The Last Contract Therapy Facility Goes In-House

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Submitted by Cory Robertson, Therapy Resource, Pennant-Idaho
Discovery Rehab and Living in rural Salmon, Idaho, is a smaller facility in a mountainous rural setting that has been using contract therapy for years. Staffing is a large challenge and was seemingly a revolving door of therapy clinicians. Early last year, the contract company brought on a new leader. This leader demonstrated excellent drive and CAPLICO culture but without the same support from the contract therapy company that Ensign-affiliated facilities appreciate. Largely because of this leader, the facility ED Steve Lish, with cluster, market and resource assistance, decided to once again bring therapy in-house. Jolene Hugo, COTA/L, TPM, leads the Therapy team at Discovery Rehab and Living and exemplifies CAPLICO while managing the difficulties of a small rural therapy department like an all-star. Here are some of her reflections on the transition:

“May of this year marked our one-year anniversary for transitioning from contract therapy to in-house therapy at Discovery. When discussing the risks versus rewards of transitioning to in-house a year ago, I was intimidated. I felt nervous because I wanted to be able to prove that our therapy department could perform well. However, during and after the transition, I felt the weight of it all lifted by all of the support that being a part of Ensign Services has to offer our Therapy team and building. Being in-house really helped our Therapy department be part of a team and not just Therapy versus Them. I have a great resource and cluster partners that are readily available to work through difficult moments and the daily challenges. I have amazing opportunities to attend meetings that have helped me grow personally and professionally as a leader. Before being part of Discovery Care Center and our Ensign affiliates, , the challenges of the role really felt heavy, but now I have the resources to confront the challenges confidently.”

Therapist Profile: Jeffrey Montesclaros, DOR, Cloverdale Healthcare

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The Red Bike: A Short Story of Redemption from Depression
My story is not about depression but more about resilience. Through our life experience, my wife and I became very resilient and we developed a problem-solver mindset.

Our story started in 2005 as newlyweds. My wife, Raissa, had this idea of migrating to the United States to pursue her adventure of traveling. Prior to that, I already had a stable job working as a team supervisor for a call center, and my wife was already enrolled by her parents to be a doctor. Our parents were not very hopeful that we would make it in Uncle Sam’s land. But my wife and I are stubborn. Needless to say, we won that battle, as we ended up in a very small town in Guymon, Oklahoma, with a population of less than 10,000. I worked multiple jobs, from a meat packing factory QA supervisor, to Walmart department manager, to liquor store attendant, to mowing lawns and doing carpentry work on weekends while my wife worked at a small hospital as a lab medical technologist. Still in our 20s, we bought our first house in 2009 in a bigger city, Tulsa, Oklahoma. Everything was set and planned, from having a stable job to getting reliable cars and having our first home.

Now we were ready to grow our family. And yes, we did. After two miscarriages, we finally had a child named Justin, and he was our bundle of joy in 2012. Sad to say “had” because the only thing that was not according to plan was having a child with a rare genetic disorder who only lived to be 18 months old. Justin was born with peroxisomal biogenesis disorder, which affects multiple systems in the body. Our little Justin suffered from frequent seizures, hypotonia, liver and kidney issues, blindness and many other health issues. He was fed through a G tube and later had a tracheostomy tube to help him breathe.
Through meeting various medical professionals, I then decided to go back to school to become a therapist. As you probably have an idea already, my child would never be able to walk, talk and experience things, let alone go to school, so I always pretended that I was going to school for him, and I promised myself not to fail him. I graduated Cum Laude but he was not there to see it.

My wife and I got so depressed during his passing. We were very devastated, to the point that we lost interest in doing things. Self-care was not there anymore. Our lawn looked like a scene from Jumanji because the grass was so tall. We were growing apart everyday as we continued to grieve the loss of a child.

One day, I came across a video about an Ironman triathlon, and it inspired me so much that I encouraged my wife to do a triathlon as she was gutsier than I. I got her a red aluminum road bike, and my first awkward, encouraging words were “Ride this or I am leaving.” When I look back, I think these were such harsh words, but hey, try dealing with a loss and it will make you say or do things that don’t make sense.

Fast forward to 2015; we moved to Santa Rosa, California, and I found work as a COTA in Cloverdale Healthcare Center. It paved the way for me in becoming the Director of Rehab, and it inspired me to work harder as we also welcomed our baby girl named Juliana, through adoption at around the same time. This is just the first chapter of my story. And as I continue with this journey with the new role I am taking, I will continue to adopt the CAPLICO culture. I will aspire to build more leaders. And I will continue to be the person that both Justin and Juliana will be proud to call their Dad.

