ACO bill in House would waive 3-midnight requirement for skilled nursing care

Certain Accountable Care Organizations would be able to send Medicare beneficiaries to a skilled nursing facility without a prior hospital stay under a bipartisan bill recently introduced in the House of Representatives.

Increasing staff-to-patient ratios improves nurse safety, researchers find

A law setting mandatory nurse-to-patient staffing ratios has reduced the number of workplace injuries for registered nurses and licensed practical nurses in California, according to recently published findings.

Also in the news for Oct. 1, 2014 . . .

CMS releases new version of software for collecting assessment information ... CT hospitals must now inform patients of observation status ... CA assisted living facilities face multiple requirements under new laws ... Govt. launches Open Payments website

RACs collected nearly $2 million from skilled nursing facilities last year, report shows

Recovery Audit Contractors recovered $1.8 million in Medicare overpayments made to skilled nursing facilities in fiscal year 2013, according to a Congressional report released Monday.

OK nursing home worker threatened to behead colleague in a terrorist act, authorities say

Police in Oklahoma City have arrested a nursing home worker who allegedly threatened to behead another staff member out of solidarity with the Islamic State in Iraq and Syria, according to news sources.

Jewish Home Lifecare named Innovator of the Year

Jewish Home Lifecare named Innovator of the Year

Jewish Home Lifecare won the top award in the Innovator of the Year category in the third annual McKnight's Excellence in Technology Awards competition.

Also in the news for Sept. 30, 2014 . . .

CMS clarifies appropriate use of power strips in long-term care resident rooms ...GAO: Integrating Medicare and Medicaid may not reduce costs on dual-eligible care ... Brookdale discriminated against worker with fibromyalgia, EEOC claims ... State standards for physician access under Medicaid managed care vary widely, OIG finds

More programs drop out of Pioneer ACO pilot

The Pioneer Accountable Care Organization program is now down to 19 programs, out of an original 32, worrying those who have pushed for skilled nursing facilities to embrace the concept.

Elderly with complicated grief benefit from targeted program, study says

Complicated grief is an under-recognized problem in the elderly, but a specific treatment can help, a new study says.

Oklahoma nursing home wins top Quality honor in McKnight's Tech Awards

Oklahoma nursing home wins top Quality honor in McKnight's Tech Awards

Cedar Creek Living Center in Norman, OK, is the Gold Award winner in the Quality category of the McKnight's Excellence in Technology Awards. A national panel of judges chose Cedar Creek on the merit of its work in using technology to reduce the use of antipsychotics.

Also in the news for Monday, Sept. 29

Nursing homes in Connecticut fined for verbal abuse ... HHS announces $212M in grants to combat chronic disease ... National Association of Medicaid Directors lays out recommendations on managed care and modernizing program.

Next stage of HIPAA audits will move quickly and result in enforcement actions against providers, official says

Next stage of HIPAA audits will move quickly and result in enforcement actions against providers, official says

Impending audits could lead to penalties for healthcare providers not complying with health information privacy laws, an official stated Wednesday.

Senators push CMS to expand program for long-term care outside nursing homes

The Centers for Medicare & Medicaid Services should loosen regulations to allow more people to receive care in the community rather than in nursing homes, a bipartisan group of Senators wrote in a recent letter to the top CMS official.

MS assisted living worker fired on first day due to pregnancy, government charges

An assisted living facility in Mississippi fired a worker hours after she started on the job because of her pregnancy, according to a lawsuit filed Thursday by the Equal Employment Opportunity Commission.

Also in the news for Sept. 26, 2014 ...

New tool for managing dementia-related behaviors ... UCLA paper emphasizes need to educate family members on risks of 'turning' fractures in nursing home residents ... 80% of healthy seniors with memory lapses develop dementia within a 12 years

41% of multi-drug resistant infections are acquired when nursing home residents are hospitalized, more attention needed, researchers find

41% of multi-drug resistant infections are acquired when nursing home residents are hospitalized, more attention needed, researchers find

A significant proportion of multi-drug resistant infections in nursing homes originate in acute care hospitals, indicating that greater coordination between settings is needed, according to recently published findings.

Residents with Alzheimer's might forget poor care but the emotional damage is lasting, study shows

A nursing home resident with Alzheimer's might forget receiving poor or negligent care, but the bad feelings created by ill treatment still could persist, University of Iowa researchers say.

