Second Quarter 2012

The FlagPOST
Productive Paranoia
In Great By Choice, Jim Collins and Morten T. Hansen studied companies that not only survived in the middle of chaos and uncertainty, but thrived. He called these companies 10Xers (pronounced ten-EX-ers) because they outperformed all others in their industry by 10 times. One of the behaviors that stood out in each of the 10X companies was what Collins calls, "productive paranoia." The companies that demonstrated productive paranoia, particularly when things were going smoothly, were better prepared and ready for changes and threats. The fear of the unknown was channeled into safety margins and buffers so that they were always prepared for unfavorable conditions.


We know that we are in the midst of sweeping healthcare reform, and our industry continues to change at a dizzying pace. Our therapy resources are working to set up systems to shore us up for any storms ahead - implementing and managing systems (versus managing people) allows our leaders to stay focused on growing our therapists and programs so that we stay vibrant and limber.


How prepared is your department? Have your therapists taken their Brainshark trainings? Are you monitoring productivity daily to ensure the accuracy of your billing? Are you considering student programs to keep our professions alive? I challenge you to assess how strong your buffer zone is during these relatively smooth times so that you are braced for what lies ahead.

Celebrating OT Month at Osborn Health and Rehab Center by Joleen Linn, Therapy Resource


As many of you know, April was National Occupational Therapy month. In an effort to provide education to the staff on the role of Occupational Therapy in a SNF setting, Osborn Health and Rehab Center hosted a week of fun and informative activities for their co-workers and residents. Occupational therapists provide extensive education to their patients and family members as part of their treatment plans, but how many times have you heard OT introduced as, "This is OT - they work with you 'above the waist.' Osborn Health and Rehab Center wanted to inform their staff that occupational therapy is more than "arm bikes, peg boards and getting people ready for PT." They felt that the best use of OT month was for staff education. Osborn2

First, they did a quick presentation at their all-staff meeting and invited everyone to participate in the week's daily activities. The OTs and COTAs made up an OT-related word search, crossword puzzle and true/false quiz. As employees completed the activity, they were presented with a "prize" consisting of chips or cookies (yes, they did bribe with food!). Then each day, Osborn Health and Rehab Center presented an activity that demonstrated how various impairments affect their residents' ability to complete basic tasks. For example, they mimicked visual deficits (blindness, macular degeneration and glaucoma) while the staff member navigated an FWW through an obstacle course and then sat down to complete a drawn maze. Another day's activity involved dominant-sided weakness post-stroke. The employee had to use his or her non-dominant hand for a balance, gross-motor, eye-hand coordination task, which consisted of balancing on one leg on an unstable surface and tossing bean bags with the non-dominant hand to win various prizes.  Other activities performed that week included a fine-motor "Minute to win it" type of game, and finally a speed, visual perceptual/cognitive task followed by root beer floats as the final reward.


The Occupational Therapy team did an excellent job of staff education, and more than once heard the comment, "Wow, is that what it is really like?" They had a good turnout and a lot of fun in achieving the objective of celebrating OT month and showing off OT!

Congratulations Brookfield Healthcare Center!
E-Prize Winner

2012 E-Prize Winner!
 See more photos of Brookfield's resident care and activities at


Look What's Happening in the World of Dementia
Helping Family and Caregivers Connect
with the Person Inside
by Gina Tucker-Roghi,Therapy Resource

One of the most exciting aspects of the Dementia Capable Care Model for me has been the ability to tap into the unique personhood that remains in each of our residents and longs to be acknowledged. Even those at the late and end stages of the dementia process have the ability to connect in a meaningful way. Our skill lies in finding what type of stimulation will awaken our clients, and teaching others effective methods, cueing strategies and techniques to elicit this same positive response.


