Last week KHCA received the following notice from AHCA President & CEO Governor Mark Parkinson. Please contact your representatives HERE and tell them that long term care providers can not afford additional cuts. Click HERE for the estimated bad debt expenditures by state. Additionally, Parkinson plans to cohost CNBC Worldwide Exchange global business program.

WHAT – Tomorrow, Tuesday, Dec. 13, 2011 Gov. Mark Parkinson will appear on CNBC’s global business program, Worldwide Exchange. Serving as cohost from 4:00-5:00am (CST), Parkinson will provide personal business insight on topics that impact investors across the globe, including the European debt crisis and the current state of the US health care system. The segment will focus on the market, investment strategies, and financial news and will feature interviews with premiere business leaders.
WHO – Governor Mark Parkinson, President & CEO American Health Care Association/National Center for Assisted Living
WHERE – CNBC (check local listings)
WHEN – Tuesday, December 13, 2011 4:00 AM (CST)

Dear AHCA Members,
House Republicans have released their plan to extend the payroll tax cut, extend therapy caps, and provide the doc fix. While these fixes are necessary, unfortunately the proposal uses skilled nursing centers, as well as other providers, as a pay-for. The total cost of the package exceeds $180 billion. Our current understanding of the bill is as follows. We should note that we are working with the affected provider community to understand confusing language.

Among the provisions in the bill is a reduction in Medicare reimbursed bad debt both for dual eligibles and private pays. The reduction begins in fiscal year 2013. For duals, Medicare reimbursable bad debt will fall from 100% to 55% by 2015. For private pays, it would phase down the payments from the current level of 70% to 55% over the same period of time.

House Republican Proposed Policy for Bad Debt Reimbursement
Fiscal Year    Duals    Non-Duals
FY 2012 *      100%     70%
FY 2013         85%       65%
FY 2014         70%       60%
FY 2015 +       55%      55%
The impact will vary from state to state. Approximately half of the states cover the full copay on Part A stays for duals. For those states, the impact is minimal. However, even those operators face the risk that their states will cease making those copayments. All indications point to the conclusion that bad debt utilization has increased. As a result, it is likely that your state will see a cut that is worse than noted on the chart. (See the impact in your state in the document attached.)
The bill does contain a two year extension of the therapy caps exceptions process, through December 2013. The bill provides for a threshold of $3,700 which is to be applied separately for physical therapy services/speech language pathology services; and an additional $3,700 for occupational therapy services. That would then trigger a manual medical review process for anything exceeding $3,700. However, as indicated above, the bill is not clear and we are working closely with the therapy community to seek clarification.
In addition, there is a requirement on claims for the inclusion of the National Provider Identifier (NPI) of the physician who reviews the therapy plan, which is of great concern. It is also important to note that the longstanding hospital outpatient therapy services caps exemptions will be eliminated.
We must fight against this additional cut. A combination of the productivity adjustments, the final rule, sequestration, Medicaid cuts, and now this, has threatened our industry. We need your help. On Monday, we will ask that you and the advocates in your states contact your two Senators and your Representative through our grassroots email program. Our message is clear: we can’t take any more cuts.
AHCA will immediately begin our efforts to stop this newest cut. We’ll be mobilizing members in states that would be hit hard by this reduction to bad debt reimbursement to have them communicate this message to both Senate Leadership and Senate Finance members.
Even though the House Republican bill will not pass the Senate in its current state – not while its largest pay-fors include cuts to the President’s health care reform law - the inclusion of bad debt in this bill is a serious problem for skilled nursing. The provision could make it through negotiations as Republicans and Democrats seek a final agreement.
AHCA will be working through the weekend. Come Monday, we will be asking you to act. We need your help in telling Congress that we just can’t take this cut.
Thanks much,
Mark
.

KHCA/kcal would like to provide you a brief update on the planned rate increase for HCBS/FE facility providers.
 
A 10.4% increase has been submitted to CMS due to the requirements facility HCBS providers must follow as opposed to non-facility settings. KDOA has not received formal approval from CMS as of yet for the rate change, but expect it to come in the next few days. However, KDOA is allowing for facilities to bill for the new rates even without the CMS approval.

Click here for a copy of the full memo from KDOA Secretary Shawn Sullivan.

Secretary Sullivan would like to invite everyone to a provider web chat on KanCare Monday, January 9, 2012 at 3 pm. All providers are invited to be involved in this innovative opportunity. Information for the web chat is below:
 
Topic: KanCare Web Chat with Secretary Sullivan
Date: Monday, January 9, 2012 Time: 3 pm, Central Standard Time
Meeting Number: 598 247 299
Password: (This meeting does not require a password.)

To join the meeting online:

1. Go to https://intercall.webex.com/intercall/j.php?ED=176728922&UID=496921972&RT=MiM3
2. If requested, enter your name and email address.
3. If a password is required, enter the meeting password: (This meeting does not require a password.)
4. Click "Join".
5. This meeting includes a teleconference, follow the instructions that appear on your screen.

