The home care agencies in Vermont are now under a. The Board of Directors of. New Rules Include Agency Designations, Minimum Services
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1 The VAHHA Voice The Newsletter of the Vermont Assembly of Home Health Agencies Vol No. 2 Summer 2007 New Rules Include Agency Designations, Minimum Services The home care agencies in Vermont are now under a new set of state rules. Starting July 1, the agencies must seek agency designation by the Department of Disabilities, Aging and Independent Living, provide a minimum set of services, assure that their board of directors have at least 51 percent consumers of home health services, and seek community input into their business plans. The rules were mandated by legislation passed in 2006 that followed an investigation by the federal Department of Justice concerning possible anti-trust practices by the then 12 nonprofit home care agencies and the Vermont Assembly of Home Health Agencies. The legislation gave the state greater control over the operations of the agencies and convinced the DOJ to drop its investigation. Under the new rules, an agency must obtain a home care designation from the Department of Disabilities, Aging, and The Board of Directors of the Central Vermont Home Health and Hospice has appointed long-time CVHHH staff member Judy Peterson, RN, BSN, as its new President and CEO to replace Eileen Blake who retires July 31, Judy has a 24-year history with CVHHH. She served as the agency s Executive Director from 1983 to In 1983 the Central Vermont Home Health Agency and the Waterbury Public Health Association merged to form CVHHH. Judy moved to the Vice President s role to work part-time as she started and reared her family. Eileen Blake, the director of the Waterbury agency, became the director of the new agency. In addition to serving as the CVHHH Vice President since 1987, Peterson has led the agency s Long Term Care Department, which also manages Health Promotion and Private Duty services. Judy has proven instrumental in Independent Living (DAIL). All 12 agencies were granted a temporary designation for one, two, or three years. Each agency must seek a new designation when its temporary designation expires and then every four years after that. Designated agencies must, at a minimum, provide or arrange for all medically necessary home health and hospice services, including High-Tech and Choices for Care (CFC) Medicaid Waiver Program services, which includes personal care. A home health agency may petition the DAIL Commissioner to cease participation in the CFC program, with 90 days notice, when an agency can demonstrate that losses from the program threaten the continuing operation of the agency, disregarding private donations and municipal and town funds. If an agency s designation is revoked, suspended or not renewed, the agency must inform the public. Judy Peterson New President and CEO of CVHHH New Rules - continued on page 4 serving as a statewide coordinator and liaison to the Vermont Department of Aging and Independent Living (DAIL) on behalf of Vermont s 11 Visiting Nurse Associations. Earlier in her career, Judy served as the Clinical Director of Lamoille Home Health and Hospice, as a Community Health Nurse at the Waterbury Public Health Association, and in the Peace Corps as Head Nurse of a rural health clinic in an impoverished area of Costa Rica. Robert C. Cody II, Chair of the Board of Directors, said: We are fortunate to have someone with Judy s credentials and sense of commitment as the next CEO of CVHHH. She has proven herself more than capable through her dedicated years of service to this agency, enduring the many changes the agency has experienced. Judy has worked well with our retiring CEO, Eileen Blake, during a time of growth and expanding technologies. Vermont is going to continue to experience significant challenges and change in long term care, said Patrick Flood, Deputy Secretary for the Agency of Human Services. We need people with Judy s experience and intimate knowledge of our system to make the right decisions and meet those challenges. Peterson - continued on page 2
2 VAHHA Voice, Summer 2007 VNAs Accept 2007 Vermont Centennial Nonprofit Awards The Visiting Nurse Association of Chittenden and Grand Isle Counties (VNA) and the Visiting Nurse Association and Hospice of Vermont and New Hampshire (VNAH of VT/NH) were recent recipients of the 2007 Vermont Centennial Nonprofit Awards. The VNAs were among five nonprofits being honored for 100 years of continuous service to Vermont s cities and towns. Secretary of State Deborah Markowitz presented commemorative plaques at a ceremony in the Cedar Creek Room at the State House in Montpelier. In her congratulatory remarks to the Centennial awardees, Secretary of State Markowitz added, We believe that it is important to recognize Vermont s oldest nonprofits for their many contributions to the State of Vermont. It takes a tremendous amount of dedication and support to keep a nonprofit active for 100 years or more. We hope that this program will deepen our understanding of how Vermont s nonprofits have enhanced our community life during the last hundred years. Accepting the honor for the VNA, President and CEO