During a recent dementia training I attended, I was brought to tears watching a video clip of a client who was being met right where he was in his dementia by a therapist using sensory stimulation techniques to bring him to life. To see this individual, who had previously been cared for in body but not in soul, awaken to the therapist's techniques was a moving experience. The types of stimulation she used were customized to the client, based on his past experiences, interests and habits in order to have the greatest impact. By using stimuli that tie into the client's long-term and procedural memories, we tap into the strongest and most durable types of memory..Read on

Dementia Capable Care Instructor Program
by Ryan Hough, Therapy Resource

What is the first thing that comes to mind when you think of a patient who has dementia? Many people tend to think of what dementia patients typically can't do - such as remember names, get dressed, brush their teeth and so on. However, I had the opportunity recently to take the Dementia Capable Care Instructor Program with the desire to bring the training I received back to each of the homes in my region. This training is designed to help anyone who is involved in caring for our residents to develop a new mindset and ideas on how to work and interact with patients who have dementia. This awesome training helps you to understand where a patient is at cognitively so that you can then formulate a plan - whether you are a therapist, an activity director, a nurse, an executive director or a maintenance worker.


As a physical therapist, I think back to all the times when I was trying to walk a patient but not having success. Through this course, you will learn spatial, verbal and tactile cues to assist you. Most important, the training inspires you to learn all you can about your patient and his or her past. The more you know, the better equipped you are to help your patient be successful. As your patients experience success with activities such as walking, getting dressed, playing cards and even feeling overall happiness, you'll discover that dementia patients have so much potential. We all strive every day to offer the best care to our residents, and this course offers tools that will help you to change these patients' care experiences for the better.


Rehab Professionals' Self-Reported Knowledge of Dementia and Competency in Treating Clients with Dementia

by Ciara Cox, PhD., Therapy Resource

  Brain Puzzle

Six Samuel Merritt University OT students and I just completed a study on rehab professionals' self-reported knowledge of dementia and self-reported competency in treating clients with dementia. We wanted to see if there was a gap between knowledge of dementia and feelings of competency in treating clients with dementia. We collected data for our study via a web-based survey. Many of those who responded to our survey work at an Ensign-affiliated operation, and we thank you for your participation.


Although the response rate to our survey was low (27 OTs, five COTAs, 20 PTs, eight PTAs and five SLPs), we had some interesting findings:As a group, OTs, COTAs, PTs, PTAs and SLPs feel both knowledgeable and competent.

  • There was no significant difference between self-reported knowledge of dementia and self-reported competency in treating clients who have dementia.
  • There was no significant difference in self-reported knowledge and competency between the three different rehab professions.
  • There were significant differences between groups of rehabilitation professionals who received different types of dementia care training and also differences related to years of experience working with clients with dementia...Read on
An Allen Cognitive Approach Improves
the CarAllen bookse We Provide  
In the United States, dementia is the most common diagnosis for nursing home residents, and the prevalence of dementia may be as high as 74 percent in nursing homes (Magaziner et al., 2000). You may have seen the statistic that 5.4 million Americans have Alzheimer's dementia (Alzheimer's Association, 2011), but did you know that another 5.4 million Americans over the age of 70 have cognitive impairment without dementia (Plassman et al., 2008)?


Ensign's E-Prize

For those of you following the E-Prize competition, you may have noticed that two of the nine finalists in this contest specifically looked at improving the lives of residents with cognitive impairments. The facilities were Julia Temple and Holladay Healthcare, and the programs both facilities implemented were based on an Allen-Cognitive approach to care. Allen's Cognitive Disability Model provides tools to evaluate the functional cognitive level of residents and gives you information on how to best interact with residents at different cognitive levels...Read on
Hollywood Marathon
Congratulations to team members from The Orchard and Whittier Hills who participated in the Hollywood Half Marathon on April 7 to 

benefit the LA Youth Network and LAUSD Beyond the Bell Program.

Massage Vibration Brings New Life to

Northern Oaks

by Billye J. Alford-Lee, PT/DOR, Northern Oaks Living & Rehab Center, Abilene, TX

Billye Alford-Lee (L) and Janet Case, PT with Mr. Lynn


Mr. Lynn has been a resident at Northern Oaks for three years with a diagnosis of quadriplegia. He has struggled with seating issues due to extensor tone in UEs and LEs. After consulting with resources Deb Ellis and Jon Anderson, we trialed a massage/vibration mat to decrease tone prior to ROM and began assessment and fitting for a new custom power wheelchair. The vibration mat worked beautifully if applied approximately 20 to 30 minutes prior to treatment. The custom power wheelchair arrived five weeks later, with a head array and mouth control driving mechanism, allowing Mr. Lynn a newfound independence in mobility and quality of life that he had not experienced in several years. He also is able to control his television with the mouthpiece, as it is synced with his remote control.


