HCBS Settings Final Rule – Intensive Supervision

To: Provider Directors


The Department of Health Care Policy and Financing (HCPF) sent an Operational Memo to Home and Community-Based Services (HCBS) providers to summarize direction given to case managers and providers regarding the application of the rights modification process for individuals in need of one-on-one (1:1), line-of-sight, and/or 24-hour supervision, under the HCBS Settings Final Rule. Please review the attached Operational Memo. 

For further information, please see contact information provided in the Operational Memo. 

Intensive Supervision Memo

OASIS D Classes *FREE*

To: Federally Certified Skilled Home Health Facilities Administrators, Directors of Nursing, OASIS Coordinators, Billing and Coding Personnel, Licensed Home Health Facilities Administrators

From: The Education and Technical Assistance (ETA) Branch of the Health Facilities and Emergency Medical Services Division (HFEMSD)

ETA will offer classes on specific OASIS topics in Montrose, Aurora, Colorado Springs, Longmont and Denver featuring OASIS D items and guidance. Aurora is filling fast. You may choose to take sessions all at once or individually as your interest and needs dictate. All registration is first-come, first-served, even for sessions within a hosting facility.

ETA reserves the right to cancel classes with low registration. Early registration is helpful.

OASIS D Basics (One Session): Course ID 1082008
This beginning three-hour class is how to get started with OASIS D.

OASIS D Item-by-Item (2 Sessions): Course ID 1082009
This practical application class reviews item-by-item data set completion. We will follow Mrs. Green’s assessment, which will require two sessions to complete. Attendance at both sessions is required to complete this class.

OASIS Quality Measures (One Session): Course ID 1066910
This course assumes familiarity with the OASIS D Item Set, covering more advanced content and application.

To see additional session details and register for on-site attendance for one of these offerings:
1. Go to http://www.train.org/ 
2. Log in to your existing TRAIN account, or new users click “Create an Account”
3. Once you’ve logged in, or created an account, Search (top right) for the appropriate Course ID. (See above for desired training)
4. Click link for desired course.
5. Click the “Registration” tab.
6. Click the “Register” button for the session you wish to attend.
7. Remember to register separately for each desired course.

A detailed example of the above process (if needed)

Questions?: Please email betty.metz@state.co.us

Call for cases: Peritonitis in patients receiving peritoneal dialysis

To: Facility Administrators, please share with your staff and your Medical Directors

From: Healthcare Associated Infections Program within Disease Control and Environmental Epidemiology.

Two health departments outside Colorado and CDC are currently investigating a cluster of peritonitis cases among patients undergoing peritoneal dialysis. Many of the peritonitis events under investigation were caused by Serratia marcescens or other gram-negative pathogens. There are no current cases in Colorado known to the Colorado Department of Public Health and Environment.

CDC is requesting U.S. clinicians report peritonitis cases in peritoneal dialysis patients treated by the same center that meet one of the following criteria:

– Two or more patients with peritonitis caused by Serratia spp. at the same dialysis center occurring since January 1, 2019.
– An increase in peritonitis caused by gram-negative organisms in patients receiving peritoneal dialysis.

To report identified cases in Colorado, please contact Alana Cilwick at Alana.Cilwick@state.co.us(please include “Peritonitis cases” in the subject line of your email) or via phone at 303-692-2727. 

Home Care Advisory Committee Membership

To: Home Care Providers and Consumers of Home Care Services 

From: Steve Cox, Program Manager, Home Care Services 

The Health Facilities and Emergency Medical Services Division of the Colorado Department of Public Health and Environment is currently accepting applications for Home Care Advisory Committee Members. 

Per statutory requirements, Home Care Advisory Committee members serve on a voluntary basis and are appointed by the Executive Director of the Colorado Department of Public Health and Environment. This committee represents providers and consumers of skilled home health services, personal care services, members of the community who are home care consumers, seniors or representatives of home care consumers, providers of Medicaid services, providers of in-home support services, and is represented by employees of the Department of Health Care Policy and Financing and Human Services. 

The Home Care Advisory Committee members meet to review and discuss the rules that govern the licensing of home care agencies in the State of Colorado and make recommendations to both the Colorado Department of Public Health and Environment and the State Board of Health. Currently, the meetings are held quarterly for two hours at the Colorado Department of Public Health and Environment. 

