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Friday, March 18, 2016

Weekly Roundup

…Reporting state and national long term care news Please disseminate relevant information to the appropriate department. q Administration q Nursing q Dietary q Activities q Social Services q Rehabilitation q Housekeeping q Maintenance q Laundry

ANHA NEWS Convention Spotlight: Learn How to Lead Multiple Generations of Employees

You’ll receive the same expertise Meagan has given to Harley-Davidson, American Express, Cadillac and more. She is co-author of the best-selling book Generations, Inc.: From Boomers to Linksters, Managing the Friction Between Generations at Work. Register Online: Mid-Year Convention Features a Revised Schedule and New Dates The 2016 ANHA Mid-Year Convention will deliver great education and network opportunities you’ve come to expect while requiring less time away from your skilled nursing care center. The convention begins Wednesday, April 27 and concludes Friday, April 29. All events will be held at the Perdido Beach Resort in Orange Beach, AL. See the attachments to view the preliminary brochure and register online.

Never before has there been so many generations in the workplace and the marketplace at the same time. Never before has there been such an opportunity for collaboration. Never before has there been such an opportunity for conflict. Nationally recognized expert and speaker Meagan Johnson will help you navigate the challenging generational waters in her unique presentation “ZAP THE GAP!”

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Reserve Your Convention Hotel Room Today You may also reserve your room at the Perdido Beach Resort. To ensure availability of rooms, all participants are encouraged to make overnight reservations by March 25. The following rates have been negotiated for Mid-Year Convention Attendees: • $174.00 per Standard/Double Room • $229.00 per Gulf Front Single/Double Room Reservations may be confirmed by contacting the hotel at 800-634-8001 or by booking online at www.perdidobeachresort.com. Individuals should identify the group name ANHA Mid-Year Convention or Booking ID# 9358 when making their reservation in order to receive the special group rate. The booking ID will be needed to confirm a reservation online. All reservations should be made prior to the cut-off date of Friday, March 25, 2016. Reservation requests received after this date will be subject to availability, and higher rates and minimum stays may apply. Online Registration Open: “AIT Preceptor Certification and Recertification” Seminar: March 23 Please mark your calendars for March 23, 2016, as ANHA will present a seminar entitled “AIT Preceptor Certification and Recertification Seminar.” This seminar will be held at the Hyatt Regency – Wynfrey Hotel in Birmingham, Alabama. The seminar will begin at 1:30 pm and conclude at 3:30 p.m. This seminar has been approved for 2 hours of continuing education for nursing home administrators. Please see the attachment more information regarding the program and registration. Handouts will be posted on www.ANHA.org. Online Registration Open: “Nursing Leadership Development Program: Lead, Follow, or Get out of the Way” Educational Seminar: April 4 Please mark your calendars for April 4, 2016, as ANHA will present a seminar entitled “Nursing Leadership Development Program: Lead, Follow, or Get out of the Way.” This seminar will be held at The Hyatt Regency - Wynfrey Hotel in Birmingham. The seminar will begin at 8:30 a.m. and conclude at 4:00 p.m. This seminar has been approved for 6 hours of continuing education for nursing home administrators. It has also been approved for 7.2 contact hours for nurses. Please see the attachment more information regarding the program and registration. Handouts will be posted on www.ANHA.org. National Nursing Home Week T-Shirts Jones Sportswear is offering National Nursing Home Week t-shirts. Please see the attached flyer for more information.

STATE NEWS

Medicaid PDL Quarterly Update Effective April 1, 2016, the Alabama Medicaid Agency will: 1. Require prior authorization (PA) for payment of esomeprazole magnesium (generic

Nexium). Brand Nexium will be preferred without PA.

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Use Dispense as Written (DAW) Code of 9 for brand Nexium. DAW Code of 9 indicates the following: Substitution Allowed by Prescriber but Plan Requests Brand. This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic substitution is permitted, but the Plan requests the brand product to be dispensed.

2. Update the Preferred Drug List (PDL) to reflect the quarterly updates. The updates are listed below:

PDL Additions Nexium Proton-Pump Inhibitors

Relpax Selective Serotonin Agonists

3. Include Vitamin D 50,000 unit capsules in the mandatory three-month maintenance supply program. Prescriptions for three-month maintenance supply medications will not count toward the monthly prescription limit. A maintenance supply prescription will be required after 60 day’s stable therapy. Please see the website for a complete listing of maintenance supply medications.

