OSHA to Continue Aggressive Enforcement in 2013

  • OIG Report February 2013 - SNF's Often Fail To Meet Care Planning and Discharge Planning Requirements

    Monday April 1, 2013

    The Office of the Inspector General (OIG) released a report February 2013 (OEI-02-09-00201) stating they found, "For 37 percent of stays, SNFs did not develop care plans that met requirements or did not provide services in accordance with care plans. For 31 percent of stays, SNFs did not meet discharge planning requirements. Medicare paid approximately $5.1 billion for stays in which SNFs did not meet these quality-of-care requirements. Additionally, reviewers found examples of poor quality care related to wound care, medication management, and therapy. These findings raise concerns about what Medicare is paying for. They also demonstrate that SNF oversight needs to be strengthened to ensure that SNFs perform appropriate care planning and discharge planning."


    The OIG made the following recommendations; "We recommend that the Centers for Medicare & Medicaid Services (CMS): (1) strengthen the regulations on care planning and discharge planning, (2) provide guidance to SNFs to improve care planning and discharge planning, (3) increase surveyor efforts to identify SNFs that do not meet care planning and discharge planning requirements and to hold these SNFs accountable, (4) link payments to meeting quality-of-care requirements, and (5) follow up on the SNFs that failed to meet care planning and discharge planning requirements or that provided poor quality care. CMS concurred with all five of our recommendations."


    You may read the entire OIG Report by clicking on the link below.

    OIG Report February 2013


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  • Alabama Supreme Court Rules in Arbitration Case

    Monday April 1, 2013

    The Alabama Supreme Court decided on a nursing home arbitration case on 3/22/2013 that has restricted somewhat the enforceability of our arbitration agreements, SSC Montgomery Cedar Crest Operating Company v. Linda Bolding, as attorney in fact and next friend of Norton Means. The decision specifically indicates that in the case of an incompetent resident, arbitration agreements will be enforced only if the person who signs the agreement has been appointed by the resident as durable power of attorney (DPOA) or has some other valid legal authority to act on the resident's behalf other than simply being the next of kin or being appointed as the sponsor.


    What appears to be missing from the decision is whether the resident was competent when the arbitration agreement was signed. Unless a resident has been adjudicated to be incompetent by a probate judge, having a diagnosis of dementia or Alzheimer's diagnosis may not necessarily mean a resident is considered incompetent. If unsure whether the resident may or may not be competent to sign, we would suggest that you have the resident sign along with the power of attorney(POA) or the signature of someone with valid legal authority to act on the resident's behalf such as a guardian, conservator, or health care proxy.


    It available, you may wish to review a copy of one of the three cognitive tests that was or has been given to the resident shortly before or after the resident signed the arbitration agreement. Although not officially guaranteed, the score could give you a clue as to whether the resident has or had the capacity to consent and sign the arbitration agreement on their own behalf.

    • With a SLUMS score of 20-21 or less consistently, the resident probably should not consent or make their own decisions unilaterally. With a score of ≤21, it would be helpful to have the legally authorized representative sign too.

    • With a BIMS score of 10 or less consistently, the resident probably should not consent or make their own decisions unilaterally. With a score of ≤10, it would be helpful to have the legally authorized representative sign too.

    • If the mini mental status score was less than 15, we presumed that they probably could not consent or make their own decisions unilaterally. With a MMSE score of ≤15, it would be helpful to have the authorized representative sign and consent too.


    In conclusion, the Alabama Supreme Court decision does seem to indicate that an arbitration agreement is enforceable against the resident and the resident's estate if it is signed by:


    1.    A competent resident;


    2.    By a family member on behalf of a competent resident; or


    3.    By an attorney in fact under a durable power of attorney.


    The decision does seem to say that an arbitration agreement is not enforceable if it is signed by:


    1.    An incompetent resident; or


    2.    A family member of an incompetent resident that has not been        

           appointed as the holder of the DPOA or appointed as another

           authorized legal representative on behalf of the resident.


    If you would like a copy of the decision or to discuss this case further, please contact Lavonya below:


    Lavonya K. Chapman, Esq., RN.|Director of Claims/Litigation
    Arthur J. Gallagher Risk Management Services, Inc.

    2200 Woodcrest Place, Suite 250

    Birmingham, Alabama 35209

    (:205.414.2649 (direct) | 7:205.414.2632 (fax)

    (:205.542.2771 (mobile)

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  • Mandatory Corporate Compliance is Here: Are you Ready?

    Tuesday April 2, 2013

    Mandatory Corporate Compliance is Here:
    Are you Ready?


    Approved for 1 hour NAB credit
    April 16, 2013
    12:00 - 1:00 Eastern
    Register Today: $79


    Under the Sections 6102 and 6401 of the Affordable Care Act (ACA), Medicare and Medicaid certified nursing homes are required to have in place a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations and in promoting quality care. To date, however, the Centers for Medicare & Medicaid Services (CMS) has yet to promulgate regulations governing the statutory requirement. Regardless, facilities must have a plan in place effective March 23, 2013. Is your facility ready?

    This webinar will:

    • Review the essential structure and elements of an effective nursing home corporate compliance program based on existing guidance and the provisions of the ACA;

    • Offer practical information to create a meaningful corporate compliance program. Provide understanding regarding how CMS guidance necessary to implement the ACA's compliance mandate is likely to impact providers.

     To register for this seminar go to www.care2learn.com

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  • Potential Liability and Regulatory Impact

    Monday April 22, 2013

    Amgen, Inc., a California-based biotechnology company, has agreed to pay the United States $24.9 million to settle allegations that it violated the False Claims Act for marketing Aranesp to treat anemia in nursing home residents.  Aranesp may be indicated in residents who have anemia associated with conditions such as renal failure, dialysis or chemotherapy but not necessarily anemia from other causes.  The government alleged that Amgen distributed materials to consultant pharmacists and nursing home staff encouraging the use of Aranesp for patients who did not have anemia associated with chronic renal failure. 


    Please see the attached release from the U. S. Department of Justice for additional details.

