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Carbon-dating compliance: What happened when…

…and how responsible are you for the sins of the past (turns out, quite a bit).

Kind of a mixed bag of things this week, so please bear with me.

First up, in looking back over the last little while of survey activity, I keep looping back around to one (possibly unanswerable) question: How many of the survey findings being generated are the result of conditions that pre-existed the prior survey? I think we can all agree that there are noncompliant conditions lurking throughout our buildings (including that pesky loaded sprinkler head we talked about a couple of weeks ago), some of which (and perhaps quite a few) are the result of actions or inactions occurring a long time ago (in a galaxy almost too close to home). I’m going to guess there are few of us that have not encountered the angst of having a surveyor pop a ceiling tile or wriggle into some crawl space and find some condition that had previously escaped prying eyes (I suspect that the most common previously undetected finding relates to things attached to sprinkler piping and supports, which supports LS.02.01.35 being the most frequently cited Joint Commission standard). And, as onerous as it may be on the face of it (and every other aspect), we are on the hook for all of it (grandfathering of conditions can help in very limited ways, but there’s really very little in the way of grandfathering noncompliant conditions and practices).

For better or worse (likely more the latter than the former), in these increasingly resource-challenged times, it is almost impossible to ferret out every little imperfection. Particularly in the sense that noncompliance happens in three dimensions—square footage just doesn’t work for this process. So, the questions I ask of you, dear readers, are these:

  • Do you proactively attempt an exhaustive search of your facility from top to bottom (and all the nooks and crannies)?
  • Do you “roll the dice” and correct deficiencies as they appear and if there’s stuff out there, let the surveyors find them?

I’m keen to see how this is going to “split.” I know if we could we would take the higher road of proactivity, but not everyone is in that position.

One other item I’ve been hanging on to for probably longer than I should relates to the management of medical gas and vacuum systems. I would hardly think that this blog is the only resource for information, commentary, etc. (though I do like to think it’s an entertaining and perhaps randomly enlightening one), there is one dedicated to the management of medical gas systems, etc., that I think you’ll find useful (and since it doesn’t publish as often, it’s an easy one to add to your bloggy queue) is sponsored by Compliant Healthcare Technologies (CHT). Recently, Tim Richards at CHT penned a blog post on upcoming changes in NFPA 99 relative to medical gases, etc. As I’ve noted once or twice in the past, I really see NFPA 99 compliance as a likely source of heartburn for facilities and safety folks in the coming survey cycles, so any resource that can increase our operational understanding of what is actually required, etc. gives us a leg up on the survey front. I encourage you to check out the information.

As a final note, it appears that we are gearing up for another wild summer of weather and I wanted to take a moment to send best wishes to those in areas already in the throes of severe weather and those that may find themselves in the same. I do believe that, as an industry, we have done some extraordinary work in the practical preparations to deal with emergencies (I would feel better if appropriate preparedness would “drive” regulatory compliance a little more closely, but perhaps in time) and I trust that we all manage the coming season with minimal impact and disruption.

Immediate Jeopardy: How much do you want to wager?

With best wishes to Alex Trebek!

Over the last couple of weeks, the folks at the Centers for Medicare & Medicaid Services (we know them by the cleverly acronymic CMS) have been busy generating lots of guidance for the folks in the field, healthcare organizations and surveyors alike. One of these missives covers the revision of Appendix Q of the State Operations Manual to provide guidance to surveyors and, (by extension) folks charged with compliance at the organizational level, for identifying Immediate Jeopardy (IJ) conditions during surveys. For those of you that have not had the dubious fortune of encountering an IJ in your organization (and I dearly hope that trend continues), it is difficult to describe the impact this can have on an organization. Short of shutting the place down, I cannot think of a more—oh I don’t know, words really seem to fall short in describing the sheer awfulness of an IJ finding.

But as they say, forewarned is forearmed (more on that delightful turn of phrase here). So let’s chat a bit about how one gets to an IJ.

The pieces that comprise an Immediate Jeopardy finding go a little something like this (the entire notification can be found here):

“To cite immediate jeopardy, surveyors determine that (1) noncompliance (2) caused or created a likelihood that serious injury, harm, impairment or death to one or more recipients would occur or recur; and (3) immediate action is necessary to prevent the occurrence or recurrence of serious injury, harm, impairment or death to one or more recipients.”