For additional PDL and coverage information, visit our drug look-up site at https://www.medicaid.alabamaservices.org/ALPortal/NDC%20Look%20Up/tabId/39/Default.aspx. The PA request form and criteria booklet, as well as a link for a PA request form that can be completed and submitted electronically online, can be found on the Agency’s website at www.medicaid.alabama.gov and should be utilized by the prescriber or the dispensing pharmacy when requesting a PA. Providers requesting PAs by mail or fax should send requests to: Health Information Designs (HID)

Medicaid Pharmacy Administrative Services P. O. Box 3210 Auburn, AL 36832-3210 Fax: 1-800-748-0116 Phone: 1-800-748-0130

Incomplete PA requests or those failing to meet Medicaid criteria will be denied. If the prescriber believes medical justification should be considered, the prescriber must document this on the form or submit a written letter of medical justification along with the PA form to HID. Additional information may be requested. Staff physicians will review this information. Policy questions concerning this provider notice should be directed to the Pharmacy Program at (334) 242-5050. Questions regarding PA procedures should be directed to the HID help desk at 1-800-748-0130.

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Nurse Aide Abuse Registry Please note that the following individuals have been placed on the Alabama Nurse Aide Abuse and/or Sanction Registry. These individuals are prohibited from working in any long-term care facility. To check nurse aides, you can use the nurse aide web site at www.adph.org (Click on Contents A-Z - located in the dark blue at the top of the screen - then Click on Nurse Aide Registry - then Click in the white box and type in the Social Security Number of the person you are trying to find. Be sure and include the dashes in the SSN.) Name Effective Date Pricilla Thomas 3/11/16 Tara Riley 3/11/16

NATIONAL NEWS Payroll Based Journal (PBJ) The July 1 deadline to submit all staffing data electronically is just a few months away. Now is a great time to register and learn about what it takes for your company to be successfully compliant. Mark your calendar to take advantage of these educational sessions TODAY! The American Health Care Association (AHCA) has posted on their website (www.ahcancal.org) a list of Time & Attendance vendors who have solutions to submit data to CMS. This list is being updated on a regular basis. If any vendors contact you to get on the list or members contact you about inaccuracies on the list please send that information to Sharon Purvis at spurvis@ahca.org. In addition, AHCA just announced a PBJ webinar (https://www.ahcancal.org/facility_operations/Pages/Electronic-Staffing-Data-Collection.aspx) on March 24 from 1:00 p.m. – 2:00 p.m. CT that will have representatives from Kronos and OnShift describing the steps and challenges members are facing when trying to submit data to CMS. The companies will not be promoting their solutions specifically, but will make some references to their products. Both are AHCA associate business members. Remember the ANHA Mid-Year Convention Educational Session: CMS Payroll Based Journal and Other Regulatory Updates will also be presented at the end of April. Background on PBJ The Centers for Medicare and Medicaid Services (CMS) has long identified staffing as one of the vital components of a nursing home’s ability to provide quality care. Over time, CMS has utilized staffing data for a myriad of purposes in an effort to more accurately and effectively gauge its impact on quality of care in nursing homes. CMS also posts staffing information on the Nursing Home Compare website, and it is used in the Nursing Home Five-Star Quality Rating System to help consumers understand the level and differences of staffing in nursing homes. Section 6106 of the Affordable Care Act (ACA) requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other

