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News/Information: LINK Vol. 19 Issue 20
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LeadingLINK Vol. 19 Issue 20

Governor Signs State Budget – On Tuesday, April 17, in front of a small crowd of mostly quiet elementary school students, Governor Rick Scott signed the $69.9 billion state budget into law at a St. Johns County Elementary School. While signing, the Governor touted this year’s budget as an “education budget.”

This year the Governor slashed $142.7 million in spending with his line-item veto. The total number of vetoes represents a decline from last year, when Scott rejected more than $310 million in individual projects.

Of the line-item vetoes, about $38.2 million were in the health- and human-services section of the budget. LeadingAge Florida staff have reviewed the budget and at this time we have not identified any items that directly target our members as a whole. Some of the projects vetoed include:


LeadingAge Florida General News

AHCA Hosts Consumer Health Care Website – The Agency for Health Care Administration (AHCA) now has a consumer health care website. The website presents health care data that can be used to look at Florida health care trends, both locally and statewide. The website provides tools to compare quality of care, performance and pricing for Florida hospitals, ambulatory surgery centers, nursing homes, health plans, hospice providers and prescription drug prices. The site also includes a list of Florida health care facilities and agencies, information on health insurance, resources for the uninsured, a health encyclopedia, and more.

For questions, feedback or to order bookmarks or pamphlets, please contact Sue Gambill at 850-412-3750.

Member News

Way to Go Marian Pearlman Nease! – Congratulations to LeadingAge Florida member, Marian Pearlman Nease, of counsel with Berger Singerman in Boca Raton, for being selected by LeadingAge to serve as a core member of its legal team.

LeadingAge Florida Affordable Housing News

2012 Annual Adjustment Factors Announced – On April 13, 2012, a Notice of the Revised Contract Rent Annual Adjustment Factors (AAFs) for 2012 was published. The AAFs are used to adjust the contract rents on the anniversary date of the assistance contract for some multifamily projects. The AAFs are effective April 13, 2012. A copy of the Federal Register containing the revised AAFs is available here.

Reminder – HUD Invites You To: "Partners in Housing" Multifamily Preservation Training – HUD is holding a free and informative workshop to explore the many issues that owners of multifamily housing properties face today. The workshop will provide you with the latest information on the available programs and resources you can leverage to sustain your property.

This training is designed for owners of properties with HUD mortgages and/or rental assistance. Senior level executive management company staff who are charged with asset management of HUD multifamily properties are also welcome. The training will focus on properties with HUD-insured or Direct loans (including Section 236, Section 221(d)(3) and Section 202 properties) and/or project-based rental assistance (Section 8 and/or Rent Supplement or RAP assistance). The training will be held at various locations around the country and a virtual broadcast is available on June 26 – 28.

Day One

  • HUD’s Role in Providing Affordable Housing
  • Affordable Housing Challenges
  • HUD Prepayment and Repayment Requirements

Day Two

  • Tools for Preservation of FHA-Insured Properties
  • Sustaining Affordable Housing via Low Income Housing Tax Credits and Refinancing
  • Preserving Section 8 Rental Assistance through Long Term 20-year Contract Renewals

Day Three

  • Preserving Section 202 Supportive Housing for the Elderly
  • Asset Management Issues related to Preservation Transactions
  • Other Rental Assistance Preservation Issues
  • Long-Term Affordable Housing Preservation

A detailed agenda is available for download. Please Note: The agenda is based on estimated durations of lessons, topics, and activities and is subject to change.

Important notes:

  • Registration is limited to one person per organization per city and to ten people per organization nationally.
  • Participants are responsible for their own travel and lodging expenses.
  • For more information and to register, please click here.

Fair Housing Summit in Orlando on April 26 – The “One Community, Many Faces: A Regional Fair Housing Summit” will be held on Thursday, April 26, 2012, at the Doubletree Downtown Hotel in Orlando. Featured guests include HUD Assistant Secretary John Trasvina and Consumer Financial Protection Bureau Assistant Director Patrice Ficklin. Online registration is available. Sponsorship and exhibitor opportunities are available. For additional information, contact Mira Tanna with Community Legal Services of Mid-Florida at (407) 841-7777, ext. 2118.

Free Webinar from the National Council on Aging – Did you ever wonder how to get the answer to a tricky question about a benefit like LIS, SNAP or Medicaid? Want ways to find out for yourself before you call an "expert" to help you? It's not that hard — you just need to know where and how to look. The National Center for Benefits Outreach and Enrollment's webinar on April 23 at 2:00 p.m. EST will offer the tools you need to get your questions answered and to frame your discussions with governmental agencies and other experts. It will help you learn how to dig into the law, the regulations, and official governmental policy guidance. Special note: As part of this training, we'll practice by walking through some actual examples of using authorities and other resources to get benefit answers. For more information and to register please click here.

The Facts on FHA's Financial Health (Written by: FHA Acting Commissioner Carol Galante) – The health of the FHA and management of its business have been frequent topics of discussion in the media and among our stakeholders in recent months. Certainly, these are important issues – to the ongoing recovery of our economy, to the future of our housing finance system, and to American taxpayers. We welcome a robust and healthy discussion of ways to further strengthen FHA, but such an exchange is only possible when it is based upon accurate information. Today, we have posted Myths and Facts Regarding the FHA Single-Family Loan Guarantee Portfolio to address a range of questions and concerns regarding the FHA and the methods used to evaluate its health.