I think you could probably imagine any number of scenarios that might fit that particular bill; by the way, one of the revisions to this guidance was a change to (2). In the revision, the term “likelihood” replaced “potential.” While I do think “likelihood” is a somewhat higher bar to meet than “potential,” I still see a lot of room for surveyor interpretation. Hopefully, the administration of this judgment call will be more judicious than not. Time will tell…

Fortunately, we do have the opportunity to get a “leg up” on the process by visiting the CMS surveyor training page and working through the education materials provided there (the education is open to providers, so don’t be scared off by the link). I have not yet partaken of the education (it’s on my to-do list) and I will surely provide an update in this space once I have done so.

Manage the environment, manage infection control risks

In looking back at 2018 (heck, even in looking back to the beginning of 2019—it already seems like forever ago and we’re only a week in!), I try to use the available data (recognizing that we will have additional data sometime towards the end of March/beginning of April when The Joint Commission (TJC) reveals its top 10 most frequently cited standards list) to hazard a guess on where things are heading as we embark upon the 2019 survey year.

First up, I do believe that the management of ligature risks is going to continue to be a “player.” We’re just about two years into TJC’s survey focus on this particular area of concern; and typically, the focus doesn’t shift until all accredited organizations have been surveyed, so I figure we’ve got just over a year to go. If you feel like revisiting those halcyon days before all the survey ugliness started, you could probably consider this the shot heard ’round the accreditation world or at least the opening salvo.

As to what other concerns lie in wait on the accreditation horizon, I am absolutely convinced that the physical environment focus is going to expand into every nook and cranny in which the environment and the management of infection control risks coexist. I am basing that prediction primarily on the incidence of healthcare-associated infections (HAI) and related stuff (and, as was the case with ligature risk, I suspect that having a good HAI track record is not going to keep you from being cited for breakdowns, gaps, etc.). We’ve certainly seen the “warning shots” relating to water management programs, the inspection, testing, and maintenance of infection control utility systems, management of temperature, humidity, air pressure relationships, general cleanliness, non-intact surfaces, construction projects, etc. Purely from a risk (and survey) management perspective, it makes all the sense in the world for the survey teams to cast an unblinking eye on the programmatic/environmental aspects of any—and every—healthcare organization. Past survey practice has certainly resulted in Condition-level deficiencies, particularly relative to air pressure relationships in critical areas, so the only question that I would have is whether they will be content with focusing on the volume of findings (which I suspect will continue to occur in greater numbers than in the past) or will they be looking to “push” follow-up survey visits. Time will tell, my friends, time will tell.

But it’s not necessarily just the environment as a function of patient care that will be under the spotlight; just recently there was a news story regarding the effects of mold on staff at a hospital in New York. TJC (as well as other accreditors including CMS) keeps an eye on healthcare-related news stories. And you can never be certain that it couldn’t happen in your “house” (it probably won’t—I know you folks do an awesome job, but that didn’t necessarily help a whole lot when it came to, for example, the management of ligature risks). Everything filters into how future surveys are administered, so any gap in process, etc., would have to be considered a survey vulnerability.

To (more or less) close the loop on this particular chain of thought (or chain of thoughtless…), the Centers for Disease Control and Prevention are offering a number of tools to help with the management of infection control risks in various healthcare settings, including ambulatory/outpatient settings. I think there is a good chance that surveys will start poking around the question of each organization’s capacity to deal with community vulnerabilities and these might just be a good way of starting to work through the analysis of those vulnerabilities and how your good planning has resulted in an appropriately robust response program.

And the wind blew the echoes of long faded voices: Some Emergency Management thoughts…

