractices and capabilities to get themost out of these assets

Research and data analysis firstrequires asking pertinent questions

Does having a higher staffto resident ratio improvequality of care

How does training influencesafety

How much money is beingspent on improving facilitieseach year in Wisconsin

How much if any overtimecauses changes in workperformance

To allow for greater use and adherenceof capturing important data thequestions themselves have to be clearand targeted These questions can arisethrough discussions of the Board of

Directors complaints from facilitiesor employees or even residents Whencertain topics or discussions starttrending therersquos usually a questionthat can be answered

The next step is determining if thequestion can be asked with dataalready available

Do we already have thisinformation

Does someone else have it

If not how can we get it

Because of the numerous reportingrequirements and usefulness of datathe majority of health information we may be interested in existssomewhere Other times surveyscan be a valuable source of dataHowever it is important to thinkabout the outcomes yoursquore seekingand all possible answers to a question when designing a survey If theanswers wonrsquot provide you withmeaningful data the survey canbe a waste of time and make it lesslikely that people will participate insubsequent surveys

Once yoursquove gathered or located thedata needed it can be analyzed anynumber of ways Several intensivesoftware programs exist for doing justthat but most people can effectivelyanswer research questions usingMicrosoft Excel From basics likefinding averages and creating chartsto regression analysis Excel can be anextremely helpful tool in visualizingresults

Data Digest

The next phase is presenting thefindings to interested parties Atthis point an informed discussioncan help drive the decisions abouthow to use the new information Within facilities administrators canuse this information to push forpolicy changes that are based on hardevidence At the association levelthis information may be used by alobbyist to educate legislators oncritical issues that exist in the sector

In the modern era facility leaderscommittee chairs and legislators willnot be swayed or moved to act unlessthey are presented with empiricaldata The knowledge and abilityexists to discover answers and leadersmust become data-driven to keep up with best practices and policies thatare ever-changing

In sum the role of data in policydecision while simply stated is acomplex evaluation and coordinationof many efforts Information isgathered through determining accuratemeasurement asking pertinentquestions awareness of contextreal worldpolicy and the understandingof the multiple levels of organizations

My job as Director of Research ampData Analysis at WHCAWiCAL isto work with members to determine what questions need answeringif and how we can answer themand provide members with theinformation that can maximize theeffectiveness of our AssociationSome of this work is done through the WHCAWiCAL Quality AssuranceCommittee which conducts regularmeetings If you would like be

Kate Van Campis the Director ofResearch and D Analysis for theWisconsin HealCare Associationand the Wiscons

Center for Assisted Living She cbe reached at katewhcawicalo

included on the distributionof the QA Committee anda WHCAWiCAL MembeBusiness Partner please senemail to infowhcawicalorg

If you would like to know more ahow data influences policy or ansubject that is driven by empdata please feel free to contact m

Trend Tracker LTC Trend Trackers is a web-based tool tha

enables long-term and post-acute care providers to acces

key information that can help their organization succeed Thexclusive benefit for AHCA members allows skilled nursing organizations to benchmark personal metrics to those o

their peers and examine ongoing quality improvement efforts LTC Trend Tracker is AHCA membersrsquo one-stop-sho

to gain timely information and valuable insight about their own performance as well as the entire professionrsquos

Use Trend Tracker to

Compare your facility to peers (within region state ownership type etc) Access AHCA Quality Measures

Access AHCA Staffing Turnover and Retention Report Design save and schedule reports

Ltctrendtrackercom

Nursing Home Compare These are the official datasets used on the Medicaregov Nursing Home CompareWebsite provided by the Centers for Medicare amp Medicaid Services These data allo w you to compare the quality o

care at every Medicare and Medicaid-certified nursing home in the country including over 15000 nationwide

Use Nursing Home Compare for information regarding

Deficiencies Penalties 5 Star Ratings

Ownership State Averages

Source httpsdatamedicaregovdatanursing-home-compare

USEFUL DATA SOURCES

Fall 2015 TINUUM | wwwwhcawicalorg



2015-16 InfluenzaImmunization UpdatePending Legislation Risks and Resources

By Deb Martin RN BSN

The flu season has arrived ndash have you gotten your flu shot yet

In long-term care organizationsas well as acute care settings it

is beneficial to increase vaccinationefforts for your staff and residents toassist in creating a herd immunity

against the flu Flu isnrsquot just aninconvenience itrsquos a killer itrsquosestimated each year between 3000up to 49000 people died due to flu-associated deaths in the United StatesMost of these flu-related deaths occurin people age 65 and older

According to the Centers for DiseaseControl and Prevention whichcombines influenza and pneumoniait is listed as the eighth leading causeof death 56979 in 2013 the mostrecent year data is available

PENDING LEGISLATION

In many states including Wisconsinhealth care facilities require employeesto be vaccinated each season Thissummer a bill was introduced that would prohibit employers fromdiscriminating against employeesvolunteers interns and contractors

who refuse to be vaccinated againstinfluenza The legislation Senate Bill218 has been referred to the SenateCommittee on Health and HumanServices

WHCAWiCAL and many otherhealth care organizations have

forwarded a joint letter to the Wisconsin State Legislators opposingthe bill Seasonal flu vaccinesare designed to protect people ndashparticularly vulnerable populationslike the frail elderly in LTC facilitiesndash against the influenza viruses mostlikely to spread and cause illnessduring an upcoming flu season which typically peaks Decemberthrough February in the UnitedStates Although there is not a wayto know how severe each yearrsquos fluseason will be the CDC makesannual recommendations based oninformation gathered from aroundthe world

DEVELOPING ANNUAL FLU VACCINES

Flu viruses are constantly changingIn the United States for this fluseason all of the 2015-16 influenzavaccine will be made to protect

Clinical Corner

against the following three viruses an ACalifornia72009

(H1N1)pdm09-like virus

an ASwitzerland97152932013 (H3N2)-like virus

a BPhuket30732013-likevirus this is a BYamagatalineage virus

How do experts know whichinfluenza virus to vaccinate againstMaking that determination is amulti-step international process

The first steps involve determining which viruses pose the biggest riskin any given year More than 100countries have national influenza

centers that conduct year-roundsurveillance for influenza the CDCnotes The staff at these centersreceive and test many thousands ofinfluenza virus samples from patients with suspected flu illness The labssend representative viruses fromthose samples to five World HealthOrganization (WHO) CollaboratingCenters for Reference and Researchon Influenza Atlanta is the locationof the US center

Next each February WHO staffconsult with experts to reviewdata generated by this worldwidenetwork of influenza labs Basedon their findings WHO makesofficial recommendations forthe composition of the seasonalinfluenza vaccine for the NorthernHemisphere

The next steps involve the productionof the vaccine A committee under theUS Food and Drug Administration(FDA) ndash the US Vaccines andRelated Biological Products AdvisoryCommittee (VRBPAC) ndash considersthe WHO recommendations andmakes a final decision aboutcomposition of seasonal flu vaccinefor the United States

This year the vaccine straincomposition for the 2015-2016influenza was announced on February26 following the WHO VaccineComposition Meeting which tookplace in Geneva Switzerland

The following week the VRBPACendorsed the WHO NorthernHemisphere flu vaccine strainselection for use in the productionof upcoming US 2015-2016 fluvaccines

