Second Quarter 2013

FlagPOST Archives
Organizational Health

"The single greatest advantage any company can achieve is organizational health. Yet it is ignored by most leaders even though it is simple, free, and available to anyone who wants it." (Lencioni, 1)


At the Director of Rehab meeting in June, our therapy leaders had an opportunity to delve into Patrick Lencioni's latest book, The Advantage,and the idea that organizational health essentially trumps all other factors in creating success. We discussed ways that we could focus our efforts on creating a cohesive team, creating clarity about what will be our unique vision, and then over-communicating that vision so that every staff member understands his or her part in the mission of the facility.


We heard ways that our facilities are setting their therapy departments apart from others, shared specific programs that could be easily implemented, and celebrated each company with a unique presentation. We also had an opportunity to ask questions and hear updates from our compliance partners, and we had a wonderful guest speaker to help us hone our clinical documentation skills.


Thank you to all who attended and made this extraordinary experience possible!   (Click here for a photo collage of some memorable moments)

The POSTettes 

By Tamala Sammons, Therapy Resource


The FlagPOST is used as a resource to share clinical and regulatory updates, successes and great programs happening across the company. From this same concept of sharing great information, the POSTettes were born. POSTettes stands for PT, OT, SLP Therapy, Education, Tips, Tricks and Examples Summarized. They are designed to be quick one- to two-page summaries that can be used as training tools to support policies, procedures and great clinical programs.


Soon to be released are some Clinical Program POSTettes and a POSTettes documentation series. They serve as reminders of information and can be posted everywhere - the portal, Green Light, memo boards, etc. They are great for a quick in-service or training for busy therapists always on the run.


We are looking forward to feedback from the field to learn what other POSTettes may be needed. We also will be recruiting clinical experts to help write and edit POSTettes on specific subjects and programs. Feel free to submit POSTette ideas to


"Talent is always conscious of its own abundance,

and does not object to sharing."

- Aleksandr Solzhenitsyn

Eddie Justensen's Surprising Comeback
Back on his feet on July 31, Justesen gets applause from the Pinnacle staff and tears of joy from his wife, Lara.
Pinnacle Nursing and Rehabilitation in Price, Utah, was recently highlighted in the success of one of their patient's rapid recovery. Joseph Serfustini, Associate Editor of the Sun Advocate wrote, "The ordeal for Eddie Justensen and his family began on Mother's Day. It was apparently a seizure that caused him to fall and hit his head -hard-on a china cabinet at home that morning. His brain swelled after the impact. The pressure produced a shutdown of just about all his voluntary functions..."
It Takes a Village ...


The Rio Grande Valley sparkled with Hollywood-inspired glamour on the night of March 7 when Village Healthcare and Rehabilitation celebrated its Grand Opening. The facility literally laid out the red carpet for guests, stakeholders, residents and families, who have made it the four-star facility that it is. Principal sponsors included Rio Grande Valley Mobile X-rays, Douglas Construction, Del Cielo Home Care, Barret Auto Gallery, Greater Valley Hospice, Verizon Wireless, Milestones Photography by Roland Hernandez, Brook Ridge Retirement Community, Just Swiss Quality, and Lifeline.


Village Healthcare and Rehabilitation in McAllen, Texas provides skilled nursing services and 'round-the-clock care for its residents. The rehabilitation department provides physical, occupational and speech therapy, to improve their quality of life. The facility just unveiled its new short-term wing, which provides an excellent atmosphere for residents to recover and return home.

Proposed Changes to MDS for Therapy October 2013

FY2014 Medicare SNF Proposed Revisions are Limited

By Tamala Sammons, Therapy Resource


The Centers for Medicare & Medicaid Services (CMS) released proposed rules for skilled nursing facilities (SNFs) that affect the documentation of Part A therapy treatment time. This policy revision proposal, effective Oct. 1, 2013, would require that distinct calendar days of treatment be recorded in the Minimum Data Set (MDS) in addition to the current requirement of treatment minutes.


For example: If a patient were a Rehab Medium with 150 minutes, but the dates of service were MWF with two disciplines treating three days, this would no longer meet the criteria. Services will have to occur over five separate days in the look-back. The scenario would need to be one discipline M/W/F and the other discipline M/Tu/Th. All other rehab categories currently run one discipline for at least five distinct calendar days in a look-back period.


