March Madness…

What, he worry? Boehner hopes for a doc fix buzzer-beater.

What, he worry? Boehner hopes for a doc fix buzzer-beater.


Good morning, ProviderNation.

The doc fix is on the clock. You’ll have heard by now that House Speaker John Boehner, R-Ohio, and House Minority Leader Nancy Pelosi, D-Calif., have worked out an in-principle deal that would repeal Medicare’s sustainable growth rate. But, as AHCA/NCAL top gun Clif Porter tells us, time is running out.

No sooner had those words left Porter’s lips, then Sen. Ron Wyden, D-Ore., called a time out. He said he was worried that some language in the grand bargain would be an attack on abortion rights, which the Distinguished Gentleman referred to as a “non-starter.”

And that’s before the play had been properly diagrammed. One of our Hill reliables tells us that the bill also doesn’t settle that nasty question of who picks up the $170-billion some check. The legislation would try to “limit” the cost of repeal-and-replace by, among other things, cutting post-acute care providers’ Medicare “market basket” to 1 percent starting in 2018.

So much time, so little to see: it’s unusual for this sector to have such attention paid to it, but Fox News’ inestimable Chad Pegram thinks this is the week “that could break the House.”

Then again, it’s the season for shot clocks, what?

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.

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Fire Sprinklers Once Again Prove Effective


Stan Szpytek

I would like to yield my blog space to my good friend and colleague, Tom Lia, executive director of the Northern Illinois Fire Sprinkler Advisory Board (NIFSAB). His team produced an excellent press release on fire sprinkler effectiveness  during a recent fire in a skilled nursing facility:

 ORLAND PARK, Ill., Feb. 19, 2015 This morning, a single fire sprinkler controlled a mattress fire at Ballard Rehabilitation, a skilled nursing facility (SNF) at 9300 Ballard Road in Des Plaines, Ill., until North Maine Fire Protection District crews provided final extinguishment. The fire sprinkler system contained the fire to a single room on the second floor and prevented major damage and possible deaths, thereby validating a Centers for Medicare & Medicaid Services (CMS) decision to require fire sprinklers in all new and existing long term care facilities nationwide.

The CMS federal rule requiring fire sprinklers in long term care facilities became effective on Aug. 13, 2013, following a five-year phase-in time frame after publication in 2008. The rule, which applies to SNFs that are regulated by CMS for Medicare and Medicaid licensure, is a direct result of two deadly nursing home fires in 2003—one in Hartford, Conn., and the other in Nashville, Tenn.

“The success of the fire sprinkler controlling the fire should be a reminder to the state of Illinois to follow up on any remaining skilled nursing facilities that have deficiencies,” says Tom Lia, executive director of the nonprofit Northern Illinois Fire Sprinkler Advisory Board.

If cited for deficiencies, SNFs must submit a plan of correction and achieve fire sprinkler installation within three months. After the three-month period, the Social Security Act requires that any facility that is not in substantial compliance will be subject to a denial of payment of new admissions and termination from Medicare participation at the end of six months.

“Fortunately, the Ballard Rehabilitation facility was compliant with the federal rule and protected by a fire sprinkler system,” says Lia. “This successful fire sprinkler activation proves the value of the federal rule and the ability of quick-response fire sprinklers to save lives and property.”

Unfortunately, the effectiveness of fire sprinklers is not fully appreciated until ignition occurs. I would like to thank Tom Lia and other fire and life safety professionals around the country who continue to “beat the drum” every day promoting the importance of installed fire suppression systems in buildings of every type of occupancy classification. While it is purely speculation, the fire that Tom wrote about could easily have been a catastrophic event. Now, it will likely be written up as a health care success story in a future edition of the National Fire Protection Association (NFPA) Journal.


NIFSAB,, is a nonprofit organization dedicated to promoting progressive legislation, raising public awareness, and educating code officials and governmental policy makers by demonstrating the proven performance of fire sprinklers in saving both lives and property.