But any discussion of FHA’s Mutual Mortgage Insurance Fund (MMIF) must start at the beginning: the health of the fund and state of the market in late 2008 to early 2009. Immediately prior to the Obama Administration taking office, FHA’s portfolio was beginning to experience significant stress as a result of economic conditions and a large volume of loans supported by seller-funded downpayments. When home prices fell and the recession deepened, these books began to default and claim at record rates. This Administration acted quickly and aggressively to avoid repeating those mistakes and to mitigate their effect on the fund, while still ensuring that FHA performs its mission of providing access to the housing market, particularly for underserved communities.

We have taken more steps since January 2009 to eliminate unnecessary credit risk and assure strong premium revenue flows than any Administration in FHA history, and those efforts continue.

To stabilize the MMIF and contribute to FHA’s ability to remain a strong and viable financing option for all credit worthy borrowers, we have instituted a series of premium increases for FHA products, including the recently announced changes to the annual and upfront premiums expected to add more than $1 billion in additional receipts for FHA beyond those anticipated in the President’s budget.

We have significantly increased oversight of lenders and enforcement of FHA requirements. With the landmark servicing settlement with the nation’s largest mortgage servicers and additional origination settlements with individual lenders and, FHA’s MMI Fund will be compensated over $900 million for losses resulting from violations of FHA requirements by servicers and originators of FHA-insured loans.

We will continue aggressive enforcement of our lender requirements to protect the Fund and American taxpayers from bad actors. But we will also clarify the rules of the road for FHA lending, as we have done through our recently published rule which outlines the process for requiring indemnification by participants in our Lender Insurance program for improperly originated loans and giving us a solid foundation for requiring repayment by lenders when those guidelines are violated.

To further decrease risk to the fund, we strengthened borrower qualification requirements to require higher downpayments for borrowers with low credit scores to ensure that FHA-insured mortgage financing is offered to individuals who can meet their mortgage obligations and truly experience the benefits of sustainable homeownership. In addition, HUD is now seeking to reduce allowable seller concessions in order to protect FHA and borrowers from the impacts of inflated appraisals.

We know that lowering costs for responsible FHA borrowers decreases their risk of default — and ultimately reduces risk to the fund. Reduced upfront and annual premiums in FHA’s Streamline Refinance program will help more FHA borrowers to take advantage of low interest rates. Moreover, by eliminating those loans from the method FHA uses to compare the relative performance of approved lenders, we have removed an important barrier to lender uptake. And finally, to better serve borrowers facing difficulties in meeting their mortgage obligations, we have made changes to our already robust mandatory loss mitigation requirements to provide additional opportunities for borrowers to remain in their homes.

This Administration has acted aggressively to strengthen and protect the mortgage insurance fund and put FHA on a sustainable path for the long term. Multiple independent analyses show that we are moving in the right direction and that the outlook for FHA and the fund is much better than it was in 2009. There are still significant risks remaining — particularly if house prices continue to decline or underlying economic conditions worsen. And in determining the most appropriate actions for FHA we will continue to balance protection of the fund with the need to ensure the continued recovery of a fragile economy.

But it is clear that FHA programs remain vital to ensuring more Americans have the opportunity to realize or maintain the economic security of the middle class. And the work this Administration has done has established a strong foundation upon which we will construct an economy built to last.

For Anyone Still Using Annual Adjustment Factors (AAFs): New Rates Now Out – HUD released the linked notice in the Federal Register, effective April 13, 2012. It is the Notice of Fiscal Year 2012 AAFs for anyone who may still be using them. Please click here to read the notice.

LeadingAge Florida Assisted Living News

Clarification on AHCA Form 1823 Section 3 – Last week at AHCA’s Joint Training, a question was asked whether an ALF provider can use their own source of information to replace or attach information about a resident to Section 3 of AHCA Form 1823 Resident Health Assessment. It was confirmed that existing ALF information, such as a service plan or other existing documentation, can be attached instead of rewriting the same information on the 1823.

LeadingAge Florida Nursing Home News

Celexa (citalopram hydrobromide) - Drug Safety Communication: Revised Recommendations, Potential Risk of Abnormal Heart Rhythms – The FDA is clarifying dosing and warning recommendations for the antidepressant Celexa (citalopram hydrobromide; also available in generic form). In August 2011, the FDA issued a Drug Safety Communication (DSC) stating that citalopram should no longer be used at doses greater than 40 mg per day because it could cause potentially dangerous abnormalities in the electrical activity of the heart. Citalopram use at any dose is discouraged in patients with certain conditions because of the risk of QT prolongation, but because it may be important for some of those patients to use citalopram, the drug label has been changed to describe the particular caution that needs to be taken when citalopram is used in such patients. The revised drug label also describes lower doses that should be used in patients over 60 years of age.


