% 2015 Turnover Rates % CNA 24.30% % LPN 22.80% % January - August RN 65.20%

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3 LHCC Turnover Rate - Nursing Department As the federal Centers for Medicare and Medicaid Services (CMS) works to update the nursing home code, we need to reduce our turnover rate each year for the next three years, a minimum of 15% by mid-year % 2015 Turnover Rates % CNA 24.30% % LPN 22.80% % January - August RN 65.20% 2014 Of the 36 employees who resigned or were terminated, 27 were regular staff and 9 were pool staff. Of the 9 pool staff - 1 was a nurse and 8 were CNAs Of the 27 regular staff - 4 were RNs, 2 were LPNs and 21 were CNAs 11 of the 36 who left our employment were terminated and 25 resigned. Of the 11 who were terminated, 0 were nurses, 9 were regular CNAs and 2 were pool CNAs. Of the 25 who resigned - 5 were regular RN/LPN staff, 2 were pool RN/LPN, 12 were regular CNAs and 6 were pool CNAs. Of the 11 who were terminated - 1 was an inactive casual, 1 for absenteeism, 8 for no-call, no-show and 1 for restrictions to-date Of the 38 employees who resigned or were terminated, 14 are regular staff and 24 were pool staff. Of the 24 pool staff - 10 were RNs, 1 was an LPN and 13 were CNAs Of the 14 regular staff - 2 were RNs, 2 were LPNs and 10 were CNAs 14 of the 38 who left our employment were terminated and 24 resigned. Of the 14 who were terminated, 0 were regular nurses, 3 were pool nurses, 6 were regular CNAs and 5 were pool CNAs Of the 24 that resigned - 4 were regular nurses, 8 were pool nurses, 7 were regular CNAs and 5 were pool CNAs Of the 14 who were terminated - 5 were inactive casual, 2 for absenteeism, 5 for no-call, no-show, 2 for restrictions *** CNAs are often a stepping stone for becoming a nurse - turnover has increased in health care since regulations changed stating nurses must first practice as a CNA befoe becoming a nurse. *** Our employee base increased with the start of the staffing pool to avoid using outside agency staff. Page 3 of 20

4 Lakeland Health Care Center 2016 Budget Request Behavior Health Customer Service Employees (Recruitment/Retention) September, 2015 LHCC Board of Trustees Meeting 1 Page 4 of 20

5 Table of Contents Highlights CIP... 4 Staffing. 5 Today s Employee Annual Employee Recruitment/Retention Plan Annual Employee Recruitment/Retention Plan 10 Federal Nursing Home Code Page 5 of 20

6 LHCC 2016 Budget Request - Highlights LHCC has been following a strategic plan that helps us meet federal regulations for a number of years: Consistent assignments ensure that we are providing care that is centered on the resident. It builds strong relationships between residents and staff, which is central to better care. With an increase in medical acuity, having meals served by certified nursing assistants helps to ensure residents safety. Culture change that recognizes all employees as resident service workers helps to transform the institutional approach of delivery of care into one that is person-directed. The creation of a Resident Relations Program that focuses on customer service. Future objectives include: Fully understanding Wisconsin s alternative payment markets. Developing an INTERACT program that addresses hospital readmissions. Actively participate in Wisconsin s Advancing Excellence Initiative. Developing a Behavior Management Program to improve dementia care and optimize behavioral health in the elderly. Reducing our turnover rate each year for the next three years, a minimum of 15% by midyear, As the federal Centers for Medicare and Medicaid Services (CMS) works to update the nursing home code, our 2016 budget request incorporates changes that will help ensure we are ready. Revenue $ 9,925,031 Expense $13,209, Requested Tax Appropriation $ 3,284, Tax Appropriation $ 3,318,353 Reduction $ 34,288 (1.03%) 3 Page 6 of 20