While the year seemed to start out relatively quietly on the emergency front (relative being a completely relative and arbitrary term—and perhaps never more so than at the moment), it appears that the various and sundry forces of nature (and un-nature) are conspiring to send 2018 out with a bang. From wildfires out West to curiously damp weather patterns in the East to some funky temperature swings in the middle, it seems preparedness levels are as critical an undertaking as ever (and frequently coming nowhere close to being over-resourced, but I guess there’s no reason that the “do more with less” mantra wouldn’t extend to the EM world), with a likely follow-up of focus by the accreditation preparedness panjandrums (more this than this, but I’m fine with either). And one area of vulnerability that I see if the regulatory noggins should swivel in this direction relates to improvements in educating folks on an ongoing basis (the Final Rule says annual, so that determines a baseline for frequency), including some sort of evidence that what you’re doing is effective. (I see lots and lots of annual evaluations that track activities/widgets without getting down to a means of determining effectiveness—another improvement opportunity!) The other “shoe” that I fear might drop is the inclusion of all those care sites you have out in the community. There are very (very, very) few healthcare organizations that are comprised of a single standalone facility; over time, acquisitions of physician practices and other community-based healthcare delivery settings have increased the complexity of physical environment compliance, including emergency management stuff. I don’t know that I’ve run into anyone who couldn’t somehow, to one degree or another, point to participation of the offsite care locations. But it typically comes as, if not quite an afterthought, then a scenario that kind of “grafts” the offsites into the exercise. And, much as I wish community exercises would include testing of response activities in which the hospital acts in a diminished or non-capacity (there’s always this sense that we’ll just keep bringing folks to the local ED), some of the events of this year have really impacted ready access to hospital services for communities. At any rate, if you have thoughts on how you are (or could be) doing a good/better job at testing preparedness across your whole healthcare network, I am all ears and I suspect that there might be some other attentive ears as well.

In closing for this week (a little late, but this truly shouldn’t be tied to just one day or week), my thanks to all that have served in the armed forces: past, present, and future. Your sacrifices continue to mean so much to our lives and I cannot thank you enough (but with the annual Day of Thanks coming up next week, I will surely try)!

Shine on you crazy fire response plan!

On the things I’ve been doing over the past couple of weeks has been reading through the EC/LS/EM standards and performance elements to see what little pesky items may have shown up since the last time I did a really thorough review. My primary intent is to see if I can find any “Easter eggs” that might provide fodder for findings because of a combination of specificity and curiosity. At any rate, while looking through the fire safety portion of the manual, I noticed a performance element that speaks to the availability of a written copy of your fire response plan. That makes sense to me; you can never completely rely on electronic access (it is very reliable, but a hard-copy backup seems reasonable). The odd component of the performance element is the specificity of the location for the fire response plan to be available—“readily available with the telephone operator or security.”

Now, I know that most folks can pull off that combo as an either/or, but there are smaller, rural facilities that may not have that capacity (I think my personal backup would be the nursing supervisor), so it makes me wonder what the survey risks are for those folks who don’t have 24/7 switchboard or security coverage. At the end of the day, I would think that you could do a risk assessment (what, another one!?!?!?) and pass it through your EC Committee (that kind of makes the Committee sound like some sort of sieve or colander) and then if the topic comes up during survey, you can push back if you happen to encounter a literalist surveyor (insert comment about the likelihood of that occurring). As there is no specific requirement to have 24/7 telephone operator or security presence (is it useful from an operational standpoint to do so, absolutely—but nowhere is it specifically required), I think that this should be an effective means of ensuring you stay out of the hot waters of survey. For me, “readily available” is the important piece of this, not so much how you make it happen.

At any rate, this may be much ado about nothing (a concept of which I am no stranger), but it was just one of those curious requirements that struck me enough to blather on for a bit.

As a closing note, a quick shout-out to the folks in the areas hit by various and sundry weather-related emergencies the past little while. I hope that things are moving quickly back to normal and kudos for keeping things going during very trying times. Over the years, I’ve worked with a number of folks down in that area and I have always been impressed with the level of preparedness. I would wish that you didn’t have to be tested so dramatically, but I am confident that you all (or all y’all, as the case may be) were able to weather the weather in appropriate fashion.

Changing (not so much) perspectives on survey trends: Infection Control and Medication Safety

By now I suspect that you’re probably seen/heard that the survey results for the first half of 2018 are only surprising to the extent that there are no surprises (well, maybe a small one, but more on that in a moment). There’s a little bit of jockeying for position, but I think that we can safely say that the focus on the physical environment (inclusive of environmental concerns relating to infection control and prevention) is continuing on apace. There’s a little bit of shifting, and the frequencies with which the various standards are being cited is a wee bit elevated, but the lion’s share of the survey results that I’ve seen are indicative of them continuing to find the stuff they will always be able to find in this era of the single deficiency gets you a survey “ding.” The continuing hegemony of LS.02.01.35 just tells me that dusty sprinklers, missing escutcheons, stacked-too-high storage, etc., can be found just about anywhere if the survey team wants to look for it.

