Rock Island County Hope Creek Care Center Board of Directors met July 17.
Rock Island County Hope Creek Care Center Board of Directors met July 17.
Here is the minutes provided by the Board:
The Hope Creek Care Center Board of Directors met at the above date and time in the Conference Room at Hope Creek Care Center, 4343 Kennedy Drive, East Moline, IL. Chair Jessey Hullon called the meeting to order at 5:31 p.m. Minutes as follows:
1) Call to order and roll call
Committee members present: Jessey Hullon, Gregg Johnson, Michael Kelly, Carol Near, Ginny Shelton, Rod Simmer (arrived at 5:35 p.m.), Bryon Tyson
Committee members absent: None
Others present: Dave Ross, Ed Langdon, Hayleigh Covella, Lynda Vogt, Patty Luecke, Kenneth Maranda, Bill Gabelmann, Tom Dryg, Cassie Baker
2) Approval of the minutes from the May 15, 2017 meeting
Motion to approve: Ginny Shelton
2nd: Michael Kelly
3) Public comments
Mr. Hullon reported that about a month ago, he went in front of the whole Rock Island County Board to give them the state of the union, so to speak, on Hope Creek. He had to present after Ms. Palmer and that’s not always an easy task to do. It went well. He had no questions coming in. The material must have been well absorbed.
Mr. Ross introduced Cassie Baker. He noted that she was the ADON. She went through interview process and is now Hope Creek’s Executive Director. Everyone applauded and welcomed Ms. Baker. Mr. Ross noted that she accepted at the perfect time: right when the state showed up for their annual survey. It was trial by fire. Ms. Baker said she learned a lot. Mr. Kelly noted that she has a great mentor. Ms. Baker agreed. Mr. Ross noted that Ms. Vogt is still here. Mr. Hullon noted that when he showed up, both Ms. Vogt and Ms. Baker were at it. Mr. Ross asked Ms. Baker if she wanted to share some things about herself. Ms. Baker said she started over in the hospital world. Hope Creek is her first place as far as long-term care. She fell in love with it immediately. Coming from the hospital world, and Mr. Kelly can probably attest to this, nurses at hospitals look at long-term nurses as the lesser of the group of nurses.
Mr. Simmer is present.
She learned coming to Hope Creek that the respect is not there. These nurses here do wound care, they’re respiratory therapists, they take care of psychological needs, and med passes that are hours long at times where at the hospital it all pops out of a machine for you. Her long story is there is an immense amount of respect for the nurses, a lot of pride here, and that is what she loves so much about Hope Creek. The team is not one individual, it is everybody. There’s a lot to work on, obviously. They’re all very aware of that and she is taking that on head on. Since Ms. Vogt took over before her, she learned a lot from her insight. She is being proactive and making sure things are on the right track. They have lost sight in the past and lost a lot of good quality nurses in past. They just have to build it back up. Sometimes that takes a little bit of patience. She’s trying to bring morale back up and a culture change, which doesn’t happen overnight.
Mr. Kelly noted that Ms. Near can appreciate that too. She’s an RN. Ms. Near added that she’s been a long-term CNA instructor too. She worked in a hospital setting and she knows how they pass those meds and walk all over looking for those residents.
Mr. Ross noted that he has a couple of financial things to talk about. He and Ms. Baker are meeting monthly and going over KPIs, or key performance indicators. He’ll go over what they went over this month and the different things they are looking at every month to see if Hope Creek is on pace with where they want to be.
Mr. Ross noted that they look at admissions and discharges. In June, there were 25 admissions and 23 discharges, so it was at +2. That’s a good thing. The census total snapshot in time was 191. That represents 90% of available beds, which is right where they want to be. Actually, it’s two over where they want to be. 189 would be 90%. Medicaid beds filled are 96 of those 191, so 50.26%, which is right where they have talked about wanting to be.
Mr. Ross reported that agency costs for June, he would like to see that at $45,000 or less. That’s kind of a lofty goal right now, but they’re working on it. Some months have been as high as $90,000 this year already. Last month it was $66,277. That’s better, but he thinks they’re all working on getting that to be improved even more. Ms. Baker and the staff have already implemented some things to work on that.