7 CIP Memory Care A East/West Connector - $345,000 A connector on the 30 bed secured memory care unit will enhance our specialty dementia care services. It will allow independent mobility to our residents. Residents who are pattern based will benefit from free ambulation and eliminate the stress of being redirected. Residents would be free to roam in an area with an outside view. The original building plans included connectors between all east/west units. A connector allows staff to function in a more efficient manner. The team concept can be better utilized, such as during employee break times and shift-to-shift reporting times. Because we have built up our building and equipment reserves, we are able to purchase from existing funds. ¾ Ton Pickup Truck with Snow Plow - $42,000 (Truck = $37,500 and Snow Plow - $4,500) We need to be able to plow during shift change in order to ensure a safe passage way for all employees coming to and from work. The Public Works Department will continue to plow parking lots and roads around the building. They cannot, however, accommodate our need for plowing at the start and end of each shift. We will be selling our current 2005 Colorado pickup truck. (estimate of sale = $3,000) Purchase from existing funds. Electric Stimulation Therapy Equipment - $12,500 Electric stimulation and ultrasound is a rehabilitation and preventive tool for partially immobilized residents. Diathermy is used to reduce pain inflammation and swelling in residents with chronic pain. We will be able to bill Medicare for these services. Based on current population we should realize between $80,000 and $140,000 additional revenues per year. Purchase from existing funds. 4 Page 7 of 20

8 STAFFING Eliminating Part Time Positions We only retain 45% of our part-time nurse aides as compared to 60% of other homes in the state. We know that our.2 FTE positions are frequently vacant. Therefore, we are requesting to eliminate eight of these vacant positions. Our current staffing patterns are such that we have extra staff on some days. It is important that we develop schedules that help meet our needs based on resident census and acuity level rather than intermittently having an extra. Therefore, we are requesting to eliminate two of these overlapping positions that are currently vacant a.5 FTE CNA and.5 RN position. Certified Medication Assistant New Position Last year we asked that, through attrition, we change three CNA positons into CMA positions. We never made these changes, based on inability to devise a plan that would cover both roles with one position. We are asking to create another Certified Medication Assistant position that will work second shift. For quite some time we have been studying the difference between a CMA and an LPN or RN passing medications. Not only do CMAs relieve nurses so that they can better meet the medical needs of residents, they are not interrupted during med passes, therefore tend to make fewer errors. Certified Nursing Assistant Enrichment Facilitator New Position Wisconsin State Statutes require that we staff at a minimum of 2.5 PPD. Without a CNA assigned to serving the meal, we staffed at 4.11 PPD (64.4% higher than required). With a CNA assigned to serving the meal, we staff at 4.70 PPD (88% higher than required). That being said, our challenge is to figure out where staff most needs help. This varies, based on the acuity level on any given day. We are asking to create a House-wide Enrichment Facilitator. Although this person will help with some CNA duties, they will not function as a CNA. They will, however, be required to be CNA certified. Some of the duties this person will be assigned are: Transportation schedule for resident medical appointments Feeding assistance Assisting CNA teams when a resident is exhibiting stressful behaviors Labeling resident clothing ***This is not an inclusive list. 5 Page 8 of 20

9 RN Behavioral Management Specialist New Position Creating a registered nurse position is essential to our newly created Behavior Management Program. We have partnered with the Walworth County Health and Human Services Department to better serve the needs of our dementia care residents while reducing the off label use of antipsychotic and antidepressant medications. We need an RN who will become a dementia care specialist on this team. Without a fully established program we will not be able to maintain our five star rating. Additional duties for this employee include acting as our Infection and Prevention Control Officer (IPCO) and helping new nurses fully understand our documentation and computer systems. Rehab Unit Manager New Position We would like to hire a Registered Nurse as a manager on the rehab unit as well as the back up to our MDS Coordinator. The average daily census on the rehab unit has increased by 4%. This, coupled with the federal government s requirement to regularly audit therapy and nursing home medical records, necessitates our taking action. This employee will be our primary admissions nurse. He/she will fully manage the unit, resident as well as employee issues. This person will work every other weekend, helping us to better accommodate weekend admissions. He/she will lead our efforts in the State of Wisconsin s Advancing Excellence Program. Scheduling Supervisor New Position Care provided by nursing homes has increased significantly in recent years. It is imperative that we start to schedule according to medical acuity levels and census numbers. One of the key components in the federal Centers for Medicare and Medicaid Services (CMS) proposed update to the nursing home code is a competency requirement for determining sufficient nursing and direct care staff based on facility assessment - including physical characteristics of the home, number of residents, acuity, range of diagnoses, and care plan content. Staffing is one of the vital components of a nursing home s ability to provide quality care. CMS is also implementing a plan that requires nursing homes to reduce their own turnover rate. We have struggled with our scheduling department for a number of years. Over the past several years we have tried different approaches to scheduling. Staff continues to be frustrated. Therefore, we are asking to eliminate one of these positions and create a scheduling supervisor position. The Scheduling/Payroll Clerk whose position is being eliminated will fill a vacancy in our Medical Records Department. 6 Page 9 of 20