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auditable data. The data, when combined with census information, can then be used to not only report on the level of staff in each nursing home, but also to report on employee turnover and tenure, which can impact the quality of care delivered. Therefore, CMS has developed a system for facilities to submit staffing and census information – Payroll-Based Journal (PBJ). This system will allow staffing and census information to be collected on a regular and more frequent basis than currently collected. It will also be auditable to ensure accuracy. All long term care facilities will have access to this system at no cost to facilities. CMS will collect staffing and census data through the PBJ system on a mandatory basis beginning on July 1, 2016. Registration for voluntary submission is currently in progress. This session will focus on the PBJ and other Survey and Regulatory issues of importance to nursing homes. ahcancalED Archived Webinar This recorded webinar provides an overview of the Electronic Staffing Data Collection) and what providers need to do to be successful in meeting its requirements. The voluntary period from October 1, 2015, until required submission of this data beginning on July 1, 2016, is the ONLY time that providers will have the opportunity to “test” the process and determine how their payroll system interfaces with the Payroll-Based Journal. When the required submission process begins, CMS will continue to require providers to submit Forms CMS 671 & CMS 672 at the time of survey. The data from these Forms will be used in calculating the Staffing Domain of the Five Star Rating System until late 2017 or early 2018. Access the webinar on demand at https://educate.ahcancal.org/products/resources-for-pbj-mandatory-electronic-staffing-data-collection-and-the-payroll-based-journal. Facilities may also want to consult the CMS website regarding PBJ at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html. CMS Issues Guidance Regarding Exit Conferences - Sharing Specific Regulatory References or Tags The Centers for Medicare and Medicaid Services (CMS) has issued a memorandum and directive to all state survey agencies regarding exit conferences. The guidance to surveyors is summarized as follows: • Advance Guidance – Procedures for Conducting the Exit Conference: The Centers for

Medicare & Medicaid Services (CMS) is clarifying guidance to surveyors regarding the procedures for conducting the exit conference in the review of compliance with Medicare or Medicaid Conditions of Participation, Conditions for Coverage, and Requirements for Participation.

• Review Exit Conference Procedures: Please review with surveyors the exit conference procedures for conducting the federal surveys to ensure consistency of this process across States.

A copy of the entire memorandum is attached.

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CMS Releases Skilled Nursing Facility Utilization and Payment Data – Announces RAC Reviews Last week the Centers for Medicare & Medicaid Services (CMS) issued a press release titled CMS releases Skilled Nursing Facility utilization and payment data as part of its efforts to increase transparency in federal health programs. The Skilled Nursing Facility Utilization and Payment Public Use File (SNF PUF - https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/SNF.html) contains information on utilization, payments, and submitted charges organized by provider, state, and resource utilization group (RUG). The data include information on 15,055 skilled nursing facilities, over 2.5 million stays, and almost $27 billion in Medicare payments for 2013.

The data set identifies individual SNFs using their six-digit identification number. Services furnished by these SNFs are grouped according to resource utilization groups (RUGs). For each SNF and RUG, the data set has the total number of stays and days provided, number of beneficiaries served, the SNF’s total and average charges, the total and average allowed amounts, the total and average Medicare payments, and the total and average Medicare standardized payments.

The data does not contain any individually identifiable information about Medicare beneficiaries and also has a number of limitations. Most notably: 1) the data does not indicate the quality of care provided by individual skilled nursing facilities, 2) the data are not risk adjusted and thus do not account for differences in the underlying severity of disease of patient populations treated by providers, and 3) the data only reflects Medicare fee-for-service (FFS) and not Medicare Advantage utilization.

The Skilled Nursing Facility PUF contains five Microsoft EXCEL tables: 1) aggregated information by provider, 2) aggregated information by provider and RUG, 3) aggregated information by RUG, 4) aggregated information by RUG and state, and 5) aggregated information on therapy minutes by provider. CMS also provides a Frequently Asked Questions (FAQ) page related to the SNF PUF data.

What you need to know – Forthcoming RAC reviews In addition to information on payments and charges, the SNF PUF contains information on two categories of RUGs for patients who receive a significant amount of therapy: Ultra-High (RU) and Very High (RV) Rehabilitation RUGs. In an associated Fact Sheet, which includes several tables and maps highlighting utilization patterns of concern to CMS, the agency describes that the results are consistent with prior CMS findings. Specifically, the SNF PUF shows that for these two RUGs, the amount of therapy provided is often very close to the minimum amount of minutes needed to qualify a patient for these categories. Based on the 2013 information in the SNF PUF data, CMS found that: • 51 percent of all RV assessments showed therapy provided between 500 and 510 minutes. • 65 percent of all RU assessments showed therapy provided between 720 and 730 minutes. • For 88 providers, all of their RV assessments showed therapy provided between 500 and 510

minutes. • For 215 providers, all of their RU assessments showed therapy provided between 720 and

730 minutes.