  • Citalopram is not recommended for use at doses greater than 40 mg per day because such doses cause too large an effect on the QT interval and confer no additional benefit.
  • Citalopram is not recommended for use in patients with congenital long QT syndrome, bradycardia, hypokalemia, or hypomagnesemia, recent acute myocardial infarction, or uncompensated heart failure.
  • Citalopram use is also not recommended in patients who are taking other drugs that prolong the QT interval.
  • The maximum recommended dose of citalopram is 20 mg per day for patients with hepatic impairment, patients who are older than 60 years of age, patients who are CYP 2C19 poor metabolizers, or patients who are taking concomitant cimetidine (Tagamet) or another CYP2C19 inhibitor, because these factors lead to increased blood levels of citalopram, increasing the risk of QT interval prolongation and Torsade de Pointes.

See the FDA Drug Safety Communication for additional recommendations for healthcare professionals and patients.

Healthcare professionals and patients are encouraged to report adverse events or side effects related to the use of these products to the FDA's MedWatch Safety Information and Adverse Event Reporting Program.
Complete and submit the report online. Download form or call 1-800-332-1088 to request a reporting form, then complete and return to the address on the pre-addressed form, or submit by fax to 1-800-FDA-0178.

Read theMedWatch safety alert, including a link to the FDA Drug Safety Communication.

AHCA Prepares for Hurricane Preparedness and Emergency Status System (ESS) Information Update – In preparation for hurricane season, remember it is important to make as many preparations as possible before a storm hits. Last week, the Agency for Health Care Administration (AHCA) sent a pre-season 2012 Hurricane letter to all health care licensees, reminding them to take time to ensure their facility is prepared for potential emergencies and disasters. The AHCA also asked all providers to update the Emergency Status System (ESS) by Wednesday, April 18, 2012.

If you have not enrolled in ESS, please do so immediately as part of your emergency preparedness. If you have previously enrolled, please take time now to verify your information. To register, please go to:

The hurricane letter is now found on the AHCA website.

It is very important to make as many preparations as possible before a storm.

  • Vendors – Contact all vendors to assure they will follow through on agreements for transportation, fuel, water, and other supplies. Consider arrangements with multiple vendors for back-up purposes.
  • Generators – Verify that your generator is in good working order. Run a load test on the generator. Identify that key parts of the generator (e.g., water pump or fuel pump, relay switch) are available.
  • Testing Emergency Generators – Hospitals and most nursing homes are required by state law to have emergency generators. Other types of providers may also have a generator. If your facility has a generator, please perform the monthly exercising of generators, under load, as required by Article 6.4 of National Fire Prevention Association (NFPA) 110, 1999 Edition, "Standard for Emergency and Standby Power Systems”.
  • Fuel – Make sure all fuel tanks are full. Make arrangements for refueling as needed for up to seven days. Have both a local and an out-of-state contract for refueling backup. Include guidance on how much fuel will be needed for the requisite size of generator and the facility size.
  • Special Needs – If you have patients/residents on dialysis, ensure they are dialyzed at their assigned centers within 24 hours of a hurricane warning. Make sure you have an emergency contact number for each dialysis center. Dialysis patients should be placed on their disaster diets and provided with a list of all dialysis facilities in the state, as well as their treatment sheets. After the storm, contact the dialysis center and see if it is operational. If it is not, call the emergency contact for the facility. If these contacts fail, call Network 7 at 1-800-826-3773. Do not assume that the local hospital can handle dialysis unless prior arrangements were made before the storm. If your patients/residents have special needs, know and be able to pass those needs and necessary supplies to the receiving facilities. Your arrangements should include sufficient staff to attend to the patients/residents at the receiving facilities.
  • Water systems – Water is often polluted and/or unreliable after a storm. If you need bottled water or large tanks of water, get them now. Assume the need for a seven-day supply.
  • Food – Have sufficient food on hand for a seven-day period for both residents and staff, with arrangements to replenish.
  • Batteries – Pre-stock batteries for necessary equipment including smoke alarms, hearing aids, IV pumps, portable phones, vital sign equipment, and electrical tapes.
  • Vehicles – Make sure all facility vehicles are in good working order, fueled, and ready to transport when needed. Obtain any needed specialty licenses (e.g. bus driver) in advance.
  • Oxygen – For patients/residents with oxygen needs, have sufficient oxygen supply for up to seven days with arrangements to replenish. Plan ahead for those with chronic pulmonary conditions.
  • Evacuation – Contact evacuation receiving facilities and transportation vendors to make certain your plan is still viable. Check with the receiving facility before a storm to ensure there is compatibility of wander guard or secure care systems. Consider a secondary evacuation plan in case your initial planned area is affected and a secondary location must be considered. Discuss who will be responsible for food, medications, supplies, etc., before a storm requires an evacuation. CONTACT THE AGENCY IF EVACUATING.
  • Loss of Power – Assure an appropriate plan for loss of power before, during, and after a storm, taking into account temperature levels and access to necessary supplies, services and staffing.
  • Review Emergency Management Plans – Check your current emergency management plans to assure they are up-to-date. Consider lessons learned from drills and previous experiences. Ensure staff are aware of the content of the plan and at a minimum, know where residents will be evacuated, how they will get there (transportation), and important contact numbers.

If residents were evacuated in response to an emergency and the facility is damaged, contact must be made with the Agency prior to returning residents to the facility. Hospitals, nursing homes, ambulatory surgery centers, and intermediate care facilities for the developmentally disabled require the Agency’s approval prior to occupying the building. Assisted living facilities and adult family care homes require approval from the local fire authority if damages required substantial renovations.