 Stan Szpytek is the president of Fire and Life Safety (FLS), and is the life safety/disaster planning consultant for the Arizona Health Care Association and California Association of Health Facilities. Szpytek is a former deputy fire chief and fire marshal with more than 35 years of experience in life safety compliance and emergency preparedness. FLS,, provides life safety and disaster planning consultative services to health care and senior living providers around the nation. He can be reached at



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Guest Blog: States Step Up For Safety…

Stan Szpytek

Stan Szpytek


As a life safety/disaster planning consultant having the privilege of working with several state associations affiliated with the American Health Care Association, I have personally witnessed the outstanding work that these organizations are doing to better prepare LTC providers for emergencies and disasters. State affiliates that have developed robust disaster planning and emergency management programs for their members clearly provide a valuable service by not only ensuring that facilities will be better prepared for crisis but will also be in a position to comply with the proposed CMS rule change on emergency preparedness.

A recent project that I completed with the Utah Health Care Association illustrates the type of comprehensive resources and consultative assistance that many state affiliates are providing to their members. This past November, two workshops were scheduled in Salt Lake City and St. George where members and other providers in the state were given the opportunity to review disaster planning concepts and emergency management trends, including the use of the Nursing Home Incident Command System (NHICS).

The morning session of the all-day program was designed to review essential disaster management information, including review of recent real-world events like the fertilizer plant tragedy in West, Texas, where a nursing home was directly impacted by a catastrophic explosion. In the afternoon, attendees participated in an interactive tabletop exercise where they were able to put the concepts learned into practice by simulating the management of a complex scenario involving a hazardous materials incident occurring near their property, first requiring the facility to shelter-in-place and subsequently requiring complete evacuation.

The final part of the day included an overview on how to address a situation involving an armed intruder/active shooter in the health care environment. Attendees learned essential concepts that focused on resident safety as well as personal safety when confronting these types of dynamic events.

The Utah Health Care Association (UHCA) has been a leader in disaster preparedness by providing its members with educational opportunities as well as tangible resources for the past several years. Some of those tangible resources were clearly evident at the November workshops, where every facility in Utah received an NHICS management board (tactical dry-erase chart) and associated tools to help manage incidents that may impact their operations. Additionally, each facility was given a complete triage kit and triage canopy (tent) to enhance their capabilities during mass casualty incidents. All of this material, as well as coordination of the workshops, was provided by UHCA in partnership with the Utah Department of Health with grant funds they receive from the Hospital Preparedness Program (HPP).

While Utah is an excellent example of some of the fine work that state affiliates around the nation have been providing their members, I have been able to see first-hand what other states, including Arizona, California, Colorado, New York, North Dakota, Rhode Island, and Texas have done to help prepare LTC providers for disaster. Disaster planning and emergency management are initiatives that should be high on the priority list of every state association. As we say in Arizona, it is essential that we make sure that our facilities are “Disaster Ready” (which is the name of AzHCA’s disaster preparedness program).

Stan Szpytek is the president of Fire and Life Safety (FLS) and is the life safety/disaster planning consultant for the Arizona Health Care Association (AzHCA) and California Association of Health Facilities. Szpytek is a former deputy fire chief and fire marshal with more than 35 years of experience in life safety compliance and emergency preparedness. Email Szpytek at

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Get Premier Kisov On The Hotline…

The doc fix has become a Stragelove-ian script.

The doc fix has become a Stragelove-ian script.

Good afternoon, ProviderNation. The fine folks at the Congressional Budget Office have gone to the Big Board and done the math on the doc fix. You’ll recall that Congress, after a lot of sound and fury earlier this year, signified little.

That means that docs are facing a 21.2 percent hair cut when the current law expires April 1. (Like all great Doomsday Machines, you see, the doc fix goes off automatically….) You can be sure that Congress-types will be on the wrong end of the hotline for a while.

Some, including Rep. Kevin Brady, R-Texas, are scrambling to avoid Doomsday for the docs in the lame duck session of Congress. That’s probably a long-shot, according to the Lobbying-American types I talked to. Just in case, though, the CBO has run the numbers on some of the proposals that were floated earlier this year. The scores (see for yourself here and here.)