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• More than one in five providers had more than 75 percent of both RU and RV assessments that showed therapy provided within 10 minutes of the minimum threshold.

CMS provided the following announcement in the Fact Sheet: “To help ensure that patient need rather than payment incentives are driving provision of therapy services, CMS is providing approval to the Medicare Fee-for-Service Recovery Auditor Contractors (RACs) to investigate this issue.” What you need to do The American Health Care Association (AHCA) is recommending that SNF providers review the information in the SNF PUF tables for 2013, especially those data that are specific to their individual nursing centers. In particular, SNF providers should review table 5) aggregated information on therapy minutes by provider. This table provides specific detail for the percentage of RU assessments with reported therapy minutes between 720 and 730 minutes in column J, and the percentage of RV assessments with reported therapy minutes between 500 and 510 minutes in column H. There is a likelihood that the RACs may focus their initial attention in the investigation assigned to them by CMS to those nursing centers at or near the 100% rate of assessments falling exactly on or within 10 minutes of the RV and RU RUG thresholds.

Next Steps AHCA will be reviewing the extensive SNF PUF data files in more detail and will be seeking more details regarding the scope of the Recovery Audit Program. July Update to 2016 HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement The Centers for Medicare & Medicaid Services (CMS) periodically updates the lists of HCPCS codes that are excluded from the consolidated billing (CB) provision of the SNF PPS. A recent CMS MLN Matters Article (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9561.pdf) describes the following update to be implemented on July 5, 2016. You should be aware that providers other than SNFs may be paid for services that are excluded from SNF PPS and CB, even for those provided to beneficiaries in a SNF stay. However, Medicare will only pay SNFs for claims for services that do not appear on the exclusion lists. Additionally, SNF CB applies to non-therapy services only when furnished to a SNF resident during a covered Part A stay; however, it applies to physical and occupational therapies, and speech-language pathology services whenever they are furnished to a SNF resident, regardless of whether Part A covers the stay. In order to assure proper payment in all settings, Medicare systems edit for services provided to SNF beneficiaries, both those that are included and those excluded from SNF CB. The updated lists for institutional and professional billing are available on the SNF Consolidated Billing web page at https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html?redirect=/SNFConsolidatedBilling/. CR 9561 (https://www.cms.gov/Regulations-and-

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Guidance/Guidance/Transmittals/Downloads/R3473CP.pdf) adds HCPCS Codes 93600, 93602, 93603, 93609, 93610, 93612, 93613, 93615, 93616, 93618-93624, 93631, 93640 - 93642, 93644, 93650, 93653, 93654, 93655, 93656, 93657, 93660, and 93662 to the Major Category 1.B Coding List for SNF Consolidated Billing, effective for dates of service on or after January 1, 2016. Note: If you have claims with dates of service on or after January 1, 2016, that are impacted by these changes and were denied/rejected prior to the implementation of CR9561, your MAC will re-open and re-process those claims that you bring to your MAC's attention. CDC Planning Guide for Public Health Emergencies The Centers for Disease Control and Prevention (CDC) has developed a Long-Term, Health, and Hospice Care Planning Guide for Public Health Emergencies, and the purpose of this plan is to assist facilities to prepare for a public health emergency. This planning guide covers six topics: • Situational awareness • Continuity of operations • Facility or agency operations • Crisis standards of care • Staffing • Fatality management This guide will assist you with your planning efforts for both public health emergencies and disaster preparedness. To use this guide please go to http://www.cdc.gov/phpr/healthcare/planning2.htm. CMS Announces Further Improvements to the Nursing Home Compare Five-Star Quality Rating System During the monthly Centers for Medicare and Medicaid Services (CMS) Open Door Forum, CMS announced further improvements to the Nursing Home Compare Five-Star Quality Rating System. Beginning with the April update CMS Nursing Home Compare will include the following new measures: 1) Percentage of short-stay residents who were successfully discharged to the community

(Claims-based) 2) Percentage of short-stay residents who have had an outpatient emergency department visit

(Claims-based) 3) Percentage of short-stay residents who were re-hospitalized after a nursing home admission