    US Department of Justice - Marketing Aranesp in Nursing Homes


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  • Out of the Penalty Box

    Wednesday April 24, 2013

    Care2Learn has recently posted a White Paper addressing the issue of avoiding unnecessary rehospitalizations. The paper states that roughly 40% of Medicare beneficiaries leaving the hospital are discharged to a post-acute setting, where the risk for rehospitalization begins, and the role of the skilled and assisted living facility and home health agency becomes critical in prevention. Effective October 2012, The Affordable Care Act instituted the Hospital Readmission Program, requiring the Centers for Medicare and Medicaid to reduce payments to hospitals with excessive 30-day readmissions. Read Out of the Penalty Box to learn about what you can do to implement evidence-based care processes and effective training, while partnering across the healthcare continuum to deliver better patient care and reduce unnecessary costs to your organization as well as CMS. Explore CMS' new payment and service delivery models of care that leverage both penalties and incentives for all healthcare providers.


    For more information click on the attachment below or visit their web site at www.care2learn.com

    Out of the Penalty Box

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  • Medicare Audit Improvement Act of 2013 (H.R. 1250)

    Wednesday April 24, 2013

    Medicare Audit Improvement Act of 2013 (H.R. 1250)
    Legislation has been introduced that would make much-needed improvements to the Recovery Audit Contractor (RAC) program and other Medicare audit programs. Representatives Sam Graves (R-MO) and Adam Schiff (D-CA) introduced the Medicare Audit Improvement Act of 2013 (H.R. 1250), which, among other measures, would:

    • Establish a consolidated limit for medical record requests
    • Improve auditor performance by implementing financial penalties and by requiring medical necessity audits to focus on widespread payment errors
    • Improve recovery auditor transparency
    • Assure due process appeals for claims reopenings
    • Allow accurate payment for rebilled claims
    • Require physician review for Medicare denials

    In a separate move, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on March 13, 2013, that would allow hospitals to be paid full Part B (outpatient) payment for inpatient claims denied during a RAC audit, when the care is found to be appropriate at the outpatient level, if the claim is one year old or less. This time limitation is particularly problematic to hospitals considering RACs audit claims for services provided during the previous three years. The Medicare Audit Improvement Act of 2013 (see above) would fix this Part B underpayment policy.

  • Revised Advanced Directives - F Tag 155

    Monday March 18, 2013

    The Centers for Medicare and Medicaid Services have made additional revisions to Surveyor Guidance at F Tag 155 in Appendix PP of the State Operations Manual.The attached document below includes the Memorandum, F155, and the Surveyor Training slides which include Interpretive Guidance and Investigative Protocol.

    Revised F155 attached below.

    Revised Advanced Directives - F Tag 155

  • F322-Gastric Tubes Revised

    Tuesday March 12, 2013

    The Centers For Medicare & Medicaid Services have revised F322 - Naso Gastric Tubes. The memo date March 8, 2013 stated that since the release of S&C 12-46-NH, CMS conducted further review of the interpretive guidelines for F tag 322 in Appendix PP of the SOM. Based on the additional internal and external stakeholder feedback the guidance and related training materials have been revised to provide additional clarification when determining compliance.


    The memo, revised F322, and training material are attached below.

     F322 Naso-Gastric Tubes Revised


    Tuesday March 19, 2013

    Recently at St. Peter's Hospital in Albany, U.S. Senator Charles E. Schumer joined Capital Region senior citizens and hospital executives to push his plan to change the Medicare law, so that elderly patients are not charged unfairly for receiving needed nursing home care after being hospitalized. Schumer noted that "observation" stay cases in hospitals, when the elderly individual is not technically an inpatient, have been on the rise in recent years, costing America's seniors thousands of dollars in medical bills. Currently, Medicare will only cover post-acute care in a skilled nursing home facility if a beneficiary has three consecutive days of hospitalization as an inpatient. Under Schumer's plan, the Improving Access to Medicare Coverage Act, "observation" stays will be counted toward the 3-day mandatory inpatient stay for Medicare to cover rehabilitation post-hospital visit.

     For example, Mr. Ike Cassuto recently broke his pelvis and spent four days at St. Peter's Hospital. In accordance with current law, St. Peter's listed him under "observation status" because no operation or procedure was performed. The consequence of this meant that Medicare will not pay for his 3-weeks in rehab that followed his hospital stay. Schumer emphasized it is the flawed Medicare law which is costing Capital Region seniors thousands of dollars.

     "In recent years, there's been a huge uptick in elderly patients under 'observation status' at Capital Region hospitals - and it's leaving seniors high and dry and hospitals no better off. A flawed Medicare law is to blame, and I have a plan to change that, so hundreds of thousands of seniors, like Mr. Cassuto, are not hit with huge rehabilitation bills after a lengthy hospital visit. This new Improving Access to Medicare Coverage Act  would allow senior citizens to count time spent under this 'observation status' towards Medicare-covered rehabilitation. If you are holed up in a hospital bed for days on end, it shouldn't matter what your billing status is, and this plan will save Capital Region seniors thousands."

     Schumer was joined by James K. Reed, President & CEO of St. Peter's Heath Partners; Mr.& Mrs. Ike Cassuto; James Barba, CEO of Albany Medical Center; Gail Myers of Statewide Senior Action and representatives from AARP. Schumer highlighted Mr. Cassuto's recent case, and explained that this is one example of hundreds of thousands. The number of observation cases has been on the rise in recent years, a consequence of policies meant to reduce Medicare expenditures. According to the Albany Times Union, St. Peter's Hospital, serving the Albany community since 1930, has reported that observation cases have nearly doubled in the past three years, with 2,560 cases in 2009 and 5,000 in 2012. This can lead to massive bills - in the tens of thousands of dollars - that senior citizens must pay for rehabilitation and nursing home care post-hospital visit.

     Schumer vowed to fight for the bipartisan Improving Access to Medicare Coverage Act  to address the flawed Medicare law. Currently, Medicare will only cover post-acute care in a skilled nursing facility if a patient has three consecutive days of hospitalization as an inpatient, not counting the day of discharge. Because of the uptick in observation cases, patients are enduring lengthier hospital stays in observation status and may unknowingly be treated under outpatient observation status for the entirety of their hospital visit. Under Schumer's legislation, observation stays will be counted toward the 3-day mandatory inpatient stay for Medicare coverage of skilled nursing facility services after a hospital visit. The Improving Access to Medicare Coverage Act of 2013 would amend title XVIII of the Social Security Act. Without being involved in billing technicalities between the hospitals and Medicare, Schumer's plan would ensure that patients 65 and older are eligible for coverage for their rehabilitation services, as long as they are in the hospital for three days.