One interesting “new” arrival to the top 10 is IC.02.01.01, which covers implementation of the organization’s infection control plan. I have seen this cited, and, interestingly enough, the findings have involved the maintenance of ice machines (at least so far) and other similar utility systems infection control equipment such as sterilizers (for which there is a specific EP under the utilities management standards). I suspect that what we have here is the beginning of a focus on how infection control and prevention oversight dovetails with the management of the physical environment. I know that this is typically a most collaborative undertaking in hospitals, but we have seen how the focus on the “low hanging fruit” can generate consternation about the overall management of programs. As I’ve noted countless times, there are no perfect environments, but if don’t/can’t get survey credit for appropriately managing those imperfections, it can be rather disheartening.

Couple other items of note in the September issue of Perspectives, mostly involving the safe preparation of medications. As you know, there are equipment, utility systems, environmental concerns, etc., that can influence the medication preparation processes. The Consistent Interpretations column focuses on that very subject and while the survey finding numbers seem to be rather modest, it does make me think that this could be an area of significant focus moving forward. I would encourage you to check out the information in Perspectives and keep a close eye on the medication preparation environment(s)—it may save you a little heartache later on.

Never say never: The ligature risk conversation continues…

I truly was thinking that perhaps I could go a couple more weeks without coming back to the ligature risk topic, but continued percolation in this area dictates otherwise. So here’s one news item and one (all too consultative) recommendation.

If you took a gander at the September issue of Briefings on Accreditation and Quality, you will have noted that the Healthcare Facilities Accreditation Program (HFAP) isn’t revising their existing standards in the wake of the recent CMS memorandum indicating that The Joint Commission’s (TJC) focus work on the subject of managing physical environment risks and behavioral health patients is an acceptable starting point (and I am very serious about that descriptor—I don’t see this ending real soon, but more on that in a moment). I’m not sure if HFAP makes as much use of Frequently Asked Questions forums as TJC does (and with that use, the “weight” of standards), so it may be that they will start to pinpoint things (strategies, etc.) outside of revising their standards (which prompts the question—at least to me—as to whether TJC will eventually carve out the FAQs into specific elements of performance…only time will tell). At any rate, HFAP had done some updating prior (already approved by CMS) to the recent CMS memorandum, but, in using existing CMS guidance (which tends not to be too specific in terms of how you do things), should be in reasonable shape. You can see a little more detail as to where the applicable HFAP standards “live” by checking out this and this. I would imagine that the other accreditation organizations are looking at/planning on how to go after this stuff in the field and I suspect that everyone is going to get a taste of over-interpretation and all that fun stuff.

In the “dropping of the other shoe” department, recent survey results are pointing towards a more concerted look at the “back end” of this whole process—clear identification of mitigation strategies, education of applicable staff to the risks and mitigation strategies, and building this whole process into ongoing competency evaluation. You really have to look at the proactive risk assessment (and please, please, please make sure that you identify everything in the environment as a risk to be managed; I know it’s a pain in the butt to think so, but there continues to be survey findings relating to items the survey team feels are risks that were not specifically identified in the assessment) as the starting point and build a whole system/program around that assessment, inclusive of initial and ongoing education, ongoing competency evaluation, etc. Once again, I would seem that we are not going to be given credit for doing the math in our (collective) head; you have to be prepared to “show” all your work, because if you don’t, you’ll find yourself with a collection of survey findings in the orange/red sections of the ol’ SAFER matrix—and that is not a good thing at all. We are (likely) not perfect in the management of behavioral health patients and that is clearly the goal/end game of this, but right now anything short of that has to be considered a vulnerability. If you self-identify a risk that you have not yet resolved and you do not specifically indicate the mitigation strategy (in very nearly all circumstances, that’s going to be one-to-one observation), then you are at survey risk. I cannot stress enough that (at least for the now) less is not more, so plan accordingly!

Wagging the dog: Can Accreditation Organizations influence each other?