In an emergency, your first contact should be your local county emergency management agency. However, if you are unable to get through to your local office, the following numbers are operational during emergencies:

  • Florida Emergency Information Line at (800) 342-3557
  • Emergency Support Function-8 at (850) 410-1822 or (800) 320-0519 (request ESF-8)
  • You may also obtain updates of information at the Florida Division of Emergency Management website at, or by calling the Agency’s Emergency Information Message Line for Health Care Providers at (888) 774-7609.

If you are evacuating your facility in response to an emergency or if you have questions, contact the Long Term Care Unit at (850) 412-4303.

CMS Draft LTC S and C Letter: Abuse, Neglect, Misappropriation of Property [F223-F226] Response Requested by Thursday, May 3 – Below for your review and/or distribution is the Centers for Medicare and Medicaid Services (CMS) draft LTC Facility Guidance to Surveyors for 42 C.F.R. §483.13(b) and (c) F223-F226 – Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property. The intent of this memo is to clarify “…issues and previous questions posed to Central Office related to the Federal requirements for abuse, neglect, mistreatment, and misappropriation of resident property for nursing homes.”

Please note that CMS is affording only a very brief period for review and comment, with a response deadline of May 8, 2012. We apologize for the short turn-around time, however as always, your input on this issue is considered both critical and invaluable. Please respond to with any recommendations for change and/or amendment ASAP, but no later than Thursday, May 3.


Facility Responsibility

  • “Even if a facility provides evidence that ‘it did everything to prevent abuse or neglect,’ the regulatory language means a facility is responsible for the actions of employees, contractors, and volunteers who are under facility management…”

I. Abuse – F223.
Definition of abuse found at §488.301: “Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.” Actions considered willful include, but are not limited to, physical abuse; verbal abuse/Mental abuse; sexual abuse; involuntary seclusion. “The failure of a witness or resident to report an allegation of abuse, neglect, mistreatment, or misappropriation of property does not refute that it has occurred. [e.g.,] if a nurse aide witnesses an act of abuse but fails to report the incident, the failure to report does not support a conclusion that the abuse did not occur. If a resident is abused…, the resident’s inability to provide information about the incident is immaterial when the abuse is substantiated by other supporting evidence.”

Surveyors are instructed to use information from a variety of sources to substantiate abuse, i.e., interviews; observation; record review.

  • Reiterates Appendix P, Task 6 – Section E. - Information Analysis for Deficiency Determination: “…If additional sources of information are not available, determine if the interviewees are reliable sources of information and if the information received is accurate. If so, citation of a deficiency may be based on resident information alone.”
    • “…Surveyors should recognize that some situations of abuse do not result in an observable physical injury or psychosocial outcome. A physical mark on a resident’s body is not needed to conclude that abuse has occurred.”
    • “The ‘reasonable person’ concept should be applied in cases where the resident’s reaction to a situation of abuse is markedly incongruent with the level of reaction the reasonable person would have to that situation or when there is no discernible response because of a resident’s mental impairment.”

Staff-to-Resident Abuse

  • “The facility is responsible for the actions of its employees…Contractors and volunteers are held to the same standard as employees.”
  • CMS 2002 memo clarification on defining and citing abuse: “Properly trained staff should be able to respond to resident behavior. CMS does not consider striking a combative resident an appropriate response. ‘Retaliation’ by staff is abuse and should be cited as such and reported to the appropriate law enforcement agency…”
  • “It is not acceptable for an employee to claim his/her action was “reflexive” or a “knee-jerk reaction” and was not intended to cause harm.”
  • In applying the reasonable person concept, “…surveyors should consider that nursing home residents are vulnerable and dependent on staff for the provision of care and services…” “…any occurrence of staff-to-resident abuse will be cited at the level of harm of G or above for noncompliance at F223.”
  • When admitting a resident “…the facility assumes responsibility to adequately assess…and provide interventions or services to meet the resident’s needs... Staff members are expected to be in control of their own behavior and understand how to work with the population.”
  • CMS clarifies this does not imply that every situation between an employee and a resident should be considered abuse, i.e., ‘accidents occur’. [e.g.s of staff/resident accidents not considered abuse: staff member trips and falls into a resident; staff member quickly turns around or backs up into a resident they did not know was there.”
  • “It is the facility’s responsibility to ensure that all staff are trained in appropriately providing a resident’s care.” [§483.152(b); Section 6121 of the ACA clarifies NAT must include dementia management and patient abuse prevention.]

Resident-to-Resident Abuse

  • “An incident involving a resident who willfully inflicts injury upon another resident should be reviewed as a potential situation of abuse under the guidance at F223.”
  • “Willful” means the individual intended the action and he/she knew or should have known the action could cause physical harm, pain, or mental anguish.”
  • “A surveyor should not automatically assume abuse did not occur when a resident is cognitively impaired since he/she may have been capable of committing a willful act.”
  • “In instances when a resident’s willful intent cannot be determined, a resident-to-resident altercation should be reviewed at F323; “The facility must ensure that…Each resident receives adequate supervision and assistance devices to prevent accidents.”

