Clinical Corner
New National Long-Term Care Survey Process to Roll Out in November 2017
By Christine Aliberto, Director of Clinical Services, Mission Viejo, CA
Currently, you will find different variations of the survey process based on the state where you operate. Depending on where your facility is located, you find yourself preparing for the Traditional Survey process or a Quality Indicator Survey (QIS). However, the Centers for Medicare and Medicaid Services (CMS) will implement a new survey process nationwide during Phase 2 (effective Nov. 28, 2017) of the three-phase implementation schedule for the new regulations released in the CMS final rule entitled, Medicare and Medicaid Programs: Reform of Requirements for Long Term Care Surveys. 
At the first national American Association of Directors of Nursing Services in September 2016, Evan Shulman, CMS Deputy Director in the Division of Nursing Homes, Survey and Certifications Group, stated: "There are positive and negative aspects to both survey processes.The QIS is computer-based and can seem regimented. The traditional process allows the surveyor a little more flexibility. The new survey process leverages practices of both." According to the recent CMS slide deck and speaker notes previewing the upcoming changes to the long-term care survey process, the new survey process is an innovative computer-based, resident-centered process that balances structure and surveyor autonomy.

Introducing Thera-Troopers!
Did you know we have an exciting new opportunity with Ensign? We are starting our very own internal travel program! What? Yes, we'll have our own internal team of travelers who will go and serve in any of our communities. We have been asked by several DORs and EDs for the past several years when we could start something like this ... well, here we go!
It's a brand-new program, and we're starting it from the ground up. Holy smokes! Sounds crazy and overwhelming, right? It definitely is, but it is much-needed and well worth the efforts. We are spending millions of dollars each year on outside contractors, registry, travelers or whatever you want to call them. It's a huge financial and cultural burden. With a typical contractor, we invite strangers into our communities and expect them to act like family, without much training on our core values. They are not invested in our people and often don't understand our culture. 
Orem Summerfest!
Orem Rehabilitation and Nursing, Orem, Utah
Orem Rehabilitation and Nursing prides itself on being heavily involved in the community it serves. The Orem Summerfest is a time in our community to celebrate its establishment.
The Grand Parade is one of the marquee events of Summerfest. Thousands line the streets to see the floats, vehicles, bands and more. Orem Rehabilitation and Nursing has been an active participant in the parade for the last couple years. It's been a great opportunity for our staff to show their pride in representing our facility as they march the streets of Orem with our facility van decorated.
This year was even more of an opportunity for us to celebrate and thank our community as we were voted "Best of Utah Valley" for rehabilitation centers. We as a facility look for these and many other opportunities to stay involved in the community and represent Orem Rehabilitation and Nursing with pride and passion.

From Jennifer Wintle, Therapy Resource and DOR, Sloan's Lake, Denver, CO
For those of you who know Kinga Gianna, you know she has been working on becoming a physical therapist since starting with us in 2013. She came to Sloan's Lake as a PT from her country of Poland, but she has been essentially battling DORA ever since. She even obtained her PT license in the State of Idaho first as they would let her sit for the licensure exam and Colorado would not.
Just recently, she got a letter from DORA with her Colorado license! We surprised Kinga with a "Miss America" type celebration complete with flowers, crown and confetti as well as a reading of Oh, the Places You'll Go! Congrats, Kinga!
Congratulations to Our Newest SPARC Award Winners!
We congratulate Avenlea Gamble and Kellye McKee, our new scholarship winners for this quarter! The SPARC (Scholarship Program And Recognition Campaign) is inspired by its namesake and the sense of liveliness and excitement that therapy students and new graduates bring to our facilities and in-house therapy programs. With this $2,000 quarterly scholarship program, we deliberately seek out those individuals who ignite a desire for excellence in themselves, their patients, their colleagues and co-workers. 
We Congratulate Our Poster Winners!
        With 102 voters and 161 votes, we have first, second and third-place winners:
1st place: License Plate Program by Patty Fantauzzo  at Julia Temple
2nd place : Initial Responses to Using an Alter-G Treadmill at Parklane West: A Case Series by  Heather Smith DPT, PT, Rosa Benade COTA, Jennifer Henderson OTR/DOR  at Park Lane West
3rd place:  Utilizing Heart Rate Variability Biofeedback in a Patient With CVA to Improve Psychophsyiological Coherence by Amanda Call, MA, OTR/L, Draper Rehabilitation and Care Center
Read below for all posters presented at the  
2017 Therapy Leadership Meeting. 
Thanks for your participation!