    "Observation stays" are specific, clinically appropriate services that treat and assess a patient in a hospital while a decision is being made as to whether patients will require further treatment as hospital inpatients, or if they are able to be discharged from the hospital. Hospitals, like St. Peter's, are following a flawed Medicare law in their treatment of many patients above 65 years old. In fact, Schumer noted, that hospitals are reimbursed less from Medicare for the treatment of patients under "observation" status than those that are inpatient. Hospitals also devote a significant amount of time and money to assuring that patients are properly classified as inpatients or outpatients.

    Isadore "Ike" Cassuto's case is among the hundreds of thousands of elderly Americans who have been placed under "observation" status during a hospital stay, and who now face medical bills that Medicare refuses to cover for rehabilitation services. Mr. Cassuto came to St. Peter's Hospital after breaking his pelvis and was a patient for four days, but the hospital had him under observation without admitting him as an inpatient. Mr. Cassuto then underwent three weeks of rehabilitation, which was not covered under his Medicare plan, leaving him with $6,000 in medical bills.

    "We thank Senator Schumer for his leadership on legislation that will promote fairness for Medicare patients who need rehabilitation following a hospitalization. Because of the uptick in the number of Medicare observation status billing codes throughout our state, NY StateWide Senior Action Council has developed a Patients' Rights Toolkit, available at  1-800-333-4374.  We encourage Medicare patients to ask about their status so that they can make informed decisions regarding their discharge plan, and uphold their rights to care through the appeals process when needed. Patients should not be forced to pay out of pocket for otherwise covered Medicare services due to institutional billing issues," said Gail Myers of the NY StateWide Senior Action Council.


    Schumer's New Plan Would Change Three-Day Requirement & Allow Time Spent In 'Observation' To Count Toward Medicare-Covered Rehabilitation - Saving Seniors Huge Costs

    Schumer Highlighted That 'Observation' Stay Cases Are Skyrocketing In Hospitals Across the Capital Region And Country, As Hospitals Comply With Flawed Medicare Law

    Schumer Will Join Ike Cassuto Who Was Put Under 'Observation Status' At the Hospital- For Days-After Breaking His Pelvis, Meaning Medicare Won't Cover Nursing Home Recovery Care, Which Can Cost Thousands


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  • The Importance of Marmet v Brown to Nursing Home Malpractice and Wrongful Death cases

    Tuesday March 19, 2013

    The U.S. Supreme Court case of Marmet Health Care Center v. Brown, decided on Feb 21, 2012, shows the advantage of a properly written and signed arbitration agreement in order to keep claims out of court where jurors decide and instead allow an arbitrator to decide the outcome.

    Before Marmet, several states completely prohibited nursing homes from compelling residents to give up their right to a jury trial and declared all arbitration agreement in nursing home admission contracts to be unconscionable.

    After Marmet Health Care Center v. Brown, nursing home owners and operators can have confidence that properly drafted and executed arbitration agreements will keep inevitable claims away from jurors.

    Litigating claims in court can lead to unexpectedly high awards. Arbitration of claims is generally seen as offering significantly less potential for runaway jury awards by eliminating the emotions that fuel them. More predictable losses should result in lower overall claim payments, safeguarding funds that are better spent caring for residents. For these reasons, many long-term-care facilities have sought to use arbitration agreements when contracting with their residents upon admission. Plaintiffs often seek grounds to avoid the enforcement of arbitration agreements, in order obtain for themselves the potential of a much larger jury award.

    The U.S. Supreme Court noted that in Marmet, arbitration agreements signed predispute, were enforceable and not void as a matter of public policy.  That Court went on to say "Congress did intend for the federal arbitration act (FAA) to take precedent over state law.

    Properly drafted and executed arbitration agreements between facilities and their residents are generally enforceable. The impact that arbitration has on dispute resolution is so important that we expect to see it used routinely. Of course, care must be taken to avoid unenforceability, as is the case with any contract.

    The most significant of these are a lack of mental capacity to consent, fraudulent inducement to sign, duress and unconscionability. Long term care facilities who choose not to utilized arbitration agreements will be well-advised to reconsider.

    Arbitration agreements will go a long way toward reducing inappropriate and huge jury awards, allowing for better provision of care for nursing home residents.

    For information on the provisions needed in arbitration agreements to increase the likelihood of being enforced or how the train your facility in getting them signed by the appropriate person(s), please contact:

    Lavonya K. Chapman, Esq., RN.|Director of Claims/Litigation
    Arthur J. Gallagher Risk Management Services, Inc.

    2200 Woodcrest Place, Suite 250

    Birmingham, Alabama 35209





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  • OSHA to Continue Aggressive Enforcement in 2013

    Wednesday March 20, 2013

    Occupational safety and health concerns are not limited to the construction and general industries anymore. Over the past four years, OSHA has become increasingly aggressive in its enforcement practices in every employment sector, rejecting collaborative efforts with employers, such as partnerships, to enhance workplace safety in favor of enforcement with higher citation classifications and enhanced penalties. With the reelection of President Obama and the understanding that Dr. David Michaels, Assistant Secretary of Labor, will remain the head of the OSHA for another four years, employers across the board can expect the agency to continue its aggressive enforcement tactics in 2013 and beyond.

    To read more about OSHA enforcement, click on the link below.

    OSHA Goodbye Carrot Hello Stick

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  • Court Lowers “Burden” of Proof for OSHA Citations

    Thursday March 21, 2013

    The U.S. Court of Appeals for the 10th Circuit rendered an opinion that not only altered the agency's burden of proof for OSHA citations but effectively reduced that burden to little more than a semantic impediment. The Court declared that OSHA, or the Secretary of Labor need not establish the elements of the long established four-part Atlantic Battery test to prove a violation but instead must only prove that a "reasonably prudent employer" would have anticipated the hazard at issue and done more to prevent it. Further, the Court found this burden met where the Secretary had simply asserted that the employer at issue failed to act as a reasonably prudent employer without offering any evidence regarding whether a reasonably prudent employer in the same industry would have even recognized the hazard and, if so, what protective measures, if any, would have been taken.