For the coming fiscal year, CMS estimates that aggregate payments to SNFs will increase by about 1.4 percent, or $500 million, for Part A services. This figure is based on a market-based inflation increase and certain downward adjustments required by law. CMS also reports in the proposed rule that facilities in fiscal year (FY) 2012 reported a decrease in group therapy. ASHA predicted this reduction based on rules initiated Oct. 1, 2011, that penalized each resident's group therapy minutes if fewer than four patients participated...Read On

Teamwork at Golden Acres =

SLP Success

By Deb Ellis, Therapy Resource - Keystone North


Sinead Thach, SLP (L) and Karen Goins, SLP (R) successfully feed their patient.

Our Golden Acres team in Dallas, Texas is celebrating an interdisciplinary effort to help a gentleman eat after 10 years of being on a PEG tube and NPO. Lucio suffered a traumatic brain injury and had severe oralpharyngeal dysphagia. Nursing had observed some recent changes in behaviors such as attempting to swallow and increased oral motor function. Speech therapy evaluated the patient, and due to the severe stage of his dysphagia, the SLP consulted with a team of SLPs to determine the best clinical pathway. The SLP workrf tirelessly to find the ideal texture and temperature of food that Lucio would be able and willing to swallow. He was initially quite resistant to different approaches, until she found the magic texture and flavor that he loved - jello!  His initial resistance soon turned to smiles and eagerness. It was wonderful to see the entire team involved in his success-even the housekeeper came in to encourage Lucio during his therapy sessions. The next step will be to do further testing to determine the safety of his PO trials, but the success and changes that the entire team has seen in Lucio has been miraculous. Thank you Golden Acres team on not giving up, collaborating professionally, and working as a team to make a difference in the life of a resident. 

Mapping Out the Framework for

 OT Student Psychosocial Internships 

By Gina Tucker-Roghi, Therapy Resource - Northern Pioneers


Sonoma Healthcare Center and Ukiah Healthcare Center welcomed Occupational Therapy Students from Dominican University for a specialized internship focused on psychosocial treatment in the Skilled Nursing Facility setting. The Accreditation Council for Occupational Therapy Education (ACOTE) has a new requirement this year for all occupational therapy students to complete a psychosocial internship, and schools are working hard to find ideal sites to meet the demand.


Robin O'Connor, DOR-Ukiah, was the fieldwork educator for student Flower Mendoza, and Chantal Thomas, DOR-Sonoma, was the fieldwork educator for student Liz Brown.  The internship was a tremendous learning experience for both the students and our staff. The interns used a variety of standardized tests to direct their care including the Sensory Profile, LACLS-5, Geriatric Depression Scale, Lifestyle Inventory, SLUMS and the Global Deterioration Scale.  These standardized tests, together with an assessment of the cognitive and psychosocial needs of the rehab patients, helped our teams address pain, anxiety, and cognitive barriers that were preventing progress with functional goals.


Gina Tucker-Roghi, our therapy resource for the Northern California facilities, is collaborating with Liz and Flower on ways that we can further enhance both the structure of the internships and the training of staff, including helping to develop behavior committees and increased trainings for our CNAs. Gina will be taking what she has learned from this pilot internship to open discussions with more Occupational Therapy schools and to help prepare all of our programs for psychosocial fieldwork.  


L to R: Robin O'Connor, DOR-Ukiah; Flower Mendoza and Elizabeth Brown, Students; Chantal Thomas, DOR-Sonoma

CMS National Partnership to Improve Dementia Care in Nursing Homes


On July 10th CMS hosted a National Provider Call that focused on the goal of improving dementia care in nursing homes. This National Partnership is focused on care that is person-centered, comprehensive, and interdisciplinary. During the call, care approaches that are person-centered and individualized were highlighted, and facility systems and tools to enhance care were discussed. Shari Ling, Deputy Chief Medical Officer at CMS, stated that the partnership promotes the 3 "R"s to providing quality dementia care...Read On

Deciphering Dysphagia with E-Stim

On Saturday, July 20, 2013, Keystone sponsored Deciphering Dysphagia with E-Stim, an 8 hour course held at Golden Acres. The seminar guided clinicians through a new approach to dysphagia treatment: AMPCARE's