Our therapy team has been so honored to work with Mr. Lynn in making a difference in his life. His amazing attitude and smile are such a joy to see, and the creative efforts of Ensign Therapy Resources and therapists have truly contributed to enhancing his comfort, independence and happiness here at Northern Oaks!

The Human Side of Physical Therapy

Submitted by Student Interns from the University of St. Augustine


JB Chua, DOR and Courtney Sinclair, SPT, Sonoma Healthcare

Physical therapy school prepares you by giving you that archetypal "toolbox" filled with various resources and skills to be constantly adjusted and fine-tuned. The more tools, the better! Since every patient is unique, each treatment must be tailored to deliver the best interventions possible. During various courses preceding my first clinical internship, I filled my toolbox with functional outcome measures, neurological interventions and about 50 pneumonics to remember everything from the cranial nerves to the eight carpal bones. I practiced NDT, PNF, MMTs and goniometry on my classmates at length, sweated through practicals and wrote hundreds of study guides. I felt eager to apply this knowledge to actual patients, not my unimpaired classmates, so that I could learn from experience. My first internship brought me to Sonoma Healthcare Center, an Ensign-affiliated sub-acute skilled nursing facility.


Terri Martin, DOR and Murphy McCarty, SPT, Cloverdale Healthcare

As a student embarking on my first internship, I had some expectations of what I should gain out of the seven weeks I was to spend at Sonoma Healthcare Center. I expected to learn, to be challenged applying my knowledge, to experience a wide variety of patients and their unique impairments. What I did not expect was that my experience would take me above and beyond these conjectures and give me an opportunity to not only utilize my "tools," but also to foster meaningful relationships with both my peers and my patients. It's the human side of physical therapy: that knack for communication, the willingness to have an open heart. These are skills no professor can teach...Read on

Mentoring is an Opportunity for Both
Therapist and Intern
by Amy Lynn Guiterrez, SLP, Village Care Center, McAllen, TX
(L to R): Amy Guiterrez SLP and Student Intern Denise


 I have been a practicing SLP for the past six years and have had the pleasure of working for Village Care Center in McAllen, TX, for five years. In 2011, I was presented with the opportunity to mentor a new graduate who was seeking to complete her CFY. I have to admit, initially I was a bit apprehensive as I did not feel I possessed the "tools" to educate and/or mentor a fellow clinician.


On July 11, 2011, Denise joined our team as an intern in Speech-Language Pathology. She has since then been a wonderful asset to our work family. Being a recent graduate, she has provided not only me, but also our whole team, with unique treatment approaches along with a different perspective. These past nine months have flown by so fast, it is astonishing to believe that it has come and gone. I remember her first day and how reluctant I was to provide her with her own list of patients. My director said to me: "She'll be fine. You can't follow her around forever, and you need to give her more than three patients!" I couldn't help but recall when I was an intern and how terrified I was; she must have been feeling the same way. Slowly but surely, I let go of the reins and realized I would always be within walking distance in case she needed anything. I am very fortunate to have had such a wonderful first experience with my CF. We had many adventures together that provided us with a number of teaching moments.


The most important thing I learned throughout this experience is that we won't always have the immediate answer, and that fear should not hinder us from taking on a task that may seem challenging. My apprehension toward becoming a mentor was unwarranted. I now understand that mentoring a fellow clinician should be viewed as a privilege. It's a learning experience for supervisor and intern both and an experience we will both carry with us.


Restorative Nursing Aide

Certification Program by Priscilla Diazdeleon, Therapy Resource


Silver Springs Rehabilitation and Nursing Center, located in Houston, Texas, has taken the lead in setting a higher standard of care and excellence for our restorative nursing program. When you see the words "restorative care," the thing that comes to mind is rehabilitation. Rehabilitation is the process of restoring and maintaining a person in good health through the use of therapy, exercise and education. Restorative programs in skilled nursing facilities are geared toward maintaining a good quality of life for all patients, allowing a better state of physical independence.