Visitor-to-Resident Abuse

  • 483.13(b): “The facility must ensure the health and safety…and that residents [are] not subjected to abuse by anyone, including…facility staff, other residents, consultants or volunteers, staff of other agencies…, family members or legal guardians, friends, or other individuals.”
  • “The facility should have appropriate policies…including how to ensure the health and safety of each resident with regard to family members or legal guardians, friends, or other individuals.”
  • Per F172, the facility must provide access to visitors/visits subject to “reasonable restrictions”. E.G.s:
  • Protecting the security of all residents, such as locking the at night;
  • Denying or providing limited/supervised access to a visitor found to be abusing, exploiting, or coercing a resident;
  • Denying access to a visitor found committing criminal acts such as theft;
  • Denying access to visitors who are inebriated or disruptive;
  • Changing visits location to assist care giving or protecting privacy…;
  • Changing how the visits are monitored, e.g., use of a log.”

II. Neglect, Mistreatment and Misappropriation of Resident Property – F224

  • §483.13(c) - Staff treatment of residents. “The mere existence of a policy does not meet the requirement at F224; the facility also must implement those policies & procedures…Measures to implement a policy can only be understood as sufficient if these measures are in place, can be readily described by staff, and provide adequate resident protections.”


  • Facility policies and procedures prohibiting neglect should address supervision; monitoring; sufficient and knowledgeable staff; appropriate oversight and support from the administration….” Implementation must ensure the facility:
    • Has an awareness of developing or changing conditions;
    • Paid attention to conditions at an early/preventable stage;
    • Took timely action… ”
  • Clarification re: potential for investigating & citing neglect:
    • Neglect can be the result of failure by an individual staff member, several staff, or failure of facility processes.
    • An act of neglect can be an act of omission or commission. Nothing precludes a surveyor from citing F224 if he/she “…identifies an aggregation of failures to provide goods and services a resident needs to maintain physical or mental health and/or prevent physical or psychosocial harm or pain.”
    • Deficiencies must be cited at the appropriate tag. However, process failures are also to be considered that could lead to a finding of neglect.
    • “Neglect should not be cited in addition to quality of care or quality of life unless the incident(s) of neglect includes a failure either for an individual resident over time or across multiple issues, or for a group of residents for a specific issue(s).”


  • “‘Mistreatment’ refers to actions that cause harm or have the potential to cause harm whether or not harm to the resident was intended.” E.G.s of mistreatment:
  1. Inappropriate management of a resident’s behavior resulting from a caregiver’s inexperience / lack of training;
  2. Taking unauthorized photos of residents…(e.g., cameras, mobile phones) and keeping or distributing them (e.g., social media, text/picture messages);
  3. When intimate relationships have developed between a staff member and a resident …When no intent to harm, it is considered an abuse of power and position & professionally unethical…;
  4. When a resident has given money or belongings to staff as a result of coercion, or because the resident believes it was necessary (e.g., in order to receive good care)…”
  • Clarification re: misappropriation of resident property vs. mistreatment relating to resident property: “Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident’s belongings or money without the resident’s consent. Mistreatment is the inappropriate use of a resident’s property with the resident’s consent obtained through coercion, solicitation, or persuasion.”

Misappropriation of Resident Property

  • Residents’ property includes all possessions, regardless of apparent value to others.”
  • Misappropriation of property includes diversion of medications, e.g., controlled substances, for staff use.
    • E.G.s of related requirements that may be considered: F309 – for evidence and/or potential outcomes such as unrelieved pain; F425 – Pharmacy Services for policies re: safeguarding, access, monitoring, administration, documentation, reconciliation and destruction of controlled drugs; F431 – pharmacy service consultation, drug records, and reconciliation of controlled drugs; F514 – accuracy of medical records for documentation of administration; F520 – QAA for how the committee monitors the provisions of controlled substances.

III. Hiring and Reporting – F225

  • ‘Clarification regarding the relationship between hiring practices and criminal convictions:
    • [F225] “…if…actions by a court of law indicate the individual is unsuited to work in a nursing home, the facility must report that individual to the nurse aide registry (if a nurse aide) or to the State licensing authorities (if licensed staff). Such a determination is not limited to mistreatment, neglect and abuse of residents and misappropriation of property, but to any treatment of residents or others that the facility determines re: the individual should not work in a nursing home…”
    • Deficiencies at F225 when a facility fails to screen a potential employee: “If a facility has not developed or implemented their policies and procedures for screening related to the abuse protocol, noncompliance should be cited at F226… If the facility employed an individual who was found guilty by a court of law of abusing a resident or had a finding entered into the State nurse aide registry, the deficiency [is] issued at F225.”
    • “…Federal regulations do not require the facility to check State or Federal registries/agencies for other than nurse aides, but the facility must conduct required screening.”