Sharonda Jones, SLP-Montebello practices application of ESP treatment during the seminar

Effective Swallowing Protocol (ESP™), an electrical stimulation treatment designed to work in conjunction with indirect (NPO) techniques to improve laryngeal elevation and enhance a swallowing posture. The ESP™ program provides clinicians with a fundamental electrophysiology-based protocol to address decreased laryngeal elevation and poor posture, which can be factors leading to aspiration or the risk of aspiration. Evidence exists to the ongoing success of this NMES technology. Taught by Rick McAdoo, MS, CCC-SLP and Russ Campbell, PT, the course included extensive education and review of the anatomy and physiology of the muscle groups associated with the swallow, and more specifically the laryngeal complex. Participants also received extensive "hands on" experience using the technique.The instructors were great! The education and training added to our tool belts, which will enable us to provide additional strategies to our treatment of dysphagia.

Dementia Capable Care: Foundation
L to R: Sarah Adams, PT and Angie Jaques, COTA discuss steps to take for dementia capable care


Deb Ellis, Therapy Resource for Keystone-North, is a certified Dementia Care Specialist Instructor for the Dementia Capable Care: Foundation course. Deb presented the course to the rehab department at Wisteria Place in Abilene, Texas, in preparation for the opening of their newly renovated secured unit at Wisteria ALF. This beautiful new unit is already completely full prior to opening. The foundation course will create a common framework for all care partners allowing residents to have the opportunity to achieve their best ability to function.


Revolutionizing Skilled Nursing Therapy 

By Lissette Maico-Tan, DPT, Mission Care, Rosemead, CA


I am probably not alone in the summation that the world of physical therapy has drastically changed in the last several years or so. I may be biased, seeing as I work in one, but it seems to me that the setting that has felt the most impact of these changes has been in the skilled nursing facility (SNF) setting. Most noteworthy was the transition from the fee-for-service payment system to the prospective payment system; then most therapists grudgingly went through the transition from paper to more sophisticated computer documentation. Let's not even get into the multitude of changes in the Medicare system itself, where the requirement for more objective and significant measures of progress is ever-growing. Because the predominant clientele of a SNF is usually medically highly involved - but less cognitively aware - elderly who at times require more sophisticated forms of encouragement, showing objective proofs of actual progress often can be difficult. 


Even fellow healthcare providers and family members alike can sometimes question just how much progress the patient is making. As humans, the old adage that "seeing is believing" is a strong weapon to use to show that what we do as therapists is working and can be measured.

The family member who lives in a different city and has not seen her mother walk for two years will question any therapist who tells her that Mom is now able to take five steps with a walker. The doctor who has been treating a patient he considers as bedbound and needs total assist for all ADLs will not believe that Mr. Smith is now able to feed himself with supervision. But what if there were a software application that a therapist could use to make this task of providing undeniable visual proof that a patient is making progress? Enter Kinesioplus software...Read On

Grand Terrace Open House

By Ludim Vasquez, C.O.T.A., Grand Terrace Health and Rehabilitation, McAllen, TX 



We are pleased to announce an outstanding open house held on April 10, 2013. We were very proud to show off our renovated patient rooms, bathrooms and new flooring. The building radiates a charming, attractive and clean atmosphere for our residents to reside in as they go through their rehabilitation process. The freshly painted walls and housewarming décor throughout the dining room, halls and sitting areas give residents as well as staff a comfortable living and working environment. Our new short-term rehabilitation wing boasts its own private dining room. Our open house gave us the opportunity to provide a tour to every single person who came to our Grand Opening.


There was an outpouring of support from our local community, such as the McAllen Chamber of Commerce, which was present to perform our ribbon-cutting ceremony as well as the Mayor of McAllen, Richard Cortez. More than 200 guests honored us with their presence that evening, and we were delighted to provide a wonderful meal, live music, fantastic gifts, prizes and great drinks thanks to our generous sponsors: RGV Mobile X-Ray, Houston Medicine Chest, Legacy Hospice, Lone Star Bank and Pepper's at Uptown.