Sharing Therapy Strategies 
License Plate Program
By Patty Fantauzzo, COTA/L, Julia Temple Healthcare Center, Englewood, CO
The Julia Temple Healthcare Center has taken steps to assist dementia patients in a variety of ways, not only through its specially designed facilities containing secured neighborhoods, but also through a unique License Plate Program. We created the License Plate Program for residents and caregivers to be able to identify their assigned wheelchairs and walkers, as well as for caregivers to quickly identify the current ACL level using a color-coded system.
For example, Mr. Rover's walker would have a laminated "Colorado" license plate with his name entered in the color blue (indicating ACL Level 5), providing some indication of the resident's cognitive abilities. All staff have been in-serviced on the program and given laminated cards with color-coded ACL levels one to five on them, along with bullet points listing the cognitive abilities for each level. Most staff have these cards attached to their lanyards.
In Mr. Rover's case, staff can tell instantly that the resident has his own equipment. It is also easier for residents to identify their own equipment if they recognize their name.  Additionally, staff can get an idea of what an ACL level 5 resident might be able to understand cognitively. Mr. Rover, for instance, may require supervision, can complete most ADLs, can complete two- to three-step tasks, and so on. Staff can also look at the back of the license plate to see if all parts to the equipment are present, such as a gait belt or a left elevating leg rest.
All residents with license plates have them care-planned as part of their cognitive care plan. The color-coded license plates, coupled with the staff's ACL level cards, facilitate easy identification of residents' cognitive abilities and ensure smooth communication between residents and caregivers.
Everybody's Onboard the Energy Bus!
Surviving a Transition Through Use of the Energy Bus
By Jennifer Ybarra, OT, DOR, McAllen Transitional Care, McAllen, TX

Last year brought on many changes for me and my team at McAllen Transitional Care Center. We were a part of the huge Legend acquisition that happened on May 1, 2016, and with that came many new, exciting and challenging times. We got through it with the help, support and guidance of way too many people to name individually, but among those are Maricela Garcia, Jon Anderson and Deb Bielek. Thank you, all!
Let's sprint forward to October 2016. I had been so focused on learning new policies, documentation procedures and compliance standards, as well as tracking new metrics, that I was beginning to feel it was all a bit too robotic and that I was missing the personal connection with my staff, which includes 25 full-time therapy team members.
Thanks to social media, I was introduced to a book by Jon Gordon titled, The Energy Bus. Wow! I read it in a day, and I immediately decided to inject positive energy and re-energize myself and my team! But how? We mobilized a plan, and over the next six weeks, I was determined to share my newfound excitement and energy! The following is an overview of the book and of the activities used to get my team on the bus.
Initial Responses to Using an Alter-G Treadmill at Parklane West: A Case Series
By Heather Smith, DPT, PT; Rosa Benade, COTA; Jennifer Henderson, OTR, DOR, Parklane West, San Antonio, Texas

At Parklane West, we posited the following problem/question: Would our physical therapy patients feel the Alter-G treadmill will benefit them long-term after the initial use? We hypothesized that they would, due to research about the Alter-G treadmill provided to each patient before initial use.   READ MORE...
Happy Feet Effect on Quality of Life
By Maresa Madsen, DOR and Team at Pinnacle Nursing & Rehab, Price, UT
About five or six years ago, Pinnacle Rehabilitation and Nursing had a program  called Happy Feet. Residents were brought to the nurses' station, and then music was played while residents were assisted down the hall to the dining room, either walking or riding in the wheelchair according to their abilities. This program has not been implemented in the past four or five years.  
Alexa and TBI Helps Patient Following 
Brain Injury
By Rock Canyon Rehabilitation, Pueblo, CO

Consider the following patient profile: A 19-year-old with traumatic brain injury secondary to assault presented with moderate deficits in immediate and short-term memory as well as temporal and spatial orientation. He was also legally blind as a result of his injury. The patient has been receiving skilled Speech Therapy at Rock Canyon since March 2017 to address...    READ MORE...
OT and SLP Co-Treatments in a Skilled Nursing Facility
Stacia Kozidis, OTR/L & Caitlin Timmins, MA, CCC-SLP
Clarion Wellness and Rehabilitation Center, Ensign Group & HCR Manor Care Waterloo