Church Hindes said, We are very pleased to be recognized for 100 years of care. For the past century, our founding principles have remained the same - nursing still defines our core culture today. We celebrate the generations of caregivers who preceded us at the VNA and we are committed to secure their promise for the future. Gaye LaCasce, Vice President of Development and Community Relations accepted the award on behalf of the VNAH of VT/NH. Peterson- Continued from page 1 Peterson, who received her nursing degree from the University of Vermont, has done Masters Work in both Statistics and Group Psychology, and received certification in Management Skills for the Non-Profit Organization from the University of Detroit. She has served on the Board of Trustees for the Central Vermont Medical Center, as Chair of its Quality Council, and most recently as Board Chair Elect. She was a presenter at the American Society on Aging National Conference in both 2006 and 2007, and has served as the Vermont Home Health Representative for various statewide focus groups and task forces including the TBI (Traumatic Brain Injury) Advisory Council, Nursing Facilities for the 21st Century, DAIL Planning Group for Housing and Supportive Services, and the Long Term Care Sustainability Study. Peterson has served on numerous Boards including the Vermont State Board of Nursing, the Vermont Professional Standards Review Organization, Project Independence, Cerebral Palsy Association, and the Washington County Drug and Alcohol Council. She previously taught Women s Health at Goddard College and Lamaze Childbirth at Gifford Memorial Hospital. Judy knows home care inside out from clinical issues to human resource concerns, from financial management to state and federal issues, and everything in between, said Peter Cobb, Executive Director of the Vermont Assembly of Home Health Agencies. Tomasz Jankowski, CEO of the VNA Health Systems of Vermont, added Judy s detailed knowledge and understanding of local, state, and national issues affecting the home care industry, coupled with her ability to synthesize, evaluate and communicate even the most complex economic and political realities, makes her uniquely qualified to lead a home care agency. Judy is an excellent candidate to assume the duties of Chief Executive Officer for Central Vermont Home and Hospice, said Daria Mason, CEO of Central Vermont Medical Center. CVHHH has an excellent reputation, was recently acknowledged for being in the top 20% in the nation for quality outcomes, and both patient and physician satisfaction are high. These accomplishments are not an accident, but reflect the excellent leadership Judy has contributed to over the years. Over the past two months, Peterson has worked closely with Blake to assure a smooth leadership transition. CVHHH faces new challenges as the demand for the services we provide for Central Vermonters is expected to increase, said Bob Cody. We are confident Judy is the right person to help meet these challenges and lead us into the future. Judy, a native Vermonter, lives in Barre Town with her husband Ron, son Matthew age 19, daughter Kate age 17, and their Golden Retriever. RN Position Available Please Contact: PACE Vermont, Inc 786 College Parkway Colchester, VT (802) pgratton@pacevermont.org EOE
3 Marilyn Moore Celebrates 50 Years of Nursing In 1957, Dwight Eisenhower was president, Elvis Presley s popularity continued to rise with the song Jailhouse Rock, and Marilyn Moore graduated from nursing school. Fifty years later Eisenhower and Presley are long gone but Marilyn is still putting her skills to work at Central Vermont Home Health and Hospice, where she recently celebrated her 50 years of nursing and 31 years with the home health agency. Marilyn graduated from Central Maine General Hospital School of Nursing (now Central Maine Medical Center) and proudly states: The school continues to be one of the few hospital-based nursing schools left in the country. After graduation, she worked as a nurse at summer camps, served on the staff of hospitals in Bangor and Portland, Maine, and went on to join the nursing staff at Dartmouth hospital in Hanover, New Hampshire. Marilyn moved to Vermont and worked at Heaton Hospital (now Heaton Woods) and Central Vermont Hospital in Berlin prior to being hired at CVHHH as a staff nurse in She was promoted to supervisor of the professional staff. In 2000, Marilyn retired from full-time work at agency. She was Coordinator of CVHHH s Systems and Compliance department. Today, Marilyn works per-diem in S&C, reviewing Medicare and Medicaid requests and evaluating cases. Marilyn has experienced many significant changes in the medical field over the course of her career. High on Terry Tyler, a Dorset resident and volunteer with Dorset Nursing Association (DNA), received the Governor s Award for Outstanding Volunteer Community Service at a ceremony hosted by Governor Jim Douglas at the State House on April 14. The Governor s Service Awards honor individuals, groups, and businesses that best exemplify the spirit of volunteerism and community service in Vermont. Tyler was honored for his lifelong dedication and commitment to DNA. A founding member in 1963, he later served as a member of