Sample swot analysis nursing home

J asper Gardens is a for-profit nursing home located on east side ofJasper, about five miles from the city center. The facility is a one-story modern building with ample parking and significant room for expansion. It is located near Medical Associates on 65 acres of land adjacent to the

newly approved highway, approximately one mile from the planned Jasper-East exit. Jasper Gardens

is licensed to operate 110 beds. T t currently operates and staffs I 06 beds in both private and semi­

private rooms,

JEFFERSON PARTNERS, LLC

Jasper Gardens is owned and operated by Jefferson Partners, LLC. 'Ibis corporation owns and oper­ ates nursing homes, assisted living facilities, retirement living communities, and adult day care cen­

ters in the greater Capital City area and statewide. Jefferson Partners is a private equity partnership of investors. None of the investors is involved in the day-to-day management of the corporation.

The partners have quarterly board meetings, and their executive committee meets monthly with the professional senior management ream co review operations and issues. Jefferson Partners acquired the

Jasper Gardens property in 1995 and has continuously invested in the property. Jefferson Partners has two operating divisions: property and management. The management

division provides centralized administrative services, such as pay roll, legal services, financial manage­

ment, and group purchasing for its facilities, and it also charges a management fee for its services.

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Case 7: Jasper Gardens Nursing Home 231

The property division owns the buildings and land, and ir leases these properties co wholly owned subsidiary corporations that manage the individual operations. As such, Jasper Gardens leases its current building and land.

The senior managemenc team of Jefferson Partners includes Ralph Jefferson, presi­ dent and CEO, and Mary Charles, RN, vice president of operations. David Fellows is the direccor of corporate development and acquisitions. Martha Wyman is the chief financial officer. 1he senior management team/central office approves the annual budget for each facility. Charles meets monthly with facility administrators co monitor operations and co address problems and issues. Jefferson Partners maintains professional offices and a small, central staff in Capital City.

HISTORY

The Jasper Gardens Nursing Home traces its hiscory back co 1960, when it was founded by Mary and John Decker. The initial facility was a former resorr that accommodated 45 residents in semiprivate rooms. During the 1970s this facility was modified co accommo­ date 70 residents and was licensed under the Medicaid and Medicare programs. In 1980, the Deckers sold the facility co the Armstrong family, who then built four new wings of patient rooms, each with 12 semiprivate rooms. On each occasion, the scate awarded a Certificate of Need (CON). This construction project (1981 to 1983) used the original srrucrure for administrative offices and common areas.

Between 1990 and 1995, the facility was modified into its current configuration with five wings and a central building for administrative patient care. In this modification, che original resort house structure was demolished and totally replaced. The original four wings were updated and modified. Jefferson Partners acquired the facility in 1995. Today the structure is modern and tastefully decorated to emphasize the residential nature of a contemporary nursing home.

Until 1992 the state CON law regulated any expansion in nursing homes char cost more than $500,000. Today the threshold for nursing homes is the same as for acure care facilities. In 1992 the Stace also ceased allowing any nursing home to expand its bed capacity 5 percent each year without a CON, regardless of cosr. It should be noted thac capicaJ coses are capped and used to determine state Medicaid rates for nursing homes; they constitute less than 5 percent co a rate calculation. Currently, che scare has placed a mora­ torium on CON applications for skilled nursing facility and intermediate care facility beds pending changes in che state CON law. However, the governor has granted permission that che number of beds in a nursing home may increase if che cotal number of nursing home beds within a county remains unchanged.

When Jasper Gardens was originally founded, the surrounding area was relatively rural. Today it is becoming more suburban, and a number of housing developments have been built nearby. A shopping center is located approximately a quarter-mile away. The

232 The Middleboro Casebook

area is expected to grow and develop significantly with the opening of the new interstate road between Jasper and Capital City.