No ACOs have reliable interoperability with external organizations, survey finds

A widespread lack of interoperable technology threatens the Accountable Care Organization model, according to recently released survey results.

Also in the news for September 25, 2014 . . .

Nursing home staff widely supportive of hospice care in the facility, but fewer say it makes their job easier ... Clinical simulations are an effective replacement for on-site nurse training ... CDC: Diabetes rate has tapered off but not for seniors

NIH announces $10M in funding to look at gender differences in clinical studies

NIH announces $10M in funding to look at gender differences in clinical studies

The National Institutes of Health is releasing $10.1 million in supplemental funding for healthcare grant recipients to explore gender differences in their research. Men are overrepresented in studies, which can obscure findings, the NIH noted. This can be especially true of diseases affecting the elderly, such as cardiac disease.

Judge reverses Medicare appeal ruling in inpatient rehab case

A federal District Court in Louisiana has reversed a Medicare Appeals Council ruling over denials for rehabilitation claims, including one involving an assisted living resident.

Study: Beer ingredient boosted cognitive function in younger test subjects, not older ones

Xanthohumol, a flavonoid found in hops and beer, increased critical thinking skills in young mice but not in older ones, according to a new study.

Also in the News for Sept. 24, 2014

CNN documents resident with Alzheimer's disease who lives in LeadingAge community... CNAs charged with neglect, falsifying business records ... Veterans with multiple chronic conditions have less hospitalizations under home-based primary care, study says.

White House creates new national strategy on antibiotics

White House creates new national strategy on antibiotics

The Obama administration has unveiled a national strategy to combat antibiotic-resistant bacteria. It includes an executive order to direct the federal government to "reduce the emergence and spread of antibiotic-resistant bacteria and to help ensure the continued availability of effective treatments for bacterial infections."

Medicaid provider agreement remains legitimate during bankruptcy proceedings, judge rules

Medicaid must continue to make payments to a Florida nursing home undergoing bankruptcy proceedings, a federal judge rule recently.

Legislator pushes for more HCBS services for Medicaid beneficiaries

Medicaid beneficiaries would have an opportunity to receive more care in a home or community-based setting if a House of Representatives bill passes.

Also in the News for Sept. 23, 2014

Trial begins in $1 billion-plus nursing home case tied to Illinois candidate for governor ... Long shifts for nurses correlate to decline in quality, European study finds ... Legally married same-sex couples are family members under HIPAA, according to HHS guidance.

Also in the news for Sept. 22, 2014

ER support program can reduce hospital admissions among seniors, study says ... Researchers find defect that may lead to Alzheimer's ... Technical glitch may cause milions in payment delays for physicians who adopted EHRs

Enterovirus hits KY nursing home

Nine residents at the Heritage Hall nursing home are confirmed to have a strain of enterovirus, according to local reports.

AHCA applauds Senate passage of IMPACT Act

The Senate approved the Improving Medicare Post-Acute Care Transformation Act, drawing praise from the American Health Care Association and the National Association for the Support of Long Term Care.

Antipsychotics reduction goal raised to 30% by end of 2016, CMS and provider groups announce

Antipsychotics reduction goal raised to 30% by end of 2016, CMS and provider groups announce

Long-term care providers are being asked to reduce the use of antipsychotic medications among residents by 25% by the end of 2015, and 30% by the end of 2016. Providers have already achieved a 17.1% reduction since 2011.

CDC issues new guidelines on pneumococcal vaccine, says LTC flu vaccination rates remain low

CDC issues new guidelines on pneumococcal vaccine, says LTC flu vaccination rates remain low

Long-term care workers continued to have low rates of flu vaccination last season, despite there being 92% vaccination coverage overall among physicians and nurses, the Centers for Disease Control and Prevention said Thursday. The agency also said seniors should receive two doses of the pneumococcal conjugate vaccine.

AL operators accused of withholding $2M in unpaid overtime, minimum wages

Four California assisted living operators are facing eight felony charges related to wage theft, tax and insurance violations, according to local reports.

Three states to examine risk, reform in Medicaid project

Alabama, Washington and Nevada are participating in a yearlong Medicaid project that could help share risk between states and the federal government, the National Governors Association said this week.