The cost estimates for a permanent fix range from around $119 billion (freeze payments at their current rate for a decade) to more than $204 billion (increase rates by Medicare Economic Index—a kind of inflation calculator for Medicare—for year one, then use MEI to increase physician rates every year thereafter).

The figures are important for a few reasons. First, both parties think the CBO has some astonishingly good ideas; second, the numbers are consistent from last year’s near miss effort at a permanent fix; third, it’s at least some indication to Lobbying-American types about how much will have to paid (if not, sadly, who stays up and who goes down).

In any case, the target is in sight. Now, where the hell is Major Kong?

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.

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Death (Panels), Be Not Proud…


All sales final?

All sales final?


Good morning, ProviderNation. Death panels, be not proud: Terminally ill patients who don’t go into hospice are dying just as quickly but are much more likely to visit emergency rooms, be admitted into hospitals, even have surgery for unrelated conditions than those who enter hospice, the fine folks at the Journal of the American Medical Association are saying.

In a new study, researchers found that Medicare had to pay an average of nearly $9,000 more to treat non-hospice, terminally ill cancer patients in their last year of life than it cost to treat patients in hospice over the same time. Those who declined hospice had “significantly more hospitalizations,” more trips to intensive care, and even more “invasive procedures … largely for acute conditions not directly related to cancer,” the researchers found.

Nearly three-quarters of those who refused hospice care wound up dying in hospitals or skilled nursing centers, versus a scant 14 percent of hospice patients who did, JAMA researchers say.

Rethinking End-Of-Life Care

What’s important about this study is that it’s comparing like with like: Researchers scoured tens of thousands of records and matched cases of people whose died after roughly the same length of time. The findings come in the midst of what appears to be a wave of critical rethinking about end-of-life care. Many in this profession are working hard to change the way they, and we, and you and I think about death, dying, and grief.

But wherever the other ironic points of light flash out, the team behind Thursday’s JAMA report say that Medicare has some thinking to do, too.

“First, the Medicare administration monitors and prosecutes hospices with inappropriately long hospice stays, creating a perceived disincentive for physicians to make early hospice referrals that are more likely to produce long stays,” the report says. “Second, Medicare does not reimburse physicians for discussions to elicit patients’ preferences for end-of-life care. Third, Medicare requires patients to formally renounce curative care before enrolling in hospice, which is thought to limit demand.”

“This Last Issue”

“This last issue,” the team says, “is particularly relevant to cancer care since patients often wish to continue active treatment irrespective of prognosis—an area of concern to payers as use of costly new targeted therapies, often oral and less toxic, becomes widespread at the end of life.”

This is a toxic issue, of course: Follow the implications down one way, and you might well find yourself feeling like a villain from a sword-and-sandals movie.

Dr. Ira Byock argues that patients shouldn't have to choose between disease treatment and palliative care.

Dr. Ira Byock argues that patients shouldn’t have to choose between disease treatment and palliative care.

But help is on the way. Dr. Ira Byock, whom many of you met in our September cover story on death, dying, and grief, argues that palliative care and disease treatment don’t have to be mutually exclusive.

“In the past,” he tells me, “skeptics questioned whether cost savings associated with hospice were predetermined by preferences of those who choose hospice to eschew aggressive treatments. This study’s matching strategy, exclusion criteria, and analyses show otherwise. Prior to enrollment, hospice users were at least as likely to choose active disease treatments as the matched controls.”

‘Welcoming Arms… Reluctant Arms’

For Byock and other advocates like him, the math isn’t all that difficult.

“The lower costs among hospice patients likely resulted from better care,” he says. “It’s not hard to understand how the mundane components of hospice care—meticulous management of pain, breathing, and bowels; crisis prevention and early crisis management; supportive counseling regarding the natural course of illness and development of an endgame; and 24-hour access to help—result in less calls to 911 and less time spent in hospitals and ICUs.”