They looked at total property taxes received. At the end of the year, they will have collected $2.46 million for Hope Creek. They don’t get it every month. For Mr. Ross’s purposes, he’s doing that on an accrual basis at $203,271/month. Through June, Hope Creek should have collected $1.43 million if they got it cyclically every month, which they don’t. Mr. Ross explained that he took revenues received minus any property taxes actually received, then added back in the accrual and looked at that compared to expenses year to date. What he wants to see is Hope Creek at 3% revenues over expenses at all times so they are always carrying a slight profit. At the end of June, they were $800,000 under, so Hope Creek had $800,000 more in expenses year to date than revenues. That’s revenues actually received. When he goes and looks at the aging report and what the state currently owes Hope Creek, they owe about $1.5 million in Medicaid and other Medicaid hospice lines. If they were to pay current what they owe right now, Hope Creek is at 9% under for the year. They want to be 3% over. That’s 12% off of where he wants to be. If just the state were to pay Hope Creek, they’d be 11% over. Right now they are actually doing very well except for the state of Illinois not paying the money they owe.
Mr. Ross noted that for the aging report, Hope Creek collected $846,000 last month. From the 120+ days, they collected almost $17,000. Any amount there is really good. For Ms. Luecke and staff, and soon to be slightly more staff to help her out, anything 120+ is good. That’s difficult. It’s very good when they collect that. There is still $4.5 million owed to the facility over all.
Mr. Ross explained that he looked at budget performance year to date, revenues and expenses and Hope Creek is down in revenues. If just the state paid, Hope Creek would be over. Mr. Ross also looked at each functional area in the facility. Every functional area is under budget right now with the exception of one that was 0.5% over. He’s not worried about that. Hope Creek is actually doing well. They are still looking at everything very closely because just because they are doing well on expenses, if revenues are not coming in they still need to address that. They need to cut somewhere at some point to reduce expenses for the year. His hope is those working on getting the state to pay the money they owe will at some point in the near future pay off now that they have a budget.
Mr. Simmer asked for a year-end prediction if the state pays. Mr. Ross said they’d end up positive for the end of the year. Mr. Simmer asked how things are as far as being paid up old versus new. Mr. Ross said he’d let Mr. Dryg or Mr. Gabelmann talk about it. They’ve been talking with Ms. Ewert about how much they can pay and when. They are still looking at not being there by the end of the year when it comes to bonds they have to pay at the end of the year. They are still not there. An extra $1.5 million over and above what they’re getting each month would help tremendously.
Mr. Gabelmann noted that he doesn’t have much to say, frankly. Mr. Ross did a wonderful job. He will throw a few numbers in. Mr. Gabelmann handed out a summary. He noted that there have been some preliminary financials and they missed the last meeting, so he did was a summary of year to date. Since the last time they presented in May, the audit got finalized so they were able to put their stamp of approval on all the financial statements. They couldn’t before that. There were no changes to what they had presented, but they didn’t know that until the audit got done. All those financial statements have been brought forward. Mr. Gabelmann said he thought he’d really briefly summarize the seven months so far this year, December through June, so he put this report together. There are a couple things he will touch on in the old reports before he jumps into that.
Mr. Gabelmann said first off, to reiterate what Mr. Ross was just talking about, he loves those key factors. Those are awesome. That’s almost what some of what he says will get to. He takes a look at three or four different items. He doesn’t get into the detailed side of where Mr. Ross is looking at the different service areas. He looks at cash receipts, cash disbursements, and loan payments. Those are the three biggest things for him relative to what’s going on. Mr. Ross's comment is going to be exactly portrayed here that they’re moving in a comfortable position toward what he would call almost a break even and Mr. Ross’s goal of 3%.
Mr. Gabelmann explained that the problem is the collection side. He would take that beyond even just the state of Illinois. However, a wonderful example is that on July 7, $209,000 came in dating back to January that was due on Medicaid. When they start getting those lumps, all of a sudden they can make a few more payments to vendors. At the end of June, the cash balance was $987,000. That’s the highest it’s been for quite a while. A major part of that was tax receipts came in at $800-some thousand in June. Prior to the payment on the tax anticipation warrant, there was a lot of discussion. Typically 85% of the cash receipts are paid. There were discussions between Ms. Ewert, Mr. Ross, Mr. Dryg, and everyone involved. Instead of paying 85% to the state, they dropped that down to $400,000 per month now that will be paid up toward the end of the year. That got paid in the first part of July. That’s still in that $900,000.