    In effect, the employer's liability is viewed in a vacuum with no reference to some recognized norms of safety recognition in the employer's industry. According to the Court, the Secretary only need to allege and prove that the specific employer's actions were "imprudent" and the violation will stand. 


    For more details please read the following attachment:


    Reasonably Prudent Employer

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  • Medical Record Documentation

    Thursday March 21, 2013

    The patient/resident medical record is the best evidence in a medical malpractice lawsuit. It is the medical record documentation, not the physician recall of details, which can most effectively defend a physician against a malpractice claim.



    Medical Record Documentation 

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  • Liberty Mutual Study - Cost of Late Accident Reporting

    Friday March 22, 2013

    The prompt reporting of claims is one of the easiest ways to lower your total cost of risk; the sooner we learn about the claim the quicker we can engage in medical and disability management.  The results of this study emphasize the importance of reporting claims as soon as possible.

    Below is a link to view the Liberty Mutual Study.

    Liberty Mutual Study - Cost of Late Accident Reporting

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  • CMS Issues Final Rule on the Requirements for for Long-Term Care Facilities; Notice of Facility Closure

    Tuesday March 26, 2013

    On March 19, CMS issued in the Federal Register, a final rule that outlines steps that long-term care facilities need to take if they decide to cease business operations.


    In the case of a facility closure, any individual who is the administrator of the facility must provide written notification of the closure and the plan for the relocation of residents at least 60 days prior to the impending closure or, if the Secretary terminates the facility's participation in Medicare or Medicaid, not later than the date the Secretary determines appropriate, according to the rule.


    It also identifies penalties for non-compliance and clarifies the responsibility of the administrator of the facility to ensure that no new residents are admitted after written notice is submitted and that the notice of closure must include a plan for transfer and adequate relocation to another facility.

    See the attachment below for details for: Medicare and Medicaid Programs; Requirements for Long Term Care (LTC) Facilities; Notice of Facility Closure

    Notice of Facility Closure

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  • Megace: Potential Liability and Regulatory Impact

    Sunday March 31, 2013

    Megace: Potential Liability and Regulatory Impact

    Par Pharmaceutical Co., has agreed to pay $45 million to settle allegations it improperly labeled and marketed its prescription drug Megace ES to elderly patients, the U.S. Department of Justice said.


    Among other things, the company was accused of criminally misbranding Megace, which was approved by the FDA to treat weight loss tied to AIDS, as a treatment for non-AIDS-related geriatric wasting.


    Despite being aware of harmful side effects, Par also targeted sales to nursing home residents with weight loss, and launched a sales force specifically for this market, according to the Justice Department.


    A representative from the company didn't immediately respond to a request for comment. On behalf of Par, Chief Executive Paul V. Campanelli pleaded guilty to criminal misdemeanor charges in a New Jersey federal court on Tuesday, the Justice Department said. The company was fined $18 million and ordered to pay $4.5 million in criminal forfeiture, and agreed to pay $22.5 million to resolve its civil liability. "Today's resolution emphasizes the importance of the U.S. government's coordinated efforts to combat health care fraud," said Stuart F. Delery, of the Justice Department's civil division. "We expect companies to make honest, lawful claims about the drugs they sell."


    Megace, a megestrol acetate drug, lacked adequate directions for use in the treatment of geriatric wasting unrelated to AIDS, a use that wasn't approved by the FDA, the Justice Department said. The civil allegations against the company were related to claims submitted to federal health-care programs for uses that weren't approved by the FDA. U.S. officials alleged that Par was aware that megestrol acetate carried potentially fatal risks for elderly patients, including a heightened potential for deep vein thrombosis and toxic reactions in patients with impaired kidney function.


    Please see the attached release from the U. S. Department of Justice for additional details. 


    We wanted you to be aware of the above information as you continue to review all medications in conjunction with your Pharmacist and physician and work with your physician on providing documentation in the event medications are used for off-labeled use. 

      US Department of Justice - Misbranding of Megace


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  • Physician Delegation of Tasks in Skilled Nursing Facilities and Nursing Facilities

    Friday May 17, 2013

    The Centers for Medicare & Medicaid Services (CMS) is publishing this article to provide clarification of Federal guidance regarding Section 3108 of the Affordable Care Act (ACA), related to physician delegation of certain tasks in SNFs and NFs to NPPs (NPPs are formerly "physician extenders") such as nurse practitioners (NPs), physician assistants (PAs), or clinical nurse specialists (CNSs).


    This article addresses the authority of NPs, Pas, or CNSs to perform certain tasks such as conducting physician visits and writing orders, and to sign certifications and re-certifications.

    Physician Delegation

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  • Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs, Issued May 8, 2013

    Wednesday May 8, 2013

    This updated Special Advisory Bulletin describes the scope and effect of the legal prohibition on payment by Federal health care programs for items or services furnished (1) by an excluded person or (2) at the medical direction or on the prescription of an excluded person. For purposes of Office of Inspector General (OIG) exclusion, payment by a Federal health care program includes amounts based on a cost report, fee schedule, prospective payment system, capitated rate, or other payment methodology. It describes how exclusions can be violated and the administrative sanctions OIG can pursue against those who have violated an exclusion. The updated Bulletin provides guidance to the health care industry on the scope and frequency of screening employees and contractors to determine whether they are excluded persons.


    OIG Exclusion from Participation

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  • Is It Time to Renew Your Medical Director Agreement?

    Friday May 17, 2013

    In an arbitration ruling in December 2011 in case of The Estate of Jane Doe versus ABC Health & Rehabilitation Center the terms specified in the Medical Director Agreement played a significant role in the Arbitration Panel ruling in favor of the defendant ABC Health and Rehab.  The Arbitration Panel members found there had been no showing that any act or omission by the nurses at ABC Health and Rehabilitation Center constituted a breach of the applicable standard of care or caused the medical problems culminating in the resident's death.   A significant factor in the favorable outcome of this case for the facility was the terms of the Medical Director Agreement.  The Medical Director Agreement stated that the Medical Director was an independent contractor; the roles of the medical director were clearly stated and did not include a responsibility to diagnose or treat patients.  Rather, the agreement clearly stipulated that any services the physician was to provide in that regard were to be in his independent role as an attending physician and the facility was not liable for the acts or omissions of the attending physician. 