For Byock, the answer is straightforward: Medicare should scrap its “arbitrary requirement” that people waive disease treatment in order to have palliative care, because “the terrible choice” currently on offer only leads “to higher costs and lower quality.”

Byock makes a living at this, of course (and he’s literally written the book on it), but for him and many others, dying well isn’t just a matter of dignity for individual souls.

“In healthy societies,” he tells me, “people are born into the welcoming arms of a community, and they die from the reluctant arms of a community.”

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.

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Let There Be Light(s): Power Strips In Long Term Care Settings…

Stan Szpytek

Stan Szpytek

Hello, ProviderNation. The current “buzz” in life safety compliance in health care is focused on the “Categorical Waiver for Power Strips Use in Patient Care Areas” that CMS issued on Sept. 26, 2014.

A number of life safety professionals around the nation are weighing in on this important matter and providing health care facilities with useful guidance and resources. Here is some comprehensive information released by Russell Phillips & Associates Oct. 16, 2014, and is shared with full permission:

The Centers for Medicare & Medicaid Services’ (CMS’) much-anticipated release of a Survey & Certification Memorandum addressing power strips provides some important clarification to the ongoing confusion and misinterpretation regarding the permitted use of power strips in health care settings. However, the CMS information also raises some new questions and leaves some definitions open for interpretation. It appears that CMS will be providing some additional clarification in the future. In the meantime, here are some clarifying points regarding power strip use and the intent of the S&C Memorandum.

There are essentially three specific components to the S&C Memorandum:

  1. Utilizing Power Strips for Medical Equipment: CMS is permitting a categorical waiver that will permit health care facilities to apply the 2012 edition of NFPA 99 (The Health Care Facilities Code) relative to power strips.
  2.  Long Term Care Exemption: Under certain circumstances, CMS is exempting long term care facilities from the prescriptive and restrictive requirements relative to power strips that are outlined in the 2012 edition of NFPA 99 (The Health Care Facilities Code).
  3. Long Term Care Exemption: Under certain circumstances, CMS is exempting long term care facilities from the prescriptive and restrictive requirements relative to power strips that are outlined in the 2012 edition of NFPA 99 (The Health Care Facilities Code).

This information will likely be applicable to other authorities having jurisdiction with CMS deemed status.

Applying The 2012 Edition Of NFPA 99 (The Health Care Facilities Code)

Historically, NFPA 99 has only included provisions for the use of power strips in anesthetizing locations. However, the 2012 edition of NFPA 99 includes provisions for using power strips to power rack-, table-, pedestal-, or cart-mounted equipment. Section outlines a number of conditions, including the necessity for the power strip to be permanently attached to the equipment assembly. When meeting all the prescribed conditions, this will permit what is already the common practice of utilizing power strips to power various medical equipment assemblies.

NFPA defines the “patient care vicinity” as a location intended for the examination and treatment of patients expanding six feet beyond the device supporting the patient (that is, bed, table, or chair) and 7.5 feet above the floor. Power strips are not permitted in the “patient care vicinity” for nonpatient care equipment, including patient personal electronic devices (that is, phones, tablets, or other portable devices). Such items must be plugged directly into a normal receptacle. Power strips may be used to power electronic devices outside of the “patient care vicinity.”

All power strips should have a UL listing. Power strips serving medical equipment should be listed as UL 1363A or UL 60601-1. Power strips serving other items such as personal electronics should be listed as UL 1363.

Long Term Care Exemption 

CMS is providing long term care facilities relief from the strict prescriptive power strip requirements in certain situations. Facilities that “do not use line-operated electrical appliances for diagnostic, therapeutic, or monitoring purposes” are exempt from the requirements outlined in the 2012 edition of NFPA 99.

Ultimately, the power strip requirements will apply if electronic medical equipment is plugged in and connected to a resident. This is intended to address higher-acuity situations where residents may be connected to monitors or similar electrical treatment or diagnostic equipment. This is not intended to encompass common equipment such as electric beds and oxygen concentrators. In these arrangements, there is not a direct electrical connection between the equipment and a resident.