10 Increase.5 FTE Social Work Position to 1.0 FTE The federal government s Partnership to Improve Dementia Care in Nursing Homes requires that we develop systems that consider residents individuality. Lakeland Health Care Center has developed systems that help us assess each individual resident s needs while monitoring the behavior pattern, intensity and frequency. The object is to learn through trial and error which non-pharmacologic interventions are most effective in lessening a targeted behavior. This type of analysis and care planning requires sufficient staffing. This individual will help educate staff so that they can recognize the signs of unmet needs. Staff needs to understand how to identify the suspect causative factor. They need to be able to track behavior changes over time. This is what true resident centered care is all about. This request was approved in 2015 when a part time social worker resigned. Change One of the LPN Medical Records Position to a Lead Position With the new ICD-10 coding systems and the requirements of the SNF Value Based- Purchasing (VBP) Program we feel that we need a lead in the three person medical records department. SNFs will be judged from two perspectives a facility s overall achievement on reducing readmissions to the hospital and how much the facility s readmission rate has improved. Only 50% - 70% of the total amount pooled from the 2% reduction will be redistributed as incentive payments to SNFs performing in the top 60% of the readmission measure. SNFs whose performance is in the bottom 40% will receive none of these dollars back. We need a lead person who will help ensure we are properly monitoring our systems. Our staffing changes represent a total increase of 1.4 FTEs. With these changes we feel that we are right-sized and able to meet the requirements of the revised Federal Nursing Home Code (see pages 11-12) 7 Page 10 of 20

11 Today s Employee We expect employees to embrace the culture change of resident centered care. As managers we need to embrace culture change regarding things that are important to the younger worker. We need to help employees obtain the right work/life balance Employees want flexibility Younger workers don t respect supervisors who are taking short cuts [hold staff accountable] Employees want to use technology and they want us to do the same Employees want to be recognized for doing a good job - not with trinkets Give an employee who is doing a good job more responsibility (that doesn t translate to more work) Staff of the month is an outdated concept Interview questions should be behavioral based, encouraging the candidate to use their critical thinking skills An add- on money amount is better than a shift premium for working additional weekends. Working towards something that is not automatic has more value. Pay is #4 on the list of what is important to a young employee. Information gathered from a Leading Age Wisconsin Work Shop Forum August, Page 11 of 20

12 2016 Annual Employee Recruitment/Retention Plan - Draft Review our policies closely change outdated dinosaur procedures a. Consider adding things such as if you find your own replacement not incurring overtime costs it does not count as an absence Add the following to the training/testing check off lists for new employees: a. New employees must schedule a meeting with the Director of Nursing within the first 30 days of employment b. New employees must schedule a meeting with the Nursing Home Administrator between days from their start date of employment c. New employees must schedule a meeting with a nurse manager between days from their start date of employment Develop a number of pilot programs: a. Possible Self-Scheduling b. Potential 12 hour shifts c. Weekend Warrior Program open to pool and part time employees Pilot programs involve a limited number of employees. Employees apply to become part of a pilot program. Those who apply must meet certain criteria. As an example: Anyone who has been disciplined for absenteeism within the last six months is ineligible. Educate our schedulers so that they know how to fully use the Kronos Scheduler Require all employees to attend a yearly re-orientation meeting during their anniversary month. These meetings will include unpacking sessions tell us what is wrong, tell us what works, tell us what tools you need to do your job. Participate in the Society for Human Resource Management (SHRM) Employee Job Satisfaction and Engagement Survey Develop a CNA ladder program employee empowerment a. Because of great performance you are invited to participate in the pilot programs b. Because of great performance you may become part of the customer service development team c. We already do this by picking our LHCC Team members based on the answers to our yearly questionnaire sent to employees 9 Page 12 of 20