If you are interested in serving as a committee member, please click on the link below for the application. 

If you have questions please contact Steve Cox, Home Care Services Manager at 303-692-2981 or Steve.Cox@state.co.us or Kristi Uitich, Home Care Services Supervisor at 303-692-6328 or Kristi.uitich@state.co.us

HCAC Application

HHA IDR Committee Meeting

This blog publishes information typically sent through the Health Facilities Web Portal to health care entities regulated by the Colorado Department of Public Health and Environment. Please note that the Web Portal is the official medium for business communication between the Department and licensed and Medicare/Medicaid certified health care entities. Health care entities should continue to monitor their portal accounts routinely.

Small ALR Facility Workgroup meeting June 20, 2019

To: Assisted Living Residence Providers and Stakeholders 

From: Elaine McManis, Health Facilities and Emergency Medical Services, Deputy Division Director

The next ALR Small Facility Workgroup meeting will be Thursday, June 20, 2:00-4:00 p.m., Building C, Room C1D on our Cherry Creek Campus. 
All non-CDPHE staff must sign in with security in Building A and get a guest badge before proceeding to Building C.

To participate by telephone:
Step #1: Dial 1-712-770-8066 
Step #2: When prompted, dial participant passcode 727084
Step #3: You will be on music hold until a few moments before 2:00 P.M.
Step #4: Very important: Please press 4* and mute your telephone to prevent background noise. 

If you would like to make a comment or ask a question, press 4* to unmute. When you are finished talking, please re-mute your telephone using 4* again. 

Very Important: Do not use speakerphones or wireless headsets; they are not compatible with the audio conferencing technology.

Meeting documents can be found at: https://drive.google.com/drive/folders/1NNrHpgqtwZHG51sOk3JTEMXXM7mgI0JW

Is Abortion Good or Evil?

Genesis 11:1-9 New Revised Standard Version (NRSV) 1: Now the whole earth had one language and the same words. 2: And as they migrated from the east, they came upon a plain in the land of Shinar and settled there. 3: And they said to one another, “Come, let us make bricks, and burn them thoroughly.” And they had brick for stone, and bitumen for mortar. 4: Then they said, “Come, let us build ourselves a city, and a tower with its top in the heavens, and let us make a name for ourselves; otherwise we shall be scattered abroad upon the face of the whole earth.” 5: The LORD came down to see the city and the tower, which mortals had built. 6: And the LORD said, “Look, they are one people, and they have all one language; and this is only the beginning of what they will do; nothing that they propose to do will now be impossible for them. 7: Come, let us go down, and confuse their language there, so that they will not understand one another’s speech.” 8: So the LORD scattered them abroad from there over the face of all the earth, and they left off building the city. 9: Therefore it was called Babel, because there the LORD confused the language of all the earth; and from there the LORD scattered them abroad over the face of all the earth.

There was a time in America when we were one people. There was a time when nothing we proposed to do seemed impossible. Our communal tower touched heaven and we certainly made a name for ourselves. Since then, a different type of Lord, similarly threatened by our success, has confused our language in a new and more insidious manner to the point where we no longer understand each other’s speech, and a frustrated populace gave up on trying, reverting to primate screeching and screaming instead. It is painful to watch, and it is agonizing to participate in the decaying remnants of our once glorious public discourse.

This is not about who says tomato and who says tomahto. The modern confusion occurs when I say tomato and you hear cucumber. There is no way for us to cook some spaghetti sauce for dinner with my tomato, or tzatziki with your cucumber. I don’t understand why I should chop some dill for the sauce when basil and oregano are the obvious choices, and you have no idea why I’m trying to boil a big pot of water instead of grabbing that Greek yogurt container from the fridge. Salt and garlic are the only things we can agree on, although in vastly different amounts, but nobody can survive on salted garlic. And so, we end up yelling at each other, and eventually we both go to bed angry, exhausted and hungry, each one of us convinced the other one is a hateful idiot and a traitorous saboteur of dinners. The Lord has prevailed.