Vaccines that give protectionagainst three viruses are called

trivalent vaccines Vaccines thatgive protection against four virusesare called quadrivalent vaccinesSome of the 2015-2016 flu vaccineis a quadrivalent vaccine and alsoprotects against an additional B virus(BBrisbane602008-like virus) Thisis a BVictoria lineage virus

Many people have asked in recentyears why canrsquot experts come up with a more accurate estimate of flu-related deaths The CDC notes thatstates donrsquot have to report individualflu cases or adult flu-related deathsto the CDC seasonal influenzais rarely listed as a cause of deathfor those who die from flu-related

complications and these deathsoften occur weeks after the initialinfection has aggravated an existingcondition or caused a person todevelop another

GREATER RISK FOR THOSE 65 AND

OLDER TAKE ACTION

Our immune systems weaken as we

Deb MartinRN BSN is anaccount executivewith CE SolutionWHCAWiCALrsquoon-line education partner She canbe reached at 855

874-6930 or via email at debmdiscovercesolutionscom

age Thatrsquos why people 65 yearolder are at greater risk of secomplications from the flu comp with young healthy adults U90 percent of all flu-related deplus more than half of flu-rehospitalizations occur in peopor older according to Flugov aDepartment of Health amp HuServices (HHS) site

The best way to prevent the flu isa flu vaccine CDC recommendeveryone 6 months of age and get a seasonal flu vaccine eachsoon after it becomes availableby October if possible

A flu vaccine protects against thviruses that research indicates wmost common during the upcoseason Immunity from vaccinsets in after about two weeks

People 65 years and older can chfrom two available flu shotsregular dose flu vaccine and a nflu vaccine designed specificalpeople 65 and older with a hdose This high dose vaccine confour times the amount of antigthe regular flu shot and is assoc with a stronger immune resfollowing vaccination

The CDC provides a wealtinfluenza information that isto understand and kept up to Much of the information inarticle was taken from the site

STAY UP-TO-DATE ON FLU INFO

The Wisconsin Department of Health Services weekly influenza

httpswwwdhswisconsingovinfluenzaindexhtm

US Department of Health and Human Services Interactive Mapping Tool

httpwwwhhsgovnvpoflu-vaccination-map

Centers for Disease Control and Prevention weekly influenza surveillance report

httpwwwcdcgovfluweeklyfluviewinteractivehtm




Over the last five years Wisconsinrsquosskilled nursing and assisted

living facilities have invested nearly$1 billion in their buildings andcampuses to provide residents withthe best modern and effective long-term care and rehab therapy servicesTodayrsquos skilled nursing and assisted

living facilities provide all of theamenities and cutting-edge therapyoptions that residents and theirfamilies have come to expect from a

long-term care community

According to data from the Wisconsin Department of Health

Services (DHS) skilled nursing andassisted living facilities invested$899996258 from 2010 to themost recently reported facilityimprovement costs this yearThese facility upgrades ensure that Wisconsinrsquos frail elderly and disabledcitizens receive the most effectivecare possible It also guaranteesthat people who need short-term

Building For The Long TermWisconsinrsquos LTC Facilities Invest $1 Billion in TheirBuildings to Provide Modern Effective Therapy

By John J Vander Meer

Cover Story

The renovation which is expecbe completed sometime next yeafeature 21 private rooms for shortrehabilitation and a modern thgym where rehabilitation secan be provided to both in-presidents and people living in theThe facility will also offer occupatphysical and speech therapy

Park Manor currently employsstaff members 135 of whomemployee owners of the EmpStock Ownership Plan Trust thatthe facility However with the fexpanding Klatkiewicz said thanumber of employees in the aredirect care as well as maintenanchouse-keeping will likely increaseresult of the addition of 20000square feet

Dove HealthCare which opseveral facilities in the Eau CChippewa Falls area also broke gon a new state-of-the-art nursinrehabilitation facility in Rice earlier this summer The facilitinclude 42 private rooms 4 private rooms two deluxe spasfireplaces and a 2500 squarerehab gym

ldquoDove Healtndash Rice Lake be Barron Cour e h a b i l i t a tdestination wiof the latest ameand services clohomerdquo said JeKiley Reg

Director of Operations for Dovis an expansion of our TransRehabilitation program windividuals spend an average of to four weeks in post-hospitalizcare in route to home By inveheavily in our staff therapy gand equipment we ensurepatients receive the most advand progressive treatmentrdquo

rehabilitation following a kneereplacement or a stroke can get high-quality transitional care in one ofthese facilities

When someone is admitted intoone of Wisconsinrsquos skilled nursingfacilities they could be there for

any number of short-term therapiesBut thatrsquos nothing new Wisconsinrsquosskilled nursing facilities have beenproviding high-quality post-acuterehabilitative care for more than 25years Post-acute care services occurimmediately after discharge from ahospital and are aimed at returningpatients home within 30 days andoften sooner

Therapy Services in Wisconsinrsquos SkilledNursing Facilities Include

State-of-the-Art Therapy GymsEquipment and Aquatics

Cutting-Edge Physical Therapy

Innovative Occupational

Therapy Advanced Speech Language

Pathology Respiratory Therapy and

Ventilator Care

Intravenous (IV) Treatment Person-Centered Care and

Services

Despite the fact that Wisconsinhas the second-worst Medicaidreimbursement system in thecountry and that most FamilyCare providers have not receivedreimbursement rate increases inseveral years Wisconsinrsquos long-termcare facilities provide some of thehighest quality care in the nation A report entitled ldquoAmericarsquos HealthRankingsrdquo released recently by theUnitedHealth Foundation ranked Wisconsin seventh in the nationfor overall health for seniors and

eighth in the nation for the qualityof skilled nursing care Several otherstudies including a 2014 nationalstudy conducted by Eljay LLChave confirmed the low Medicaidreimbursement and high qualitymeasures of Wisconsinrsquos long-termcare facilities in recent years

lsquoA LEAP OF FAITHrsquo

The increasing demand for skillednursing and assisted living carecaused by the aging Baby Boomerpopulation have made operatorsscrutinize their long-term plansfor providing long-term care In Wisconsin a DHS study found thatthe over-85 population will increase140 percent between 2010 and 2040 As a result of this increasing needproviders have still found new waysto invest in their buildings despitethe statersquos limited reimbursement

ldquoWisconsinrsquos providersare committed to

providing the bestcare in the bestenvironment and weare pretty muchtaking a leap offaith that our costs

are going to get coveredrdquo said DebKlatkiewicz NHA at Park ManorLtd in Park Falls WI ldquoUnlesstherersquos someone out there gettingyounger on a daily basis these areservices that people will continue toneed hellip Wersquore going to have a lotmore people need all kinds of careThe need for short-term care hasexploded in the last couple of yearsrdquo

This summer Park Manor Ltd a100 licensed bed skilled nursingfacility broke ground on a $6million renovation that will providethe Price County community witha facility that offers area residentsstate-of-the-art therapy treatmentand equipment The project will alsocreate numerous local construction

jobs

ldquoPark Manor has an economicimpact on our area of over $12millionrdquo Klatkiewicz said ldquoMost ofthe work on our building project hasbeen done at the local level hellip Wegave our general contractor a list ofevery local contractor that we haveused over the years to give them theopportunity to bid on the projectrdquo