Another thing is receivables were only up $18,000 last month at the end of June. That’s a real positive because collections are an issue, but when they are billing out close to $1 million and only accrue $18,000, that’s been one of the smallest accounts receivable there has been, which is a compliment to Ms. Luecke. Another thing Mr. Gabelmann wanted to point out is payables at the end of June. Everybody almost gags when they see $1.1 million in payables. Payables were down $60,000 at the end of June and rolling into July and they had a couple big things come in July. They originally planned for $365,000 to pay out this month. Mr. Gabelmann asked Mr. Dryg what they’re looking at now. Mr. Dryg said $450,000. That’s a combination of $200,000 coming from the state from January and paying down less against the tax anticipation warrant from the tax receipts. There should be some working down of the payables at this point.
Mr. Gabelmann said there are some real positive things showing up. June was a good month. As Mr. Ross mentioned, the receivable side of collections was only $854,000. Those are all good things happening even in lieu of that. Part of that is billings are flat out down with that wing closed. They are not seeing $1.1 million in billings every month.
Mr. Simmer asked, with that wing closed, if they still owe bed tax for it. Mr. Dryg said it’s based on census.
Mr. Gabelmann explained that on the sheet he handed out, he will briefly explain what he has done there. The far left hand column says, “Accrual basis.” That’s what this financial statement reflects. It’s a full accrual basis as if Hope Creek was a normal C Corporation paying taxes on every income it has. The middle column is adjustments that have occurred every month to get the modified accrual basis in the far right column. That’s the basis that Ms. Palmer shows in her Rock Island County general ledger. Mr. Gabelmann explained that the columns that are key ones for him equate to cash availability and cash position. That’s how those differences affect Hope Creek on accounts receivable, accounts payable, and the tax anticipation warrant balance. Those columns show the November 30 final audited numbers, the accounts receivable for November 30 which was the end of the last fiscal year and start of this fiscal year. That was right at $4 million. The accounts payable balance was $1.15 million owed. The tax anticipation warrant balance was $1 million.
Mr. Gabelmann said he will start with December. Hope Creek has items on an accrual basis, which Mr. Ross just mentioned. One of the biggest they accrue for is the tax levy. On an accrual basis, that’s really money that is going to be coming in, and on a monthly basis they allocate it. On a cash basis, which is the way the county recognizes the revenue coming forward other than the year-end sixty days issue, looking at the modified accrual basis for December, the first month of the fiscal year, the total inflows were $1.56 million on accrual and actual inflows were $1.37 million. That’s cash basis receipts. For outflows, operating expenses don’t change. That’s the same format Mr. Ross was talking about with the payable side. Mr. Gabelmann noted that he pulls out depreciation, amortization, and also accrues debt service. That’s primarily the interest expense on a monthly basis. When they modify it to a modified accrual, it shows Hope Creek can bill out $1.3 and collect $1.36, which in December decreased receivables by $36,000. Looking below, if operating expenses are really $1.14 million, they don’t modify those, but the payable balance got paid down in December. At the end of December where it says net for the month, receivables were down to $983,000 on payables and $1 million on the tax anticipation warrant. That’s the format for December. Those are the key things to take a look at as things move forward.
Mr. Gabelmann continued to January, the next month on the report. Mr. Gabelmann noted that that was one of the worst collections versus billing months. There was a $130,000 increase in that month on receivables in January. They already know that $200,000 alone of that was the January Medicaid that just got collected this month. That’s where they start looking at what’s going on with the cash position and cash flow. Payables went up $73,000 that month, but cash flow wasn’t that good. That’s how this is flowing. The next thing to look at is the January outflows number. That’s $1,382,000 on the modified accrual basis compared to the February outflow number of $1,115,000. Mr. Gabelmann said he’s trying to point out some trends, but he’s not going to go through every month unless someone really has a deep desire to.