    Are the roles of your Medical Director in your Medical Director Agreement clearly defined and separate from any acts he/she may engage is as attending physician who has a responsibility to diagnose and treat patients?  If not you may wish to review your contract with your corporate counsel and decide if clarification is needed to this area or any other areas of the agreement.


    A sample Medical Director Agreement for your review is available from the American Medical Director Association at the link below. We do not recommend any changes to your agreement without review and discussion with your corporate counsel. 



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  • Corporate Compliance and Ethics Program Requirement

    Thursday May 30, 2013

    The Patient Protection and Affordable Care Act (PPACA) required all Medicare/Medicaid Skilled Nursing Facilities to have an effective Compliance and Ethics Program in place by March 23, 2013.


    The primary purpose of the Compliance and Ethics Program is to prevent, detect, and correct any fraud, abuse, or waste, to promote quality of care, and to have an operational Compliance and Ethics Program in place to meet applicable federal, state, and local laws and regulations. In order to avoid potential exposure nursing facility providers should take steps to implement the required Compliance and Ethics Program.


    Robinson Adams - Arthur J. Gallagher has partnered with Associated Long Term Care Insurance Company, Johnston Barton Proctor & Rose and Care2Learn to assist you with the development of your Compliance and Ethics Program and training along with answering any questions you may have concerning this program.  


    Information from Johnston Barton Proctor & Rose on how they can help you develop your Corporate Compliance Program:


                  Long Term Care - Corporate Compliance Management

                                  Johnston Barton Proctor & Rose


    Our law firm, in partnership with Robinson Adams - Arthur J. Gallagher, has developed a Corporate Compliance Program Template (the "Template") to assist long term care facilities in meeting this requirement.


    Our Template includes a corporate compliance program, employee manual, copies of the applicable statutes  and  regulations,  in-service  log  and  instructions,  corporate  compliance  hotline  information,  and corporate  compliance  log and instructions.  The charge for the Template is $500.00.  Our law firm is also available to assist you with customizing and implementing the Template for your facility at a discounted rate.


    If your facility is interested in purchasing the Template or if our firm can provide your facility with any other assistance in meeting the compliance program requirements of PPACA,  please call Angie Cameron at (205) 458-9489.




    You may also contact Stu DeVust at Care2Learn at 941-465-4578 to find out how you can enroll in the following Corporate Compliance Online Courses:

    1. Corporate Compliance - What You Need to Know (USS-11600)  

    2. Corporate Compliance - What You Need to Know for Assisted Living (USS-11600A)      

    3. Corporate Compliance and the Deficit Reduction Act for Management (USS-11200)     


    Please contact Russ Crouch at 205-414-1390, or our vendor partners, if you need additional information or assistance.

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  • Advanced Copy: Dementia Care in Nursing Homes: Clarification to Appendix P State Operations Manual (SOM) and Appendix PP in the SOM for F309 - Quality of Care and F329 - Unnecessary Drugs

    Thursday June 20, 2013

    Guidance - This memo conveys clarification to Appendices P and PP related to nursing home residents with dementia and unnecessary drug use. • Training - Mandatory surveyor trainings are available online at  


    S&C 13-35

    Advanced Copy: Dementia Care in Nursing Homes

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  • Release of Mandatory Surveyor Training Program on Care of Persons with Dementia and Unnecessary Antipsychotic Medication Use - Release of Third Video

    Thursday June 20, 2013

    S&C: 13-34-ALL Memo

    Release of Training Materials:The Survey and Certification Group (SCG) is providing the third and final training program on the care of persons with dementia and unnecessary antipsychotic medication use. The first two programs were made available in January 2013; the third program will be released after May 31, 2013.


    Program Content and Design:The third program is a video-streaming that discusses how to cite severity. The first program provides survey basics related to care of persons with dementia and unnecessary medications. The second program is an interactive self-study with video clips that walks through portions of an actual nursing home survey. • Target Audience: These three programs are mandatory for all State and Regional Office surveyors and optional for other interested personnel. Surveyors have until August 31, 2013 to view the final training. The deadline to view the first two programs was April 30, 2013. 


    Release of Mandatory Surveyor Training Program on Care of Persons with Dementia and Unnecessary Antipsychotic Medication Use - Release of Third Video

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  • American Health Care Association Quality Improvement Toolkits and Webinars

    Friday June 21, 2013

    AHCA has available and free to all AHCA members the 4 Key Strategies to Retain New Hires and Reduce Employee Turnover (toolkit and webinar) and the Clinical Considerations of Antipsychotic Management (Toolkit and webinar): http://qualityinitiative.ahcancal.org. This resource uses a process framework, based on the Nursing Process, to identify care objectives and expectations. It identifies tools and resources to help providers successfully manage antipsychotic medication use at the resident and facility level. The guide focuses on 7 critical steps needed to ensure quality outcomes that are successful and continuous.


    Members will need to log-in to access the toolkits, as it is a member-only benefit. If log-in information is needed, please contact your facility Administrator or State Association and they can give you the information you need.

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  • OIG - Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings

    Friday June 21, 2013

    June 2013 OEI-07-11-00010


    In 2011, Medicare paid between 18 and 30 percent more than other insurers for 20 high-volume and/or high-expenditure lab tests. Medicare could have saved $910 million, or 38 percent, on these lab tests if it had paid providers at the lowest established rate in each geographic area. State Medicaid programs and 83 percent of FEHB plans use the Medicare CLFS as a basis for establishing their own fee schedules and payment rates, although most pay less. However, unlike Medicare, FEHB programs incorporate factors such as competitor information, changes in technology used in performing lab tests, and provider requests in their payment rates. Some State Medicaid programs and FEHB plans required copayments for lab tests, which, in effect, lowered the costs of lab tests for the insurer.


    The OIG recommend that the Centers for Medicare & Medicaid Services (CMS) seek legislation that would allow it to establish lower payment rates for lab tests and consider seeking legislation to institute copayments and deductibles for lab tests. In its comments, CMS stated that it is exploring whether it has authority under current statute to revise payments for lab tests consistent with OIG's recommendation and that a proposal to establish "deductibles and coinsurance" for lab tests is not included in the fiscal year 2014 President's Budget.


    To read the complete report click on the pdf below.