Continued on P

ldquoThe increasing demand for skilled nursing and

assisted living carecaused by the aging

Baby Boomer populationhave made operatorsscrutinize their long-

term plans for providinglong-term carerdquo




T he story is hardly unique A woman in her late-80s begins to

decline with memory issues stops some ofher favorite activities like cooking sewingand gardening and eventually forgetsto eat or drink for days Her hygienesuffers she seems confused and uneasy atfamily events no longer recognizes somefamily members or neighbors and evenbecomes incontinent It is at that pointthat the family cannot find a solution tothe growing care needs and decides that itis in the best interest of everyone for herto move into a nursing home Becausethe symptoms have been ignored for solong she is placed directly onto a specialcare unit

care training programs in conjunction with the Alzheimerrsquos AssociationItrsquos called CARESreg and the trainingprograms are for both professional carestaff as well as family members

They include Integrated professional programs

on dementia basics Advanced topics Dementia-related behavior Activities of daily living End-of-life dementia care Dementia care strategies for

families in a home setting

The programs incorporate evidence-based care strategies based upona comprehensive review of theacademic literature published by the Alzheimerrsquos Association

The programs also include anoverarching framework to care calledthe CARESreg Approach This five-step protocol is easy for staff andfamilies to learn and remember andis the ldquowhat to dordquo with anyone withdementia at any level of decline andin any care situation CARES is anacronym that stands for C-Connect with the Person A-Assess BehaviorR-Respond Behavior E-Evaluation What Works and S-Share withOthers The programs introduce theCARES Approach and then integrateit into all topics of discussion Forexample when talking about pain ordressing or wandering it is all done within the context of CARES andldquowhat you can dordquo in any situation

Another aspect that sets the CAREStraining apart from others in themarketplace is the real video footageTwenty years ago when I workedon the project for the VA someonesuggested hiring actors to play theroles of people with dementia andfamily members It seemed reallycounter intuitive to do this if you wanted to capture actual dementia

That was my grandmother ThereseMorzinski As it happens I hadstarted a small educational consultingcompany a few years earlier and worked on an Alzheimerrsquos diseaseproject with the Department ofVeterans Affairs As my grandmotherdeclined I began to recognize someof the signs as they were occurring It was quite surreal I was able to helpmy mom and her siblings throughsome difficult decisions as best Icould I also facilitated conversations with some of the Alzheimerrsquos expertsI had met during my work with theVA I remember thinking at onepoint ldquoThere are national expertsthat I have access to that otherfamilies living right across the street

would never have access tordquo Even with access to these experts ourfamily still went through so muchsadness loss and pain I decided I wanted to use my small business todo something about that

My small business HealthCareInteractive has now spent the past decadedeveloping a suite of online dementia

CARES Online Training andAlzheimerrsquos AssociationessentiALZ CertificationPersonal Connection to Alzheimerrsquos Leads

to Development of Online Dementia CareTraining and Certification Program

By John Hobday

Stakeholder Spotlight

For more informat ion Call 8002362619 x 260 Email infogohmecomVisit gohmecom

GOHME | 2021 Riverside Drive | Green Bay WI 54301

Strategic Partners

SPS Ask us about pricing for

Save dollars without sacrificing qualityLocal provider local service Thatrsquos GOHME

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Continued on Pg 18

Senior Living

Insurance SpecialistAccess to major insurance carriers

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I remember thinking atone point ldquoThere arenational experts that I

have access to that other families living right

across the street wouldnever have access tordquo




care in progress Instead we decidedto get consent from families and filmonly real people with dementia realfamilies and real staff members Fastforward 20 years and our companyhas filmed only real people in caresettings like skilled nursing facilitiesassisted living facilities hospicecenters hospitals and individualhomes in 18 states and 2 countriesFilming real people is definitely moredifficult ndash especially when you arefilming someone with dementia Butit makes for one of the most authentictraining experiences possible

The CARES programs even includebefore-and-after video scenariosusing the CARES Approach Wefilm a care scenario which usuallyends up being less than ideal careThen we film again using the

CARES Approach The difference isstunning and all has to do with thelsquoC-Connect with the Personrsquo andlsquoA-Assess Behaviorrsquo steps These arethe same care situations with thesame caregivers with the same realperson with dementia or Alzheimerrsquosdisease The only take away staff andfamilies can have with this approachis to say ldquoOh my gosh I have

Print |

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Stakeholder Spotlight Continued

something to do with the behavior ofthe person I am caring forrdquo They arenot being ldquodifficultrdquo and they are notbeing ldquochallengingrdquo In most cases we have found that they are simplyresponding to the person caring forthem If you change your approachyou change the personrsquos responseand in fact the entire care outcomeBeginning in late 2011 theHealthCare Interactive team worked to integrate our fiveCARES training programs with the Alzheimerrsquos Association essentiALZreg certification program EssentiALZevaluates knowledge of the evidence-based practice strategies from the Alzheimerrsquos Association practicerecommendations that are integrated

into CARES Anyone completingan eligible CARES program cantake a certification exam with the Alzheimerrsquos Association If they passthey can list the certification on theirresume and display their certificate within their work organizationCARES online dementia caretraining and essentiALZ certificationfrom the Alzheimerrsquos Association hasbeen used nationally and in over 50countries worldwide

CARES online training and Alzheimerrsquos Association essentiALZreg certification are

recommended by the Centers for Medicare

and Medicaid Services (CMS) and the Wisconsin Health Care Association

(WHCA) The American Health Care Association (AHCA) and the National

Center for Assisted Living (NCAL)

recommend CARES to help reduce theoff-label use of antipsychotics

I think my grandmother would bequite proud of the difference we havemade for people with dementia theirfamily members and the caregivers who provide such good care for themday in and day out She was a prettysimple woman who lived in a verysmall house I think she would be

surprised at the difference we havemade and how the past 10 years haveunfolded ndash all because of her

John Hobday is theCEO and Founderof HealthCareInteractive IncHe can be reachedat jhobday hcinteractivecom

For More Information on

CARESreg online training andessentiALZ Certification

wwwmcinteractivecomcares

and wwwalzorgessentiALZ

For questions about our CARESreg

programs Alzheimers Association

essentiALZ certification or

which programs are right for

your organization to meet state

demential training requirements

call us at 952-928-7722

TRANSPARENCY gt FLEXIB ILITY gt SAVIN GS 800-642-3020 wwwNavigatorGPOcom

Navigator Group Purchasing Inc is the experienced leader in

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Cover Story Continued

With an opening expected in thesummer of next year the newMedicare- and Medicaid-certifiedfacility will employ about 100part-time and full-time positionsincluding nursing therapynutritional services recreation andenvironmental services

Michael SchankeBoard Presidentof the WisconsinHealth Care Association hasmoved forward witha renovation projectat his Menashafacility as well

The $45 million buildingrenovation and repurposing projectat Oakridge Gardens will relocateand upgrade the rehabilitation areato better accommodate short-termpost-acute patients The facility willinclude private patient rooms adining room dedicated to the rehabarea and community space forpatients to socialize

ldquoThe building projects that Wisconsinrsquos long-term care facilitieshave undertaken in recent years arenot limited to any ownership typeor region of the staterdquo Schanke saidldquoThe staff at Oakridge Gardens andat long-term care facilities aroundthe State of Wisconsin are dedicatedto ensuring that their residents havebest quality carerdquo

THE MULTIPLIER EFFECT

The flow of dollars spent byLTC facilities within the statersquoseconomy expands dramatically asthe money passes into the hands ofemployees and local businesses andorganizations through which thefacility and its employees purchasegoods and services The firms withinthe goods and service chain in turnpay wages and salaries and themselvespurchase goods and services furtheralong the chain