(Claims-based) 4) Percentage of short-stay residents who made improvements in function (MDS-based) 5) Percentage of long-stay residents whose ability to move independently worsened (MDS-

based) 6) Percentage of long-stay residents who received an antianxiety or hypnotic medication (MDS-

based)

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Beginning in July 2016, five of the measures will be used in the calculation of Five-Star Quality Rating QM ratings. Antianxiety/hypnotic medication measure will not be used in Five-Star due to concerns about its specificity and appropriate thresholds for star ratings. CMS reports that the five added QMs to the Five-Star Quality Rating will be phased in from July 2016 through January 2017. In addition, the American Health Care Association (AHCA) hosted a webinar summarizing the new CMS quality measures that will be added to Nursing Home Compare and the Five-Star Quality Rating System. For those who were unable to participate, the recorded presentation is now available and can be accessed at http://www.eomeetingcenter.com/se/Meetings/Playback.aspx?meeting.id=703146. Members can also find other resources including answers to questions about the new changes, and measurement specifics on the ahcancalED website at https://educate.ahcancal.org/LearnED. Note: Members MUST login using their AHCA username and password to access resources on ahcancalED. ANHA will update you on this new development as further information is released.

OTHER NEWS AHCA Webinar: A Common Sense Approach to Diabetes Management in Post-Acute and Long Term Care • Date: April 5, 2016 • Time: 1:00 p.m. - 2:15 p.m. CT • Registration Information: https://educate.ahcancal.org/products/a-common-sense-approach-

to-diabetes-management-in-post-acute-and-long-term-care Patients with diabetes constitute some of the most medically complex patients in nursing centers. They usually have existing complications, are prone to frequent infections, cardiovascular events, injurious falls, electrolyte disturbances, cognitive impairment, weight fluctuations and hypoglycemia. They have a greater degree of functional impairment and dependence and constitute some of the “heaviest care” needs. The challenges of managing diabetes in post-acute and long term care may be characterized as attributable to resident and disease, facility, staff and practitioner, and medication management factors. Treatment regimens vary widely, may be unnecessarily complex, and place the patient at risk of hypoglycemia. This webinar will discuss systematic and evidence-based approaches to improve the diabetes management in post-acute and long term care, including the recently released position statement from American Diabetes Association and Clinical Practice Guidelines from the American Medical Directors Association.

Speakers: • Naushira Pandya, M.D., CMD, FACP, Professor and Chair, Department of Geriatrics

Director, Geriatrics Education Center, Immediate Past president, AMDA Society for Post- Acute and Long-Term Care Medicine, Nova Southeastern University College of Osteopathic Medicine

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• Holly Harmon, RN, MBA, LNHA, Senior Director of Clinical Services, American Health Care Association

Learning Objectives: • Review the challenges in diabetes management from the patient, facility, and practitioner

perspectives. • Describe a systematic approach to pharmacotherapy, individualizing control, and monitoring

of glycemia, and of diabetes care at the patient and facility level. • Provide examples of selection of treatment regimens, discontinuation of sliding scale insulin,

minimization of hypoglycemia risk, and diabetes care at the end of life. A Message from KEPRO: PHI Security Incidents Recently, KEPRO has received protected health information (PHI) from various providers that was not related to KEPRO's services or was not attributable to a review/appeal we are working on currently. This is considered an external security incident, which violates HIPAA regulations. Under our contractual guidelines, we are required to report incidents of this type to QualityNet, a subcontractor for the Centers for Medicare & Medicaid Services (CMS), for tracking purposes. Providers should follow their internal processes regarding HIPAA compliance. By alerting providers to this concern, we hope that they will look at their own internal processes, to assist KEPRO with resolving this concern. Click here http://www.hipaasurvivalguide.com/hipaa-regulations/164-304.php for more information about HIPAA security incidents, provided by the HIPAA Survival Guide. If you have questions or need additional information, please contact Cheryl A. Cook, RN at 813-280-8256, ext. 7201 or Cheryl.Cook@bfcc2.hcqis.org. National Partnership to Improve Dementia Care and QAPI Provider Call The National Partnership to Improve Dementia Care in Nursing Homes and QAPI are partnering on MLN Connects Calls to broaden discussions related to quality of life, quality of care, and safety issues. The National Partnership was developed to improve dementia care in nursing homes through the use of individualized, comprehensive care approaches to reduce the use of unnecessary antipsychotic medications. QAPI standards expand the level and scope of quality activities to ensure that facilities continuously identify and correct quality deficiencies and sustain performance improvement. This call will focus on infection control, highlighting Antibiotic Stewardship and community-wide efforts, including a presentation from a nursing home administrator. Common concerns related to the clash between individualized, person-centered care and the medical model of controlling infections will also be addressed. This is critical for residents with dementia, who often struggle to complete complex tasks and may have issues with continence. Additionally, CMS subject matter experts will share information about the upcoming Infection Control Pilot Project, as well as updates on the progress of the National Partnership and Quality Assurance and Performance Improvement (QAPI). A question and answer session will follow the presentations.