What separates Silver Springs' restorative program from others is the rigorous training and testing that their restorative aides must complete and master before being labeled a Certified Restorative Nursing Aide. The training at Silver Springs has been organized and conducted by Keystone Therapy and Clinical Resources, Priscilla Diazdeleon and Arlene De La Cruz. They chose Silver Springs as the test pilot facility for the Restorative Aide Certification Program. Conducting the restorative aide certification process at Silver Springs has been Sonny Gonzalez, PTA. The program consists of 16 specific areas of care or modules that are systematically taught over the course of three months. Training includes both lecture and lab components. All trainees also receive a binder containing all the educational material for each module. At the end of the training, the CNAs undergo both written and practical testing over each module. The first group of Certified Restorative Aides received their certificates on July 8, 2011. Look for the Certified Restorative Nursing Aide Program to continue to be modified and improved upon and hopefully come to an Ensign-affiliated facility near you in the future.  

Certified Restorative Nursing Aides at Silver Springs
 show their certificates of achievement

Educational Journey

by Jesus Rodriguez, OT, Grand Terrace Rehab and Healthcare, McAllen, TX

 J Rodriguez

Getting an education can be a challenging experience for many. Imagine adding other factors to the equation, such as family and full-time employment. This can make it difficult for those who work and attend college to be successful in achieving that goal. In addition, many believe that the traditional route of getting an education going from high school straight through college still exists. However, this is not true. Many students are now obligated or choose to work in order to pay for school or to avoid loans. Furthermore, not everyone chooses to go to college after high school or complete a higher education at once. This is true for me.


My road to getting an education has been a journey. I graduated from an occupational therapy assistant program in May 1999 and initiated my practice shortly thereafter. After a few years off, I received a second associate's degree in interdisciplinary studies in 2004. I took some time off to allow my wife to attend college and get her degree, and then I started school again on a part-time basis, wanting to continue my education but not knowing in what discipline. I finally chose to go back to OT school and earned a Bachelor's Degree in Health Service Technologies in 2008. In 2009, I initiated the COTA to MOT bridge program at Texas Woman's University in Denton. I am graduating this year and with great feelings of relief...Read On

The Lodge at Willow Bend 

by Jessie Dees, DOR, Willow Bend Nursing and Rehab, Mesquite, TX


For months now, I have wanted to sit down and type up this article to share my thoughts and reflections on Willow Bend's Rehab Department. I have been here for 15 months, and looking back, we have come so far. I walked into a department that was struggling to maintain a caseload and keep current on paperwork, while also considering an addition to the building that was a concrete slab and wood studs. Today, our department is quickly growing with team-oriented therapists and techs. Our long-term, short-term and outpatient caseloads continue to expand faster than any of us ever imagined. The timeliness of paperwork completion is much improved through numerous systems we have developed, implemented, and continue to modify. We have improved our presence within the building and in the community. On January 12 of this year, we accepted our first patient into "The Lodge," our newly renovated Rehab area. We were all excited at the future possibilities and secretly anxious about the unknown... Read On
Willowbend Team

UAB Training for

Constrained-Induced Therapy 

by Franco Yap, PT, Alta Vista Rehabilitation & Healthcare, Brownsville, TX



With advancements in neuro-imaging and the publication of more and more research in the realm of neurologic recovery, there has been a greater awareness and understanding into the mysteries of the brain. Recovery after a stroke is possible. The centuries-old notion that the adult brain is fixed and unchanging is now being reexamined and questioned. Arguably, the most important breakthrough in neuroscience since scientists first sketched out the brain's basic anatomy is the revolutionary discovery of Neuroplasticity. This concept that the brain is malleable and able to recover and change, even after an injury, continues to show a lot of hope for those dealing with neurologic injury.


Recently, the University of Alabama has been offering a week-long constrained-induced (CI) therapy training course for clinicians. CI therapy has been derived from basic behavioral neuroscience research with primates, pioneered by Dr. Edward Taub of the UAB CI Therapy Research Group...Read On

Geriatric Sports Medicine -

Total Shoulder, Hip and Knee

by Nelson Layos, Therapy Resource


This is the third year that we are providing seminar/CEU credits for Flagstone and Touchstone therapists. This year, the topic is Geriatric Sports Medicine presented by Wilson Seminars. It will be held July 14 and 15 (and is already full with more than 90 participants). The later dates are September 8 and 9 on the same topic to accommodate the rest of Flagstone and Touchstone therapists. We have received overwhelming responses from our therapists, and they are hoping that Ensign Therapy will continue with the programs.