Today, when I say Socialism, I see a democratic nation with a generous welfare system and thriving private economy, like Sweden or Denmark. You see Cuba or Venezuela, with millions starving in the streets while murderous, mustached dictators are wallowing in palatial riches. When I say Capitalism, I see hundreds of thousands of businesses innovating and competing to serve their customers while creating a land of plenty for all. You see racist, bigoted, exploitative tyranny of a few billionaire owned corporations, employing slave labor tactics to enrich themselves further while the rest of us starve to death. And that’s where the conversation ends, and the yelling commences. There can be no further discussion, no objective analysis, no learning and certainly no compromise. From both our perspectives, this is a fight between Good and Evil. You don’t discuss things, let alone compromise, with Evil.


Now let’s discuss abortion, which is perhaps the ultimate example of how fake language acts as a paralyzing venom in service of our predators. If you listen to the public debate now raging on social media and all other media, you would surmise that the battle lines are drawn between two distinct camps. The “pro-choice” camp stating that abortion is Good, without any caveats, and the “pro-life” camp which insists that terminating a pregnancy is Evil, again with no caveats. If you propose to restrict abortion in some cases, you are enslaving women. If you suggest allowing some abortions in special circumstances, you are a baby killer. Both pro-choice and pro-life terms were carefully selected to make polite debate impossible. You cannot be anti-choice or anti-life without being Evil. There is no terminology for anything in between. Oh sure, you can launch into a tirade, but nobody will listen to Evil.

Fake language creates fake realities. Few if any Americans are absolutist pro-life or pro-choice. There is a spectrum of opinions and feelings that was rendered all but inaudible once the screeching, screaming and yelling has begun. Recent polls (grossly tilted towards non-religious people) show that while most Americans label themselves pro-life or pro-choice, only 27% (at most, and likely a lot less) are firmly entrenched at the ends of the spectrum. The remaining vast majority is somehow rendered irrelevant in the current shouting match. If you want to stay relevant in this circus, we call public debate, or rather electioneering politics, you must recite the precise words of the gospel. And when opposing gospel reciters meet, this is what Babel sounds like:

Pro-death: Government has no business telling women what to do with their bodies. My body, my choice. Male members of the old white patriarchy have no say in this debate anyway, because they don’t have a uterus. Besides, the Supreme Court decided this already and we have a constitutional right to abortion.

Pro-coercion: The Supreme Court decision was wrong and must be overturned. Abortion is murder. Plain and simple. You don’t have a right to murder other persons, even if they were not born yet. Killing a baby in the eighth or ninth month of pregnancy, by tearing her to pieces in the womb, and finishing the job after birth if she survives, is infanticide. Is that okay with you?

Pro-death: Do you seriously want to prosecute and jail a twelve years old girl who was raped by her uncle and got pregnant? Do you want to force little girls to carry babies? Those late abortions don’t really happen, except in extreme cases to save the woman’s life. It’s a far-right myth. You’re watching too much Fox News.  So that’s a straw man, but sure go ahead, I’m sure you don’t care if women die and children are jailed. 

Pro-coercion: Oh yeah, you go ahead, lecture me about caring for children, while you massacre hundreds and thousands of babies every year. And if that wasn’t enough, now I’m supposed to finance your Commie holocaust. F*** off….

Pro-death: You’re the biggest hypocrite I’ve ever met, and a liar too. If you care so much for children, how come you refuse to fund public education and early childhood programs? How come you keep sending so many black boys to prison? You’re just a racist Trumpkin, in addition to clearly being a rabid misogynist, and I bet you love putting immigrant children in cages too. You can f*** off yourself… Idiot…

And on and on it goes. Note that both sides put forward reductio ad absurdum arguments, while responding solely with tangentially related ad hominem attacks on their interlocutor. Why is that? Well, maybe it’s because nobody in their right mind can defend imprisoning twelve-year-old rape victims, just like nobody in their right mind can defend terminating a perfectly good baby five minutes before it is due to be born. It is disheartening, but it is also a good sign that we haven’t gone completely mad just yet. Another thing to notice is that on both sides people are either not fully aware of simple facts or would much rather conduct this Babylonian conversation on a fact-free emotional level.

Did you know, for example, that when the Roe v. Wade decision was issued, plenty of progressive voices found it poorly reasoned and even counterproductive? None other than Justice Ruth Bader Ginsburg is on the record saying that “the Court ventured too far in the change it ordered and presented an incomplete justification for its action”. Now make no mistake, RBG is staunchly pro-choice, but the Court may have done more harm than good here, by impatiently stepping out of the judicial lane and into the legislative one, at a time when progress was slowly but surely being made in various States.