For long term care facilities that meet the exception, power strips can be utilized for items such as cell phones, tablets, and other personal electronics. However, the following requirements and best practices have not changed:

  1. Do not use multiple plug adaptors or power strips to compensate for an inadequate number of permanent electrical outlets. If permanent electrical devices in a room exceed the number of wall electrical outlets, consider having additional electrical outlets installed by a licensed electrician.
  2. Power strips can be considered for items such as computers, tablets, clocks, audio devices, and temporary electrical items used by a resident or patient that are powered or charged in a sleeping room.
  3. Do not use receptacle “splitters,” and do not “daisy chain” (connect multiple) power strips together.

As always, your state and/or local Authority Having Jurisdiction ultimately has the final say in what they will or will not accept.

Categorical Waiver

To take advantage of the categorical waiver option, the health care facility is not required to formally apply or communicate with CMS. Rather, it must document its decision to utilize the power strip categorical waiver provision. Additionally, the organization must make the survey team aware of its application of the categorical waiver at the survey opening meeting / conference for any life safety compliance related survey.

A template for the categorical waiver and other excellent resources can be obtained from Russell Phillips & Associates in their resource library.

Other American Health Care Association (AHCA) state affiliates like the California Association of Health Facilities (CAHF) are providing their members with ongoing technical consultative support by releasing information like these excerpts from a bulletin recently developed by Jason Belden, CAHF’s facility Infrastructure policy analyst / program liaison:

“As many of you know, CMS has issued a survey and certification letter that has relaxed or reversed some of the guidelines for use of power strips in patient rooms. This is still not a blanket acceptance for the use of power strips in patient rooms, however. We have received a number of questions due to the technical nature of the memo regarding what are patient care areas, what are examples of line-operated patient care electrical equipment, what type of power strips are OK to be used, and where can they be mounted.” 

“When mounting the UL 1363A or 60601-1 power strips, they must be mounted to the device itself. Mounting brackets can be purchased to directly mount the equipment without having to drill holes. Once that power strip is mounted, other devices can be connected to it, providing the total amount of amperage doesn’t exceed 75 percent of the listed maximum amperage. The other power strips cannot be mounted, but they must follow traditional location guidelines. They can’t pose a tripping hazard, they can’t be located in an area that is regularly subject to water, they can’t hang off the ground, etc.”

All of this information is certainly good news for providers. Be sure to follow the guidance presented in this article and work with all of applicable Authorities Having Jurisdiction (AHJ) and your facility’s management team to ensure that the right types of electrical power strips are being utilized in a safe and compliant manner in your facility.

Stan Szpytek is the president of Fire and Life Safety (FLS) and is the life safety/disaster planning consultant for the Arizona Health Care Association and California Association of Health Facilities. Szpytek is a former deputy fire chief and fire marshal with more than 35 years of experience in life safety compliance and emergency preparedness. FLS provides life safety and disaster planning consultative services to health care and senior living providers around the nation. For more information, visit or email Szpytek at

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Death and The September Night…


The unmentionable odour of death

Offends the September night…

—W.H. Auden, “September 1, 1939”

Good morning, ProviderNation. Maybe it’s a seasonal thing—here in the decadent capital, the leaves are doing their lustrous wonders, the mercury sinks in the mouth of a dying day, and twilight comes earlier and earlier—or maybe it’s psychic convergence.

In any case, death is in the air.

It’s about time.

Shanda Fur Die Goyim

You’ll have seen our little effort to make sense of death, dying, and grief in the September issue. I remain proud of the work, but I have to admit that John Morley and the fine folks at JAMDA have wiped at least some of the smug off my face. No sooner had I let slip the September cover, feeling peacock proud of having dealt with a matter that so many providers had consigned to the shanda fur die goyim bin, when I see that Morley and Angela Sanford had stolen a march: Their essay in the August issue of JAMDA, “The God Card: Spirituality in the Nursing Home” is brilliant enough on its own, but it’s accompanied by an op-ed and an original study on palliative sedation in nursing homes.