Also in the news for Sept. 19, 2014

Americans are the most worried about losing their eyesight as they age, poll says .... AHCA says MedPAC Chairman is 'spot-on' with three-day stay comments ... Medicare Advantage enrollment rises for fifth straight year, CMS says.

Post-acute standardized assessment bill passes House

Post-acute standardized assessment bill passes House

A bill that would standardize data in post-acute settings moved closer to reality after a House of Representatives voice vote in its favor Tuesday. The House's approval of the Improving Medicare Post-Acute Care Transformation Act (IMPACT) drew praise from the American Health Care Association/National Center for Assisted Living.

ACA hasn't created more part-time workers, analysis says

Despite fears to the contrary, there's no evidence that the Affordable Care Act increased part-time work before 2014, according to a new analysis.

Also in the News for Sept. 18, 2014

Arkansas' charity protection statute could protect nursing home in lawsuit... Institute of Medicine releases end-of-life report ...Congressional roundtable group says Medicare telehealth rules need to be updated

Medicare Part B could have saved $110 million, OIG asserts

If the Medicare Part B program had used average Medicare Part D drug dispensing and fee rates, it would have saved the government $110 million in 2011, according to a report from the Department of Health and Human Services Office of Inspector General released Sept. 16.

House leader urges HHS to end settlements meant to cut Medicare backlog

The Department of Health and Human Services may not have had the authority to offer providers special settlements to help clear a huge backlog of Medicare appeals, a leading Congressman said in a recent letter to the agency. Rep. Kevin Brady (R-TX) is urging HHS to halt the new settlement process.

One-fifth of caregivers take 6 months or longer to choose a senior housing option for a loved one, poll finds

A significant number of people take six months or longer to choose a senior care or housing option for a loved one, recently released survey results showed.

CMS releases updated Minimum Data Set manual

CMS releases updated Minimum Data Set manual

The Centers for Medicare & Medicaid Services released an updated version of the Minimum Data Set 3.0 Resident Assessment Instrument manual Friday.

Also in the news for September 17, 2014 . . .

ACOs continue to improve quality but savings remain elusive ... Bladder training should be option No. 1 for urge incontinence in women, physicians group recommends ... Scottish association releases fall prevention guidelines for long-term care

$1.3 million settlement marks second recent deal over SNF supervision of therapy providers

$1.3 million settlement marks second recent deal over SNF supervision of therapy providers

A Maryland nursing home company has agreed to a $1.3 million settlement over charges that it did not prevent overbilling by its contracted therapy provider, federal authorities announced Monday. This is the second such settlement this month involving therapy company RehabCare Group East Inc.

MedPAC chairman: Three-day stay requirement is 'archaic'

The government should pay for skilled nursing care without a preliminary three-day hospital stay, and the recovery auditor program should be reformed, Medicare Payment Advisory Commission members said at a meeting Friday.

Nursing homes can't carve out billing, collections in arbitration agreements, AR Supreme Court rules

A nursing home arbitration agreement largely reserved the provider's rights to sue residents while limiting residents' legal options, causing it to fail a "mutual obligation" requirement, the Arkansas Supreme Court recently ruled .

Also in the news for September 16, 2014 . . .

Falls may cause post-traumatic stress in seniors, study finds ... Government issues new model notices of HIPAA privacy practices for providers to use ... Switch to ICD-10 could make it difficult to track patient safety trends

Assisted living communities continue to make a terrible first impression on prospective customers, university program finds

Assisted living communities continue to make a terrible first impression on prospective customers, university program finds

Assisted living communities consistently do not make a good first impression with prospective customers, and they haven't improved this skill set in the last decade, according to data from George Mason University in Virginia.

Latecomers to hospice frequently are male, have certain cancers, Penn researchers find

Men and patients with certain types of cancer are among those less likely to enroll in hospice, suggesting that healthcare providers should focus on presenting these groups with all their end-of-life care options, according to newly published findings.

Nursing homes should think twice before using a well-known tool for diagnosing depression, researchers say

A familiar tool for diagnosing depression in dementia patients might not be very effective in the nursing home setting, according to findings recently published in The American Journal of Geriatric Psychiatry.

Also in the news for September 15, 2014 . . .