Mr. Gabelmann noted that June is what they just talked about. Charges for services on an accrual basis were $918,000 in June. That was down almost $200,000 from the previous month as the beds are closing up. Actual cash collected on services was $900,000, but the receivable balance still went up $18,000. For outflows, as Mr. Ross just mentioned, agency alone was down to $60,000ish. Total operating expenses were down $102,000 for June. A big chunk of that was agency alone. What he likes doing on this spreadsheet is a quick snapshot of what’s going on. For cash flow, the last page shows the net change for the year for accounts receivable, accounts payable, and the tax anticipation warrant. Accounts receivable is up $540,000 from the start of the year. As Mr. Ross mentioned, a big piece of it is private pay is up quite a bit, but there’s $140,000 alone that’s with collections that is now attempting to be collected. As of June 30, accounts receivable was $540,000 up. They just collected $209,000 of that old stuff. Realistically, that’s even down now to $329,000. The tax anticipation warrant is up $750,000. In the first part of July, $400,000 was paid down on that. The payables for the whole year through June 30 are actually down $30,000. They are considering paying off even more than the current month accrual of $300-some thousand. Mr. Gabelmann explained that every one of these numbers is in these financial statements they got finals on. It’s a nice way to snapshot and take a look at key figures. He thinks what Mr. Ross is talking about, the key indicators, are just awesome. Those are good track marks.
Mr. Hullon asked when Hope Creek officially quit billing for that [closed] wing. Mr. Gabelmann said May. April was when they shut it down. Mr. Hullon asked, if in June they collected $918,000, are they tracking how much less it is. He’s not seeing operating expenses getting lower. Mr. Gabelmann explained that operating expenses from May to June were down $101,000. Mr. Ross noted that a lot of that is agency. Mr. Gabelmann said that’s absolutely right; that’s why these are some of the same. His benchmarks are a little bit different than the KPIs, but he’s getting to the same thing.
Mr. Dryg noted that the bills Ms. Helms was putting in per month were running around $400,000. Last month they were $330,000, so it’s less. He has seen that come down to $370,000; $350,000; and now $330,000 per month. It is trending down. As Mr. Ross said, if they look at the budget performance report, the costs are all under budget. Revenue is under budget too, but that’s partly the way the county accounts for things at the end of the year. They’ve taken 60 days off the front of the year and pushed it into last year. Until they do that again, the revenues won’t track.
Mr. Gabelmann noted that on the cash flow receivables analysis, as he mentioned the receivables are up $540,000. $200,000 came in right away in the first part of July which was nice, though it’s hard to say it’s nice to get it in when it’s been due since January, but at least that piece got kicked up. Some were sent out for collections. Looking at the receivables aging report, there are about four line items on there that are flat out scary. The Medicaid at the end of June was $1.3 million alone. Out of that, probably at least half a million is more than 120 days old. Medicare A is at $474,000 with $157,000 up in that 210 day range. Managed care and Medicaid pending, they can’t really do much about Medicaid pending, but managed care has $100,000 hanging out way back. For private pay and resident liability, the current receivable balance is at about $1.27 million, of which $700,000 is past 210 days. The concept of getting cash flow down to the bottom is reducing cost and increasing collections. Billings are up, but they are not being collected. Mr. Hullon noted that billings don’t pay bills. Cash does.
Mr. Hullon asked what exactly resident liability is. It’s $246,000. Ms. Luecke said it’s the portion the state says a resident has to pay out of their income. Mr. Hullon asked if those are Medicaid residents. Ms. Luecke said yes. It’s each month’s income. Mr. Simmer asked how they are doing collecting that. Ms. Luecke said it depends on who they are after.
Mr. Simmer noted that when they first took this over, Hope Creek had 30 people sitting here who were not paying a dime. They got on top of that but there are still problems when they get in here with getting them qualified and established. He asked how they are going forward and what the plan is to continue progress and stop some of this stuff. He noted that at his office, if he doesn’t get it at the front desk, it gets less and less likely to get it in. He asked what they can do up front rather than waiting, because 90% of that is probably uncollectable. Mr. Ross said for the upfront part, he’s not sure. He can tell Mr. Simmer that they are working through, all the staff is, auditing internally who of the existing residents are paying bills and who isn’t. For the ones that aren’t, they’re looking at how far back they are. They did a brief audit the other day with three people and found one that had significant money owed to the facility. He doesn’t remember exactly what it was. They have identified other things they need to do. They’ll take a look at all existing residents and see where they are at and what they can do. He doesn’t want to continue having them necessarily in the facility if they’re not going to pay. There are other factors, of course.