the Board of Trustees, and as President of the DNA Board for three years. Upon retirement from the Board, Tyler was named an Honorary DNA Trustee, and has continued chairing the Building and Grounds Committee and assisting with vital fundraising initiatives. We are so grateful for the countless hours that Terry has given, and continues to give, to our organization, says DNA representative Karin Hegedus who nominated Tyler for the VAHHA Voice, Summer 2007 that list is increased use of technology. Computers cut down on human interaction, Marilyn notes, but she adds technology offers increased accuracy and efficiency. Of course, another significant change is shorter hospital stays resulting in the increased need for home care services. I do miss the teaching role I once had with nurses, Marilyn says thinking back over her career. I enjoyed that close interaction with staff. However, she acknowledges the important role she continues to play at home health. CVHHH is a great place to work, with warm and caring people. I especially appreciate it at the stage of life I m in now. When asked what she has enjoyed most about her nursing career, Marilyn mentions working with patients. I enjoyed working with one patient at a time, where that person is treated as an individual and you respect where they were coming from, not where you are coming from. Home care is one-on-one in their home and you are involved with the whole family. That relationship is very special. DNA Volunteer Receives Governor s Award for Outstanding Volunteer Community Service award. He always gives 150% to everything he undertakes and can be found with a smile on his face and a humorous story to tell. Dorset Nursing Association, the smallest Visiting Nurse Association in Vermont for many years, serves Dorset, Rupert, Pawlet and surrounding areas. Need Home Care Services? Call HOMECARE
4 VAHHA Voice, Summer 2007 Home Care Rules - Continued from page 1 This notice shall be in the form of a paid legal notice in the local newspaper, published within fifteen (15) days following the suspension or revocation of the designation. A certificate of need (CON) from the Department of Banking, Insurance Securities and Health Care Administration is required. A new CON is needed if more than 50% ownership of the agency is transferred. The DAIL Commissioner may grant a variance from these rules if she determines that strict compliance would impose a substantial hardship on the home health agency; the home health agency would otherwise meet the goal of the statutory provision or the rule; and a variance would not result in decreased service to or protections of the health, safety or welfare of the individuals in their designated service area. Agencies must now prove that they are fiscally sound. If not, and if the agency could cease operations and leave hundreds of Vermonters without home care, the state can appoint a director to help the agency resolve its problems. Each home health agency must develop a local community services plan and revise that plan at least once every four years. The board of directors for each not-for-profit agency must now be representative of the demographic makeup of the area served by the agency or by the health facility governed by the board. A majority of the members of the board shall be composed of individuals who have received or currently are receiving services from the agency. The board president shall survey board members annually and certify to the Commissioner that the composition of the board meets the requirements of this rule. The composition of the board shall be confirmed by the home health agency s annual independent audit. A home health agency also must establish an effective, ongoing, data-driven quality assessment and performance improvement program that reflects the full range of home health agency services, including those services furnished under contract or arrangement. Priorities for performance improvement activities should: (a) Focus on high risk, highvolume, or problem prone areas; (b) Consider the incidence, prevalence, and severity of problems in those areas; (c) Focus on practices that affect patient safety; and (d) Identify trends in tracked errors and adverse patient events. The writing of these rules was a cooperative process between the state, advocates and home care representatives, said Peter Cobb, Executive Director of the Vermont Assembly of Home health Agencies, the trade association that represents the 11 nonprofit home care agencies. It was a long process, nearly two years, from start to finish, but in the end everyone felt that the rules meet the intent of the law. According to Cobb, the VAHHA member agencies are working hard to make sure that they comply with all the new rules. Home Care Rules at a Glance 1. Agency must be designated by the Department of Disabilities, Aging and Independent Living (DAIL) to operate. 2. Agency must have a Certificate of Need. 3. Agency programs must include traditional Medicare/Medicaid, High Tech, and Choices for Care (CFC) services. 4. Agency may petition DAIL to drop CFC but only if financially stressed. 5. Agency can seek financial relief in extraordinary circumstances. 6. All shared agreements between agencies must be approved by the DAIL Commissioner. 