13 2017 Employee Recruitment/Retention Plan - Draft If the 12 hour shift pilot program is successful, consider expanding the program. Develop CNA coaching positions as part of the 2017 budget process a. A coach in each neighborhood during each shift b. This employee becomes a mentor. c. Employees who have questions or concerns have an immediate source - a peer - to contact. Consider a pick-up premium for part time employees. 10 Page 13 of 20

14 BRIEF ANALYSIS OF SOME OF THE PROPOSED CHANGES TO THE FEDERAL NURSING HOME CODE Incorporates the Affordable Care Act (ACA) provisions on quality assurance Quality Assurance Project Improvement (QAPI) Addresses competencies-based and facility assessment requirements for nursing care staff Revises admission, transfer and discharge rights to apply to all transfers of resident care Requires a baseline care plan for each resident within 48 hours of admission, including instructions needed to provide effective and person-centered care meeting professional standards Requires nurse aide, food and nutrition services and a social worker be added to the Interdisciplinary Team that develops a comprehensive care plan Requires facilities to document the resident s goals for admission and include discharge planning in the care plan must include resident treatment preferences and goals Requires that residents who have not used psychotropic drugs not be given these drugs unless medically necessary; receive gradual dose reductions and behavioral interventions Psychotropic drugs will include any drug that affects brain activities associated with mental processes and behavior PRN (as needed) orders for psychotropic drugs would be limited to 48 hours Requires facilities to employ staff with appropriate competencies to carry out dietary services in accordance with resident assessments and individual care plans Clarifies that quality of care AND quality of life are overarching principles in all care and services Determines minimum requirements for activities director Requires an in-person evaluation by a physician, physician s assistant, nurse practitioner, or clinical nurse specialist before an unscheduled transfer to a hospital Adds a competencies/skill set requirement for determining sufficient nursing and direct care staff based on a facility assessment, including but not limited to: number of residents, acuity, range diagnosis, and care plan content. Focuses on provision of necessary behavioral health care and services to residents in accordance with their comprehensive assessment and plan of care Requires staff to have appropriate competencies to provide behavioral health care and services Adds gerontology bachelor s degree to the minimum social worker educational requirements Requires that the director of food and nutrition services be a certified dietary manager, certified food service manager, or be certified for food service management and safety by a national certifying body or have an associate s degree or higher degree in food service management or hospitality 11 Page 14 of 20

15 Requires menus to reflect religious, cultural and ethnic needs and preferences Requires availability of suitable, nourishing alternative meals and snacks for residents who want to eat at non-traditional times or outside of scheduled meal times Clarifies that facilities may use produce grown in facility gardens Requires designation of an Infection and Prevention Control Officer (IPCO) Requires each facility to have in operation an ethics program Requires additional staff training effective communication, compliance and ethics, and behavioral health 12 Page 15 of 20

16 Lakeland Health Care Center 2015 Net Position for Future Building/Equipment Net position of $1,813,917 is available above the county s policy to maintain a 20% minimum net position balance. Current balances for equipment and building internal allowances of net position in the LHCC fund are: Equipment Allowance $ 292,876 Building Allowance $1,335,492 Walworth County staff recommends the following 2015 additions be made to these internal allowances: Equipment Allowance $ 813,917 Building Allowance $1,000,000 $1,813,917 Net position shall be adjusted to the following balances: Equipment Allowance $1,106,793 Building Allowance $2,335,492 $3,442,285 Page 16 of 20

17 Memorandum Lakeland Health Care Center To: Cc: From: Lakeland Health Care Center Board of Trustees David Bretl, Administrator Dale Wilson, Human Resources Director Bernie Janiszewski, Nursing Home Administrator Date: September 9, 2015 RE: Early Implementation of Personnel Change As part of the 2016 budget we are requesting to eliminate a Scheduling/Payroll Clerk position and create a Scheduling Supervisor position. Care provided by nursing homes has increased significantly in recent years. It is imperative that we start to schedule according to medical acuity levels, range of diagnosis and each resident s individual plan of care. As the Centers for Medicare and Medicaid Services (CMS) revises the Nursing Home Code, we need to implement a plan that helps us to reduce our turn over rate in each of the next three years, a minimum of 15% by mid We need to hire a skillful employee who will be able to fully utilize the Kronos timekeeping and payroll systems in order for us to meet the new federal requirements in long term care. Due to a current opening in our Medical Records Department we are asking for early implementation so that the Scheduling/Payroll Clerk whose position is being eliminated can move into this vacant position. The additional $4,841 needed will be covered by the cost savings of the vacant medical records position County Road NN Elkhorn, WI (Tel) (Fax) Page 17 of 20