Occupational therapy and speech-language pathology co-treatment sessions provide comprehensive intervention and could fill a research gap on the benefits of this collaborative approach to advance patient outcomes in a SNF setting.
Example of game available in emWave Pro™ program. As patient coherence improves, the rainbow extends to the pot of gold and gold coins can be earned.
Utilizing Heart Rate Variability Biofeedback in a Patient With CVA to Improve  Psychophsyiological Coherence
Amanda Call, MA, OTR/L, DOR, Draper Rehabilitation and Care Center, Draper, UT

At Draper Rehabilitation and Care Center, we treated a 74-year-old female patient who sustained L hemispheric hemorrhagic CVA. She presented with a host of symptoms...and was reaching a plateau with therapies because of difficulty regulating her emotions, which caused increased tone and aphasia.

Passport to Home: An Interdisciplinary 
Case Report
By C. Scott Hollander, PT, PDT; Sarah Koning, MSOT, OTR/L; and Megan Bennett, MS, CCC-SLP, Olympia Transitional Care and Rehabilitation, Olympia, WA

We all know it's true: There's no place like home. That's exactly what our 70-year-old female patient expressed upon admission at Olympia Transitional Care and Rehabilitation     READ MORE...
Improving the Patient Experience Through Patient-Centered Care
By  Park Manor Rehabilitation Center, Walla Walla, WA

Patient Centered Care isn't just taking good care of our patients. It is a holistic philosophy of including the patient and their family members in as many decisions and system/facility improvements as possible. It means offering choices whenever possible, thereby giving our elders more control over their lives. 
A COPD Case Study
By Rochelle Lefton, MA, OTR; Michelle Scribner, MSLP; Heather Cox, DPT; Susan Garcia, COTA; Jesusa Herrera, PTA, Northeast Nursing and Rehabilitation,San Antonio, TX

At Northeast Nursing and Rehabilitation, we cared for a 77-year-old white male who had been recently hospitalized for acute cholecystitis. His PMH included CAD, a pacemaker, cardiac stents, HTN and COPD.     READ MORE...
Group Therapy Versus Individual Therapy
By The Entire Rehab Team, led by Tracy Carrier, DOR, Chandler Post Acute & Rehabilitation, 
Chandler, AZ

As our payers become more complex, we as therapists need to discover ways to get better outcomes, in less time, with less reimbursement. Toward that end, we compared the functional outcomes, using the CARE item set, of our Medicaid skilled patients receiving more minutes of group therapy, as opposed to only individual minutes per our contract guidelines. We also compared the outcomes of our Medicaid patients who received group therapy to all of our patients who received all modes of therapy.  READ MORE...
An activity that is meaningful for the resident adapted to maximize her success based on her abilities. As part of the Bathing Without A Battle process, she knows that she gets to participate in this meaningful activity post adapted/modified bathing tasks, which decreases her negative behaviors and increases her participation in the bathing process.

Bathing Without a Battle
By Tyler Johnson, OTR/L, DOR and Joni Johnson, COTA/L, TPM,  Northbrook Healthcare Center, Willits, CA

It's not uncommon for residents to resist showering, and as therapists, we work to ease their anxieties while supporting our staff. At Northbrook Healthcare Center, we've implemented strategies that have proved successful in encouraging residents to participate in bathing routines and even find enjoyment in the process.
We had a resident exhibiting negative behaviors, i.e., slapping staff, yelling and cursing when CNAs approached her for a shower. Documented refusals resulted in a referral to our occupational therapy department for the Abilities Care Program and our Bathing Without a Battle program.
Navigating and Surviving the 
Managed Care Jungle
Andy Cisneros, PTA, Therapy Program Manager, Legend Oaks, West San Antonio, TX
Our skilled population has gradually shifted from traditional Medicare Part A to Managed Care Part A. Therefore, our treatment focus has had to shift as well. We are no longer focusing on progressing to prior level of function, but rather progressing to next level of care..    READ MORE...
Global Deterioration Scale OT Practice Implementation
Amber Howard, DOR, Legend Oaks Healthcare and Rehabilitation, North Austin, TX

As healthcare professionals, we often discuss dementia in the context of various stages, that is, how far a person's dementia has progressed. Sometimes, we'll define a person's stage simply as early-stage, middle-stage or late-stage; however, to be more exact, we use the Global Deterioration Scale (GDS)    READ MORE...  
Oral Hygiene Program
By Grand Terrace Rehabilitation and Nursing, Therapy Department, McAllen, TX