7. Agency must have a Quality Improvement Plan. 8. Agency must share information on CFC patients with State Ombudsman Program. 9. Agency must have a Disaster Plan. 10. Board of Directors must be comprised or at least 51% of people who have gotten home care services (family members are included). 11. Agency must have an advisory group comprised of various health care professionals. 12. Agency must have approved policies on complaints and discontinuation of services. 13. Agency must develop a community action plan and provide for community input into the writing of the plan. 14. Agency must be financially sound. 15. Agency must provide adequate staff to meet needs of the people in its service area. 16. Agency must provide results of patient satisfaction surveys and other quality data to DAIL. 4
5 VAHHA Voice, Summer 2007 Medicaid Home Care Rates Match Medicare Per-Visit Rates Starting July 1, 2007, Vermont Medicaid homecare payments matched the Medicare per-visit payments as the 2007 Legislature approved money to raise the state rates to match the federal payments. The key issue for home care this session was increasing Medicaid payments, said Peter Cobb, Executive Director of the Vermont Assembly of Home Health Agencies, the trade association that represents the 11 nonprofit home care agencies. The VAHHA members made a compelling case and convinced lawmakers on both the House and Senate Appropriations committees to increase home health funding to raise the rates to the federal level. We greatly appreciate the willingness by both committees to listen to us, especially at a time when there was little money and great demand. In addition to the increases in Medicaid payments, the payments for the programs funded by the Department of Disabilities, Aging and Independent Living were raised across-the-board, by 3.7%. This is a huge step in the right direction, Cobb said. Unfortunately, however, the job is not finished. According to Cobb, even with the extra money, the agencies should lose about three million dollars providing service to state-funded programs this year. Part of the problem, Cobb said, is the Medicaid tax. Agencies pay over $5 million a year in taxes to the state. We understand the need for the tax and realize that the state badly needs this money, Cobb said. The state earns approximately $1.50 in federal match for every $1 paid by the home care agencies. Hospitals and nursing home are also taxed. The total federal match earned by the state from the taxes paid by the three provider groups exceeds $100 million. The problem is not the tax, it is the bottom line. Agencies continue to lose lots of money serving state programs, losses that cannot continue indefinitely, Cobb added. Cobb said home care representatives recently took their concerns to state official. We re hopeful that the progress made this year will continue and adjustments, either a lower tax or higher rates, will be included in the Fiscal Year 2009 budget. When the taxes paid are subtracted from the payments, home care agencies don t really get Medicare rates but rather the net payments are about 20% less. What we need to do, is get the net payments to match the Medicare rates. Cobb said. DAIL Gets Alzheimer s Grant The Department of Disabilities, Aging and Independent Living (DAIL) has won a grant to develop and implement a one-year project to improve services for individuals with Alzheimer s Disease and Related Disorders (ADRD) and to expand existing services and resources for family caregivers. Expected outcomes include streamlined access to dementia services, reduced caregiver stress resulting from a safer home environment, earlier diagnosis of ADRD, increased safety of residents living in congregate settings and development of a state plan on ADRD. The project will provide: a final report, dementia capable ADRC services, a home safety assessment checklist, and a state plan on ADRD. Expected Outcomes: Increased knowledge and skills about ADRD and family caregiving among ADRC partners as reflected by training evaluations. Addition of information about ADRD to the State database resulting in increased ability of ADRC staff to assist callers and for consumers to access ADRD information themselves. Positive results for referral and assistance services for dementia care provided by ADRC staff as measured by consumer surveys. Positive results for referral and assistance services for family caregiving by staff as measured by consumer surveys. Guidelines for other states developing ADRCs in rural areas and/or serving individuals with ADRD Direct Care Worker Registry Set to Begin The Department of Disability, Aging and Independent Living got $100,000 from the 08 Appropriation bill to set up a registry for direct care workers. DAIL is seeking a contractor to work with a steering committee/advisory group. Merle Edwards-Orr will oversee the project from DAIL. DAIL is drafting an RFP for the project and will convene a committee to review the proposals. 5