Kiley and Klatkiewicz say thesignificant investment they are makingin their buildings not only enablethem to continue providing great

care but collectively has a significantimpact on the statersquos economy

Dennis Winters the economist fromNorthStar Economics Inc whoauthored a report on the economicimpact of Wisconsinrsquos skilled nursingfacilities said the statersquos SNFs alonealready have a greater impact onemployment than that of the paperplastics real estate and accommodat ionrsquosindustries in Wisconsin

The NorthStar 2013 report found thatthe Wisconsinrsquos skilled nursing facilities Contribute over $55 billion

to the statersquos economy Employ 52306 workers an

equivalent of over 37137 full-time equivalent positions andcreate another 27316 jobs

Spend almost $29 billion onpayroll and good and servicesin Wisconsin

Generate over $250 millionin state income sales andproperty taxes

The jobs available in long-term

Continued on Pg 24

SKILLED NURSING AND ASSISTED LIVING FACILITY CONSTRUCTION PROJECTS APPROVED BY DHS FROM 2010 THROUGH JUNE 2015

Year Nursing Homes Assisted Living Total

2010 $12481065243 $3790238244 $16271303487

2011 $10032804770 $3922911013 $13955715783

2012 $8250816380 $6940766400 $15191582780

2013 $5861588380 $7769577720 $13631166100

2014 $7791229400 $11657138260 $19448367660

Subtotal $44417504173 $34080631637 $78498135810

Five-year Avg $8883500835 $6816126327 $15699627162

2015 ytd $5830770020 $5670719992 $11501490012

Total $50248274193 $39751351629 $89999625822

Source Department of Health Services data provided to the Wisconsin Health Care Association and LeadingAge Wisconsin July 2015

Serving Facilities in South Central WI

125 S Thompson Rd | Sun Prairie WI 53590

Phone (608) 837-8002 | Fax (608) 837-8005

wwwoconnellpha rmacylongtermca recom

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Experience Matters

Providing quality rehab services to patienand long term care facilities since 1977

MJCarecom

Our Mission is to provide rehabilitationand related services in an atmosphere

of integrity trust and compassionglorifying God in all that we do

Respect n Integrity Innovation n Service Excellenc Quality n Education

MJ Care Values

JaneBeisserOTRVicePresident

2448S 102ndStreetMilwaukeeWisconsin53227

(414)329-2429

JaneBeissermjcarecom




Many long-term care providers arefinding themselves facing acute

difficulties in recruiting and retainingstaff qualified Not surprisingly manyare looking to third-party agencies toaddress their staffing gaps as they seekto fill open positions Helpful Yes

Worry free No

Many providers erroneously thinkthat since temporary staffing workersare not their ldquodirect employeesrdquo theydo not assume any employment orlabor law responsibilities as to theseindividuals Unfortunately this isnot true as in some circumstancesproviders can be considered ldquojointemployersrdquo of temporary workers which may expose the providerto responsibilities towards thecontracted personnel

The single most important step thata provider can take to lessen its risksas to temporary workers is to get thestaffing contract right Donrsquot ignoreit Donrsquot skim over it Donrsquot readthrough everything but the difficult-to-understand ldquolegal stuffrdquo

DIVISION OF LABOR ON TRADITIONAL

EMPLOYMENT ISSUES

Which entity is going to do whatI-9 verification Issue paychecksHandle employee investigationsClarity it critical But beware as thecontractual description of whichentity is doing what can be used byplaintiffrsquos counsel to help establish joint employment For example itcan be used to show the providerdirects and controls workers onday-to-day assignments a hallmarkof joint employment If the staffingcompany is not pledging to protectyou through an indemnificationclause careful attention to this areais particularly important

COVENANTS NOT TO COMPETESome staffing contracts state thatproviders will not solicit workers forat least six months or a year after anassignment ends This means that youcannot just hire the worker if you wishConsider negotiating a reduction inthe amount of time that you have to wait or the ldquobuy-outrdquo amount

LICENSURE CONFIRMATION

Contractual clarity with regardsto assuring personnel have currentand appropriate licenses andorcredentials is critical As providersare often billing for the services ofspecific licensed positions a lapse inan individualrsquos license or deception asto qualifications can place a providerin a position of at a minimumhaving to make repayment forservices billed Stating to an auditorthat ldquothey were not my employeerdquo

will likely not be a defense to theoverall obligation that their servicesare provided by qualified personnelIndependent verification by theprovider regardless of contractualterms should be considered

LTC Legal Letter

Staffing Agency WorkersDonrsquot Assume You AreAvoiding Employment LawRequirements And RisksBy Brian Purtell and Scott Paler

What terms should you pay particularattention to Here are a few

TERMINATION OF CONTRACT

What does the contract say aboutyour ability to exit the contract Areyou required to provide 60 daysrsquo written notice Or 6 monthsrsquo noticeOr can you terminate at will Themore flexibility you have to exitthe more you can press the staffingagency to meet your needs

INDEMNIFICATION

It is not unusual for temporary workersto sue for alleged discrimination lackof overtime payments harassmentand other customary employmentconcerns When they sue do theysue just the staffing company (theirsupposed employer) or do they suethe staffing company and the providerUsually both Plaintiffsrsquo attorneys notsurprisingly believe that two ldquodeeppocketsrdquo are usually better than oneMoreover it is typically much morepossible to deem the provider a ldquojointemployerrdquo than providers realize

To reduce risk consider negotiating on

indemnification clause with the staffingcompany under which the staffingcompany agrees to reimburse you forany damage award and costs undercertain or all circumstances in which a worker or a third-party brings an actionThe broader the indemnification thebetter It is important to negotiate wisely on this issue

SCREENING FOR WISCONSIN

CAREGIVER PURPOSESEXCLUSION

As providers have obligations to assurethat individuals providing servicesare properly screened includingcertain prohibitions about allowingindividuals to serve in a caregivercapacity it is essential that theagreement contain a clear explanationas to who bears responsibility for thescreening of individuals to be placed within the facility

Typically this would be an expectationon the agency that is the employerof record however providers shouldassure that the screening includeat a minimum compliance with Wisconsinrsquos caregiver backgroundcheck law initial and ongoingchecking the assure the individual isnot an ldquoexcluded individualrdquo for whombilling cannot be made to a Medicareor Medicaid program for their services

as well as assuring the currency andaccuracy of the individualrsquos license orrelated credentials

Screening requirements shouldaddress not only the need for aninitial screening but also the need forongoing checks They should take intoaccount procedures required underapplicable background screening lawssuch as the Fair Credit Reporting Act (FCRA) as well Lawsuitsattacking entities for failing to followbackground screening proceduralrequirements are on the rise

Note This article has been written byBrian Purtell and Scott Paler Partnersat DeWitt Ross amp Stevens SC Itshould not be considered legal advicebut instead general information Forlegal advice on specific contractscontractual issues or businessrelationships please contact counsel

Brian Purtell ishareholder at Madison officeDeWitt Ross Stevens SC He serves at the Direof Legal Serv for the Wisco

Health Care Association and Wisconsin Center for Assisted Livand the Executive Director of Wisconsin Center for Assisted LivHe can be reached at (608) 252-9and brpdewittrosscom

Scott Paler isshareholder at Madison officeDeWitt Ross Stevens SC

Chair of the Laand EmploymPractice Group

can be reached at (608) 252-9and sxpdewittrosscom

The single most importantstep that a provider cantake is to get the staffing

contract rightrdquo





care are relatively recession-proofand cannot be outsourced theyoffer readily accessible employmentand career ladders for individualsdisplaced workers and students Atthe same time these jobs provideessential services for the statersquos frailand elderly citizens