Therapy Dream Team Partnership at La Canada Care Center: Leading with Humility and Ambition

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Submitted by Shelby Donahoo, Therapy Resource, Bandera-Tucson
Meet Annie Combs, TPM, and Jesus Salazar, assistant TPM at La Canada Care Center. Annie and Jesus were hired into their respective roles at the same time in November 2021. Wanting to strengthen La Canada leadership for the facility and for Rehab, ED Mike Bostwick made the decision to bring on both of them to support each other as first-time department managers.

They were a team from day one: no ego, just respect for each other, sharing new ideas for the department and responsibilities. While Annie had completed the DORiTO program, Jesus had not, and he started in February 2022. Annie made sure Jesus was applying and doing the DORiTO lessons in real-time at the facility as they occurred. Jesus said this made a world of difference in his learning experience.

The facility was having some issues with Nursing and Rehab communication, impacting group and LTC treatment sessions. Missed visits, low group, productivity, and tension affecting morale were issues. Brainstorming with Annie for his Capstone project, Jesus created a structure for scheduling and communicating individual and group sessions. He involved Nursing in patient goals and group participation. From February to May, productivity, group and concurrent, and most importantly GG outcomes improved tremendously.

Recently, Annie and Jesus took it upon themselves to go out to their Alma Mater, Pima Community College, and market for every single building in Tucson, not just their own. And they had a blast doing it! While learning herself, Annie supported her partner in his success, thereby multiplying leadership growth. By being a humble leader, she showed what true leadership qualities look like.

Moments of Truth

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Submitted by Angie Taylor, COTA/TPM, Shawnee Post Acute Care, Overland Park, KS
Moments of truth come in all shapes and sizes. Sometimes it can be a moment of truth that shines through in our normal day-to-day job duties and roles that we have. As therapists, we are constantly advocating for our residents, but sometimes this advocacy goes above and beyond others. Our PTA Buddy Eblen did that for one of our residents. Kacie came to us initially with a fracture, then developed COVID pneumonia and had a long road to recovery to return back home with her Mom and daughter. Due to all these conditions, Kacie had a slow recovery where, at times, we were not sure if she would rehab home.

Buddy was the voice and champion who kept fighting for Kacie and encouraging her not to give up. He was able to consistently work with her to make the functional progress with stairs and ambulation that she needed to achieve to return home. It is hard to put into words how far she came from dealing with her clinical issues, depression, anxiety and fears. Buddy was the one constant voice of encouragement, drive, motivation, and compassion that she needed to overcome all those issues.

We all need someone to be that voice for us. Buddy was that voice for Kacie, and the result was she was able to rehab to the point of returning home, something she felt early on she would not achieve, in large part due to the relationship between Buddy and Kacie with his insight and dedication to be her champion! We are blessed to have a therapist like Buddy who truly embraces his ability to positively make a difference in people’s lives and has the strength and determination to work through challenges and never give up on others.

Flag Celebration: Meadowview Nursing and Rehabilitation

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Submitted by Dominic DeLaquil, PT CEEAA, Therapy Resource, Idaho & Nevada

Meadowview Nursing and Rehabilitation in Nampa, Idaho recently celebrated winning the facility’s first Flag!

Prior to acquisition in May 2017, Meadowview (formerly Midland Care Center) was struggling. The reputation in the community was poor, culture in the facility was lacking, and Therapy was contract and had a strong “us versus them” mentality. Since then, Meadowview has undergone a complete transformation. The building has been remodeled, and an 18-bed skilled unit was added with a new and improved therapy gym. Therapy moved in-house, the culture throughout the building is one of the best throughout the organization, and Meadowview is now a facility of choice in the community.

In addition, Meadowview has become a leadership development powerhouse. Two of the nurses have gone on to become DONs in cluster facilities, and another nurse has become the ED at a cluster facility!
At the recent Flag ceremony, it was a true celebration. The ED, Melissa Truesdell, thanked the staff for all of their hard work and dedication. The DON, Jeremy Withers, gave a heartfelt speech where he kept coming back to how incredible the staff has been at “loving on the residents” and how that has been the driving factor in Meadowview’s transformation and success. And Tess Hurley, Physical Therapist, asked for a minute with the mic so she could heap praise on their DOR, Kristen Bailey. She thanked Kristen for supporting the therapists in being creative with treatments and growth ideas as well as positively challenging them to always be the best versions of themselves.