Did you know that in Roe the Court asserted that a woman’s right to an abortion is “fundamental”, but only for the first three months of a pregnancy and only in consultation with a physician? After that the State has its own rights to intervene with or outright deny this fundamental right, due to competing interests. Later, in Planned Parenthood v. Casey, the court discarded the medically outdated trimester framework and introduced a dynamic “viability” concept, bolstering the power of States to interfere with a woman’s fundamental right to an abortion, as long as no “undue burden” is imposed on the woman. Neither Roe nor Casey are giving women full rights to terminate a pregnancy whenever and however they see fit. Both Roe and Casey grant States the right to curtail reproductive autonomy of women, if they so choose.

In 1973 the Court decided Roe with a clear 7 to 2 majority. Ten years later, in Casey, the Court splintered into multiple plurality opinions with only one narrow 5 to 4 majority decision to uphold Roe with adjustments in favor of the States. I can’t even begin to guess how the lines will be drawn if an abortion case comes before the Court today. We share this country with one third of a billion other people. Societal consensus on important issues is rare, difficult, and takes decades if not centuries of patient and serious discourse to build. That’s why we have fifty States. We either relearn how to meaningfully communicate and compromise with each other or we will perish in most unnecessary and painful ways.

How to Counter Medical/ Health Care/ Public Health Disinformation

It used to be so simple.  Yes, we had to cope with deception in marketing.  Commercial sponsors of clinical research were known to manipulate the research, and even suppress research with results unfavorable to them.  Key opinion leaders spun medical education and the media.  But it was all releatively straightforward in some senses.  It was all at least mostly based on medical knowledge and clinical research.  The purposes of the spin and deception were commercial: the goal was selling more products or services.  With some digging, the conflicts of interest sometimes could be discovered.

But that was before stealth health policy advocacy morphed into propaganda and disinformation (look here).  Disinformation campaigns were everywhere, and even in one case, were supercharged by a disinformation campaign run by a hostile foreign power, apparently meant to destabilize western democracies (look here).  We are now drowning in a sea of propaganda and disinformation.

What can health care professionals do before we go under?

How Medical/ Health Care/ Public Health Disinformation Works

A May, 2019, MedPage article entitled “a prescription for treating fake health news,” noted how the rise of social media enabled disinformation:

Although patients’ misconceptions, lack of logic, and superstitions have complicated the work of doctors since the first doctors existed, the advent of social media has taken the problem to a new dimension.

With social media, patients can more easily find misinformation, says Dominique Brossard, PhD, chair of the University of Wisconsin-Madison Department of Life Sciences Communication. They can also share that misinformation more easily.

The articles listed a series of factors that increased the potency of disinformation spread by social media:

Lies may spread faster than the truth. Researchers at the Massachusetts Institute of Technology analyzed a set of about 126,000 news stories disseminated on Twitter from 2006 to 2017. They found that more people retweeted false information than true information. The researchers speculated that people may have passed along the fake news more readily because it was more novel and evoked more emotion.

In addition, social media enhances repitition of false messages:

The wide dissemination means that some patients may receive the same false messages repetitively. In another study, Yale researchers found that the more often people receive the same message, the more likely they are to believe it, even when the message is labeled as disputed by social media fact checkers.

Also, people attend more to the immediate source of information than its origin:

when people are evaluating the reliability of health information shared online, they care more about who shared the information than they do about the original source, according to an American Press Institute study.

The article went on to discuss how individual physicians could help individual patients understand how disinformation may dupe them.  However, this is is a retail solution to a huge wholesale problem.

What Can Health Professionals Do on Social Media to Counter Disinformation?

Note that while we know something about how medical/ health care/ public health disinformation is spread, we still know little about the cause of the plague.  Unlike the old style of deception, it is not obviously based on the self-interest of companies trying to sell products or services.  Nonetheless, we need to fight disinformation even if we do not fully understand its causes.  And we know a little bit about how that could be done. The bottom line is that health care professionals need to use the same social media that is spreading disinformation to counter it with the truth.

Two recent articles specifically encouraged physicians to get online now. 