INCREASING SUPPLY MODERN AMENITIES

Winters said that based on theconstruction projects approved byDHS for the first half of 2015 itappears that the economic impactfor the current year will surpass theaverage of the past five years

A 2015 report by NorthStarEconomics Inc authored by Winters based on the data obtainedfrom DHS and commissioned by WHCAWiCAL and LeadingAge Wisconsin found that the five-yearconstruction spending average for Wisconsinrsquos skilled nursing andassisted living facilities is $157million This spending translates intothe creation of a significant numberof jobs every year

Winters who also serves as theChief Economist of the WisconsinDepartment of Workforce Development stated that anestablished jobs multiplier producesa calculated estimate that over thefive-year period covered in the data

skilled nursing and assisted livingfacility construction projects

Created over 16635construction-related jobsaveraging 3327 jobsyear

Generated new tax revenuesof $65 million

Yielded $13 million in taxrevenues per year

In fact Klatkiewicz and otherproviders say that the amount ofmoney that providers invest in theirfacilities is almost certainly morethan the numbers reported to the Wisconsin Department of HealthServices because they donrsquot includemany of the investments facilitiesmake in furnishings and otherelements that create a homelikeenvironment one of the many thingson which providers are surveyed

ldquoIn our experienceover the past fewyears there has mostdefinitely been anincrease in skillednursing and assistedliving projectsrdquosaid Wayne A Dau Architect with River

Valley Architects Inc a design firmbased in Chippewa Falls WI ldquoThereseems to be a close balance between(skilled nursing and assisted livingfacilities) except for the fact that

the SNF project tends to be newreplacement facilities while the ALprojects are more additions to existingfacilities or converting existing SNFareas to ALrdquo

ldquoThe senior housingconstruction markethas become asignificant market in Wisconsin We haveseen skilled nursingtherapy facilitieshospice care andother senior housing

type projects boom as of laterdquo said Jason Plante Vice President of Marketamp Johnson an Eau Claire-basedconstruction firm ldquoCurrently we haveover $75 million in senior housingprojects under construction which isour highest amount in recent historyrdquo

Dau and Plante said they have seennumerous trends in long-term carefacility construction that are designedand proven to lead to improvedpatient and resident outcomes

ldquoThe integration of natural light intothe center core of the resident livingspaces has become a mustrdquo Dau saidldquoWith the numerous studies availablenow which describe both the physicaland mental benefits of sunlight andour bodies need to set its lsquodaily clockrsquo why wouldnrsquot you strive to achieve the

Continued on P

presence of natural light As designers we have integrated this philosophy ofdesign into all project typesrdquo

Dau said over the past several yearsthere has been an obvious increasein resident-orientated design andless concentration on staff-orientateddesign which involves a designconcept based on giving the residentthe greatest freedom of choice

Plante said most of the newer facilitiescenter around private rooms with niceensuite bathrooms state-of-the-artspa rooms community-based designsor ldquopodsrdquo that feature smaller moreintimate dining and living areas

ldquoAlmost all the facilities are designedaround a more homelike atmospherefor the residences including privatebed and bathroomsrdquo Plante said ldquoAs

we plan or lay these areas out muchof the conversation is focused on howcare providers can most efficientlyprovide services to the resident with

minimal disruptionsrdquo

MAINSTREET INVESTMENTS

Earlier this year an Indiana-based realestate development company soughtan amendment to the 2015-17 StateBudget that would have lifted the statersquosnursing facility bed moratorium that hasbeen in place for decades by creating acare category called ldquoTransitional Carerdquo

Mainstreet Investments the companyseeking the special exemption waslooking to build 26 ldquotransitional carerdquo100-bed facilities that would have beenregulated just like nursing facilities but would have allowed the facilities tocherry-pick Medicare and private-payresidents and ignore Wisconsinrsquos poor

frail elderly and disabled residentsdepend on Medicaid as their soupayment for health care

While lobbyists for MainInvestmentrsquos proposal have poto flashy numbers of econgeneration ndash their proposal wredirect the existing economic imthat Wisconsinrsquos skilled nufacilities already generate

With nearly 20 percent of Wiscoskilled nursing beds ndash over 6ndash currently unoccupied (a76 buildings worth of avacapacity) Wisconsinrsquos skilled nufacility operators have unifoexpressed significant oppoto such an effort If adoptedproposal would undermine exskilled nursing facilities and mamore difficult for providers to reand retain front-line caregivers

ldquoI would warn against out ofdevelopers who in the nameconomic development are tto convince you that Wiscoprovider community needs thethis staterdquo Kiley said ldquoOur rcome from a long-term c ommitto the communities we serve work hand-in-hand with our care partners and we ensureall residents receive the care deserve Legislators should invthose providers that are provenperformers already operating istate They did this a few yearsby providing incentives to buildfacilities through the reimburseformula That is a more pruapproach than trusting ou

TOTAL ECONOMIC IMPACT OF WISCONSINrsquoS SKILLED NURSING FACILITIES

Category Direct Impact Economic Multiplier Economic Contribution

Payroll net Taxes and Leakages $1016611222 25 $2381286264

Purchases of Good amp Services $1298178768 23 $3000936325

Wisconsin Personal Income Tax $44861493 28 $127110555

Property Taxes $12986880 28 $36797026

TOTAL $ 2372638363 $5546130170

Source 2013 NorthStar Economics Report ldquoNursing Homesrsquo Contribution To Wisconsinrsquos Economy amp Employment

Jobs Creation of Wisconsinrsquos Skilled Nursing Facilities

Job Creator Head Count FTE Equivalent

Total Number of Nursing Home Workers 52306 37137

Jobs-to-Jobs additions 14272

Nursing Homes Business Spending-to-Jobs 13044

Total FTE Jobs Created 64453

Source Economic Analysis Nursing Homesrsquo Contribution to Wisconsinrsquos Economy amp EmploymentNorthStar Economics March 2013




entities who develop and look formanagement contractsrdquo

Kiley and many other providersbelieve that allowing real estatedevelopers to build so many newfacilities will flood the LTC facilitymarket and force many long-standingcare communities out of businessThis wouldnrsquot create new jobs but would simply move jobs from onefacility to another

During a luncheonnewsmaker interviewseries hosted by Wisconsin HealthNews in July WisconsinDepartment of HealthServices Secretary KittyRhoades stated thatthere is no need for an

additional care category for ldquoTransitionalCarerdquo as is being sought by MainstreetInvestments

Rhoades further stated that WisconsinrsquosLTC providers have been doingtransitional rehabilitative care for yearsand there are only a few counties inthe state where occupancy is evenclose to 90 percent indicating that while there is demand it is nowherenear the threshold required to lift themoratorium on adding licensed beds

STAFFING CRISIS

The real problem isnrsquot the supplyof beds providers say itrsquos the lackof supply of frontline caregiversIncreasingly because of the statersquos lowMedicaid reimbursement rate andthe salary prospective employees cansecure with other companies such asMcDonalds Wal-Mart and Kwik Tripfrontline caregivers are increasinglydifficult to recruit and retain

ldquoThe system is under-funded nowand wersquore expected to provide moreand more care with more and moreregulationsrdquo Klatkiewcz said ldquoThisis an important resource for everycommunity hellip We could hire 4-5employees right now but the peopleare just not availablerdquo