The facility introduced Resident Community Councils in 2007, which give resi­ dents opporrnnities co meet with the staff to express their wishes and preferences. Jasper Gardens has been recognized as a regional leader in empowering residents and creating a homelike atmosphere. Its promotion materials stress this and cite many examples:

The residents have choices with respect to how they want to live. We promise to listen and strive to accommodate resident choices so that we can fulfill their wishes for daily living. A "fine dining" program is available to a different group of residents daily. We create a restaurant-like atmosphere here with fine china, silverware, and food and per­ sonal service. Residents go to local restaurants regularly in groups, by themselves, or bring food back to their rooms for private dining. Bathing or showering times are hon­ ored by request for time, day, and frequency. Staff members have consistent a�sign­ ments of residents for continuity of care and familiarity of daily routines for residents. The facility makes available its facilities and space to the community for meetings and social functions.

For the past four years, Jasper Gardens has been a semifinalist in the statewide competition for the Quality-of-Life Award granted by the governor to the nursing home best able to demonstrate its commitment to resident independence and to giving patients choices regarding their care and services.

PATIENT SERVICES

Jasper Gardens is licensed by the state to operate 110 nursing home beds. It accepts all forms of payment. It is 100 percent Medicare- and Medicaid-certified and fully approved to provide skilled nursing and rehabilitation services covered by Medicare. Medicaid cov­ ers most patients. Physical therapy (PT), occupational therapy (On, recreation therapy, and speech therapy (ST) services are available onsitc. These rehabilitation services are also available to area citizens as outpatients. These outpatients use either Medicare Part B or commercial insurance to cover associated charges.

Jasper Gardens classifies its patients and residents and many of its services using "intermediate care" and "skilled care." The term resident implies an individual with an average length of stay (ALOS) of more than three months, whereas the term patient means an individual with an ALOS of fewer than I 00 days. Intermediate care services emphasize long-term residual services. In 2014, the ALOS for intermediate care patients is 2.8 years and has been increasing. The average age of current residents is 87 and has slowly been increasing. Some residents in chis category have the ability to pay for care when they are initially admitted. Many, however, after spending down their available personal resources,

Case 7: Jasper Gardens Nursing Home 233

have their care financed by Medicaid. The average spend-down period for the residents ofJasper Gardens, over che past five years, has dropped from 16 months to 13 months. A

few patienrs in this category are covered by private nursing home insurance or insurance provided by the US Department of Veterans Affairs.

Skilled care patients are in the nursing home for pose-hospital rehabilitation. Patients older than 65 years of age rely on Medicare as their primary insurance. These patiencs make use of PT, OT, and ST services. 1hose not eligible for Medicare typically rely on a private health insurance plan to cover these services. In 2014 the ALOS for Medicare patients was 36.2 days; it has been decreasing over the past five years. However, 40 percent

of Medicare patients stay beyond 60 days. For patients covered by private or commercial health insurance, the ALOS in 2014 was 24.3 days.

Registered nurses (RNs), licensed practical nurses (LPNs), licensed nursing assis­ tants (LNAs), and medication nursing assistants (MNAs) provide nursing services. A part­ time registered dietitian supervises all food services. Social work services are provided during che admissions process and are available on an in-patient basis. Pharmacy services are provided on contract by DRUGCO, Inc.

The medical director is James A. Child, DO. He is board certified in family practice and gerontology, and he operates a practice in Jasper with Ors. Freda Evans and David

Dodger. Ors. Evans and Dodger provide backup on-call services at Jasper Gardens as needed. All three are active medical staff members at Webster Hospital and have consulting medical staff privileges at Osteopathic Medical Center in Capital City. Dr. Child devotes approximately one day per week to his patienrs in Jasper Gardens.

The facility is physically divided into five adjacent wings. Four of the five wings have nine semiprivate rooms and two private rooms. The facility has eight private rooms in coral. These four wings were part of the original 1980 construction and have been modified

over the years to accommodate larger low1ges and patient common areas. The fifth wing, added in 1995, has 13 semiprivate rooms and houses the rehabilitation services depart­ ment. Each wing also has a nursing station, a shower room, and a small library. Wireless

Internet is available throughout the entire facility. The beauty salon and barbershop are locaced in the central commons area. Most patients enter Jasper Gardens following dis­ charge from an area hospital. Primary referral sources include the hospitals locared in

Middleboro and Capital City.