6 VAHHA Voice, Summer 2007 Vermont, New Hampshire, and Connecticut Propose Rural Floor The home care associations in Vermont, Connecticut and New Hampshire have joined together to propose adoption of a rural floor policy for Medicare home health payments, similar to the policy that exists for hospitals. Under this policy, home health agency payments would be based on either the wage index for the region or on a rural floor (minimum), whichever is higher. If this policy were approved, the payments to the home care agencies in Chittenden and Franklin counties would be raised to match the payments of the other nine VAHHA member agencies in the state. Background The Medicare wage index is a major component of the Medicare home health rate calculation. The wage index has become more problematic over time due to the unintended consequences of changes in hospital payment policies on other providers, such as home health agencies. The hospital inpatient prospective payment system has features that mitigate the harmful effect of inadequate wage indices. Hospitals can apply to be reclassified to a neighboring region with a higher wage index. They also have a rural floor provision in their rule that states no hospital s index can be below the rural wage index for the state. No such provisions are available to home health agencies. As a result, there is a growing differential between what home health agencies and hospitals receive from Medicare for labor costs putting home health agencies at a significant disadvantage when competing for labor. VAHHA office administrator, Lindy Hatcher, received her Masters of Science in Administration in May 2007 from Saint Michael s College in Colchester, Vermont. She specialized in Nonprofit Management and took courses in Web design, Organizational Behavior, Marketing, and Business Planning and Control. Lindy enjoyed the MSA program. She said, It is a collaborative mix of quality leadership and management skills. We explored teamwork, effective written and oral communication, creative problemsolving, and ethical practices. In addition to working at VAHHA, Hatcher serves as co-chair and founder of the Central Vermont Aging in Place Committee. She is also on the Steering Committee of the Disproportionate Impact on New England In 2004, the Centers for Medicare & Medicaid Services (CMS) made a decision to exclude Critical Access Hospitals from the wage index calculation. This change disadvantaged home care agencies in suburban areas and the Northeast in particular. In 2005, the geographic regions used in applying the wage index were revised, and core based statistical areas (CBSAs) were introduced. The impact of that change has also harmed a number of New England regions. CMS cost analysis of the 2007 final Medicare payment rule for home health showed that payment rates were reduced by 1.2 percent in New England solely due to updating the wage index from one year to the next. This was easily the largest drop in the country and had the effect of wiping out one-third of the market basket update for New England home health agencies. In many counties, the wage index decline exceeded the market basket update. New Hampshire Legislator Proposes Rural Floor New Hampshire Congresswoman Carol Shea-Porter has introduced a bill to address wage index problems facing New Hampshire hospitals and home health providers. The bill, HR 2741, creates a rural floor for the wage index applied to home health reimbursement rates for NH only. If passed, no home health agency in NH would be subject to a wage index any lower than the rural wage index for the state. In addition, the legislation sets the wage index floor for NH hospitals at the 2007 level, protecting hospitals from an anticipated decrease in the rural floor next year. Hatcher Receives Masters from Saint Michael s College Care Management Network of Vermont and a member of the Vermont Elder Resource Group. In June, Lindy was elected Vice President of the Vermont Federation of Business and Professional Women and President of the local Central Vermont chapter Mid-State BPW. She also is an advisor on the Vermont Commission on Women, and enjoys dabbling in lobbying and politics. When asked what s next on her agenda, Hatcher said, I am taking some time off to enjoy the summer and spend some time hanging out with my family. My kids made me promise to wait at least a year or two to start my Ph.D. Lindy has worked for nine years for VAHHA and has, over that period, earned both her Masters degree and a Bachelor s degree. 6
7 The Board of Overseers of the Visiting Nurse Association & Hospice of Vermont and New Hampshire has elected six new members to its Board of Trustees at the agency s annual meeting on June 20, 2007: Diane Crowley is an attorney affiliated with John Hughes in the practice of civil litigation. She has been president of the ILEAD learning institute at Dartmouth College and taught a course on legal issues in healthcare at New England College. Diane also served on the school committee in Lyme, NH. where she resides with her husband, George Hano. Martin Downs has works as a freelance medical journalist and had been an editor at CBSHealthwatch.com. He holds Master s in Public Health (MPH) from Dartmouth College. Martin lives in Meriden, NH with his wife, Zara, and two-year old daughter, Esme. George Hartmann had a long career in business in Providence, RI, before moving to Lyme with his wife, Ann. He is both a flyer and sailor of long standing. He