Mr. Simmer said they need to find out as soon as possible so they know where they’re at and the facility knows. These things never come to fruition. They will not see that money. He asked how they can eliminate that. They’ve been talking about it for a long time, so what can they do differently. He asked if they can get paid up front. He has his girl up front going, “Cash, credit card, or check?” Mr. Ross noted that he did just authorize a request to begin accepting credit card payments. They are doing that now. That just started. Mr. Simmer explained that payments get paid less and their portion would be less, they need to readjust that. If they’re not getting as much, they need to readjust that with the state. There’s paperwork and garbage to go through to back collect. It’s difficult to get that once they’re out the door. Once they’re in, no one wants to kick grandma out of the home, but how do they get it up front?
Ms. Baker noted that Ms. Luecke’s time has been spread very thin. They are looking at getting her assistance. The more help she has, the more she can collect and can stay on top of things. She’s only one person.
Mr. Hullon noted that the cash cow outside of insurance companies is usually private pay. Ms. Luecke explained that Medicaid is pending, they’re still considered private pay. There’s a family she’s working with diligently that has a private pay balance over $70,000, but the state hasn’t gotten everything together. She’s working with that family. They came in today with a lawyer to get dad’s financial power of attorney signed over. That just takes time, especially when it has to go through the office of the inspector general.
Mr. Hullon noted that to make this thing realistic, they’ve got almost $1.9 million sitting in 210 days. He asked when they are going to write that off and if they can turn all of that over to the collection agency and at least get numbers that actually make sense. They’ve talked about this for six months now and he hasn’t seen any action on it. Mr. Gabelmann explained that there’s a reserve of over $900,000. At the last analysis, 20% of that total balance is being used. Technically, there’s already $950,000 being reserved. On the write off side, if something in there is over 365 days old, he thinks they need to take a serious look at getting it off. That’s part of what that $950,000 is. One reason he doesn’t necessarily promote getting off this system is this is what is kicking out statements and billings. They have similar issues with his business. On occasion, he gets a call from an attorney that says, “Quit sending them statements or go to court.” At least he knows they’re getting irritated enough that every once in a while he gets a payment from someone that is way past due. In that regard, this needs to be more cleaned up. There’s a lot of work going on. He’ll throw his two cents in that if they could get some help collecting this, even if it cost $50,000 a year and they collected $200,000, but things are tight for justifying a new position. Mr. Ross said they just did that internally. It’s not that much. He’s finalizing the job description and getting someone hired for just this reason. Mr. Gabelmann said that’s excellent. It’s the same with a collection agency on some of those older ones. If they’re going to take even 75%, once that’s out the door and gone he’d rather have 25% than nothing. Mr. Hullon suggested hiring the employee and letting them do something else and let the collection agency worry about it. It’s dead money. Mr. Gabelmann noted that the credit card, he loves. Once Hope Creek gets paid on the credit card, it’s the credit card company’s problem to collect it. Let them worry about it. He said, “Thumbs up on that move.”
Mr. Tyson asked, on the 210-day category, what the trend is. He asked if six months ago it was higher or lower. Mr. Gabelmann said there’s $4 million total outstanding, but he really doesn’t know. Mr. Hullon said it’s trending higher. Mr. Simmer noted that month to month it’s pretty similar, it just gets further back and further back as it goes. Mr. Hullon said that Ms. Luecke concentrates on the money today versus money from five months ago. That’s more practical. They know it will fall back. Ms. Luecke agreed.