     OIG - Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings

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  • Gallagher Monthly Minute - June 2013

    Wednesday June 26, 2013

    Tips to Control the Risk with Communication

    Gallagher Monthly Minute - June 2013

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  • Release of Medical Records of Deceased Residents

    Friday July 12, 2013

    In Alabama, one has the right to obtain a deceased resident's medical records from an Alabama health care provider if the requester is the personal representative (such as the executor or administrator) of the deceased resident's estate.

    The new HIPAA privacy final rule passed 3/26/2013 with a compliance deadline of 9/23/2013. The new final HIPPA rule says that those family members, relatives, and others who had access to the health information of the deceased prior to death, but had not qualified as a "personal representative"(PR) of the decedent under HIPAA Privacy Rule 164.502(g)(4) the final Privacy Rule allows covered entities (facility) to disclose a decedent's protected health information(PHI) to family members and others who were involved in the care or payment for care of the descendent prior to death, unless doing so is inconsistent with any prior expressed preference of the individual that is known to the covered entity. Whether to adhere to the new HIPAA final rule is now at the discretion of the facility and is not mandatory.

    We do not plan to make any changes to our current procedure unless the facility/covered entity directs us to do so. As such, we will still require a written request for the deceased resident's medical records signed by the personal representative of the estate on a HIPAA compliant release form along with the accompanying legal authority from the Probate court naming the requester as the PR.

    This recent HIPAA amendment is addressed under number 2 below and authorizes the covered entity to produce protected health information or medical records to individuals who are not the PR, so long as those individuals were involved in the decedent's care/payment, need the PHI for that purpose and the decedent did not express a preference (that was known to the covered entity) for his/her PHI to not be released to the individual now seeking it. It will be interesting to see how this new HIPAA amendment plays out. Under this new amendment, the covered entity has the discretion to produce the PHI or not; HIPAA does not require that the covered entity produce, but rather permits the disclosure.

    Under HIPAA, the confidentiality of a resident's protected health information continues after the resident's death. In general, the covered entity is not required to disclose a decedent's PHI to anyone other than the decedent's personal representative. The covered entity must (1) verify the identity of the individual and (2) verify that the individual has the legal authority to access the decedent's PHI. Recent amendments to the HIPAA privacy rule limit the time period for which the covered entity must protect a decedent's PHI to 50 years after the person's death. See45 C.F.R. 164.502(f). HIPAA provides for disclosure of a decedent's PHI as follows:

    (1)Disclosure of PHI to Personal Representative- upon verification of identity and legal authority, the personal representative must be treated as the individual for purposes of disclosure

    See 45 C.F .R. 164.502(g)(1)Standard: Personal representatives.As specified in  this paragraph, a covered entity must, except as provided in paragraphs (g)(3) and (g)( 5) of this section, treat a personal representative as the individual for purposes of this subchapter.

    See 45 C.F.R. 164.502(g)(4)Implementation specification: Deceased individuals.  If under applicable law an executor, administrator, or other person has authority to act on behalf of a deceased individual or of the individual's estate, a covered  entity must treat such person as a personal representative under this subchapter,  with respect to protected health information relevant to such personal representation.

    (2) Disclosure of PHI to family member, other relative, or close personal friend of decedent - The covered entity is permitted, but not required to disclose PHI to theseindividuals so long as the individual was involved in the decedent's care or payment for healthcare prior to death and the PHI is relevant to the family member, other relative or close personal friend's involvement; the disclosure also must not be contrary to the decedent's prior expressed preference. [1]

    See 45 C.F.R 164.510(b)Standard: Uses and disclosures for involvement in the  individual's care and notification purposes-

    (1) Permitted uses and disclosures.  (i) A covered entity may, in accordance with paragraphs (b )(2), (b )(3), or (b )(5) of this section, disclose to a family member, other relative, or a close personal friend  of the individual, or any other person identified by the individual, the protected health information directly relevant to such person's involvment with the individual's health care or payment related to the individual's health care.

    See 45 C.F.R. 164.510(b)(5)Uses and disclosures when the individual is  deceased.If the individual is deceased, a covered entity may disclose to a family  member, or other persons identified in paragraph (b) (1) of this section who were  involved in the individual's care or payment for health care prior to the  individual's death, protected health information of the individual that is relevant to such person's involvement, unless doing so is inconsistent with any prior  expressed preference of the individual that is known to the covered entity.

    (3) Disclosure of PHI to law enforcement- if the covered entity has suspicion that death may have resulted from a criminal act, then disclosure is permitted.

    See 45 C.F.R. 164.512 Uses and disclosures for which an authorization or  opportunity to agree or object is not required. A covered entity may use or  disclose protected health information without the written authorization of the  individual, as described in § 164.508, or the opportunity for the individual to  agree or object as described in§ 164.510, in the situations covered by this section, subject to the applicable requirements of this section. When the covered entity is  required by this section to inform the individual of, or when the individual may  agree to, a use or disclosure permitted by this section, the covered entity's  information and the individual's agreement may be given orally.

    See 45 C.F.R. 164.512(f)(4)Permitted disclosure: Decedents. A covered entity  may disclose protected health information about an individual who has died to a  law enforcement official for the purpose of alerting law enforcement of the death  of the individual if the covered entity has a suspicion that such death may have  resulted from criminal conduct.

    (4) Disclosure of PHI to Coroners and Medical Examiners

    See 45 C.F.R. 164.512(g)Standard: Uses and disclosures about decedents-(1)  Coroners and medical examiners. A covered entity may disclose protected health  information to a coroner or medical examaniner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law. A covered entity that also performs the duties of a coroner or medical examiner may use protected health information for the purposes described in this paragraph.

    (5) Disclosure of PHI to Funeral Directors

    See 45 C.F.R. 164.512(g)(2) Funeral directors. A covered entity may disclose  protected health information to funeral directors, consistent with applicable law,  as necessary to carry out their duties with respect to the decedent. If necessary for  funeral directors to carry out their duties, the covered entity may disclose the  protected health information prior to, and in reasonable anticipation of, the  individual's death.