ORGANIZATION

Jasper Gardens is organized using a flat management structure. The senior management team reporrs to the administrator who in turn reports ro Mary Charles, the vice president of operations for Jefferson Partners LLC (located in Capital City). The senior management team meets weekly to review the budget reporcs furnished by Jefferson Partners. Each of the senior managers supervises and directs multiple departments and staff.

234 The Middleboro Casebook

Jayne Winters, NHA, is the licensed administrator ofJasper Gardens. She is a grad­

uate of an eastern university and holds an undergraduate degree in health services manage­

ment. On her grad_uation in 2006, she completed her administrator-in-training program at

a Jefferson Partners facility in Capital City. Upon completion of this program, she earned

her state license and was appointed as assistant administrator at Jefferson Partners' larg­ est nursing home, an assisted living and congregate living (apartment) facility in Capital City. She was appointed administrator of Jasper Gardens in 2010. Winters is active in the

statewide association of long-term care administrators and lives in Jasper. Winters also

manages all aspects of personnel and human resources administration. For example, her

office releases all advertisements for employment and screens all applicants. Wage and sal­

ary rates arc set during the annual budgeting process, with changes requiring the approval

of Jefferson Partners. Winters and her administrative assistant, Carol Hyde, administer all

employment (including employment background checks) and benefit policies. 1

Over the past 18 months, employees have filed formal grievances related co "unfair

interpretations" involving annual and sick leave policies, merit pay adjustments, and rates

paid co part-time workers who work on national holidays. During this same period, three employees were discharged for failure to perform stated duties. It should be noted that one

of Winters's first actions as administrator was the dismissal of three employees for nepo­

tism. This action is still remembered by many of the staff, who felt the dismissals were not necessary, especially because these employees were hired before a formal policy on nepo­

tism was instituted. Recently two other employees were discharged for poor attendance

and work performance. Winters is also responsible for all advertising and promotional

programs designed to call attention to the facility.

When interviewed, Winters indicated that Medicaid pricing bas continued to force

Jasper Gardens to carefully reconsider all staffing levels and in some instances co reduce

staffing. She indicated that any nursing home-and especially Jasper Gardens-works

within slim annual financial margins and that small staffing increases could easily evapo­

rate its modest profitability. She also indicated that her employment contract does include

certain incentives and penalties related to quality of care and financial performance. When asked to identify and discuss significant issues, she noted chat for the past

two years Jasper Gardens has received a deficiency-free survey from the state Department

of Health-Level B. This, she explained, is a significant improvement over the conditions

that existed when she was hired. Prior to 2010, the state survey team awarded Jasper Gar­

dens scores that indicated widespread potential for more than minimal harm to patients (Levels E and F). Winters stated that the positive surveys over the past three years were the

result of a solid and dedicated team effort and changes in some job responsibilities. She

also indicated that, over her four-year career at Jasper Gardens, patient acuity and levels of

need have increased: "The intensity of needed care has increased significantly. More and

more of our older residents are exhibiting behavioral problems. Even though our staffing

has remained about the same, our residents seem co need more and more care."

Case 7: Jasper Gardens Nursing Home 235

Three years ago, Jasper Gardens' workers' compensation rates doubled based on its history of worker injuries. The most common injury has been back strains and pulls asso­ ciated with assisting and lifting residents from their heds. During 2014, because of new policies and the arrival of new equipment ro help staff assist residents, no staff member

reported back injuries. No union has ever represented the hourly staff at Jasper Gardens. Unofficially,

Winters &d indicate that she and her management team have heard rumors char a local union in Capital City will be sending cards co the hourly staff to determine whether che staff wants the union co represent their interests. A union formally approached che staff four years ago. If a sufficient number of cards are returned to the union, it will petition the scare labor board for permission to hold an election and form a bargaining unit.