In last week’s issue of HCPro’s Accreditation Insider, there was an item regarding the decision of the folks at the Healthcare Facilities Accreditation Program (HFAP) to update their Infection Control standards for acute care hospitals, with the intent of alignment with CMS expectations (you can find the article here) We’ve certainly covered the concerns relative to Legionella and the management of risks associated with aerosolizing water systems and this may only be a move to catch up on ground already covered by other accreditation organizations (our friends in Chicago already require the minimization of pathogenic biological agents in cooling towers, domestic hot- and cold-water systems, and other aerosolizing water systems), but I’m thinking it might also be something of a “tell” as to where survey focus might be drifting as we embark upon the second half of 2018. Certainly, waterborne pathogens are of critical importance to manage as a function of patient vulnerability (ideally, we want folks to get better during their hospital stays), so it makes perfect sense for this to be on the radar to some degree. At this point, the memorandum from CMS outlining their concerns has been with us for about a year, with an immediate effective date, so hopefully you are well-entrenched in managing those water systems. If this one is still on your to-do list, I think it’s probably advisable to making it a priority to get it to your “to-done” list. But you should definitely check out the latest “clarification” from CMS. While the memo indicates that this does not impose any new expectations or requirements, it does make it a little clearer as to what surveyors are supposed to be checking.

As I think Mr. Gershwin once opined about summer and the easiness of living, it would be nice to be able to set a spell and take one’s shoes off, but vigilance is always the order of the day.

On a somewhat lighter note, I just finished reading Our Towns – A 100,000 Mile Journey Into The Heart of America, which outlines the efforts of a number of (mostly smallish) municipalities across the United States in positioning themselves for a positive future (positive positioning—I kind of like that). The focus is mostly on the socioeconomics of different parts of the country, with a focus on how diversity can be employed in bettering a community (that’s probably a little ham-handed as a descriptor, but you can find an excerpt here if you like). As my work allows me to travel to a lot of places, while I haven’t been to a lot of the same destinations as the Fallows, I do recognize a lot of the stories and a lot of the challenges facing folks lately (and I think you might, too). I would describe the tone of the book as hopeful, so if you’re looking for something to read at beach/pond/summer cottage, etc., you might consider giving Our Towns a shot.

 

Inadvertent inundations: Oh, what fun! 2017 most frequently stubbed toes during survey!

As luck would have it, the latest (April 2018) edition of Perspectives landed on the door step the other day (it’s really tough to pull off the home delivery option now that it is an all-electronic publication) and included therein is not a ton of EC/LS/EM content unless you count (which, of course, we do) the listings of the most frequently cited standards during the 2017 survey season. And, to the continued surprise of absolutely no one that is paying attention, conditions and practices related to the physical environment occupy all 10 of the top spots (I remain firm in my “counting” IC.02.02.01 as a physical environment standard—it’s the intersection of IC and the environment and always will be IMHO).

While there are certainly no surprises as to how this list sorts itself out (though I am a little curious/concerned about the rise of fire alarm and suppression system inspection, testing & maintenance documentation rising to the top spot—makes me wonder what little code-geeky infraction brought on by the adoption of the updated Life Safety Code® and other applicable NFPA standards has been the culprit—maybe some of it is related to annual door inspection activities cited before CMS extended the initial compliance due date), it clearly signals that the surveying of the physical environment is going to be a significant focus for the survey process until such time as it starts to decline in “fruit-bearing.” I do wish that there was a way to figure out for sure which of the findings are coming via the LS survey or during those pesky patient tracer activities (documentation is almost certainly the LS surveyor and I’d wager that a lot of the safe, functional environment findings are coming from tracers), but I guess that’s a data set just beyond our grasp. For those of you interested in how things “fell,” let’s do the numbers (cue: Stormy Weather):

  • #1 with an 86% finding rate – documentation of fire alarm and suppression systems
  • #2 with a 73% finding rate – managing utility systems risks
  • #3 with a 72% finding rate – maintenance of smoke and other lesser barrier elements
  • #4 with a 72% finding rate – risk of infections associated with equipment and supplies
  • #5 with a 70% finding rate – safe, functional environment
  • #6 with a 66% finding rate – maintenance of fire and other greater barrier elements
  • #7 with a 63% finding rate – hazardous materials risk stuff
  • #8 with a 62% finding rate – integrity of egress
  • #9 with a 62% finding rate – inspection, testing & maintenance of utility systems equipment
  • #10 with a 59% finding rate – inspection, testing & maintenance of medical gas & vacuum systems equipment

Again, I can’t imagine that you folks are at all surprised by this, so I guess my question for you all would be this: Does this make you think about changing your organization’s preparation activities or are you comfortable with giving up a few “small” findings and avoiding anything that would get you into big trouble? I don’t know that I’ve heard of any recent surveys in which there were zero findings in the environment (if so, congratulations! And perhaps most importantly: What’s your secret?), so it does look like this is going to be the list for the next little while.