Mr. Gabelmann pointed out that cash flow now looks horrendous. Right now in December, it’s showing a $2,000,000 deficit after the bond payment. That shows the entire $1.75 million tax anticipation warrant paid back, has the payables completely current, and also includes the payment of overhead and insurance for the year, which has to be paid to the General Fund too. Realistically, he’s going to piggy back on Mr. Ross’s comments here, if they’re running 9% low, one thing they’re not taking into consideration is operation-wise it’s very close. If they get 3% positive, that’s the number that’s going to be necessary. What’s not taken into consideration is the $1.4 million debt service that has to occur. That is down to $14 million. If they can hang on 14 more years, it’s going to be phenomenal. That’s a long ways out. Realistically, right now, these projections have to be modified. He’s showing $1.1 million in receipts. That’s not happening when billings are dropping down. Year to date through June, the average monthly cash collected is $997,000. That does not include property taxes or the Intergovernmental Transfer. That’s really not too bad. This month is going to be a big month because of that $209,000 and a couple other big deposits. The other side is expenditures are starting to drop. As Mr. Dryg mentioned, when they first started in August, that was running $400,000/month. This month was $330,000. Some figures have to be modified. This shows Hope Creek completely out of debt except for the next bond payments. Everything is paid off. They know that’s not going to happen. He’s warning or suggesting to everyone right now, come the end of the year for that tax anticipation warrant, they are going to have to renew it again. If they do $1 million and have a remaining payable balance of around $700,000, it could be close to Hope Creek making that payment without having to do much more borrowing. That’s based on $1 million/month of cash receipts outside of the tax levy coming in. It looks like Hope Creek might end the year in no worse a position than it was at the start of the year. With the transition and what’s going on, he’s saying that’s not too bad if they can do that. It’s a good start. Ms. Baker noted that, especially identifying all these areas to improve on, there’s nowhere to go but up unless you just sit back and watch fall apart.
Mr. Gabelmann noted that he said several months ago Hope Creek was looking good and then cash receipts nosedived. Then the following month they got $1.3 million in cash receipts. So if that happens toward the end of the year, they’re talking anywhere from $1 million to $1.5 million. They’re at $1.75 million now on the tax anticipation warrant. If everything is managed, it might be very close.
5) Discuss recent state survey
Mr. Ross explained that about a month or month and a half ago, the state came in and did their annual survey. Hope Creek staff was preparing for it for some time. They conducted a brief mock survey and addressed the areas they knew the state had paid attention to in their prior survey. The state came in and Hope Creek ended up with a total of 15 tags on the facility. One was an IJ, or immediate jeopardy. That IJ was from a brand new law that passed which Hope Creek was unaware of and he guesses a lot of homes in the area were unaware of. Mr. Kelly asked when the law passed. Mr. Ross said in October 2016. He was told a lot of homes were not aware of it, right, wrong, or indifferent.
Mr. Simmer asked if hospitals have the same standards. Multiple people said no. Mr. Simmer said that makes no sense.
Mr. Ross explained that what the IJ essentially was is Hope Creek had side rails on the beds. The new law has a very specific regimen to have side rails approved. He was told Hope Creek didn’t follow every step exactly and was cited because of the hazard that someone could get hurt. They took the side rails off and were working on their options. A couple of weeks later, the state gets a hotline complaint, comes in, then cites Hope Creek for taking the side rails off. Ms. Near asked if they were fined. Mr. Ross said not as of now, but he expects they will be for the IJ. He doesn’t believe they will be for having taken them off. They are looking at getting assist rails on the beds. Ms. Baker said they’re called bed mobility aids. Mr. Ross said they’re to help residents in and out of bed, not keep them in. Hospital beds where everyone goes in have side rails.
Ms. Near said she has been in another facility the last couple of weeks and they have side rails and they’re a long term facility. Mr. Ross said they haven’t been inspected yet, apparently. Ms. Shelton said that may have something to do with the inspector. Mr. Ross said that’s always a strong possibility. It’s a team of 15 people or so. A personality is developed amongst the group. Staff is working on the plan of correction and he believes they have finalized it. They will get that to the state so they can move on.