A number of residents use electric wheelchairs and carts for transportation around the nursing home and use chem to frequent the small park on the grounds of the facility. In two instances over the past 18 months, "crashes" inside the facility have injured three residents. fu the area has developed with wider roads and sidewalks, a small number of residents also have begun to use their personal mobility cares to go to the local shopping center. To leave the building and grounds of Jasper Gardens, a resident must secure per­ mission from the supervising nurse and take a wireless phone furnished by the nursing home. Legal counsel is reviewing this practice co ensure chat it is in keeping with current laws and regulations. Two different families have requested that the residents be restricted to using the cans only on the property of the nursing home. Current policies do not allow for these restrictions unless they are based on appropriate legal (e.g., power of attorney) or medical orders. Medicare purchases these cares for any mobility-impaired individual who is 65 years old or older. Recently an ambulatory resident, who had walked to a local shopping center, became disoriented and had co be brought back co Jasper Gardens by the

police. This is the fifth such instance within the past six months. When interviewed, Winters said:

I am very pleased with the progress we have made here over the past four years. The facility

looks good, the staff is dedicated, and the owners are comfortable with our [profit] mar­

gins. We have been challenged to get our personnel system in better shape and have been

responsive to needs of our workers. I sincerely hope that we do not unionize, although we

fully support our employees' rights in this area. I know that Jefferson Partners is going to

want us to continue to develop this facility. Especially with the new interstate road, which will

significantly cut down on the travel time between Jasper and Capital City, we may have the

potential for open senior living apartments and an assisted-living facility here on our current

campus. We have the space and a great deal of the infrastructure to move in this direction.

When asked about .the management reports she relies on, Winters said that her "dashboard report" is critical to ncr ability to stay abreast of the management issues in the

236 The Middleboro Casebook

facility. This weekly report includes the following information for the latest week, month,

quarter, and year to dace:

+ Revenue and expense budget performance

+ Payroll information: budgeted versus actual hours, dollars, and overtime

+ Patient census by payer

+ Admissions and discharges

+ Therapy revenue, expenses, and hours

+ Employee health insurance claims submitted

+ Primary quality indicators:

Facility-acquired pressure ulcers

Falls

Injuries

Weight loss

Reportable events

Acure discharges

Michele Regan, RN, is director of nursing and patient services at Jasper Gardens. She holds an undergraduate degree in nursing and master's degree in geriatric nursing. She has more than 20 years of professional experience in long-term care nursing. She joined the nursing staff at Jasper Gardens as the day-shift charge nurse in 2004. She was appointed

to her current position in 2009. She supervises the day (7:00 a.m.-3:00 p.m.), evening

(3:00 p.m.-11 :00 p.m.), and night (11:00 p.m.-7:00 a.m.) nursing supervisors. There are two day-shift charge nurses. Each is responsible for approximately half of the patients.

Aside from supervising all nursing servict::s, Regan also supervises the ancillary services unit

(i.e., P'f, OT, ST, and respirarory therapy) and the recreation unit, and she coordinates all pharmaceutical services. When interviewed she discussed staffing and management issues.

She indicated that (surprisingly) Jasper Gardens rarely has experienced any problem hir­ ing qualified RNs and LPNs. She indicated that Jasper Gardens experiences the expected turnover in its LNA workforce and that she would like to hire more MNAs when LNA

openings occur. She also indicated that staff scheduling was always an issue: "We seem to

be in a cacch-22. Recently we have begun to hire more part-time staff. But scheduling them and relying on them to work a few extra hours to help us cover a shift here and there has been difficult and disappointing. In the past we hired some floating full-time staff to cover

Case 7: Jasper Gardens Nursing Home 237

as needed, bur we moved to part-time staff co save money. This move seems to have made staffing much more difficult. It appears that the critical complaint of our part-time staff is that they do not have sick leave, something very important ro them when they have sick children." '

Regan did speak positively about the certified therapeutic recreation specialists who now staff che recreation department. Jasper Gardens began hiring certified specialises in this department four years ago, and it has "led to our recreation services deparcmenr being one of the best in the state."