[An original Compaq 286 Portable, the original Microsoft DOS based “portable,” actually “luggable” computer]

In June, 2019, a CNBC article profiled one physician pioneer who urged all concerned health care professionals to confront disinformation on social media.

The antidote to fake health news? According to Austin Chiang, the
first chief medical social media officer at a top hospital, it’s to
drown out untrustworthy content with tweets, pics and posts from medical
experts that the average American can relate to.

Chiang is a Harvard-trained gastroenterologist with a side passion for social media. On Instagram, where he refers to himself as a ‘“GI Doctor,’ he has 20,000 followers, making him one of the most influential docs

Note that,

Every few days, he’ll share a selfie or a photo of himself in scrubs
along with captions about the latest research or insights from
conferences he attends, or advice to patients trying to sort our real
information from rumors. He’s also active on Twitter, Microsoft’s LinkedIn and  Facebook (which owns Instagram).

He exhorted his fellow physicians to get involved:

‘This is the biggest crisis we have right now in health care,’ said
Chiang. ‘Everyone should be out there, but I realize I’m one of the

According to Chiang, doctors have historically been
reluctant to build a following on social media for a variety of reasons.
They view it as a waste of time, they don’t know how, or they fear they
might say the wrong thing and get in trouble with an employer. Others
prefer to spend their time communicating with their peers via academic

But as Chiang points out, most consumers do not pore
over the latest scientific literature
. So health professionals need to
take the time to start connecting with them where they do spend their
time — and that’s on Facebook and Instagram.

So he’s working to recruit an army of physicians, nurses, patient advocates, and other health professionals to get online.

Similarly, a June, 2019, commentary in the Lancet by social media pioneer Dr Jennifer Gunter, an obstetrician-gynecologist, who described her realization

Clearly, we needed a better medical internet. So, I decided to help fix it. I started blogging to help parents navigate the gauntlet of prematurity, but greeted with so much misinformation and disinformation about vaccines I began to think about my own field, gynaecology. What disastrous information were my patients finding online?

The answer was

There was not just misinformation and disinformation about medical care. Practical day-to-day things, not typically addressed by medicine, were especially ripe for abuse—for example, how to select menstrual pads or pubic hair grooming. And many sites contained even greater dangers, notably, exposure to anti-vaccine or other medical conspiracy theories.

We have huge gaps in medicine—in both the science and how we communicate, especially in women’s health—but much of what I found when I first started my online quest and what I still find today is exploiting those deficiencies, not fixing them.

Her exhortation was:

The more I see fake medical news, the more I realise we need to use all mediums and media to tackle it. The glut of medical misinformation is real and it harms. It turns people away from vaccines, fluoride, and leads them to useless products. And don’t underestimate the weight of ‘it can’t hurt, so why not?’ advice. Whether it is useless underwear changes or forgoing all sugar, it compounds desperation when it is ineffective. And snake oil peddlers are always standing by with a confidence we evidence-based practitioners can only dream to emulate.

Everything we read and share builds the internet, so we in medicine should especially take that to heart.

But Dr Jen, as she is now widely known, also had some practical advice for health care professionals out to defend the truth on social media:

First, a very simple beginning:

How does one even try? Find good medical content and post it on Facebook, Twitter, or the social media platform that works best for you. Even in a small circle of friends and family you can make a difference. If you read something accurate, well sourced, and bias free click the like button. The more clicks the greater the chance that piece will appear favourably in an algorithm. Ignore bad pieces—social extinction is the best strategy.

 Then learn some simple rules:

Everyone should learn the following four basic rules of internet health hygiene. The first is never read the comments as ad-hominem attacks beneath the content can lead people to question the very facts that were just presented. The second is avoid sharing bad information—even in jest. We are all primed to remember the fantastical and sadly medical truths are usually stodgy. Also, sharing makes the bad content more popular algorithmically speaking. The third is don’t get information from anyone selling product. Bias has an impact. And finally, steer clear of content from practitioners who are against vaccination or who recommend homeopathy.

Meanwhile, do not neglect to provide your patients with accurate information, or spreading the truth by older means:

Guiding your patients to accurate information is also important. Find good online resources and offer them as handouts or e-mail the links directly if you can do that securely. Your patients are looking online, whether they tell you or not. Offering them curated content from trusted sites, such as the National Health Service in the UK or professional medical societies, validates their search efforts and I believe it makes people more likely to share with their health-care provider what they found online.

