Jasper Gardens Nursing Home SWOT Analysis

SWOT Analysis Template Strengths Weaknesses Opportunities Threats © 2016 Laureate Education, Inc. Page 1 of 1 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. 230 r I: Case 7: Jasper Gardens Nursing Home 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. Jasper Gardens Nursing Home SWOT Analysis

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 231 232 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 Nursing Home SWOT Analysis

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 seriv ces emphasize long-term residual services. In 2014, the ALOS for intermediate care patients is 2.8 years and has been increasing. Jasper Gardens Nursing Home SWOT Analysis

The average age of current residents is 87 and has slo wly 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 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 P T, 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 LNAs) tants ( , 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 Mid dleboro and Capital City. ORGANIZATION Jasper Gardens is organized using a flat management structure. Jasper Gardens Nursing Home SWOT Analysis

The senior management team reporrs to the administrator who in turn reports ro M ary 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. 233 234 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 ofJasper 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. Jasper Gardens Nursing Home SWOT Analysis

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 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. Jasper Gardens Nursing Home SWOT Analysis

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 235 236 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. W hen 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 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 positivel Jasper Gardens Nursing Home SWOT Analysis