Working with the medical director, Dr. Child, Regan is also responsible for the formulary, ensuring that adequate pharmacy stock is maintained and that appropriate inventory safeguards are effective. She is responsible for the ordering and inventory of all medical supplies. Medical supplies arc purchased using contracts negotiated and adminis­ tered by Jefferson Partners.

When asked what changes she would like co see, she stated, "Our current policy concerning residents being hospitalized and then returning may need to be reconsidered." She stared, "Our current policy is char we will not keep a bed open for a resident who is admirred to a hospital unless they pay for it during their hospitalization or absence. If the bed is nor paid for, we will refill it after 24 hours. We also have a I 0-day limit on how long any bed may be unoccupied even if the per diem charges are being paid." She con­ tinued, "This can really cause problems for our residents, but we need to keep our beds full. lhe situation is just not good for our residents, even though it might be a required

business practice. We really try co accommodate our residents, but frequently we can't." She also indicated that a plan to dedicate one wing to patients with Alzheimer's disease and dementia, an idea recently discussed with the owners, might be needed and that such a wing would expand the range of patient care services offered.

Margaret Hemp is the director of admissions and social services. She has an under­ graduate degree and a master's degree in social work and more than 15 years of professional experience. Prior to her appointment as director of admissions in 1999, she held a similar position at another nursing home in Capital City. She meets with all prospective residents and their families. She also helps potential and current residents qualify for Medicaid. Periodically she leads the team that reviews the medical and social needs of all residents, and she files reports as needed. Each resident maintains a modest cash account co support

certain purchases (e.g., beauty shop). Hemp manages this system in keeping with federal and state regulations. Aside from working with the discharge teams at the hospitals located in Middleboro and Capital City, she also has regular contact with the Hillsboro County Home Health Agency and the home health agencies located in Capital City. When inter- viewed, she stated:

Overall, Jasper Gardens is not unique. We have a dedicated staff. Our resident popula­

tion is getting older, and recent Medicare admissions have required significantly more

238 The Middleboro Casebook

therapy and services than in the past. Changing federal and state regulations covering

Medicaid eligibility make aspects of my job demanding. I spend a great deal of time

completing the minimum data set on residents to be admitted, and I spend time with

our nursing supervisors filing reports on our current residents.

We really do reflect the community we serve. Our residents, for the most part, come

from right around here, although the new interstate should bring us even more Capital

City residents. We are fortunate that a significant number of our residents have family

and friends in the area who still visit them. We seem to have more visitors than other

homes that I am aware of. I enjoy working here.

Ralph Doyle is the director of plane operations. He is responsible for all aspects of

rhe physical facility, including maintenance, laundry, and housekeeping services. His sraff also runs the van that takes residents to appointments and on shopping trips. lie retired from rhe military in 2004 and has served in this role at Jasper Gardens since 2006. Prior to his current employment, he was the associate director of facilities at another nursing home in Capital Ciry. Under Doyle's leadership, Jasper Gardens has received no negative reports or citations regarding any aspect of facility, including fire safety inspections. In 2011,

Jasper Gardens installed new onsite generators. Jasper Gardens has the ability co function

"off the electric grid" for a maximum of 12 days. This addition completed a plan to make

this home energy independent to ensure the safety of all residents. When interviewed he stated:

Well, those electric carts-some call them scooters-really cause us problems. Most

can't be stored inside the facility because of existing regulations covering their recharg­

ing. We have had to develop a space in another building for their storage, and we bring

them in and out as the residents want them. Maybe they should be banned, especially

inside the facility, as they can frequently mark or damage our floors and walls. Some­

times l feel that we are running a valet service for these carts. Overall, this is a solid

facility. It is clean and relatively modern and well lighted. I am proud of how our staff

has made this older facility look good. Now that we are energy independent, I sleep

better at night. We also have a staff that understands our need to periodically have fire

and emergency drills. This has helped a great deal. One of my many duties, however,

is security. While all staff members wear badges and are instructed to question any

visitors they do not know, it frequently comes down to my staff being called. I question

whether we can and should remain as open as we are. Residents can potentially leave

anytime they want, and outsiders can enter multiple doors from 7:00 a.m. to 8:oo p.m.

before the building is "locked" for night. This may be an issue that needs attention.