At Grand Terrace, we have implemented an Oral Hygiene Program with great success for residents.  ...The oral hygiene program has benefited residents, caregivers, therapy and the facility. Not only have we boosted awareness of the importance of providing good oral care, but we have also enhanced residents' self-efficacy.    READ MORE...
Improving Proprioception and Ankle Strategy With New Balance Pad
By C. Scott Hollander, DPT, Olympia Transitional Care and Rehabilitation, Olympia, WA
Last year, Ensign therapists were introduced to a new balance pad system called  the Sanddu ne Stepper. It is said to have significant effects on improving proprioception and ankle strategy in patients with a neurological diagnosis.

The device is constructed of a combination of memory foam and closed cell foam, which causes a rapid rebound of the memory foam, increasing the challenge and resistance with each step. This also equalizes the reaction force on the feet when the patient is standing, making the device respond closer to the patient environment.
Online Training Modules to Develop the Skills, Knowledge and Attitudes Required to Implement the Abilities Care Approach® 
By Gina Tucker-Roghi, OTD, OTR/L, Therapy Resource, Northern CA

Clients with dementia living in skilled nursing facilities have occupational needs that are often unmet. ...The online training program is available to OT practitioners and students through Ensign-affiliated SNFs. It incorporates effective teaching methods, including opportunities for student reflection, interaction with content, self-assessment of learning and application .    READ MORE...
Allen Cognitive Testing
Rachel Kolden, OTR, Legend Oaks Nursing and Rehabilitation, Kyle, Texas

What Is ACLS?
The ACLS is a standardized test that is used mostly by occupational therapists to determine functional cognition and individual ability to problem-solve and follow directions. It was first proposed by Claudia K. Allen, MA, OT, FAOTA.
Rachel Kolden spent many hours watching videos from the ACLS website and YouTube to make sure she was comfortable administering the test properly. She started using the ACLS with the skilled patients as a standardized test and has now progressed to using it with long-term residents.
Why perform the ACLS in your facility?
  • It allows the therapist to establish a baseline for each resident for future screens
  • It's a starting point to establish improved quality of care
  • It helps create functional maintenance programs
  • It helps to identify Part B patients who may have been overlooked before
  • It's another valuable tool to add to your toolbox
To find out more about Allen Cognitive Testing, visit

Falling Leaf Program: Implementing a Fall Prevention Program
Nicole Veniegas, DOR, MS, OTR/L; Kathryn Case, MOT, OTR/L, Magnolia Post Acute Care, El Cajon, CA
After noticing a recent increase in falls and fall-related injuries at our building, we wanted to better understand the mechanisms of the falls and implement a comprehensive, interdisciplinary fall prevention program.    READ MORE...
Bladder Training Program/Continence Improvement Program
Kumar Pradeep, DPT, DOR, Legend Oaks Healthcare and Rehabilitation, South San Antonio, TX

Urinary incontinence is a hidden epidemic. UI is among the 10 most common  chronic conditions in the United States and is even more common than hypertension, depression or diabetes.  A majority of residents in skilled nursing facilities have some degree of incontinence. UI is quite costly in terms of quality of life of residents and the financial impact on facilities...    READ MORE...
Physical Mobility Scale Is an Effective Standard Test for Skilled Rehab
By Scott Langdale, PT/DPT, DOR, Beacon Hill Rehabilitation, Longview, WA
When it comes to our long-term care patients, many of our standard tests simply do not serve them well in regard to monitoring subtle changes over time. Standard tests such as the BERG, DGI and Tinneti are not good for patients who are wheelchair-bound.
ADL Billing Versus Self CARE Item Set Change
By Tonya Haynes, PT, DOR, Mountain View Care Center, Tucson, AZ

At Mountain View Care Center, we questioned whether there is a correlation  between the amount of activities of daily living (ADLs) the occupational therapy staff  has been providing to patients with changes in their' functional level upon discharge.  We chose to compare this by analyzing...    READ MORE...

Stratifying Risk for Hospital Readmission and Assessing Safe Discharge
Ian M. Campbell, SPT, Gateway Transitional Care Center, Pocatello, ID

At Gateway Transitional Care Center, we've found that administrators and clinicians can work together to stratify residents' risk for re-hospitalization. Below, we've provided some data to aid in understanding the current statistics associated with hospital readmission from skilled nursing facilities.     READ MORE...