graduated from Dartmouth College and is currently a member of the Upper Valley Men s Chorus. Lucretia (Lu) Martin served as Special Assistant to four Dartmouth presidents from During that time, 7 VAHHA Voice, Summer 2007 New Members on VNAH of VT and NH Board of Trustees Franklin County Home Health Agency has received a silver award from Governor James Douglas for its worksite wellness program. Franklin won the award in the category for companies with employees. Six individuals and 42 employers recently received awards from Douglas and Melissa Johnson, executive director of the President s Council on Physical Fitness and Sports. The awards recognize activities that help promote healthy behavior and prevent disease. The awards for Work Site Wellness honor employers that support staff, access to physical fitness activities, and promote good health on and Four clinicians with the Rutland Area Visiting Nurse Association & Hospice received the national designation of COS-C, Certificate for OASIS Specialist - Clinical. Staff nurses Betty Bishop, RN, Audrey Eary, RN, and Peg Ryan- Heibler, RN and physical therapist Jeannie Cushman, PT, MS achieved the COS-C designation after successfully completing a 100 item, 2½ hour exam. Initiated in October of 2004, over 1,400 home care clinicians from around the country have achieved this status and over 1,800 have taken the exam. she also served as Director of Development and directed Dartmouth s Will to Excel Capital Campaign in the 1990 s. She has also been Dartmouth s Director of Major Gifts. Lu is currently a member of the Overseers of the Montshire Museum, the Corporation of Howe Library, the Corporation of the Dartmouth Hitchcock Medical Center, the Friends of the Hopkins Center and the Hood Museum. She lives in Orford with her husband, Peter. Karen Marks grew up in the Upper Valley and returned here 6 years ago. She lives in Lyme with her husband and three children. She has a BA from Cornell University and a JD from George Washington Law School. Her legal practice has focused on civil rights litigation. She currently works in Admissions at Tuck School, Dartmouth College. Robin G. Taft is an RN currently employed at Dartmouth Hitchcock Medical Center as a staff nurse. She is working on her Master s degree in Organization and Management at Antioch College New England. She lives with her husband in the Rutland, VT area. They have two grown sons. She loves gardening, and her passion is working towards improving elder care in the hospital and nursing facilities. Franklin Wins Silver Award for Promoting Health and Fitness RAVNAH Clinicians Receive OASIS Certification off the job. Each summer the Agency s Employee Health & Wellness Committee presents an agency-wide Summer Activity Challenge, in which participants track time spent on fitness activities to earn cash and prizes. Throughout the year health information is posted on Agency bulletin boards and employee newsletters and staff meetings have featured speakers on wellness topics. An Employee Fitness Fund reimburses employees $100 annually for wellness purchases including bicycle parts, pool passes, nicotine kits, Pilates mats, running shoes, ski passes, exercise DVDs, hiking boots and hockey league memberships. The Outcome Assessment Information Set (OASIS) is a quality measure used in home health agencies across the country to enhance care for patients in the home. It is a key component of Medicare s partnership with the home care industry to foster and monitor improved home health care outcomes and is an integral part of the revised Conditions of Participation for Medicare-certified home health agencies.
8 Vermont Assembly of Home Health Agencies, Inc. 10 Main Street Montpelier, Vermont Address Service Requested Questions? Call Non-Profit US Postage PAID Montpelier, VT Permit No. 71 Member Agencies: Addison County Home Health & Hospice, Bennington Area Home Health Agency, Caledonia Home Health Care and Hospice, Central Vermont Home Health & Hospice, Dorset Nursing Association, Franklin County Home Health, Lamoille Home Health & Hospice, Manchester Health Services, Orleans, Essex VNA & Hospice, Rutland Area VNA & Hospice, Visiting Nurse Alliance of Vermont & New Hampshire, VNA of Chittenden & Grand Isle Counties. Blue Cross/Blue Shield Box 186 Montpelier, Vermont VAHHA Voice Contributors LifePlus 338 Commerce Street Williston, Vermont McKesson One Post Street San Francisco, CA Brad Borbidge, P.A. Five Warren Street Concord, NH Enterprise Fleet Management 3A Enterprise Rd Billerica, MA Keene Medical Products P.O. Box 439 Meriden Road Lebanon, NH Merriam-Graves Medical Products Vermont Locations Bennington, Rutland, St. Johnsbury & Winooski New Hampshire Location Lebanon Northeast Healthcare Quality Foundation 15 Old Rollinsford Rd Suite 302 Dover, NH Picker Business Systems 2096A Silas Deane Highway Suite F, P.O. Box 889 Rocky Hill, CT VALIC 156 Main Street, 2nd Floor Montpelier, Vermont White Oak Systems 8 Research Parkway Wallingford, CT
1998 Following a Summit on the Hill, led by the First Lady, President Clinton, directed the US Department of Labor to announce the availability of Implementation Grants. The Child Care Services Division
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