    (6) Disclosure of PHI for Research Purposes-The covered entity is permitted to disclose PHI for research subject to various criteria not set out fully herein

    See45 C.F.R. 164.512(iii)Research on decedent's information. The covered  entity obtains from the researcher:

    (A) Representation that the use or disclosure sought is solely for research on the  protected health information of decedents;

    (B) Documentation, at the request of the covered entity, of the death of such  individuals; and

    (C) Representation that the protected health infomation for which use or disclosure is sought is necessary for the research purposes.

    Member may login to review new and revised related forms.


    Lavonya K. Chapman, Esq., RN, Claims Compliance Director

    Arthur J. Gallagher Risk Management Services, Inc.

    2200 Woodcrest Place, Suite 250

    Birmingham, AL  35209


    (205) 414-2649 (direct)

    (205) 414-2632 (fax)

    (205) 542-2771 (mobile)


    To visit the LTC Provider University website go to   www.ltcpu.com

     [1]Attached is an excerpt from the Federal Register which discusses this new amendment to the HIPAA Rule. It is helpful and explains in some detail the rationale, concerns, etc. behind extending permissible disclosures of PHI to family members, other relatives and close friends of the decedent who would not qualify as a personal representative and otherwise would not have access to the decedent's PHI.

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  • Partnering with you on Risk Control

    Tuesday August 6, 2013

    Robinson-Adams logo 



    There have been recent newspaper articles in the United States reporting outbreaks of Legionnaires' disease in retirement communities.  Legionnaires' disease is not contagious but is contracted when people breathe in tiny droplets of contaminated water from sources such as showers, water fountains, whirlpool tubs, etc.   The Centers for Disease Control and Prevention have many resources available on this topic for you to review relating to symptoms, causes, prevention and surveillance.  For additional information, please reference CDC.gov.  http://www.cdc.gov/legionella/about/




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  • New Alabama Law Permits Employees to Have Guns in Vehicles on Employee Property

    Tuesday August 6, 2013

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    Section 40-12-143 of the Alabama Code, made by Senate Bill 286, permits employees to have guns in their vehicles on their Employer's property. It may be a good time for facilities to evaluate their current work place safety policies.  Our partner, Johnston Barton Proctor & Rose, developed a detailed summary of this new amendment that went into effect on August 1, 2013.  We have included the summary below. For additional information on Section 40-12-143 of the Alabama Code you can contact Angie C. Cameron or Sarah C. Blutter at Johnston Barton Proctor & Rose LLP.  

    New Alabama Law Permits Employees to Have Guns in Vehicles on Employer Property

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  • OSHA's Revised Hazard Communication Standard - Globally Harmonized System Webcast

    Thursday August 8, 2013

    The Arthur J Gallagher Loss Control Practice Group developed a webcast providing an overview of OSHA's Globally Harmonized System mandatory regulation that provides insight on how to be compliant with this regulation. You can view this webcast by clicking on the following link:


    Risk Management Strategies Webcast Special Edition Series:

    OSHA's Revised Hazard Communication Standard - Globally Harmonized System Webcast

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  • CMS Finalizes Contract Requirements Between Long Term Care Facility and Hospice Service

    Monday August 12, 2013

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    Contract Requirements between Long Term Care Facilities and Hospice Service Providers


    On June 27, 2013 CMS released the final ruling on contract requirements between long term care providers and Hospice Services.  This regulation will be effective on August 26, 2013.   Because there are similar services provided by both long term care facilities and hospice providers it is possible for residents to receive the same services or conflicting services from both companies.  The rationale behind the final ruling from CMS is to help ensure safe and quality care for residents by requiring a written agreement between the long term care facility and the hospice provider outlining the services that will be provided by both entities. 


    When hospice services are provided in long term care facilities then each facility is responsible for ensuring that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of these services.  The long term care facility must meet the requirements of the contract between the hospice provider and the long term care facility and this contract must be signed by an authorized representative of the hospice service provider and the long term care facility before hospice care can be provided to residents at the facility. The written agreement must address issues such as:


    • The services hospice will provide
    • The hospice's responsibilities for determining the appropriate hospice plan of care
    • The services the long term care facility will continue to provide, based on each resident's plan of care
    • A communication process including how the communication will be documented between the long term care facility and the hospice service, to ensure that the needs of the resident are addressed and met 24 hours per day
    • A provision that the long term care facility will immediately notify the hospice service about the following:  1) a significant change in the resident's physical, mental, social or emotional status; 2) clinical complications that suggest a need to alter the plan of care; 3) a need to transfer the resident from the long term care facility for any condition; and 4) the resident's death
    • A provision stating that the hospice service assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided
    • An agreement that it is the long term care facility's responsibility to furnish 24 hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs
    • A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling; social work; providing medical supplies, durable medical equipment, and drugs; and all other services that are necessary for the care of the resident's terminal illness and related conditions
    • A provision that when the long term care facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the long term care personnel may administer the therapies whether permitted by State law
    • A provision stating that the long term care facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physician abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the facility becomes aware of the alleged violation
    • A delineation of the responsibilities of the hospice and the facility to provide bereavement services to the long term facility staff

    The final ruling also states that the long term care facility must designate a member of the facility's interdisciplinary team to be responsible for working with hospice representatives. This team member must have a clinical background. 


    In addition to the CMS requirements in the agreement between the long term care facility and the hospice provider that are outlined above, from a risk management perspective, you should also consider adding the following additional provisions to the contract between your facility and the hospice provider:


    • Independent Contractor provision - this agreement clarifies that the contractor is not a facility employee and therefore not subject to the facility's worker's compensation benefits or professional liability insurance coverage


    • Hold Harmless provision - this agreement clarifies that one or both parties agree to not hold the other responsible for damages.  This agreement indemnifies one or both parties by agreeing to not hold the other responsible for any legal liability or losses as a result of a specified incident or action
    • Insurance coverage by both parties - this clause states that each entity will carry their own general/professional liability insurance.  This provision without a hold harmless/indemnification clause is only helpful if both the facility and third party contractor are co-defendants.   In other words, if the third party contractor is not a party to a claim against the facility, the third party contractor's liability insurance will not hold harmless or indemnify the facility

    The facility may want to consult with its Corporate Counsel before finalizing the language in the contract between the facility and the hospice provider, or with any other third party. 


    To read the complete final rule, the Federal Register is attached.  