And just as I’m recovering from my vertigo of watching Morley and company scoop me, the Institute of Medicine releases, “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.” Meanwhile, AHCA super-lobbyist Clif Porter (and all-around decent chap) gives us an interview for the October issue of Provider in which he tells us that providers ought to look to hospice as a model for building goodwill with the public and with lawmakers.

So it appears that providers are more willing to talk openly about death and dying and grief than I had given them credit for.

‘Good Death’ Aspiration

Still, no one will claim that this refreshingly morbid September closes the conversation. And however much the Big Public may hymn the virtues of “a good death,” the attitude still seems aspirational.

“I wish there were a way we could get out into our communities,” says Robin Hillier, owner and operator of Lake Rehabilitation and Nursing Center in Conneaut, Ohio. “Having these discussions about what we want for ourselves at the end of life is something that we need to have throughout our lives. We all talk about estate planning, and tax planning, but not enough people do enough about end-of-life care.”

Robin Hillier

Robin Hillier

Hillier has acquired a grim expertise on grief and mourning. Not only does her center care for and treat the elderly, but it also has a pediatric unit.

“One of the biggest rewards for my staff is working with those people, because they have an opportunity to develop lifelong relationships,” she says. “But one of the problems is when one of those residents dies, it’s much harder. You’re sad when someone who’s older died, but you can celebrate a long life, well lived: It’s just much harder when someone young dies.”

That’s why The Talk starts early and continues often at Lake Pointe, Hillier tells me.

“We take that seriously, we talk about it clearly, and we want to provide you with the support you need to deal with it,” Hillier says at every new staff orientation (and beyond).

Family Values

Staff grief is only one mountain to climb, though. The biggest one is often families of the dying. (In fact, an earlier study in JAMDA found that nearly three-quarters of staff reported family members as a hindrance to offering quality end-of-life care.)

Debbie Meade

Debbie Meade

“We have to balance between a resident and families, often,” says Debbie Meade of Health Management, in Georgia. “The resident is tired. They’re tired of the fight. And there are times when they’re just ready to go. And they know it.”

For families, though, it’s often hard to “let go,” Meade says. The guilt, the sense of betrayal, the fear of loss all overwhelm families at what is literally the last minute. (But even the Supreme Court sometimes seems to struggle with teasing out the difference between letting someone die and actually killing them.)

“That’s where we miss the boat,” Meade says.

‘Your Mom Is Not Here Anymore’

Meade says that these are the moments where providers must find their voices.

“I had a resident—the flesh was literally rotting off her body. And the family had a feeding tube in her,” she recalls. “I sat down with the family and said, ‘I’m sorry, I can’t let you do this anymore. Do you understand that your mom is not here anymore?’”

The reasons so many providers balk at such blunt talk are easy to understand, Meade says. The fear of lawsuits, the fear of honesty—it’s all human, all too human. “They think they’ve given up on them, and they think they’re not doing what’s right,” she says.

But the consequences of human failure are absolutely inhumane, Meade says.

“We don’t sit down and have those honest conversations. And that’s when the resident suffers, when you watch the family not having enough love and courage to let them go to that better place,” she says. 

‘Granny Wants To Go’

Like so many in her line of work, Meade has dearly won experience. She had to help her beloved grandmother die. A vivacious, vibrant woman, “Granny” had been up and about until one more stroke drew a curtain down on her. Meade instantly moved her grandmother into Health Management’s skilled nursing center.

“I was trying to feed her, and she closed her mouth and shook her head, No. I said, ‘You don’t want to eat?’ She shook her head. No. I called my Dad and said, ‘Granny wants to go.’

“I know I did what she wanted,” Meade says. “She just looked me in the eyes and shook her head. And I knew what that meant.”

It took seven days for Granny to die. But she did so peacefully, and on her own terms. Meade says she misses her grandmother every day, but regrets nothing. She hopes that she and other providers can find ways to pass on what they’ve learned.

“It’s something that we need to talk about more,” she says. “It’s something we need to share.”

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.











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