18 Worker's Compensation for July Lakeland Health Care Center Walworth County Nursing Home Administrator's Report July, 2015 Injuries 6 Time Lost hrs Claims filed 2 July Overtime $15,267 Resident Stats for July Beginning Census 119 Discharges 9 Admissions 11 Ending Census 119 Deaths 2 Referrals 39 Patient Mix Average for the month of July: Medicaid 59.29% Medicare 12.30% Private Pay 28.41% Average daily census = Medicare Private Pay Medicaid % by pay source Medicare Private Pay Medicaid Please feel free to call or me with any questions or reporting suggestions. Bernie Janiszewski bjanisze@co.walworth.wi.us Page 18 of 20

19 Worker's Compensation for August Lakeland Health Care Center Walworth County Nursing Home Administrator's Report August, 2015 Injuries 7 Time Lost 0 Claims filed 0 August Overtime $12,177 Resident Stats for August Beginning Census 119 Discharges 9 Admissions 12 Ending Census 119 Deaths 3 Referrals 40 Patient Mix Average for the month of August: Medicaid 61.66% Medicare 12.75% Private Pay 25.59% Average daily census = Medicare Private Pay Medicaid % by pay source Medicare Private Pay Medicaid Please feel free to call or me with any questions or reporting suggestions. Bernie Janiszewski bjanisze@co.walworth.wi.us Page 19 of 20

20 Lakeland Health Care Center Upcoming Events September/ October Senior Fair Day Sept 3rd All Day Frank & Bill Sing-A-Long Sept 3rd 2:00p.m. Memory Unit Inspirational Word Art Project Sept 9th and 10th Resident Council Sept 10th 11:00a.m. Frank & Bill Sing-A-Long Sept 10th 2:00p.m. National Patriot Day Sept 11th 2:00p.m. Grandparents Day Celebration Sept 13th All day Packer/Bear Party Sept 13th Noon Music with Bradley Sept 14th 2:00p.m. Goodwill Shopping Sept 16th 10:00a.m. Resident Game Night Sept 16th 7:00p.m. Fundraiser Luncheon Sept 17th 10:30a.m. Frank & Bill Sing-A-Long Sept 17th 2:00p.m. LHCC Resident Alzheimer's Walk w/ Special Events to Follow Sept 18th 1:30p.m. Goodwill Shopping Sept 23rd 10:00a.m. Frank & Bill Sing-A-Long Sept 24th 2:00p.m. UW Whitewater Students Resume Weekly Visits w/ Residents Sept 24th 3:30p.m. Ice Cream Social with Lakeland Church Sept 27th 3:30p.m Frank & Bill Sing-A-Long Oct 1st 2:00p.m. UW Whitewater Activities w/ Residents Oct 1st 3:30p.m. Frank & Bill Sing-A-Long Oct 8th 2:00p.m. UW Whitewater Activities w/ Residents Oct 8th 3:30p.m. Memory Café' Oct 10th 10:00a.m. Fundraiser Luncheon Oct 15th 10:30a.m. Frank & Bill Sing-A-Long Oct 15th 2:00p.m. UW Whitewater Activities w/ Residents Oct 15th 3:30p.m. Great American Beer Festival Happy Hour Oct 16th 1:30p.m. Octoberfest Polka Band Oct 20th 2:00p.m. Game Nite Oct 21st 7:00p.m Frank & Bill Sing-A-Long Oct 22nd 2:00p.m. UW Whitewater Activities w/ Residents Oct 22nd 3:30p.m. Public Trick or Treating at LHCC w/ Residents Oct 31st 2:00 p.m Page 20 of 20