Immediate Reporting:

  • CMS recognizes that State reporting requirements vary and can exceed or be more specific than Federal requirements. E.G., some SAs require that all falls be reported. “The SA should continue to manage and investigate these cases under their licensure authority; these cases do not necessarily meet the Federal definition of abuse, neglect or mistreatment.” If these occurrences do meet the [Fed] definition…, the SA must assess whether the requirements for reporting and investigation under (F225) are met...
  • If the facts lead a reasonable person to suspect a violation has occurred, it is unnecessary for an individual to “allege” abuse, neglect, mistreatment or misappropriation of property.
  • CMS previously clarified that “immediately” means as soon as possible, but should not exceed 24 hrs after discovery of the incident…[It has been reported that] “…some providers take 24 hrs to investigate all alleged violations and only report the incident if substantiated. This does not meet the intent of the requirement.”
  • “The intent of F225 is that as soon as the facility is aware of a situation that meets reporting requirements, the administrator, and other officials must be immediately notified in accordance with State law, including the State Survey Agency. “…surveyors determine whether the allegation was reported as soon as possible...Reporting is not expected to take 24 hours.”
  • Some facilities [reportedly] conduct investigations prior to reporting. “While it may be necessary for a facility to make an initial evaluation as to whether or not an incident potentially meets…the reporting criteria, thorough investigation should be completed after reporting the allegation. E.G., upon discovery of an injury, the facility must immediately evaluate whether the injury is an ‘injury of unknown source; if the criteria is met, an immediate report is required; If something is missing, the facility may initially determine if the item was misplaced…
  • An initial evaluation is not necessary for allegations of staff-to-resident abuse; these instances must be reported immediately.”

IV. Policies and Procedures - F226 - Staff Treatment of Residents

  • Failure to develop policies for each of the key components of an abuse prevention program supports a deficiency at F226.
  • A facility’s failure to implement its own policies and procedures may result in a deficiency at F223 or F224 and, if applicable, at F226. Surveyors should not take this to mean a deficiency at F223 or F224 automatically results in a deficiency at F226.
  • While the same findings may support a deficiency at F223 or F224 and, if applicable, F226, surveyors must document how the incident is related to the improper development or implementation of the policies and procedures.
  • If F223 or F224 and F226 are cited, surveyors should not assume that the deficiencies are always cited at the same scope and severity. E.G., a cite at F223 for abuse at an isolated scope may have an associated cite at F226 at widespread, re: if failure to develop and/or implement policies and procedures have the potential to affect all residents.


  • “Because providers of nursing care have frequent, relatively unsupervised access to vulnerable people and their property, the facility should conduct a reasonable and prudent background investigation and reference check before hiring employees.”
  • “Because many of the nursing facility’s services are furnished under arrangement, e.g., with registry, contracted, agency staff, the nursing facility also should require these individuals to be subject to the same scrutiny by their agency…”
  • Nursing homes “…are not required by regulation to perform criminal background checks on all staff; however, CMS has specified that facilities should check all references, and make ‘reasonable efforts’ to uncover criminal backgrounds.”

A Message From AHCA Secretary Liz Dudek – AHCA Secretary Liz Dudek issued the following letter this week:

“We all should be taking an active role in our own health care, and there are many resources available to help us do that. One great tool where consumers can find health care information and compare Florida health care facilities and providers is The website is presented by the Agency for Health Care Administration, the state agency that licenses and regulates health care facilities and manages the Florida Medicaid program.

If you are already familiar with, you will discover the Agency has launched a new, fresh look to the site to enhance the navigation and to make it more visually appealing. For those of you who haven’t yet discovered, I invite you to visit the website today. The following are just a couple of ways can be of use to you and your loved ones:

  • The Facility/ Provider Locator tool allows users to find Florida hospitals, home health agencies, assisted living facilities, nursing homes, and other providers licensed by the Agency. The site includes addresses and driving directions; links to inspection reports, complaint investigations, and quality care comparison tools; and where applicable, bed types, specialty licenses, service area, and special programs.
  • A variety of quality-of-care and pricing-comparison tools on help consumers make informed health care choices.
    • Hospitals and Ambulatory Surgery Centers – Find the number of ambulatory surgery visits and number of hospital stays at Florida facilities as well as a range of charges for 150 medical conditions and procedures. Hospital data also includes the average length of stay and rates for readmission, mortality, and complications/infections.
    • Health Plans – View quality of care measures and the results of a member satisfaction survey, as well as links to additional health insurance information.
    • Florida Nursing Home Guide – Find information on individual nursing homes and their inspection performance.
    • Hospice providers – View the findings of the Family Evaluation of Hospice Care survey that is given to families whose loved ones received hospice care.
    • Prescription Drug Prices – Link to to compare prices of the 150 most commonly used prescription drugs.
  • The Health Encyclopedia and the Symptom Navigator include thousands of articles, illustrations, and videos. Many of the articles link to health care data on procedures performed at Florida hospitals and ambulatory surgery centers.
  • The Medicaid Link is a good place to find answers to many questions and includes links to Web content as well as contact information. Topics include Medicaid eligibility, where to apply, covered services, link to a list of doctors, the Florida Medicaid consumer brochure, and more.
  • If you or a loved one is uninsured or under insured, you may find helpful information from the Medical Help Resources section of the website. It lists programs that provide information, referral, direct medical care, or some help with the cost of medical care and other expenses.

I invite you to visit today. Let me know what you think of the website and if you have questions or comments, there is a contact AHCA link where you can send the Agency a message.”

LeadingAge Florida Education News

Don't Miss Important Infection Prevention Symposiums – Two informational symposiums on infection prevention, each with a different focus; have been planned for your convenience. Join your colleagues Thursday, May 3, from 8:30 a.m. – 4:00 p.m., at the Moosehaven, Inc. Auditorium in Orange Park for the first Infection Prevention Symposium. This symposium will provide the latest information on Clostridium difficile, preventing the spread of infections, and disease control presented by featured experts from Centers for Disease Control, Florida Department of Health, Hospitals and Long-term Care Communities.