Many of our guests included liaisons, nurses, therapists, physicians and key community people. They were so impressed with the upgrades and renovations of our facility...Read On

Beatrice Health & Rehabilitation Participates in Parkview Village Health Fair


On Friday, August 9, Beatrice Health & Rehab was excited to take part in their community health fair and take advantage of their new equipment to help with balance assessments. The event drew huge crowds and was publicized in the Beatrice, Nebraska newspaper and at the Gage County Fair. "This is a great opportunity for us," explained DOR Jana Maschman, "and the first time we have been able to participate in this event! Yay! Biodex screens, here we come!"

Community Reintegration--The Fun Way!  



Skilled residents at Montebello Wellness Center in Houston, Texas, are looking forward to enjoying rides on their new bus! Planned in conjunction with the facility's activities director, the colorful bus will be promoting Montebello while being used in transporting residents for community reintegration techniques.

Welcome to Our Newest SNFs!



Omaha Nursing and Rehabilitation Center is a 70-bed facility located in Omaha, Nebraska. This is a 4-star facility that has a strong reputation for great quality of care and excellent outcomes in the Omaha community. Ken Davis is the new Administrator, along with Linda Thiede as the new DNS. Darin Foster, SLP, has joined our team as the first in-house therapy member on July 9 and is diligently working on finding the right partners in his therapy team to completely transition to in-house. We are very grateful to our company partners, who have and will play a significant part in helping this addition to the Gateway family (the first acquisition since the original nine in July 2011) become a great blessing in the lives of the people we will serve in the Omaha Community!


Keystone North:

Legacy Rehabilitation and Living is a 147-bed facility located in Amarillo, Texas. This March 1 acquisition is led by Operations Manager Brett Webb and Director of Nursing, Linda Diaz. The hand-picked rehabilitation team strives to provide quality care with a focus on functional outcomes. The rehab team continues to work toward building relationships with referral sources and sending thank-you cards to hospital case managers with each referral. We perform graduation ceremonies for patients that complete rehab and discharge home with our "Return to Home Program." Our hedgehog concept is ACP equipment, which we are able to market in this area and surrounding communities, unlike our competitors. We also capitalize on in-house therapy services that focus on quality of care to our residents and patients.  


Keystone South:

San Marcos Rehab & Healthcare Center, located in San Marcos, Texas, is a 129-bed facility with a census of 80 and seven skilled. Curtis Merring, DOR; David Holt, operations manager; and Sandra Groth, DON are working together with their teams to become the facility of choice in the area. San Marcos, home to Texas State University, is conveniently situated halfway between San Antonio and Austin. Although San Marcos is within easy driving distance of these metropolitan areas, it remains a world away from the hustle and bustle of big city life, providing the perfect setting for long-time residents.


The Courtyard and La Villa Rehabilitation & Healthcare Centers of Victoria, Texas, are within minutes of each other and will be sharing a team of in-house therapists led by DORs Martha Mann at The Courtyard and Marise Dudley at La Villa. Congratulations also to Mary Jane Arredondo, ED, and Cynthia Stanley, DON. Census is a challenge, but Mary Jane and Cynthia are amazing, and we have no doubt that they will be very successful there. Victoria, Texas, is a historic town not far from the beautiful beaches of the Gulf of Mexico. It offers affordable living paired with excellent schools, low taxes and a family- friendly environment. With these three new facilities, Keystone South now has 13 facilities, and we are so very excited about the new additions.



It was a crisp, clear, morning in beautiful Redmond, Washington, and the sun was rising over the rugged Cascade mountain range to the East. The weather was appropriate for the historic moment when Pennant welcomed Redmond Care and Rehabilitation Center on board as its 10th facility and first acquisition of 2013.


Redmond is an upscale city of 55,000 located about 30 minutes northeast of Seattle. Historically, the city has been renowned for its high-tech industry, and it is currently the headquarters of Microsoft Corp. and Nintendo of America. Now, we're committed to adding exceptional skilled nursing and rehab to that reputation. As staff arrived this morning, they were greeted by the smell of fresh-baked pancakes and waffles, which were being served by David Welker, the new administrator, and his cluster partners. David will be joining Veronica Gutierrez, RN MN, who had been serving as Director of Nursing prior to transition. Redmond Care is a 4-star skilled nursing facility with 110 operational beds that has a history of compassionate clinical care and a good reputation in the Redmond community. In the past, rehabilitation services have been provided through contract companies. However, Redmond Care is now staffed with its own team of therapists led by Mina Thekkethala, OTR/L.