Thank you falletin me: Some survey-related (and otherwise random) thoughts

The first order of business is a word of thanks to anyone and everyone within the sound of my “voice” – I truly appreciate you (sometimes invisible) folks out there in the audience. It continues to be a rare treat having the opportunity to converse with you on a regular basis (the rarer treat is when I get to actually meet folks in the flesh—definitely a delightful happenstance when it occurs) and I hope that I’ve managed to carry on this little slice ‘o safety without being boring, pedantic, etc. Oftentimes, compliance stuff is rather more torturous than not, but what’s the point of doing something if you can’t have a little fun amidst the abject seriousness of it all…

Next up, a couple of items that have appeared during recent surveys that signal (in some instances) a clarification of intent and/or a change in the focus of the physical environment surveys. Some of this you will find endlessly aggravating, particularly if you get cited for it; some of it has the overpowering stench of inevitability as the regulatory folks find new and inventive ways to keep the numbers of findings at record levels. In no particular order:

 

  • In the wake of the clarifying information relative to the management of ligature risks, make sure that (and this is primarily in the ED/regular inpatient settings) for the risk items you have identified as being medically or clinically necessary/essential to the appropriate care of behavioral health patients, make sure that your risk assessment specifically identifies the inherent risks of the remaining risks. For example, if you need to have a medical bed (with side rails, etc.) in the room, make sure that all the specific risk elements of that (or “the”) medical bed are clearly enumerated in the risk assessment. Saw a survey result recently for which the finding was not that the bed was in the room (the finding specifically noted that the bed was medically necessary), but that the risk assessment did not clearly identify the individual components of the bed: side rails, electrical cord, etc. The survey finding indicated that the risk management strategy employed by the organization was appropriate (in this instance, using 1:1 staffing for the at-risk patients), the only “issue” was not identifying the component risks in the risk assessment. I think/hope that this is something of an overreach and if I find out that there is some clarifying information forthcoming, I will surely share it with you.
  • Those of you with older facilities (and perhaps some “younger” facilities as well) are often faced with the proliferation of electrical panels (and sometimes medical gas zone shutoff valves) that are located in spots for which it is almost impossible to ensure that equipment, etc., is not parked directly in front of the panel, etc. Sometimes the panels, etc., are located in the corridors (it really does make one appreciate electrical closets!); some of you may even have the abject misfortune of having electrical panels in your utility rooms (my condolences); and others have panels out in the operational area of busy locations like food services/kitchen areas. I wish that I had good news to impart, but there do seem to be at least a couple of surveyors heck-bent on citing each and every instance of obstructed access to electrical panels. And don’t get me started on corridor med gas shutoffs with electrical receptacles installed directly underneath. Sometimes I wonder if we would run into these types of conditions if the folks doing the design work actually had to live in the space once it is constructed…
  • Staying on the electrical side of things, I’ve also seen an increase in recent findings relating to the use (primarily in patient care areas) of relocatable power taps/power strips/etc. I know the appropriate management of these devices has been “hittable” for a little while now and perhaps there was an unspoken “honeymoon” period for the industry to get things going in the right direction. If that is the case, it appears that the honeymoon is over, so you (particularly if “you” are in the bucket for survey in the next little while) probably should focus a bit on power arrangements in the areas where equipment use and power needs tend to be exponential. I still think the resources provided by ASHE are worth checking out if you have not already done so. It just might save you a painful survey experience.

Closing out, I leave you with this thought/opportunity; I won’t pretend to have an answer for it, but perhaps someone out there in the audience might. Fortunately, it doesn’t happen very often to me personally, but as I get to visit and meet new folks all the time, I am always fascinated by a certain type of individual: they will pledge that they will do anything to help the cause, with the unspoken understanding that that help hinges on their not having to do anything. Sort of a “ask me anything and if it involves no effort on my part, I’ll be all over it.” Again, fortunately, there doesn’t appear to be a proliferation of these folks in healthcare, and if the sounds completely foreign to you, that’s great. But if anyone has any tips for managing the eager-to-pledge non-participant, I’m all ears.

A most joyous and restful Thanksgiving to you and yours!