It was a touching celebration and even included the ED Melissa trying her hand at ice-sculpting under the tutelage of another ED in the market that is an accomplished ice-sculptor! Congratulations, Meadowview!

Millions Are Likely Suffering from Brain Fog and Other Cognitive Impairments Post COVID-19 Infection

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By Elyse Matson, MA CCC-SLP, SLP Resource/Ensign Services
It is estimated that nearly 100 million people have contracted Covid-19. Long-lasting symptoms occur in nearly one in four people, even when they were not hospitalized. The primary complaints of those with persistent issues are brain fog and cognitive fatigue. That means millions of people are walking around with cognitive issues likely affecting their lives.

In a recent conference from ASHA, Rebecca Boersma, SLP of George Washington University Hospital, described a new outpatient treatment protocol to address these issues. These new patients are primarily female with a mean age of mid-40s. Recovery from these subtle but debilitating deficits does not follow the normal recovery timeline and tends to be remitting and relapsing in nature. Prominent deficits including attention, working memory, word finding, cognitive fatigue and processing speed.

Boersma utilizes assessment and treatment approaches common in the post-concussive population, including motivational interviewing, collaborative goal setting, and a variety of scales and tools to assess patient perception of communication, fatigue and cognition. These include the Modified Fatigue Impact Scale, the LaTrobe Communication Questionnaire, and the Multifactorial Memory Questionnaire.
Treatment focuses on a person-centered approach and utilizes proven treatments such as the meta-cognitive strategy, dynamic coaching and managing fatigue.

In our outpatient programs, we have an opportunity to seek out and help some of those suffering with Long COVID. Is this a program you can implement in your facility? For more information and to obtain the protocol, email Elyse Matson ematson@ensignservices.net.

IDDSI Diet Training Keeps on Giving

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Photo: Kyle Hosman-ST; Karin Martindale-Assistant Dietary; Sarah Lanning-ST

Submitted by Angie Taylor, COTA/TPM, Shawnee Post Acute Care, Overland Park, KS

We usually get to see the beginning stages of new trainings, but it is so important to see that training carry over at the facility level. Shawnee PARC has done an outstanding job of rolling out the IDDSI program and, most importantly, fully collaborating with the Dietary department and Nursing staff to roll out the program completely with ongoing training and reinforcement to ensure accuracy.

It started after our IDDSI diet training from the resources that sparked a full IDT discussion and from collaborating on what strategies would ensure that we roll out a successful program. This included Speech Therapy, Dietary Management, Dietary staff and Nursing staff. The best strategy we determined was establishing a consistent, reliable line of communication. The team decided the easiest and most efficient way was to establish a Tiger Text account that was set up for dietary communication only. We included dietary management/staff and Speech Therapists, and they utilize that platform to request specialty trays to trial, ensure correct diets, communicate specific resident wants/needs, or any pertinent changes.

The IDT then decided to carry over correct diet level for snacks: the Speech Therapist labeled and s/u snack trays in each dining room, clearly labeling the correct diet level and ensuring the appropriate snacks were placed in each bin. This established consistent carryover and facility-wide understanding of the levels. We have enjoyed seeing the collaboration and processes develop, but more importantly, we realized that establishing a partnership and seeing that partnership grow into a strong and sustainable program would have never happened without the training and support the resources provided.

Let’s Talk Long-Term Care Programming: Tips and Tricks for SLPs working with Dementia

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By Nicole King MA, CCC-SLP, Julia Temple Health Care Center, Englewood, CO
Use meal times to your advantage! Not only can you check in on your swallowing patients, but it is a great time to address following directions, sequencing, and attention during simple functional tasks — such as adding cream and sugar to their coffee, hand hygiene, cutting up their food, etc.
It is also a great time to address communication and social interactions. The facility is their home. Tasks that might not be functional for your skilled population are functional and meaningful in LTC and memory care neighborhoods — for example, deciding which snack they want, finding their room, participating in activities, and deciding when and where they will eat.

Partner up with Activities or the Chaplain. They can provide the task, but you can provide the skilled eye, environmental modifications, and dynamic cueing that allows the residents to participate in a meaningful and engaged way. Maybe your restless patient needs to be able to come and go from the area, or certain residents shouldn’t sit near each other. It could be the resident needs parallel involvement that allows them to participate but with less environmental stimuli and/or distractions.

Don’t be afraid to “hang out” in the memory care neighborhood. Using a naturalistic approach allows you to see patterns in behavior, identify triggers of agitation, find other patients to evaluate, and get to know the staff better. I also try to do my documentation there because it provides me with more time to observe and engage.