Mr. Kelly asked if Hope Creek has a policy in place where residents can, if the law says they have to have [side rails], then someone can sign a release form to have them off if they are required on or vice versa. He asked if they can get any signatures by the patients or powers of attorney for people saying they do or don’t want them. Ms. Baker explained that no matter how many consents they obtain from families, it doesn’t clear Hope Creek of the liability that harm could be caused. Potential to be harmed is the key. Hope Creek was red flagged because back in March, they had an incident regarding a dementia resident who had rolled out of her bed. Her head was between the bed and the side rail. She also had her arm holding on to the side rail. When this occurred, they had to do an incident report because it was an unintentional change of plan. It was a fall. She didn’t mean to roll out. With that fall, she wasn’t able to rest on the floor on the side mat with her high/low bed. She was stuck. In the incident report, it stated that she was wedged. The nurse wrote that she was “wedged.” The same nurse gave her report after they inspected stating that when she was holding on, she had to verbally ask her to self-release. When she let go, her body went down to the floor, which led staff to believe she was not wedged. She was holding on because she didn’t know what to do. The state said her ear was red so harm was caused, but they did not classify it as harm actually caused. They said her ear was red, so clearly she was entrapped in her bed rail. You can get a red ear from lying on your pillow at night. That’s all speculation. Long story short, Hope Creek should have removed the side rails immediately, but they viewed it as a different scenario. Mr. Ross is absolutely right: it depends on who comes in and inspects. With the state survey, she saw a lot of things that she hasn’t seen before. She hasn’t been in a lot of surveys and hasn’t been in long-term care, but she does know that with this particular situation, it was not the norm. [With the inspectors], there was some inter-team.Ms. Vogt said personality conflicts. Ms. Baker said there was a lot of disorganization. They were asking a lot from Hope Creek’s team. They’d ask her for one thing, then the DON, then the restorative director, then the unit manager. She thinks next year they need to reel the in the surveyors and understand that this is their facility and if the state is asking stuff from them, it needs to come from the DON and Administrator only. It caused issues with communication between staff. Some things were handed over that shouldn’t have been. As far as how the nurse put “wedged,” they are educating nurses on documentation and charts. Normally they don’t give internal documentation to IDPH. Now they can have access to that staff. Now they need to teach nurses and CNAs to chart internal documents the same way they would for a chart. Sometimes it’s a double edged sword. Too much information is bad. Too little information is bad. Finding just right is very hard to do at times. All they can do is keep educating.
Mr. Johnson noted that in October 2016, this changed. He asked what the state does when there is a change in regulations. He asked if Hope Creek has a compliance officer and if so, who it would be now and who it was in October. Ms. Baker said they technically didn’t have a full-time compliance officer then. Ms. Vogt is now. Ms. Vogt noted that it was 782 pages of regulations. There wasn’t just a code. It was 782 pages. The problem is that being a standalone facility has some negatives. She can’t sit in an office and review 782 pages of regulations. Ms. Baker said they could pay consultants. Mr. Johnson said the state doesn’t do a clear job of notifying facilities of what has changed from month to month. Ms. Vogt noted that it comes from CMS. Ms. Baker noted that as of right now, she has signed up for three or four, soon to be five once her license comes in, notifications. There’s also a summit coming from Chicago that goes through Medicare changes for the year. Hope Creek just didn’t have enough resources before. They are getting on track to having those. Ms. Vogt noted that in the future, she’s going back to compliance officer. Mr. Johnson said the state should do better if it’s going to impact facilities. Ms. Vogt said they figure if they put it in print, you will read it. That isn’t always realistic. Ms. Baker added that the verbiage is not black and white. It’s about perception. When they get here they say, “That’s not what that is,” but they don’t know because the definition wasn’t stated anywhere. Ms. Vogt noted that the perception of surveyors changes from one survey to next.