Osteoarthritis is a disease characterized by degeneration of cartilage and its underlying bone within a joint as well as bony overgrowth. The breakdown of these tissues eventually leads to pain and joint stiffness. With decreased activity, patients can expect a vicious cycle of increased pain and impaired mobility. Currently in the United States, there are more than 231,000 total hip replacements, 542,000 total knee replacements and 40,000 total shoulder replacements performed per year. Projections state this number will quadruple by 2030...Read On 

Kinesiotaping Brings Positive Outcomes

by Rhianna Wagers-Hughes, PT, DPT, CEEAA, CSST and future CKTP


Kinesiotaping became popular during the 2008 Beijing Olympics when Kerri Walsh of the U.S. Beach Volleyball Team utilized kinesiotape to her right shoulder during the games. I was interested in learning a new taping method for my geriatric patients in the skilled nursing setting due to what I had read about the benefits of the tape. Kinesiotape is used to facilitate the body's natural healing process while providing support and stability to muscles and joints without restricting the body's range of motion as well as providing extended soft tissue manipulation to prolong the benefits of manual therapy administered within the clinical setting. Latex-free and wearable for days at a time, Kinesio® Tex Tape is safe for populations ranging from pediatric to geriatric, and successfully treats a variety of orthopedic, neuromuscular, neurological and other medical conditions.


I registered for KT1 and 2 in January 2010 and learned the basic methods of kinesiotaping from Amy Stahl PT, CKTI. Immediately, I was able to apply the methods to the geriatric population for lymphatic corrections and facilitation for post-CVA PT in the skilled nursing setting. I contacted the KinesioTaping Association International (KTA) for a specialized geriatric application course so that I could learn specific techniques for the geriatric population. I learned that not many therapists were utilizing the taping techniques with this specific population, so I contacted the APTA and the Geriatric Section so that I could start some case studies with the geriatric population. I have received support from the APTA and KTA in the form of free tape, mounds of information and research articles, and techniques to use with my geriatric patients.


I recently have taken KT3 in McAllen, Texas to learn advanced kinesiotaping techniques for the whole body and to apply the new techniques with the geriatric population at my facility. Outcomes are positive with lymphatic corrections, mechanical corrections and fascial corrections to improve functional mobility and ADL performance with all orthopedic, neurological and neuromuscular patients. I will be taking my certification exam to become a certified kinesiotaping practitioner (CKTP) to add to the many tools in my toolbox to improve the quality of life for my patients.

Bridging the Gap:

Clinical Research and Rehabilitation

by Curtis Merring, OT/DOR, Wellington Place, Temple, TX 


Professionals and administrators in any rehabilitation setting need intrinsic motivation to pursue evidence-based treatment strategies to stay ahead of market adjustments and reimbursement trends. In our current healthcare system of cost-cutting and cost-saving payers such as Medicare (the lifeline of skilled nursing facilities), it is only a matter of time before regulators request from facilities quantifiable results of treatments. Active participation in this process, including preemptively taking these steps, will put any organization or facility at an advantage.

In my experience as a therapist, it has been rare to witness therapists who review current research when planning their treatment strategies, and current trends show no remarkable change in their approach. This is problematic for both established therapists and new graduates entering the field. Therapists in the field are used to the status quo of not integrating research or evidence. New graduates, equipped with the newest evidence- based treatment strategies and the know-how for obtaining this information, come into a field that is dominated with non-evidence-based practice... Read On

Issue: 2

In This Issue
Celebrating OT Month at Osborn Health and Rehab
Congratulations Brookfield...E-Prize Winner!
Look What's Happening in the World of Dementia
Helping Family and Caregivers Connect with the Person Inside
Dementia Capable Care Instructor Program
Rehab Professionals' Self-Reported Knowledge of Dementia
Allen Cognitive Approach Improves the Care We Provide
Hollywood Half Marathon Runners
Massage Vibration Brings New Life to Northern Oaks
The Human Side of Pysical Therapy
Mentoring is An Opportunity for Both Therapist and Intern
Restorative Nursing Aide Certification Program
Educational Journey
The Lodge at Willow Bend
UAB Training for Constrained-Induced Therapy
Geriatric Sports Medicine - Total Shoulder, Hip and Knee
Kinesiotaping Produces Positive Outcomes
Bridging the Gap: Clinical Research and Rehabilitation
The Compliance Corner...Ask Lorraine