Take credit for what you are doing! Don’t assume that the intervention or strategy is obvious to everyone. Sometimes the smallest change can make all the difference. At JT, we had a patient who played with her food during meals and it upset nearby residents. After assessing her response to her environment over a few meals and analyzing how she engaged with her surroundings and staff, it hit me. She only played with her food on the days her appetite was low. It was her way of letting us know she was full.

Think outside the box and step out of your comfort zone! Let go of the idea that your therapy should look a certain way. Language and communication opportunities are everywhere. Remember it isn’t always about restoring lost skills/function, but changing the environment or how we interact with them, or creating opportunities for them to succeed based on the skills they still have.

Documentation. We all know documentation is important, but with LTC therapy and skilled maintenance, it is crucial. To an outsider, it might look like you just sat next to a patient during an activity. But what you actually did was “facilitated optimal patient participation during preferred leisure task by incorporating dynamic cueing hierarchy, environmental modifications, errorless learning techniques, and spared skills.” Always document the functions or presentations that you assessed in order to know what to do, and exactly how what you saw guided the interventions you selected. The skill lies in the assessment you performed, and how you acted on that assessment.

Goals. The questions I get asked most frequently are related to setting goals. Here are a few of my favorites:

  • Patient will demonstrate ability to use verbal and nonverbal communication to make decisions related to preferences during care tasks and daily routine with MOD A to facilitate highest level of independence on nursing unit
  • Patient will maintain ability to complete 3-4 conversational exchanges related to direct and observable topics using multisensory stimuli in order to reduce risk of social isolation and decrease in meaningful interactions
  • Patient will maintain current level of cognitive communication function to actively participate (following along with handout, switching between tasks, singing along, etc.) in weekly worship service with MIN-MOD A in order to preserve quality of life and highest level of independence with leisure activities of choice
  • And finally, remember that being able to support ongoing therapy for maintaining function requires evidence that only you can do what needs to be done. Once the patient’s function looks consistent, or what you need to do changes very little from session to session then it’s time to phase yourself out and hand over those activities to others.

Behind the Scenes Superstar: Lori Whitman

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This month, we are pleased to spotlight an amazing resource and friend, Lori Whitman. Lori is our accounts payable resource and provides incredible support to our therapy department.

Lori just celebrated her 9th anniversary with Ensign Services in May and lives our culture to its fullest. You can see her expressions of culture and focuses during simple interactions over e-mail with a nugget typically added to her signature line, which she changes up to recognize the seasons and the holidays, as well.

Lori is a true California native and grew up in Huntington Beach, CA. She is one of three with an older sister and younger brother. She has been living in Aliso Viejo, CA for 29 years, where she enjoys her weekends hiking with girlfriends and exploring new places, spending time with friends and family and an occasional off-roading jeep adventure with her husband! These off-roading adventures have taken them to beautiful places that they may not have seen otherwise and it has sparked an interest in buying an RV to take them to other areas throughout the United States, which they hope to do next year.

Lori has two sons and her younger son, Austin is 27 and getting married to Kayla in October this year up in Lake Arrowhead. Austin is pursuing his Masters of Family Therapy at Cal State Long Beach, which is Lori’s alma mater. Her older son, Ryan, is 36 and lives in Panama City, Florida. Lori’s mom lives in an IL/AL in Huntington Beach and she also spends time helping her mom and enjoying moments together.

When asked about what she loves most about her job, Lori shared that she loves the interactions with her co-workers and all the people she supports at her WA facilities as well as the Service Center departments and field. She then shot some therapy love our way by saying, “My favorite, of course, is the AP support for our Therapy Department. It puts a smile on my face knowing I am helping in some small way by paying invoices for Seminars/Educational materials for our nurses and therapy resources who bring new innovations to our facilities to help the residents.”

For those who attended this year’s Therapy Leadership Experience in April, you may have had the opportunity to interact with Lori a little bit during the Lip Sync contest. Lori was one of our judges and expressed that it warms her heart to see how much fun everyone was having. If you had the chance to meet her, you’ll notice that she is fit and healthy, which she attributes to the hiking on local trails, hiking on the beach, and working out in the gym. She has also finished many 10Ks and a few half-marathons over the years. Lori is such a positive person and expresses gratitude for her many blessings, which surely contributes to her well-being.

We are all truly blessed to have Lori Whitman a part of our lives as our AP resource and our friend. We are so grateful for everything she does for us. Lori makes US better.