According to 2013 cost reports themost recently analyzed Medicaidis the source of payment for 65percent of the individuals receivingcare in Wisconsin nursing facilities As labor constitutes over 75 percentof resident care costs the levelof staffing wages and employeebenefits the resources a facility has isdependent on the level of Medicaidreimbursement it receives from thestate Moreover the inflexibility ofMedicaid as a funding source makesattracting the necessary staffinglet alone moving forward with a

building project very difficult

ldquoThe biggest concern for the agingBaby Boomer population is thecaregiver staffing crisis We need areimbursement formula that willallow long-term care providersto compete in the health caremarketplacerdquo Kiley said ldquoWe areseeing the wage gap between LTCand acute grow at an alarming rate Additionally other industries arepaying wages that are making italmost impossible for us bring newCNAs into the workplace This crisisneeds to be addressed through thereimbursement system soon beforethis statewide staffing shortage stiflesall the progress we made as a providercommunityrdquo

Providers like Kiley and Klatkiewczsay that an investment of targetedMedicaid funding to frontlinecaregivers will allow facilities toprovide deserved wage increases totheir staff while at the same timeimproving the quality of life of those who receive and provide care

ldquoMany providers are takingsubstantial risk to provide highquality services in the communitiesthey serverdquo Kiley said ldquoWe careabout our reputation and ourresults We are not developers whoare in this for the quick buck We are willing to do whatever isnecessary to prepare for the futureand the expectations that will comefrom the aging Baby Boomersrdquo


John J Vander Meeris the Director ofCommunications for the WisconsinHealth Care Association and theWisconsin Center for Assisted Living

He can be reached at johnwhcawicalorg

Tax Revenue Generation of Wisconsinrsquos Skilled Nursing Facilities

Tax Revenue Generation Tax Revenue

Employee Tax Revenue $141411212

Staff Generated Jobs Tax Revenue $53548446

Nursing Homes Taxes and Fees $12896880

N ur si ng Ho me Sp en di ng Ge ne ra te d Job s Ta x Rev en ue $48 938 768

Total State Tax Revenue Generated $ 256885306


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WelcomeMilestones

The Fall 2015 issue of Continuum is being released asa part of the 2015 WHCAWiCAL Fall Conventionand comes at the same time that our community ofproviders offers its best wishes in retirement to one ofour Associationrsquos long-standing champions

This summer WHCA Executive Director Thomas PMoore informed the WHCA Board of Directors of hisintention to retire in early 2016 Tom first aligned with WHCA (then known as the Wisconsin Nursing Home Association) in 1984 serving as its first in-house LegalCounsel He was appointed by the Board of Directorsto the Executive Director position in January 1986 when the Associationrsquos first Executive Director GeorgeF MacKenzie stepped down after 30 years of service

In his 32 years of service as Executive Director Tom hasadvanced and represented the interests of the Associationand its membership before the respective administrationsof 5 US Presidents and 5 state Governors

ldquoGiven the scope intensity of the unceasing changethe profession and membership have experienced overthe past thirty years my tenure as Executive Directorseems to have passed in the blink of any eyerdquo he saidin the announcement of his retirement ldquoHowever Irealize that successfully addressing the new and complexchallenges that loom on the horizon will require anenormous commitment of additional time and energythat is difficult to reconcile with the DOB that appearson my driverrsquos licensehellip Itrsquos a perfect and exciting timefor me personally and WHCAWiCAL professionallyto move onrdquo

WHCA Board President Mike Schanke offered thefollowing in the announcement of Tomrsquos retirementldquoThroughout his tenure as Executive Director Tomhas steered WHCA through many complicated

problems in the areas of reimbursement regulatory legislative affairsrdquo Schanke said ldquoTom has faithfand impartially represented the varied interests of profession these many years and I know I speak for entire membership in offering Tom our best wishehis retirementrdquo

In this issue of Continuum WHCAWiCAL offers readarticles on several topics of concern to our statersquos long-tecare providers The Cover Story in this issue highligthe significant investment that providers are making

ensure that our residents receive the best care possiIn Stakeholder Spotlight HealthCare Interactive C John Hobday offers insights into the origins of WHC WiCALrsquos new on-line dementia education partnerCapitol Connection we breakdown the 2015-17 SBudget signed into law over the summer and previthe upcoming fall floor period

In the other sections of the magazine the LTC LeLetter explains some of the potential legal implicatiof using a staffing agency a new column DDigest offers background on the use of data in public policymaking process and finally in ClinCorner WHCAWiCALrsquos on-line education partCE Solutions offers insight on the issue of influeimmunizations