GA puts controversial nursing home rate hike on hold ... Most Americans OK with gay couples in assisted living ... Commerce Dept: Healthcare revenue rebounded in Q2

Giving nurses more control over their schedules could lower pressure ulcer rates, findings suggest

Giving nurses more control over their schedules could lower pressure ulcer rates, findings suggest

Nursing homes might be able to cut their pressure ulcer rates by giving nurses more control over when they work, according to findings forthcoming in the Journal of Applied Gerontology.

Nursing homes tend to administer high-risk medications to returning residents, study shows

Nursing homes may be ratcheting up high-risk medication use for certain residents who return to the facility after a stay in the hospital, according to recently published findings.

Nursing home agrees to $225,000 settlement over charges of asbestos exposure

A California nursing home has agreed to a $225,000 settlement over charges that it did not handle asbestos properly during a renovation, according to local news sources.

Also in the news for September 12, 2014 . . .

AMDA to feds: Will assisted living be excluded from plan to reimburse chronic care services? ... People with rare type AB blood have doubled risk of cognitive decline, researchers say ... Grieving older people are more at risk for infections than younger people, research shows

Long-Term Care Commission members shed light on financing deliberations, urge continued political pressure

Long-Term Care Commission members shed light on financing deliberations, urge continued political pressure

Long-term services and supports should be a major focus of next year's White House Conference on Aging, and advocates should work to keep financing reform in the spotlight during the upcoming mid-term Congressional elections, according to members of the federal Commission on Long-Term Care.

Facility failed to address erratic behavior of nurse who later shot a resident and herself, lawsuit charges

A Pennsylvania nursing home failed to intervene when a nurse began acting erratically in the days before killing herself and a resident last November, according to a lawsuit filed Friday in Lackawanna County Court.

NC nursing home reaches $35,000 settlement over charges it discriminated against disabled worker

A North Carolina long-term care company has reached a $35,000 settlement over charges that it discriminated against a cook/dietary aide with a physical impairment, the Equal Employment Opportunity Commission announced Wednesday.

Also in the news for September 11, 2014 . . .

Anti-anxiety drugs increase Alzheimer's risk in seniors ... Healthcare workers wash their hands more when around colleagues

More than 50% of dementia patients in nursing homes are given potentially pointless and dangerous drugs when near death, study finds

More than 50% of dementia patients in nursing homes are given potentially pointless and dangerous drugs when near death, study finds

Nursing homes administer largely pointless and potentially harmful drugs to a majority of residents with advanced dementia, according to findings in Jama Internal Medicine.

Little Sisters of the Poor presses contraceptive mandate case, says government's latest solution isn't good enough

The Little Sisters of the Poor is not satisfied with the federal government's recent regulations and will continue its challenge against the Affordable Care Act's contraception mandate, the Catholic long-term care provider stated in a legal brief filed Monday.

Genesis nursing home agrees to $75,000 settlement over charges of discriminating against a deaf worker

A New Jersey nursing home has agreed to a $75,000 settlement to resolve charges that it discriminated against a potential employee because of his deafness, federal authorities announced Monday.

Also in the news for September 10, 2014 . . .

DOJ launches elder abuse website with resources for working with victims ... CNA and her daughter stole $60,000 from nursing home resident, authorities charge

Today's the day: McKnight's Fall Online Expo offers 3 free CE webcasts

Today's the day: McKnight's Fall Online Expo offers 3 free CE webcasts

McKnight's second Fall Online Expo takes place today, bringing long-term care professionals three free webcasts for continuing education credit. Experts will discuss regulatory compliance, strategies for working with difficult families and residents, and tips for managed care success.

CMS should publicly push Congress to reform therapy payment system, long-term care provider association urges

The Centers for Medicare & Medicaid Services should openly urge Congress to change the way therapy services are reimbursed, the nation's largest long-term care provider association stated in recent written comments to CMS Administrator Marilyn Tavenner.

Long-term care facilities could collect residents' unused prescription drugs under new federal regulation to combat abuse

Long-term care facilities will have a role to play in a new prescription drug take-back effort aimed at curbing addiction and abuse, U.S. Attorney General Eric Holder announced Monday.

Also in the news for September 9, 2014 . . .