The second symposium will take place Tuesday, May 22, from 8:30 a.m. – 4:00 p.m. at Village on the Green in Longwood. This symposium will focus on Carbapenem-Resistant Enterobacteriaceae, preventing the spread of infections and disease control and also will include expert presenters from Centers for Disease Control, Florida Department of Health, Hospitals and Long-term Care Communities.

Both important symposiums are being funded by a grant from the Florida Department of Health and were developed specifically for RNs, LPNs, CNAs, Dietary, Housekeeping, Social Workers and other Front Line Clinical Staff working in Long-term Care. Cost is $20 per symposium, including lunch and breaks. Participants will earn up to six (6) continuing education units. Register on the Events Calendar Page at

CNA Train the Trainer Session Offered on May 9 in Winter Park – Register today for our CNA Train the Trainer educational session on Wednesday, May 9, from 9 a.m. to 3 p.m. in Winter Park. This course, generously written and developed by Westminster Services, Inc., will provide your RNs with the required education and training necessary to teach the CNA course and to prepare your nursing assistant students to challenge and pass the CNA exam. Nursing home administrators, nurses and social workers can earn 5 CEUs. To register or for more information, click here.

Financing and Strategic Positioning Workshop Planned – Financing and strategic positioning training will be offered Thursday, May 24, in Winter Park at The Mayflower Retirement Center, Inc.. The workshop has been designed for CEOs, CFOs, key board members and other community professionals. It will combine timely topics, experienced faculty, and networking opportunities with colleagues interested in the state of senior living and capital markets. LeadingAge Florida is partnering on this training with Ziegler, an industry leader focusing on cutting-edge finance and strategic positioning trends affecting today’s senior living providers. LeadingAge Florida is providing up to six contact hours of credit for nursing home administrators, nurses and social workers. Ziegler is providing up to six CPEs for CPAs. For additional information or to register today, click here.

HR Workshop Offered May 23 – LeadingAge Florida will host an educational HR Workshop on Wednesday, May 23, 8:30 a.m. – 4:30 p.m., in Winter Park at The Mayflower Retirement Community, a LeadingAge Florida member. Titled “Human Resources: The Sustainable Capital for the New Era”, the workshop is appropriate for Human Resource Professionals, CEOs, COOs, CFOs, Administrators, Directors and Managers of Florida nursing homes, assisted living and continuing care retirement communities. The workshop will focus on health care reform and employment law updates, the Fair Labor Standards Act, audits, employee retention, and wellness. Click here for a complete agenda and list of topics. LeadingAge is providing up to 6.5 contact hours of credit for nursing home administrators, nurses and social workers. This program has been submitted to the HR Certification Institute for review for HR professionals.

Please note: the workshop will be the day before the Zeigler/LeadingAge Florida CFO Conference and at the same location. Register online. If you have any questions, please contact Susan Tobin, Director of Education and Events, at (850) 671-3700.

Scholarships Available, Apply by June 15 – The “Scott Boord Career Development Scholarship Program” provides staff from LeadingAge Florida member communities with an opportunity to attend either a LeadingAge Florida or LeadingAge educational event held throughout the year. The scholarship is funded by proceeds from LeadingAge Florida’s Silent Auction, held each year in conjunction with LeadingAge Florida’s Annual Convention & Exposition and LeadingAge Florida’s Affordable Housing, Service Coordinator and Home and Community-Based Workshops. The funds can be used to cover registration fees, travel, and other conference-related expenses. For more information about the scholarship program, please click here. To access the application, please click here. To apply, complete the application and supporting documentation and either mail or fax to LeadingAge Florida.

MDS 3.0 / RUG IV Distance Learning Series – Don’t miss the remaining opportunities to participate in a series of affordable, up-to-date distance learning educational sessions about the process of completing the Minimum Data Set (MDS) 3.0, compliments of LeadingAge Florida, LeadingAge Ohio, and Plante Moran. The next Learning Series is scheduled for Wednesday, April 25. MDS 3.0 has undergone several revisions since its inception Oct. 1, 2010, with more expected April 1, 2012. The MDS drives everything in long-term care (survey, quality indicators/quality measures, data for Nursing Home Compare, reimbursement) and with the new process, accuracy of the MDS will be a challenge for the interdisciplinary team. We will break down the MDS 3.0 section by section, plus we are offering two sessions designed for the senior leadership of your organization. Each live session provides one (1) CEU.

Successful surveys demand accurate MDSs. To provide the best information to consumers, the community must generate accurate MDSs. Rightful reimbursement for Medicare and Medicaid requires an accurate MDS. Each of these 12, 90-minute live webinar sessions is designed to build on one another and fit the current needs of all disciplines involved in the assessment process. Each session will include time for questions and answers. The team can hear and see the same information at the same time via audio format; no travel expenses for the community and continuing education certificates are conveniently accessed via Plante Moran's website. Click here for more information and to register for one or more of the sessions below.