Mountain View Rehabilitation and Care Center is a beautiful 82-bed facility located in Marysville, about 30 miles north of Seattle. True to its name, the Mountain View campus overlooks the rugged peaks of North Cascades National Park to the Northeast and the waters of Puget Sound to the Southwest. As one of just two facilities in the fast-growing Marysville area, Mountain View has the potential to quickly become a great contributor to the community. Mountain View is also an exciting addition to the Mojo cluster - we now have three facilities within a 20-mile radius. The facility will be led by Brandon Bodily, a well-connected and experienced administrator, who left a local five-star building with a recent perfect survey to join the Mountain View team, and Jen Kociaj is the excellent and highly qualified rehab director.


With the sun shining, bald eagles soaring overhead and the beautiful evergreen forests all around, it is a great day to be part of Pennant and Ensign in Washington!

Journey to Wellness - photo correction
We apologize! In the Q1 2013 issue of The FlagPOST, we posted an incorrect photo of the patient described in Journey to Wellness. Please click here to see the article and correct photo on our website

Issue: 5

In This Issue
The POSTettes
Eddie Justensen's Surprising Comeback
It Takes a Village
Proposed Changes to MDS for Therapy Oct 2013
Teamwork at Golden Acres = SLP Success
Mapping Out the Framework for OT Student Psychosocial Internships
CMS National Partnership to Improve Dementia Care
Deciphering Dysphagia with EStim
Dementia Capable Care: Foundation Course
Kinesioplus: Revolutionizing Skilled Nursing Therapy
Grand Terrace Open House
Beatrice Participates in Parkview Village Health Fair
Community Reintegration--The Fun Way!
Welcome to Our Newest SNFs!
Journey to Wellness - Photo Correction

The Compliance Corner 


 By Merrisue Corris, Lead Compliance Partner-Bandera and Flagstone 


Q. Why is the accuracy of the selection of the onset date so important?


A: It is pertinent to the reason for picking up the resident for skilled therapy.


Choose a date that reflects:

  • The recent change in medical status as noted by a hospitalization
  • A new or additional diagnoses
  • A recent decline or exacerbation of a previous condition or functional limitation
  • A noted safety risk (e.g., recent fall, aspiration, increased confusion, or change in judgment)
  • The date the physician, nursing or other staff noted and documented a referral to therapy for screening or evaluation due to a change in function or skill level
  • The date upon which a therapy screen noted a change in function was completed
  • A recent change in function or medical status

Q. Is the onset date based on the medical diagnosis or the treatment diagnosis?


A. It is based on the date that the patient first became aware of the symptoms/illness/condition which is the medical diagnosis (See CMS Manual Pub 100-04 Medicate Claims Processing Transmittal 1555).


Q: Why are clarification orders required, and why do they need to match the POC?


A: Clarification orders define the POC/UPOC. Since the clarification orders define the POC/UPOC, it is very important to make sure the clarification orders match the POC/UPOC, especially for frequency, duration and CPT procedures and interventions. If the clarification orders do not match the POC/UPOC, there is a high risk for denial due to potentially delivering services that were not ordered and/or the POC/UPOC may not be followed correctly, which also could be a practice act issue. Clarification orders help to protect us until the POC/UPOC has been signed and dated by the physician, although they are not a substitute for a POC/UPOC according to Independent Review Organizations (IROs).


Clarification orders and extension orders must include:

  • Specific therapy discipline (OT, PT, ST)
  • Frequency (i.e., 5x/wk); not a range (3-5x/wk)
  • Anticipated duration (no more than 90 days); not a range (6-8wks)
  • CPT procedures (i.e., therapy interventions) as listed in the POC/UPOC
  • Must specify type of physical agent modality - not modalities, but specific type of modality such as ultrasound, E-stim, etc., since there are many different types of physical agent modalities
  • Treatment diagnosis

If the frequency/duration of the plan changes from the active clarification and the POC/UPOC, a new clarification order must be written. (For additional information related to clarification orders, see Ensign Therapy Services Policy & Procedure #106.)


Please address any questions to your Therapy Resource or Lead Compliance Partner



Mary Spaeder, Editor 

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