Nearly 50% of older adults need help with daily activities and long-term care system is falling short, analysis finds ... Single-dose flu drug safely alleviates symptoms in clinical trials ... Trial in nursing home case involving IL gubernatorial candidate Bruce Rauner set for Sept. 22 ... Nursing home owner tells jury he paid former CT governor through shady arrangement

$3.8 million settlement shows nursing homes must oversee their therapy providers, feds say

Two long-term care companies have agreed to a $3.75 million settlement over charges that they failed to sufficiently control an outside therapy provider's billing and care practices, the Department of Justice announced Friday.

One day to go: McKnight's Fall Online Expo returns with 3 free CE webcasts

One day to go: McKnight's Fall Online Expo returns with 3 free CE webcasts

McKnight's second Fall Online Expo will take place tomorrow, featuring three free webcasts on pressing long-term care issues. Attendees can earn continuing education credit while learning about regulatory compliance, strategies for handling difficult families and residents, and tips for finding success with managed care.

The government plans a 'computer matching program' to combat improper Medicare, Medicaid payments

The government plans to start a "computer matching program" to reduce improper payments from government health programs to providers and other entities, the Centers for Medicare & Medicaid Services announced in a memorandum Friday.

Also in the news for September 8, 2014 . . .

CMS issues memo on therapy coding changes ... Home care workers join strikes for a higher minimum wage ... National Assisted Living Week kicks off

SNFs may not be able to take on hospital patient overflow during disasters, report on Katrina and Midwest floods shows

SNFs may not be able to take on hospital patient overflow during disasters, report on Katrina and Midwest floods shows

Disaster preparation plans should not necessarily count on skilled nursing facilities to handle additional patients that hospitals cannot accommodate, according to newly published findings.

Massive HIPAA breach linked to Heartbleed bug highlights huge security risk facing healthcare sector, expert says

A historically large data breach at Community Health Systems has been linked to the infamous Heartbleed bug, which could lead to a "tipping point" in how healthcare providers approach data storage and security, according to Forbes contributor Dan Munro.

LTC nurse could face 4 years in prison for alleged morphine mistake, cover-up

A nurse has been indicted for allegedly administering morphine to a nursing home resident by mistake and covering up her error while the resident experienced a health emergency, New York Attorney General Eric Schneiderman announced Thursday.

Also in the news for September 5, 2014 . . .

Research breakthrough suggests new therapy for diabetic wounds ... Growing ranks of female researchers put the focus on why Alzheimer's attacks women, Washington Post reports ... 3 former nursing home workers face multiple abuse and neglect charges

Nursing homes face federal False Claims Act charges for allegedly overmedicating residents with antipsychotics, other drugs

Nursing homes face federal False Claims Act charges for allegedly overmedicating residents with antipsychotics, other drugs

Two California nursing homes routinely overmedicated residents with antipsychotics and other drugs "for the convenience of management," according to federal charges announced Wednesday by the Office of Inspector General.

Federal judge blocks new RAC contracts

Adding to the ongoing controversy around Medicare's Recovery Audit Contractor program, a judge has ruled that the government cannot award new RAC contracts until disputed payment terms are resolved.

Expenditures on nursing home, CCRC care projected to rise 69% over next decade

Spending on nursing care and continuing care retirement communities is expected to roughly keep pace with total U.S. healthcare spending during the next decade, according to a government report released Wednesday.

Also in the news for September 4, 2014 . . .

State AG seeks dismissal of charges that a health inspector drove nursing home residents to revolt ... Nursing home lawsuit over active shooter drill is part of a larger pattern, WSJ reports ... Google, AbbVie to tackle age-related diseases ... Antimicrobial lock solutions reduce catheter-associated infections by 70%

CMS offers a deal to hospitals to cut Medicare appeals backlog

CMS offers a deal to hospitals to cut Medicare appeals backlog

In an effort to trim the huge backlog of Medicare claims appeals that has stymied long-term care and other providers, the government is offering a new way to settle some cases. Hospitals could receive a partial payment if they withdraw appeals related to inpatient status, the Centers for Medicare & Medicaid Services announced in an email Friday.

Long-term care financing is especially hard for older people who rent their homes, and that number is rising: Harvard/AARP report

Younger baby boomers might have particularly difficult problems paying for long-term care because they have lower rates of homeownership than previous generations, according to a report released Monday by the Harvard Joint Center for Housing Studies and the AARP.

NJ physicians to face charges that they kept people as inpatients to qualify them for SNF coverage, judge rules

A whistleblower can continue to pursue charges that a number of New Jersey physicians improperly designated Medicare beneficiaries as inpatients and sometimes prolonged their hospital stay to qualify them for skilled nursing care, a federal judge recently ruled.