Accountability and Skilled Documentation
By Larissa Osio, DOR, MS OTR/L, 
Granite Creek Health and Rehabilitation, Prescott, Arizona
"Employees want to know why they have to produce and deliver services by using certain methods. To be good at holding your staff accountable, you must be good at teaching. Teach about the consequences." - Crucial Accountability
Did you know that poor documentation quality has a bigger financial impact than productivity does? It's true! In general, while you save $0.02 for every 1 percent productivity increase, billing minutes pulled out during an audit will have a much greater financial loss:
Our dedicated "Serenity Room" has a butterfly light that is always on. No one should ever pass alone or in the dark. We have a group of volunteers that sit with our residents who are passing if they have no family available.
Celebrate Life! 
Lana Mathis, DOR, Granite Mesa Health Center, 
Marble Falls, TX

" It is time for us all to stand and cheer for the doer, the achiever - the one who recognizes the challenge and does something about it." - Vince Lombardi
At Granite Mesa, we honor and celebrate life. As our residents transition from one place to another, we honor them as they leave the building. We provide client-centered service that follows our Ensign philosophies of "Celebration" and "Love One Another."
  • It gives us satisfaction and facilitates unity among the departments at Granite Mesa to celebrate the transition of our residents.
  • It honors the patient and families that let us care for their loved ones.
  • It boosts residents' confidence level as they walk out the door.
"The best and most beautiful things in the world cannot be seen or even touched; they must be felt with the heart." - Helen Keller
Closed Pulse Irrigation
Michael Ong, PT & Marisa Parker, DOR/SLP, Legacy Rehabilitation and Living, Amarillo, TX

At Legacy Rehabilitation and Living, we'll never forget the case of our 62-year-old male patient who was hospitalized for an infected gangrenous left Achilles ulcer with cellulitis. The client was told that his leg would have to be amputated - something no patient ever wants to hear. However, after Closed Pulse Irrigation (CPI), he was able to return to his home without an amputation.
What Is CPI?
Closed Pulse Irrigation (CPI) creates a clean micro-environment with pulsed hydromechanical stimulation to enhance rates of granulation, epithelialization and wound bed contracture. CPI provides safe, selective mechanical hydro-debridement to disrupt and remove bacterial bioburden, necrotic tissue and debris while avoiding harm to normal tissue.
We're thrilled at the outcome of this patient's treatment, and we're confident that with the help of CPI, we'll be able to help many more patients in the future.
Algorithm of Evidence Based Practice & 
Standardized Test
Presented at the 2017 Leadership Meeting by Southland Rehabilitation, Norwalk, CA
Moments of Truth
From the Springs at Pacific Regent, La Jolla, CA

No matter how often or how many DME we order, some pieces can become critically low overnight. This recently occurred with FWWs. We had a large influx of new PTs who all required their own FWW.  Shayna Wachendorf, a PTA, immediately sensed the urgency and took the personal responsibility to help. Instead of just asking for more FWWs, which can take days to come in, she searched out, found and bought the walkers our residents needed. Shanya did not even ask first if she'd be reimbursed (which of course she was) because she put our residents first. She packed them up in her little sport coup and brought them the next morning so our residents would not miss a beat while the FWWs we ordered came in. She is a true example of loving one another!

Recently our rehab aide/assistant program manager, Farah Layno, noticed one of our PTAs did not come in at her normal time, but was not "late" by any standard. Farah is close with our whole staff and knows where they are at all times, so she expressed true concern. Instead of simply going about her day and waiting to hear from the late employee, she reached out to the employee's sister and oldest son. Farah was able to get in touch with the eldest son, who was able to return home and check on our late employee. It turns out that she became seriously ill overnight, and when her son found her, she was unresponsive with a fever over 105. She was rushed to the nearest hospital by 911 where emergency protocols were initiated to stabilize her. Later that night, she was admitted to the ICU for further testing, but was responsive and able to communicate with her family. She is currently stable, but remains in ICU. No doubt, had Farah not acted, we would be grieving the loss of a true member of our family. 
From Natalie Blasczienski, DOR, Legend Oaks Healthcare, Euless, TX

We wanted to share this sweet poem submitted by a patient as a gift to the team at Legend Healthcare at Euless! He wrote it and had his wife printed it out nicely for us. Enjoy!

Rehab is no walk in the park
It's a task to get up to the mark
To increase your strength and mobility
Which are very important, believe you me