As always thank you for taking the time to readContinu

Sincerely

John J Vander MeerManaging EditorContinuum

983158 983158 983158

Fall 2015








Cell 608-738-1141


Advertiser Index

IlluminAge



McKesson Medical


HME Home Medical

WHCAWiCAL SC



Wipfli



MJ Care


CE Solutions


ContentsFall 2015




CLINICAL CORNER






14

16

22

12

10



Assisted Living


Madison WI 53703

Phone 6082570125


Managing Editor

John J Vander Meer

Publisher

Dean Gille

Editor

Melissa Keller

Account Manager

Abbie McDowell

Creative Director

Sara Rice

Layout amp Design

David Cox

Published by

1155 Wilburn Road








address






2

4

4

9

9

17

17

17

18

20

20

20

21

21

27

28





By Jim McGinn

Capitol Connection

















Continued on



























bull

BILLING SERVICES








and ASSOCIATES



East 8006547240 | West 8006540418



Getting more means











James McGinn






By Kate Van Camp


















Data Digest

















Ltctrendtrackercom







USEFUL DATA SOURCES











PENDING LEGISLATION







Clinical Corner

















OLDER TAKE ACTION



























Cover Story















Ventilator Care


Services









jobs


Continued on P






















By John Hobday




Strategic Partners




bull Wound CareNPWT





bull Med B Billing

Continued on Pg 18

Senior Living










1-800-242-7001



wwwsecurityinsnet


Service Corporation


6082570125













Print |



























call us at 952-928-7722





GetFREE


facility

Subscribe Today

Foodservicewith a

Family-owned








bull Theme events

bull 9 dietitians
























Continued on Pg 24



2010 $12481065243 $3790238244 $16271303487

2011 $10032804770 $3922911013 $13955715783

2012 $8250816380 $6940766400 $15191582780

2013 $5861588380 $7769577720 $13631166100

2014 $7791229400 $11657138260 $19448367660

Subtotal $44417504173 $34080631637 $78498135810

Five-year Avg $8883500835 $6816126327 $15699627162

2015 ytd $5830770020 $5670719992 $11501490012

Total $50248274193 $39751351629 $89999625822




Phone (608) 837-8002 | Fax (608) 837-8005




EST D 1977

Experience Matters


MJCarecom




MJ Care Values



(414)329-2429







Worry free No




EMPLOYMENT ISSUES






LTC Legal Letter





INDEMNIFICATION

















contract rightrdquo






















Continued on P



















Property Taxes $12986880 28 $36797026

TOTAL $ 2372638363 $5546130170

















STAFFING CRISIS




















Contact me











Contact us

866-650-3400












Madison WI 53703









Cell 608-738-1141


Advertiser Index

IlluminAge



McKesson Medical


HME Home Medical

WHCAWiCAL SC



Wipfli



MJ Care


CE Solutions


ContentsFall 2015




CLINICAL CORNER






14

16

22

12

10



Assisted Living


Madison WI 53703

Phone 6082570125


Managing Editor

John J Vander Meer

Publisher

Dean Gille

Editor

Melissa Keller

Account Manager

Abbie McDowell

Creative Director

Sara Rice

Layout amp Design

David Cox

Published by

1155 Wilburn Road








address






2

4

4

9

9

17

17

17

18

20

20

20

21

21

27

28





By Jim McGinn

Capitol Connection

















Continued on



























bull

BILLING SERVICES








and ASSOCIATES



East 8006547240 | West 8006540418



Getting more means











James McGinn






By Kate Van Camp


















Data Digest

















Ltctrendtrackercom







USEFUL DATA SOURCES











PENDING LEGISLATION







Clinical Corner

















OLDER TAKE ACTION



























Cover Story















Ventilator Care


Services









jobs


Continued on P






















By John Hobday




Strategic Partners




bull Wound CareNPWT





bull Med B Billing

Continued on Pg 18

Senior Living










1-800-242-7001



wwwsecurityinsnet


Service Corporation


6082570125













Print |



























call us at 952-928-7722





GetFREE


facility

Subscribe Today

Foodservicewith a

Family-owned








bull Theme events

bull 9 dietitians
























Continued on Pg 24



2010 $12481065243 $3790238244 $16271303487

2011 $10032804770 $3922911013 $13955715783

2012 $8250816380 $6940766400 $15191582780

2013 $5861588380 $7769577720 $13631166100

2014 $7791229400 $11657138260 $19448367660

Subtotal $44417504173 $34080631637 $78498135810

Five-year Avg $8883500835 $6816126327 $15699627162

2015 ytd $5830770020 $5670719992 $11501490012

Total $50248274193 $39751351629 $89999625822




Phone (608) 837-8002 | Fax (608) 837-8005




EST D 1977

Experience Matters


MJCarecom




MJ Care Values



(414)329-2429







Worry free No




EMPLOYMENT ISSUES






LTC Legal Letter





INDEMNIFICATION

















contract rightrdquo






















Continued on P



















Property Taxes $12986880 28 $36797026

TOTAL $ 2372638363 $5546130170

















STAFFING CRISIS




















Contact me











Contact us

866-650-3400












Madison WI 53703





By Jim McGinn

Capitol Connection

















Continued on



























bull

BILLING SERVICES








and ASSOCIATES



East 8006547240 | West 8006540418



Getting more means











James McGinn






By Kate Van Camp


















Data Digest

















Ltctrendtrackercom







USEFUL DATA SOURCES











PENDING LEGISLATION







Clinical Corner

















OLDER TAKE ACTION



























Cover Story















Ventilator Care


Services









jobs


Continued on P






















By John Hobday




Strategic Partners




bull Wound CareNPWT





bull Med B Billing

Continued on Pg 18

Senior Living










1-800-242-7001



wwwsecurityinsnet


Service Corporation


6082570125













Print |



























call us at 952-928-7722





GetFREE


facility

Subscribe Today

Foodservicewith a

Family-owned








bull Theme events

bull 9 dietitians
























Continued on Pg 24



2010 $12481065243 $3790238244 $16271303487

2011 $10032804770 $3922911013 $13955715783

2012 $8250816380 $6940766400 $15191582780

2013 $5861588380 $7769577720 $13631166100

2014 $7791229400 $11657138260 $19448367660

Subtotal $44417504173 $34080631637 $78498135810

Five-year Avg $8883500835 $6816126327 $15699627162

2015 ytd $5830770020 $5670719992 $11501490012

Total $50248274193 $39751351629 $89999625822




Phone (608) 837-8002 | Fax (608) 837-8005




EST D 1977

Experience Matters


MJCarecom




MJ Care Values



(414)329-2429







Worry free No




EMPLOYMENT ISSUES






LTC Legal Letter





INDEMNIFICATION

















contract rightrdquo






















Continued on P



















Property Taxes $12986880 28 $36797026

TOTAL $ 2372638363 $5546130170

















STAFFING CRISIS




















Contact me











Contact us

866-650-3400












Madison WI 53703













bull

BILLING SERVICES








and ASSOCIATES



East 8006547240 | West 8006540418



Getting more means











James McGinn






By Kate Van Camp


















Data Digest

















Ltctrendtrackercom







USEFUL DATA SOURCES











PENDING LEGISLATION







Clinical Corner

















OLDER TAKE ACTION



























Cover Story















Ventilator Care


Services









jobs


Continued on P






















By John Hobday




Strategic Partners




bull Wound CareNPWT





bull Med B Billing

Continued on Pg 18

Senior Living










1-800-242-7001



wwwsecurityinsnet


Service Corporation


6082570125













Print |



























call us at 952-928-7722





GetFREE


facility

Subscribe Today

Foodservicewith a

Family-owned








bull Theme events

bull 9 dietitians
























Continued on Pg 24



2010 $12481065243 $3790238244 $16271303487

2011 $10032804770 $3922911013 $13955715783

2012 $8250816380 $6940766400 $15191582780

2013 $5861588380 $7769577720 $13631166100

2014 $7791229400 $11657138260 $19448367660

Subtotal $44417504173 $34080631637 $78498135810

Five-year Avg $8883500835 $6816126327 $15699627162

2015 ytd $5830770020 $5670719992 $11501490012

Total $50248274193 $39751351629 $89999625822




Phone (608) 837-8002 | Fax (608) 837-8005




EST D 1977

Experience Matters


MJCarecom




MJ Care Values



(414)329-2429







Worry free No




EMPLOYMENT ISSUES






LTC Legal Letter





INDEMNIFICATION

















contract rightrdquo






















Continued on P



















Property Taxes $12986880 28 $36797026

TOTAL $ 2372638363 $5546130170

















STAFFING CRISIS




















Contact me











Contact us

866-650-3400












Madison WI 53703





By Kate Van Camp


















Data Digest

















Ltctrendtrackercom