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National Partnership to Improve Dementia Care and QAPI • MLN Connects® National Provider Call • Thursday, April 28 • 12:30 - 2:00 p.m. CT

Discussion Topics:

• Antibiotic Stewardship, involving urinary tract and respiratory infections • Infection Control Pilot Project • QAPI • National Partnership

Target Audience: Consumer and advocacy groups, nursing home providers, surveyor community, prescribers, professional associations, and other interested stakeholders. To register visit MLN Connects Event Registration at http://www.eventsvc.com/blhtechnologies. Space may be limited, register early. Clinical Practice Adds New Resources Online The American Health Care Association (AHCA) recently released Building Prevention into Every Day Practice: Framework for Successful Clinical Outcomes. Success in achieving positive resident/patient outcomes is even more critical now than ever before. The link between quality and payment in long term and post-acute care is growing stronger, as evidenced by the SNF Value Based Purchasing Program (VBP), Improving Post-Acute Care Transformation (IMPACT) Act, SNF Quality Reporting Program (QRP) and more. In addition, regulatory activity is intensifying and the Five-Star Rating system and Nursing Home Compare have been revised and will add items in the future as it broadens public reporting and transparency. Most importantly, consumers expect and deserve high quality care. The AHCA Clinical Practice Committee designed and built Building Prevention into Every Day Practice: Framework for Successful Clinical Outcomes, which outlines key elements from both an organizational and clinical nature that are critical to successful clinical and organizational outcomes. Positively, these elements reflect common denominators that cross multiple care situations. Therefore, instead of being yet another initiative or single focused project to achieve just one outcome, it is a way of acting, thinking and being that will benefit multiple areas across an organization. Applying this framework into practice will provide a strong foundation for improved resident/patient outcomes in addition to more efficient use of staff, time, and resources. Supplemental materials to support applying the framework into every day practice are posted on the website at http://www.ahcancal.org/facility_operations/Clinical_Practice/Pages/Building-Prevention-into-Practice.aspx including video vignettes, worksheets, conversation starters with key takeaways and probing questions, checklists for what you can do as an individual and for what an organization can do. Embark on the journey through the Framework today!

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CALENDAR OF EVENTS Date Event Location Time March 18 ANHA Region 1 Meeting All Steak 12:00 p.m. RSVP: Brian Scheri Cullman 256-740-5400, bscheri@mhnrc.com March 18 ANHA Region 5 Meeting Golden Ranch 12:00 p.m. RSVP: Eldridge Stewart Selma 334-682-4231, estewart@frontiernet.net April 6 ANHA Region 9 Meeting Senior Care Pharmacy 12:00 p.m. RSVP: John Burchfield Northport 205-391-3600, john.burchfield@northporthealth.com CEU provided for administrators and nurses April 27-29 ANHA Mid-Year Convention Perdido Beach Resort Orange Beach May 24 ANHA Region 3 Meeting Galleria Woods 12:00 p.m. RSVP: Kevin Ball Birmingham 205-788-6330, kball@ballhealth.com Guest Speaker: Karen Golson, Medicaid District Supervisor

Alabama Nursing Home Association 4156 Carmichael RoaduMontgomery, AL 36106uPH: (334) 271-6214uFAX: (334) 244-6509

Links: Alabama Nursing Home Association http://www.anha.org

AL Board of Examiners of Nursing Home Administrators http://www.alboenha.state.al.us AL Dept. of Public Health http://www.adph.org

CMS http://cms.gov