Create content, be it quality medical research in a journal or opinion pieces for the lay press. 

For those who heed these exhortations, know that fighting disinformation will not be easy.  In particular, expect strident opposition, as discussed in a commentary in the May, 2019, BMJ by David Oliver, using examples pertaining to debating anti-vaccination fanatics:

Persuading individual parents is one thing. But trying to debate with the more determined anti-vaccination activists can be a futile endeavour, not played by the rules healthcare experts are used to.

Every scientific paper in support of the cause (whatever its quality) and every commentator sympathetic to the cause (expert or not) is selectively harvested and cited. Allegedly hidden harms and risks of vaccination are highlighted. If you’re not a genuine content expert it’s impossible to wade through each individual source to appraise it or understand its limitations. If you really are a content expert, steeped in the science and leadership of mass vaccination—or an official body, from Public Health England through to WHO or the UN—you’ll be labelled as being close to (and influenced by) the vaccine manufacturers, and the impartiality of your advice will be questioned.

Reports of outbreaks and rising infections will be dismissed: ‘How many of those cases were actually verified?’ The severity of the disease we’re trying to prevent will also be questioned. Measles and other preventable childhood infections can kill or bring serious long term damage and disability, but these consequences will be minimised to suit the cause. You’ll be told that not all vaccinated people mount a sustained immune response (which is precisely why we need a high uptake for herd immunity).

Don’t be surprised if your defence of mass vaccination against refuseniks leads to attacks on social media or impassioned private correspondence. If you push back, the whole cycle will start again.

The idea of children developing natural, normal immunity through exposure to infections will be romanticised. Arguments about the collective societal need to vaccinate our own children so that we don’t put other children at risk will be either ignored or represented as a callous attack on parents and dismissal of their concerns—potentially a bad look for doctors and nurses, even when acting for a greater cause. And suggestions that vaccine refusers are putting their own children at risk will be used to make those doctors look even worse.

However, while it may not be reasonable to expect to convince whoever are the people who are central to the spread of disinformation that they are wrong.  Instead, the goal should be to decrease the spread of disinformation by informing those who have not yet become cultists.

Final Exhortations

However, this is not the time for the faint-hearted.  While one may not persuade the fanatics, but have some hope that it is possible to advance the truth.   Do not forget the importance of the battle.

To quote a June, 2019, Bloomberg op-ed about the the need to challenge disinformation in the political sphere,

The culture war gets a lot of attention, in part because it’s easy both to understand and to pick a side. But it’s the epistemology war – the partisan effort to break the power of facts, knowledge and expertise, and to destroy the means of assessing them — that will determine whether the U.S. can secure a decent society in the future.

Have courage, because:

That war is Sisyphean, with victory perpetually subject to savage reversals.

What we have to do is

roll the stone uphill day after day.


Speak. Repeat. Speak again. Lace up your Marine boots and put on your Republican suit. There’s a war on.

Nursing Home Roundtable (LTC Advisory)

To: Nursing Home NHA’s, DON’s and other stakeholders

From: Jo Tansey, Section Manager Nursing Facilities

Attached are FAQ’s regarding handwashing and the use of alcohol based hand rubs, prepared by the Healthcare-Associated Infections/Antimicrobial Resistance Program here at CDPHE. Our nursing home survey teams will be using this guidance when investigating concerns about hand hygiene and infection control.

Alcohol Based Hand Rubs Frequently Asked Questions

Patient Driven Payment Model (PDPM) and Annual Payment Update (APU) Aids

To: Federally Certified Skilled Nursing Facilities Administrators, Directors of Nursing, MDS Coordinators, Billing and Coding Personnel, Licensed Nursing Facilities Administrators

From: The Education and Technical Assistance (ETA) Branch of the Health Facilities and Emergency Medical Services Division (HFEMSD)

CMS has provided new training and clarification material on the new Medicare reimbursement methods anticipated for October 1, 2019.

The Provider Preview Reports used to determine eligibility for the maximum Market Basket rate are changing. SNF QRP Provider Preview reports are automatically filed into your facility’s Casper Inbox. The next refresh with new measures on the report is slated for August 1, 2019.

Questions?: Please email betty.metz@state.co.us