Also in the news for September 3, 2014 . . .

Scientists develop 'e-nose' for sniffing out C. diff ... MDS data aligns well with Medicare claims, research confirms ... Seniors might improve immune response by popping an ibuprofen

CMS updates coding instructions for hospice site of service, principal diagnosis

CMS updates coding instructions for hospice site of service, principal diagnosis

A new Medicare hospice manual update includes instructions for which principal diagnosis codes are acceptable, and clarifies which codes should be used for services in a skilled versus non-skilled nursing facility. Billing staffs should be aware of these changes, which go into effect Oct. 1, the Centers for Medicare & Medicaid Services stated in an educational memorandum sent Friday via email.

Vast majority of nursing home residents chronically constipated, and it's not well controlled, researchers say

Chronic constipation is highly prevalent in nursing homes and not well controlled, leading to a high likelihood that residents develop fecal impaction, according to findings from a first-of-its kind study.

Federal judge dismisses nursing home 'kickback' case; upholds large X-ray company's 'swapping' method of billing

The way mobile x-ray company Mobilex bills nursing homes is acceptable, a federal judge recently determined. Mobilex is the nation's largest provider of mobile diagnostic services. It had been facing whistleblower charges that it effectively paid kickbacks to nursing homes through an arrangement known as "swapping."

Also in the news for September 2, 2014 . . .

Inspectors cite LA nursing homes for dangerous practices but supervisors change reports to benefit facilities ... Feds join whistleblower suit charging that hospice billed for ineligible patients ... Magnetic pulses to the head could boost memory in people with Alzheimer's, Northwestern researchers say

Profile: AHCA's money player

Profile: AHCA's money player

If there's a prevailing theme around the hours American Health Care Association senior fellow Elise Smith keeps, it's that they are constant.

Residents cheer tractor parade

Residents cheer tractor parade

Many residents of the Oskaloosa Care Center in southern Iowa used to be farmers. They're reminded of their past by the cornfield next to the nursing home — and, once a year, by a parade of antique tractors.

Success without silos

Success without silos

Minimum data set coordinators should get as much support as possible from colleagues as they navigate data set changes and ever-evolving requirements

Enhancing well-being

Enhancing well-being

I set out to re-examine dementia from a different framework — one that takes us beyond "interventions" and "programs" to a proactive, strength-based approach.

Redoing readmissions

Redoing readmissions

When people are discharged from the hospital following an illness, injury or surgery, that's often not the end of the story.

Dirty hands needed

Dirty hands needed

Gardening is magic. Gardening is mindfulness. Gardening is therapist, physician and personal trainer without spandex or a copay. And now researchers have confirmed that gardening can help nursing home patients suffering with dementia.

Complainers, take note: This one is all for you

Complainers, take note: This one is all for you

As a long-term caregiver, you get yelled at, told off, put down and dumped on regularly — and that's during good weeks.

They're not all ingrates

They're not all ingrates

It's no surprise that staff turnover remains alarmingly high at many long-term care communities.

You're the detective

You're the detective

In the evidence-based healthcare world, you need to become a real Sherlock (or Shirley) Holmes to take your clues (data) and put them together logically (analyze the data) to make analytics-based decisions to solve your facility's most challenging mysteries.

Taking the final steps

Taking the final steps

Ashby Ponds opens all levels of care as it realizes the vision for a fully operating continuing care retirement community in Virginia

Nurse sues facility over live hostage drill

A nurse who said she was not warned that she would be threatened and "taken hostage" by a gunman during an emergency preparedness drill is suing her former Colorado nursing home employer for compensatory, punitive and actual economic damages.

Provider: Judge improperly prodded $14 million award

Provider: Judge improperly prodded $14 million award

Representatives of a now-defunct Massachusetts nursing home say they will appeal a jury's $14 million award to the family of a former resident who died in 2008, partly because they feel a judge inappropriately prodded jurors into an inflated figure.

60 seconds with ... Ed McMahon, Ph.D.

60 seconds with ... Ed McMahon, Ph.D.

Q: You recently received the Mary K. Ousley Champion of Quality Award from the American Health Care Association. What are some of the biggest current obstacles to improving quality in long-term care?

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