Learning Series Schedule – Please note that each event is scheduled for 1 - 2:30 p.m. EST

  • April 25: Under the Hood–ADLs and Bladder and Bowel (Nursing, Therapy)
  • May 15: Listen–Interviews (Cognition, Mood, Preferences, Pain) (Nursing, Social Services, Activities)
  • May 30: Tune Up: Therapies and Restorative Programs (Nursing, Therapy)
  • June 14: No Dents on the Exterior–Skin (Nursing)
  • June 20: Pit Stop–Nutritional Status and the Associated CAAs (Dietary)
  • June 27: Caution–Falls and Accidents (includes Section B) (Nursing, Activities)
  • July 19: Driving Through the Rest of the Obstacles in the Assessment (Nursing)
  • July 24: The Finish Line–RUG IV and Medicare Skilling (Nursing, Therapy)

Join LeadingAge Florida at our 49th Convention! – Join us at our 49th Annual Convention and Exposition in Orlando Monday, July 23 through Wednesday, July 25, with pre-convention sessions on Sunday, July 22, including Strategic Visioning, Preceptor Training, and Preceptor Refresher. It’s more than an education program – it is an essential ingredient to advancing innovation, quality and mission sustainability. The magic of meeting really comes down to the power of community. The place where members come together and share ideas to make our world a better place to grow old.

This year’s featured keynote speaker is Craig A. Anderson, Sr., who will present the “Five Proven Leadership Tools to WIN in a Reformed Healthcare Environment”. Other topics, highlights and sessions include:

  • Medical Errors
  • Avoiding Landmines: Successfully Navigating the CCRC at Home Model
  • Creating an ACO-Aligned Marketing Strategy
  • Medicaid Managed Care – What To Do Now
  • The Future of Affordable Housing
  • Money Matters: the Cost of Culture Change
  • Reducing Cognitive-Linguistic Decline
  • Nursing’s Role in Combatting the Medicare Payment Reductions
  • Equity CCRC Models
  • Energy Renaissance: the New Energy Paradigm
  • Insuring Compliance with Medication Management and Hospice Care in ALFs
  • 150 exhibits featuring cutting-edge products and services

The Convention and Exposition offers 24 hours of continuing education credit for nursing home administrators, nurses and social workers. For more information or to register today, click here.

Upcoming Events:

  • April 23 – Florida Night Get Together, in conjunction with LeadingAge's PEAK Conference (Washington, DC)
  • April 25 – MDS 3.0/RUG IV Distance Learning Series, next event (see complete schedule above)
  • May 3 – Healthcare Associated Infection Prevention for nursing home front-line staff: Focus to include Clostridium difficile (C-diff) (Jacksonville)
  • May 9 – CNA “Train the Trainer” (Orlando)
  • May 22 – Healthcare Associated Infection Prevention for long-term care including front-line staff: Focus to include Carbapenem resistant Enterobaceriaceae (CRE) (Orlando)
  • May 23 – HR Workshop (Orlando)
  • May 24 – Finance and Strategic Positioning Workshop (Orlando)
  • July 22 – Preceptor Refresher Course (JW Marriott Grande Lakes)
  • July 22 – Preceptor Training Workshop (JW Marriott Grande Lakes)
  • July 22 – Strategic Visioning Workshop (Orlando)
  • July 23-25 – 49th Annual Convention and Exposition (JW Marriott Grande Lakes)
  • Sept. 12-14 – LeadingAge Florida’s Affordable Housing Conference (Jacksonville)
  • October 9 – CNA “Train the Trainer” (Orlando)
  • November 8 – Maintenance Workshop (Orlando)


Value First

Return Your Forms To Receive Nationally Negotiated Pricing Through Value 1st GPO – Don’t forget to sign up to receive first-rate pricing through Value First, an option for our members to purchase a wide array of supplies and services, with no cost to enroll and no obligation to purchase. Members can enroll in Value First and participate in other Group Purchasing Organizations at the same time.

Value First is owned by LeadingAge Florida along with LeadingAge and 24 other state associations, and is partnered with national group purchasing specialist MedAssets. The portfolio of more than 400 vendors includes food distributors, medical supplies, therapy, facility operations, furniture, equipment, technology, and construction services.

LeadingAge Florida-member communities received customized enrollment packets in May 2011, so be sure to sign and return the forms to start receiving national first-rate pricing today! By doing so, LeadingAge Florida will receive credit for your orders, which will help enable us bring you even more member services.

If you have any questions, please visit the Value First website or contact David Steinhardt at LeadingAge Florida at (850) 228-3001 or (850) 671-3700.

Copyright 2012 – Publication of the LeadingAge Florida (formerly FAHSA).

LeadingAge Florida Chair: Brian L. Robare
LeadingAge Florida President/CEO: Janegale Boyd
Managing Editor: Casey Stoutamire

Copyright Information: Copies of the articles and other information in this publication may be noncommercially reproduced for the purpose of educational or scientific advancement. Otherwise, no part of this publication may be reproduced or utilized in any form or by any means, mechanical or electronic, including photocopying, microfilm and recording, or by any information storage and retrieval system, without the written permission of the editor.

Correspondence: Should be addressed to: Editor, 1812 Riggins Road, Tallahassee, FL 32308. For telephone inquiries, call (850) 671-3700. Or email LeadingAge Florida at © 2012 LeadingAge Florida. All rights reserved.

Disclaimer: The information contained in this correspondence is not intended as a substitute for legal advice. Please discuss any information gathered from this or any other LeadingAge Florida publications with your legal counsel in the context of your particular situation before implementing any new policies or procedures.

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