Clarifying Skilled Nursing and Therapy

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By Lori O’Hara, CCC-SLP, Skilled Reimbursement Resource
IDRS (Interdisciplinary Documentation and Reimbursement Systems)

From CMS:

  • Skilled nursing/therapy services are those services that are so complex they can only be safely and effectively provided by a nurse or under the supervision of a nurse/therapist.
  • Coverage does not turn on the presence or absence of an individual’s potential for improvement from nursing/therapy care, but rather on the beneficiary’s need for skilled care.
  • A condition that would not ordinarily require skilled nursing/therapy services may nevertheless require them under certain circumstances: the patient’s medical complications require the skills of a registered nurse/therapist to perform a type of service that would otherwise be considered non-skilled; or (b) the needed services are of such complexity that the skills of a nurse/therapist are required to furnish the services.

Frequency:

  • To support a Part A episode, nursing services must be provided (and documented) 7x/week; to support a Part A episode, therapy must provide (and document) services at least 5x/week.
  • Please note: The importance of a particular service to an individual patient, or the frequency with which it must be performed, does not, by itself, make it a skilled service.

Defining Skilled Nursing Services
These nursing services automatically support a Part A episode when provided (and documented). They include but are not limited to:

  • Intravenous or intramuscular injections and intravenous feeding
  • Enteral feeding that comprises at least 26 percent of daily calorie requirements and provides at least 501 milliliters of fluid per day
  • Naso-pharyngeal and tracheotomy aspiration
  • Insertion, sterile irrigation, and replacement of suprapubic catheters
  • Treatment of decubitus ulcers, of a severity rated at Stage 3 or worse, or a widespread skin disorder until/unless the wound is deemed chronic
  • Heat treatments that have been specifically ordered by a physician as part of active treatment and that require observation by skilled nursing personnel to evaluate the patient’s progress adequately

Other interventions are considered skilled nursing in their initial phases but would be considered unskilled once the patient is stable and the regimen well-established:

  • Application of dressings involving prescription medications and aseptic techniques
  • Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing, that are part of active treatment and require the presence of skilled nursing personnel, e.g., the institution and supervision of bowel and bladder training programs
  • Initial phases of a regimen involving administration of medical gasses such as bronchodilator therapy
  • Care of a colostomy during the early post-operative period in the presence of associated complications; the need for skilled nursing care during this period must be justified and documented in the patient’s medical record
  • Initial care-planning and comprehensive assessments

Many other things might be skilled, if the documentation supported that they were complex enough that they required the skills of a licensed nurse:

  • Assessment of medical presentation
  • Observation and monitoring of new or potentially unstable conditions
  • Some skin treatments
  • Some respiratory treatments
  • Implementation of physician’s orders

Other things to consider:

  • There are often state regulations that limit a patient’s ability to keep or self-administer medications. But even so, administration of routine medications is not considered a skilled service by CMS.
  • Wound-vac treatments are administered to heal very complex wounds, but because they are not a daily service. they will never, by themselves, be enough to support a Part A episode.
  • Trachs are intimidating apparatus that are generally present only in vulnerable patients. But the presence of a trach is not enough to sustain a Part A episode (although treatments or suction provided through the trach often are).
  • Likewise, just having a PEG tube is not enough to sustain a Part A episode — the patient must be meeting a minimum caloric/fluid amount as it’s the complexity of administering the feeds and assessing for residuals that requires the skills of a nurse.
  • A service that is ordinarily considered nonskilled could be considered a skilled service in cases in which, because of special medical complications, skilled nursing or skilled rehabilitation personnel are required to perform or supervise it or to observe the patient. The key in these situations is great documentation to capture and clarify the “special medical complications.”

Documentation:
It is expected that the documentation in the patient’s medical record will reflect the need for the skilled services provided. The patient’s medical record is also expected to provide important communication among all members of the care team regarding the development, course, and outcomes of the skilled observations, assessments, treatment, and training performed. Taken as a whole, then, the documentation in the patient’s medical record should illustrate the degree to which the patient is accomplishing the goals as outlined in the care plan. In this way, the documentation will serve to demonstrate why a skilled service is needed.

The patient’s medical record must have documentation as appropriate that captures:

  • The history and physical exam pertinent to the patient’s care, including the response or changes in behavior to previously administered skilled services
  • The skilled services provided
  • The patient’s response to the skilled services provided during the current visit
  • The plan for future care based on the rationale of prior results
  • A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences
  • The complexity of the service to be performed
  • Any other pertinent characteristics of the beneficiary

References:
https://www.hhs.gov/guidance/document/benefit-policy-manual-chapter-8-extended-care-coverage