It should be noted that, based on Doyle's recommendation, all residents who want ro use motorized wheelchairs and carts must complete driving lessons done by a trained instructor and earn a scooter license from Jasper Gardens.

Case 7: Jasper Gardens Nursing Home 239

Bonnie Keana is the senior administrative assistant and bookkeeper. She is respon­ sible for preparing the payroll and supervising the posting of the financial journal and the general ledger. Based on information she prepares, Jefferson Partners provides budget status reports every week and interim financial statements monthly. Keana is also in charge of local purchasing, and she supervises the reception staff.

MANAGEMENT OPERATIONS

Every Tuesday morning, Winters, Regan, and Hemp meet to review the sracus of all patients. Data include quality measures used by the Medicare Quality Improvement Organization and Centers for Medicare & Medicaid Services (CMS) as well as ocher data reported to Jefferson Partners. Once a month this committee includes others (including the medical director) as needed from its Continuous Quality Improvement Comminee and reviews all data to determine which patients and CMS items need attention, why, and the creaunent and prevention approaches being used.

Every Friday morning, Winters, Regan, and Hemp plus Doyle and Keana meet as the management team and review the most recent dashboard report, budget status report, and other issues needing management's attention.

CURRENT ISSUES

PERSONNEL AND UNION ACTIVITY

When interviewed, Winters and Regan both indicated char access to qualified professional staff was not a major problem. They stated, "We have been able to hire highly qualified professionals who have generally stayed with us for significant periods of time." Over the years, ho�cver, some wages have nor kept pace with the regional market. This rrend has been directly traceable to Medicaid rates paid by the state. Over the past ten years, state Medicaid rates have fallen from being the tench highest in the United Scares co the eighth lowest.

Four years ago, the hourly employees were mailed cards and mer regularly with union organizers from Capital City. This effort did not yield a sufficient number of staff ro petition to form a bargaining wiit. Two years ago, as part of study done by an external con­ sulcanc, employees expressed three primary job concerns. They were concerned that wages were below market norms, that benefits were administered unfairly, and that job expecta­ tions were unclear. After this study, Jefferson Partners did authorize some wage changes and committed ro follow a standardized system of benefits for all employe�. This system is described in a new and expanded employee manual, which has nor yet been published. The study also instructed the administrator to review and update all job descriptions and co enhance the system of annual evaluation. Merit pay was introduced in 2013 but has met with mixed reviews and results. F.�mr years ago, the personnel system was ad hoc and poorly defined. It still exhibits a number of shorccomings. For example, a number of employees remain confused about their eligibility for cercain bendic:. ,md how co �e benefits.

240 The Middleboro Casebook

REHABILITATION SERVICES UTILIZATION

Rehabilitation services (i.e., PT, OT, ST, and respiratory therapy) are available for nursing

home residents as well as members of the community. Most pay for these services using

Medicare Part B or private insurance. Outpatient utilization continues to be almost nonex­

istent. Currently, individuals in need of ambulatory rehabilitation services typically travel to either Capital City or Middleboro. Jefferson Partners has asked Jasper Gardens for a

plan to address this potential market as part of the upcoming review of the draft budget

for 2016. Jasper Gardens estimates chat for 2015, service demands (in relative value units, or

RVUs) will be 5,000 units in PT, 7,500 units in OT, and 700 units in ST. Space exists to address the needs of more patients. Note that workers' compensation provides an annual

limit of up to 24 PT and/or OT visit per year per injury. Jasper Gardens' 2015 staffing devoted co providing patient services (in FTEs) for this department will be