Ms. Near asked if there’s been an increase in falls with the rails off. Ms. Baker said yes. Ms. Shelton said of course. Mr. Simmer asked about the steps to get these back on. Mr. Ross said there are five steps. Mr. Simmer asked what they are. Ms. Baker said the risks very much outweigh the benefits. If they want to keep them, first they have to do an assessment. If during the assessment there is even one slight grey area, they are going to get tagged. If the assessment is great and goes through and they assess everyone in the building, which Hope Creek already did, if they want to put them on because the assessment says they are able to, they get a doctor’s order. Once they get a doctor’s order, they have to get that family consent Mr. Kelly was talking about. Once that’s approved, then they can put them back on. Once they’re on, they have to have maintenance audit them on a daily basis because the beds are so old. If they use them once, they become loose. There are regulations on how far from the bed they need to be. It’s too much work. They’d need a whole team just to do bed rails. Hope Creek is planning on going side rail free and get bed mobility devices. They are called Halos. They’re circular units. Residents cannot fit their arms or appendages in them and cannot become entrapped. They are not cheap, though. She looked at all different vendors across the United States and found a couple, but the ones with the least risk of entrapment are through Direct Supply. The other one is from Australia. No other company has even come up with this. It’s a new federal regulation that came out. Even suppliers don’t have the right adaptive devices. Mr. Simmer asked if they can have lower beds. Ms. Baker said they do, but that doesn’t help with mobility side to side, so then they’re taking away freedom of movement in the tag. Mr. Ross said then there’s a tag for resident rights.
Mr. Tyson asked for more information on the Halo. He asked what it is and if it fits on the side of the bed. Ms. Baker said it has a little latch that fits on the side of the bed. It’s a circle and residents can use it to move side to side, but it shouldn’t stop them from getting out of bed. The state doesn’t look at a side rail as keeping someone in bed. That’s restraint. They can only use side rails for bed mobility purposes. That’s where they get it. If a person needs bed mobility, they’ll take off the side rail and give them a bed mobility device. There’s no assessment, doctor’s order, or consent. It takes out the risk of getting another tag.
Ms. Near asked how much they are. Ms. Baker said it’s on her desk. She thinks it was $250.
Mr. Simmer asked what they are made of. Ms. Baker said plastic.
Mr. Kelly asked if maintenance has to get involved. Ms. Baker said there are no audits. She thinks it was $250 for two, she thinks. They got a deal through Direct Supply. The more they purchase, the better the deal. They ordered five to make sure that current residents who are complaining about bed mobility and independence get one right away.
Mr. Kelly noted that Ms. Baker might be aware of this, but in 1990 when he was an RN/DON at a long-term care facility in another state, these very issues were being debated in the nursing profession. It had gone on for decades prior to the 1970s or 1980s. That’s how long debates about this have been going on amongst nurses. He sleeps on a rather large bed with his wife and can hardly imagine himself in a bed like this, a single twin bed. One night and he’d be on the floor if he didn’t have a rail. He tosses and turns.
Mr. Tyson asked how the state cited Hope Creek for taking the rails off. Ms. Baker explained that the state even said that it’s a double edged sword. Yes, they took them off for safety reasons, but residents have rights so they should have had adaptive equipment before they removed them. Mr. Johnson asked how the state can tell you that you owe them money and then not tell you what it’s for. They do it all the time.
6) Board of Directors member opportunity for brief comments (no decisions will be made)
Mr. Kelly asked if the IJ is still in place. Ms. Baker said yes. Mr. Simmer asked if they’re still at just one star or if they took that away. Ms. Baker said they still have one. They can’t go lower than that. She was talking earlier with Mr. Hullon about how just because they got an IJ, they don’t necessarily look at the star rating staying at one because of that. There are quality measures they can do to increase the star rating. It’s a whole big algorithm that would take a meeting to teach. Just because they get an IJ or a poor state survey, that’s not what defines Hope Creek. A lot of other measures can bring up the star rating and bring up admissions.
Ms. Near asked if they can bring in students from Blackhawk for CNA classes. Ms. Vogt said not with an IJ.
Mr. Tyson noted that it hurts marketing as well. Ms. Vogt said it depends on how they market. She talked with Ms. Kettler about marketing to the positive. There are a lot of positive things going on. She can take a couple of indicators to the public of things Hope Creek is doing well. Mr. Ross said there are a lot. There really are. Mr. Tyson said people do research and look at the ratings. Ms. Vogt said the other thing to stress there, which she talked to Ms. Kettler at length about, is to remember that a lot of that information is anywhere from 3-12 months old. If she takes the current data as opposed to what’s on the CMS website, she can actually disprove the information out there. Mr. Simmer noted that if they explained the first IJ tag and the stupidity of the second one, people will say, “Okay. It’s just the state.”
Motion to adjourn: Rod Simmer 2nd: Ginny Shelton Meeting adjourned at 6:31 p.m. by Chair Jessey Hullon