      Federal Register - Long Term Care Hospice Contracts


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  • CMS Manual System Transmittal 86

    Friday August 16, 2013

    CMS Manual System Transmittal 86

    Revisions to State Operations Manual (SOM) Chapter 5

    EFFECTIVE DATE: July 19, 2013

    IMPLEMENTATION DATE: July 19, 2013  

    CMS Manual System Transmittal 


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  • Complying with Medicare Signature Requirements

    Friday August 16, 2013

    Complying with Medicare Signature Requirements


    The attached fact sheet describes common Comprehensive Error Rate Testing (CERT) Program errors related to signature requirements and provides information on the documentation needed to support a claim submitted to Medicare for medical services.


    Click on the pdf below to read the entire document from DHHS.

    Complying with Medicare Signature Requirements

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  • Complimentary Seminar! Healthcare Forum

    Friday September 13, 2013

    Safety Seminar

    Healthcare Forum

    Friday October 4, 9am -3pm

    Arthur J. Gallagher                                                                                  

    Robinson Adams Insurance

    2200 Woodcrest Place, Suite 250

    Birmingham, AL 35209

      Click here to register!

    Arthur J. Gallagher, in partnership with Liberty Mutual Insurance, is offering a complimentary Healthcare seminar to help recognize and reduce risk in the healthcare industry. The training covers a variety of safety and health topics specific to exposures faced by healthcare workers.

    As a result of this training, participants will be able to:

    • Evaluate slips and falls and implement prevention strategies
    • Modify internal patient handling policies to include industry best practices
    • Develop methods to track and measure safety performance
    • Address the challenges and impact associated with an aging workforce
    • Determine the impact of shiftwork on employees

    This seminar is designed for Arthur J. Gallagher Risk Management Services and their clients who want to help reduce risk within their operation.  Complimentary continental breakfast and lunch will be provided.  Please register early as seats are limited.

    If you have any questions email us at  Risk Control Learning or contact our Training Specialists at 877-588-2016. 

    Gallagher LogoLiberty Mutual Logo

  • Accident Investigation - October

    Wednesday October 2, 2013

    A thorough accident investigation procedure is an important part of any safety program. It is essential that an employer understand what caused an accident to happen and what can be done to prevent a recurrence. This article provides you with information on when to begin the accident investigation and the steps that should be followed during the investigation process.  

    Click on the link to view the article:  Accident Investigation - October

    Accident Investigation - October

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  • Risk Management Safety Insight

    Monday October 21, 2013


    It is well recognized that employer knowledge is required for OSHA to establish a violation. Under most circumstances, this element can be satisfied when a supervisor, manager or foreman, who are agents of the employer, witnesses an employee exposed to a hazard, but does nothing about it.  But what happens when the supervisor, manager, or foreman is the individual violating OSHA's regulations?  

    The article below examines a recent Federal Court of Appeal's decision rejecting OSHA's interpretation, and how that decision may affect OSHA's ability to prove a violation in the first place as well as the employer's ability to prove unavoidable supervisor misconduct affirmative defense.  

    Risk Management Safety Insight

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  • Fire Safety

    Monday December 2, 2013

    A Minute for Safety, by Arthur J. Gallagher & Co.


    You are responsible for fire prevention and the safety of your coworkers in the event of a fire.  The best way to prevent workplace fires is to be aware of and on the lookout for potential fire hazards.  Employees should be trained about fire hazards and about what to do in the event of a fire.  This article will review the steps to take to reduce the risks from fire occurring in the workplace and what to do if one should occur:                                                                                                   Fire Safety

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  • Handling Funds Following the Death of a Medicaid Resident

    Thursday November 21, 2013

    Alabama Medicaid Agency - Medicaid Alert

    TO: Nursing Home Providers

    The purpose of this alert is to clarify the procedures associated with handling funds following the death of a Medicaid-eligible nursing home resident. The Medicaid Administrative Codes 560-X-10-.14(3)(f) and 560-X-22-.25(5)(e) and the Social Security Administration Guide for Representative Payees require that nursing homes,upon the death of a resident, release any funds being held at the facility in the resident's name to the administrator of the deceased resident's estate. In the event that there is not a person who has been appointed to act as the administrator of the estate, the funds should be sent to the Alabama State Treasurer's Office, Unclaimed Property Division.  In an effort to ensure that all Alabama nursing home facilities are in compliance with the rules and regulations pertaining to the handling of the funds of deceased residents, the following instructions are provided in the pdf below.

    Handling Funds Following the Death of a Medicaid Resident 

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  • MLN Matters Number - MM8458

    Thursday December 12, 2013

    In the regulations at42 CFR 409.32(c), the level of care criteria for SNF coverage specifies that the "… restoration potential of a patient is not the deciding factor in determining whether skilled services are needed." In addition, on January 24, 2013, the Court approved the settlement concerning the Jimmo v. Sebeliuscase which has eventually resulted in new guidelines for skilled care and skilled therapy.


    The Centers for Medicare & Medicaid Services has now revised the Medicare Benefit Policy Manual, Publication #: 100-02, Chapter 8, § 20.1.2-Determination of Coverage, to clarify that skilled care and skilled therapy may be covered even for conditions that will not improve.


    In the past many thought that Medicare coverage of skilled nursing care or therapy required documentation that a resident or Medicare beneficiary must have the potential for improvement from the nursing care or therapy.  The manual revisions, now clarifies that skilled care may be needed to maintain a current condition or prevent or slow a resident/patient's deterioration. The manual also includes specific examples of documenting skilled care.


    Until theMedicare Benefit Policy Manualis updated, see the attachedMLN Matters Number: MM8458 or Related CR Transmittal #: R175BP. Effective Date: January 7, 2014,for guidance.


    Please click on the MLN Matters article below:

    MLN Matters Number - MM8458


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  • Cardiopulmonary Resuscitation (CPR) in Nursing Homes

    Monday December 16, 2013

    Prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with that resident's advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. CPR- certified staff must be available at all times.  


    Please click on the article below to read the Memorandum regarding CPR in Nursing Homes:  

    Cardiopulmonary Resuscitation (CPR) in Nursing Homes

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  • Key Cares

    Thursday December 26, 2013

    This Key Cares article focuses on winter fire prevention, and highlights methods to prevent the most common causes of home and workplace fires. This article also features information about obesity and body mass index. Please click on the link below to access the article.



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