USEFUL DATA SOURCES











PENDING LEGISLATION







Clinical Corner

















OLDER TAKE ACTION



























Cover Story















Ventilator Care


Services









jobs


Continued on P






















By John Hobday




Strategic Partners




bull Wound CareNPWT





bull Med B Billing

Continued on Pg 18

Senior Living










1-800-242-7001



wwwsecurityinsnet


Service Corporation


6082570125













Print |



























call us at 952-928-7722





GetFREE


facility

Subscribe Today

Foodservicewith a

Family-owned








bull Theme events

bull 9 dietitians
























Continued on Pg 24



2010 $12481065243 $3790238244 $16271303487

2011 $10032804770 $3922911013 $13955715783

2012 $8250816380 $6940766400 $15191582780

2013 $5861588380 $7769577720 $13631166100

2014 $7791229400 $11657138260 $19448367660

Subtotal $44417504173 $34080631637 $78498135810

Five-year Avg $8883500835 $6816126327 $15699627162

2015 ytd $5830770020 $5670719992 $11501490012

Total $50248274193 $39751351629 $89999625822




Phone (608) 837-8002 | Fax (608) 837-8005




EST D 1977

Experience Matters


MJCarecom




MJ Care Values



(414)329-2429







Worry free No




EMPLOYMENT ISSUES






LTC Legal Letter





INDEMNIFICATION

















contract rightrdquo






















Continued on P



















Property Taxes $12986880 28 $36797026

TOTAL $ 2372638363 $5546130170

















STAFFING CRISIS




















Contact me











Contact us

866-650-3400












Madison WI 53703











PENDING LEGISLATION







Clinical Corner

















OLDER TAKE ACTION



























Cover Story















Ventilator Care


Services









jobs


Continued on P






















By John Hobday




Strategic Partners




bull Wound CareNPWT





bull Med B Billing

Continued on Pg 18

Senior Living










1-800-242-7001



wwwsecurityinsnet


Service Corporation


6082570125













Print |



























call us at 952-928-7722





GetFREE


facility

Subscribe Today

Foodservicewith a

Family-owned








bull Theme events

bull 9 dietitians
























Continued on Pg 24



2010 $12481065243 $3790238244 $16271303487

2011 $10032804770 $3922911013 $13955715783

2012 $8250816380 $6940766400 $15191582780

2013 $5861588380 $7769577720 $13631166100

2014 $7791229400 $11657138260 $19448367660

Subtotal $44417504173 $34080631637 $78498135810

Five-year Avg $8883500835 $6816126327 $15699627162

2015 ytd $5830770020 $5670719992 $11501490012

Total $50248274193 $39751351629 $89999625822




Phone (608) 837-8002 | Fax (608) 837-8005




EST D 1977

Experience Matters


MJCarecom




MJ Care Values



(414)329-2429







Worry free No




EMPLOYMENT ISSUES






LTC Legal Letter





INDEMNIFICATION

















contract rightrdquo






















Continued on P



















Property Taxes $12986880 28 $36797026

TOTAL $ 2372638363 $5546130170

















STAFFING CRISIS




















Contact me











Contact us

866-650-3400












Madison WI 53703












Cover Story















Ventilator Care


Services









jobs


Continued on P






















By John Hobday




Strategic Partners




bull Wound CareNPWT





bull Med B Billing

Continued on Pg 18

Senior Living










1-800-242-7001



wwwsecurityinsnet


Service Corporation


6082570125













Print |



























call us at 952-928-7722





GetFREE


facility

Subscribe Today

Foodservicewith a

Family-owned








bull Theme events

bull 9 dietitians
























Continued on Pg 24



2010 $12481065243 $3790238244 $16271303487

2011 $10032804770 $3922911013 $13955715783

2012 $8250816380 $6940766400 $15191582780

2013 $5861588380 $7769577720 $13631166100

2014 $7791229400 $11657138260 $19448367660

Subtotal $44417504173 $34080631637 $78498135810

Five-year Avg $8883500835 $6816126327 $15699627162

2015 ytd $5830770020 $5670719992 $11501490012

Total $50248274193 $39751351629 $89999625822




Phone (608) 837-8002 | Fax (608) 837-8005




EST D 1977

Experience Matters


MJCarecom




MJ Care Values



(414)329-2429







Worry free No




EMPLOYMENT ISSUES






LTC Legal Letter





INDEMNIFICATION

















contract rightrdquo






















Continued on P



















Property Taxes $12986880 28 $36797026

TOTAL $ 2372638363 $5546130170

















STAFFING CRISIS




















Contact me











Contact us

866-650-3400












Madison WI 53703


















By John Hobday




Strategic Partners




bull Wound CareNPWT





bull Med B Billing

Continued on Pg 18

Senior Living










1-800-242-7001



wwwsecurityinsnet


Service Corporation


6082570125













Print |



























call us at 952-928-7722





GetFREE


facility

Subscribe Today

Foodservicewith a

Family-owned








bull Theme events

bull 9 dietitians
























Continued on Pg 24



2010 $12481065243 $3790238244 $16271303487

2011 $10032804770 $3922911013 $13955715783

2012 $8250816380 $6940766400 $15191582780

2013 $5861588380 $7769577720 $13631166100

2014 $7791229400 $11657138260 $19448367660

Subtotal $44417504173 $34080631637 $78498135810

Five-year Avg $8883500835 $6816126327 $15699627162

2015 ytd $5830770020 $5670719992 $11501490012

Total $50248274193 $39751351629 $89999625822




Phone (608) 837-8002 | Fax (608) 837-8005




EST D 1977

Experience Matters


MJCarecom




MJ Care Values



(414)329-2429







Worry free No




EMPLOYMENT ISSUES






LTC Legal Letter





INDEMNIFICATION

















contract rightrdquo






















Continued on P



















Property Taxes $12986880 28 $36797026

TOTAL $ 2372638363 $5546130170

















STAFFING CRISIS




















Contact me











Contact us

866-650-3400












Madison WI 53703







Print |



























call us at 952-928-7722





GetFREE


facility

Subscribe Today

Foodservicewith a

Family-owned








bull Theme events

bull 9 dietitians
























Continued on Pg 24



2010 $12481065243 $3790238244 $16271303487

2011 $10032804770 $3922911013 $13955715783

2012 $8250816380 $6940766400 $15191582780

2013 $5861588380 $7769577720 $13631166100

2014 $7791229400 $11657138260 $19448367660

Subtotal $44417504173 $34080631637 $78498135810

Five-year Avg $8883500835 $6816126327 $15699627162

2015 ytd $5830770020 $5670719992 $11501490012

Total $50248274193 $39751351629 $89999625822




Phone (608) 837-8002 | Fax (608) 837-8005




EST D 1977

Experience Matters


MJCarecom




MJ Care Values



(414)329-2429







Worry free No




EMPLOYMENT ISSUES






LTC Legal Letter





INDEMNIFICATION

















contract rightrdquo






















Continued on P



















Property Taxes $12986880 28 $36797026

TOTAL $ 2372638363 $5546130170

















STAFFING CRISIS




















Contact me











Contact us

866-650-3400












Madison WI 53703




















Continued on Pg 24



2010 $12481065243 $3790238244 $16271303487

2011 $10032804770 $3922911013 $13955715783

2012 $8250816380 $6940766400 $15191582780

2013 $5861588380 $7769577720 $13631166100

2014 $7791229400 $11657138260 $19448367660

Subtotal $44417504173 $34080631637 $78498135810

Five-year Avg $8883500835 $6816126327 $15699627162

2015 ytd $5830770020 $5670719992 $11501490012

Total $50248274193 $39751351629 $89999625822




Phone (608) 837-8002 | Fax (608) 837-8005




EST D 1977

Experience Matters


MJCarecom




MJ Care Values



(414)329-2429







Worry free No




EMPLOYMENT ISSUES






LTC Legal Letter





INDEMNIFICATION

















contract rightrdquo






















Continued on P



















Property Taxes $12986880 28 $36797026

TOTAL $ 2372638363 $5546130170

















STAFFING CRISIS




















Contact me











Contact us

866-650-3400












Madison WI 53703






Worry free No




EMPLOYMENT ISSUES






LTC Legal Letter





INDEMNIFICATION

















contract rightrdquo






















Continued on P



















Property Taxes $12986880 28 $36797026

TOTAL $ 2372638363 $5546130170

















STAFFING CRISIS




















Contact me











Contact us

866-650-3400












Madison WI 53703






















Continued on P



















Property Taxes $12986880 28 $36797026

TOTAL $ 2372638363 $5546130170

















STAFFING CRISIS




















Contact me











Contact us

866-650-3400












Madison WI 53703









STAFFING CRISIS




















Contact me











Contact us

866-650-3400












Madison WI 53703











Madison WI 53703


continuum fall 2015

Documents