Have you thought about advancing your education? Or, perhaps even advancing your degree? Many of our facilities offer programs to assist you with living your "passion for knowledge." Some of these programs include financial support for continuing education courses. Other programs may include tuition
reimbursement for university courses or certification credit. Through one of our most recent relationships with the Rocky Mountain University of Health Professions (RMUoHP), we will be tailoring some courses to fit your needs in the area of leadership development. The RMUoHP also offers post-graduate doctoral programs in both Physical and Occupational Therapy, which are designed to meet the needs of the working learner. If the pocket book is a little tight right now, take advantage of the new courses being added to our Learning Management System, Brainshark. Not only are the Brainshark courses helpful for navigating through our ever-changing healthcare environment, but our development plans include information to challenge you to grow as therapists and leaders. Watch for a release mid-summer 2012 on the Allen Cognitive Levels, Part I. And Part II, being released in August, will include demonstration training for administering components of the Allen Cognitive Battery of Assessment Tools.  


If you haven't had an opportunity to attend a learning event sponsored by your therapy resource team at Ensign Services, please watch for upcoming opportunities. During the past 6 months, we have partnered with facilities in different states throughout our company to bring a variety of educational events to you. South Texas has co-sponsored Kinesio Taping I, II, and III. The KT I and II course will be offered in Dallas, Provo, Arizona and Southern California sometime over the next few months. Therapy Resources Gina Tucker-Roghi, Ryan Hough and Debbie Ellis have also become certified trainers in an 8-hour course on Dementia Care, and they are beginning to schedule trainings with interested facilities in select areas. We are developing a seating and positioning training to assist with filling a need identified by several of our DOR's. Our Southern California Resources are working with education specialists to offer modalities courses. We are also looking to offer another CI Certification Course sometime later this year...Read On


Ask Lorraine... 

Lorraine Finnegan, Therapy/Compliance Resource

 Q. Our doctors often don't date their signatures. Is this OK as long as we have the signatures on the documents?

A. No. All signatures should have dates, as these dates allow us to prove timeliness and actually validate the signature itself. If your MDs are not dating their signatures, talk with the facility administrator and DNS to see if the matter can be discussed with the doctors. Often, they just need a reminder. A concerted effort should be made by every facility to ensure all signatures have dates.


Q. Do I really need to document missed treatments when the service log matrix clearly shows the treatment was missed?

A. Yes. All missed treatments and the reason why should be documented in the patient's record in a daily treatment note. When the patient does not receive all the treatments in a week as authorized by the MD, then the therapist should explain why. Missed treatments may impact the patient's progress and may also support a documented decline (for example, if the patient was sick). Documentation of these treatments also allows the therapist to show what efforts were made to help meet the patient's needs and to show that every attempt was made to provide the services that the MD ordered for the patient.


Q. What if I forgot to bill for a patient and I realize the error a few days later?

A. Each licensed therapist is expected to bill all charges for treatments provided on the day of treatment. It is imperative to enter billing documentation while the skilled treatment provided is fresh in your memory so that it accurately reflects the treatment provided to the patient. Speak to your DOR immediately. Make sure the DOR knows you are billing late, as it could affect an MDS, or change a RUG that has already been calculated or an export that has already occurred for the previous month.


Q. When the caseload increases, we get behind on progress notes. What should we do?

A. Ensign's Best Practice is that Part A documentation of weekly progress notes are completed every seven days, and Part B weekly progress notes are completed every fifth visit, AND within 48 hours or two days of the due date. Utilize Rehab Optima's hot list under documentation due or overdue. If paperwork does get behind, the DOR/Resource should be notified to review caseloads and possible need for additional staffing. It is imperative to accurately document all patient care in a timely manner.




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Mary Spaeder, Editor