To join the teleconference only 

Provide your phone number when you join the meeting to receive a call back. Alternatively, you can call:
Call-in toll-free number: 1-866-6207326  (US/Canada)
Call-in number: 1-678-9818305  (US/Canada)
Conference Code: 123 227 6937

During the months of October and November, KHCA, LeadingAge Kansas and KACE hosted regional roundtables with KDOA Director of Survey & Certification Audrey Sunderraj and each survey district’s regional manager. Thank you so much to host homes Pioneer Ridge, Lawrence; Homestead of Salina; Larksfield Place, Wichita; and Chanute Healthcare. During these meetings, the issue of reporting abuse, neglect and exploitation was discussed.  Providers were directed to use the attached CMS S&C notice 05-09 as a guide for reporting requirements and to abandon the state “decision tree” which was used in the past. Other topics of discussion included the top deficiencies in the state and the goal of consistency across the regions.

Providers expressed gratitude for the opportunity to meet with KDOA staff and requested that additional roundtables be scheduled on an ongoing basis.

The Kansas State Fire Marshal's Office has two new items for your review. The first is a reminder of resident smoking safety in long term care facilities. The second is the lastest issue of The Trumpet - the quarterly newsletter from the KSFMO.Click here for the smoking safety update and here for The Trumpet.

The Kansas Adult Care Home Administrator regulations, which outline time frame requirements for completing NAB testing requirements, have been updated.  The regulations became effective October 14, 2011.  Below are excerpts from the regulations:

K.A.R. 28-38-18(a) Each candidate for licensure as an adult care home administrator shall be required to pass a national examination and a state law examination for adult care home administration approved by the board.  Each candidate shall take the national test within 12 months of completing an administrator-in-training practicum unless for good cause the board grants an extension. 

K.A.R. 28-38-18(e) A candidate who has failed three national examinations shall not submit a new application for examination until the candidate has received board approval for a course of additional education or training, or both, signed by the candidate, the preceptor, and the candidate’s practicum coordinator, and complete the approved course of additional education or training, or both.  The course of additional education or training, or both, shall include an additional 40 hours of administrator-in-training instruction in each of the “domains of practice,” as defined in K.A.R. 28-38-29, for which the candidate received a raw score below 75 percent on the national examination. 

K.A.R. 28-38-18(f) Each candidate who completes the required 40 hours of additional administrator-in-training education or training, or both, in each of the domains of practice for which the candidate received a raw score below 75 percent on the national examination shall be eligible to submit a new application for the national examination.  If the candidate fails the fourth attempt, the candidate shall remain eligible to submit an application for a fifth attempt to pass the national examination. 

K.A.R. 28-38-18(g) A candidate who has failed five national examinations shall not submit a new application for examination until the candidate has completed a second 480-hour administrator-in-training practicum that is conducted by an accredited college or university or an equivalent educational training practicum, as specified in K.A.R. 28-38-19(a)(2).

K.A.R.  28-38-18(i) each candidate shall be given a period of 36 months from the date the candidate completed an initial administrator-in-training practicum or a second practicum under paragraph (g) of this regulation to take and pass the national examination. 

Click here for a highlighted view of the changes.

The Centers for Medicare & Medicaid Services (CMS) in October released a final rule for establishing Accountable Care Organizations (ACOs), replacing key parts of its much-scorned ACO draft rule proposal with more financial enticements and a reduction in the number of quality measures in the plan.

In the December issue of AHCA/NCAL's Provider Magazine the following comment was made:

 “The final rule strikes a better balance,” said Jonathan Blum, CMS deputy director and director of the Center for Medicare, referring to modifications made to ease bottom-line concerns of stakeholders with new financial incentives, while at the same time maintaining quality improvement models.

The major changes from the draft include CMS reducing by half the number of quality measures from 65 to 33, the elimination of the electronic health records requirement, and the introduction of a payment model that allows ACOs to share on the first dollar once a minimum savings rate has been established.

KHCA/kcal staff asked AHCA "to clarify that the ACOs final rule released in October does in fact eliminate the electronic health records requirement scheduled to go into effect in 2014. Are there other provisions still in place that would require EHR?"

AHCA's Research Director Peter Gruhn answered,"Yes, the EHR requirements are no longer required.  I do not believe there are any other provisions.  Having said that, given that achieving the triple aim likely requires greater communication and care coordination, as well as various quality measurement tracking requirements, having an EMR/EHR would likely help."

To read the entire article in Provider Magazine, please click here.

 Join AHCA/NCAL for its fourth annual symposium on quality performance in long term care.  The AHCA/NCAL Quality Symposium: Inspiring Excellence in Long Term Care conference, will take place February 23-24, 2012 at the Westin Galleria hotel in Houston, TX.

Register Online

The Registration Deadline is January 31, 2012

Once again, AHCA/NCAL will be hosting Poster Session for Best Practices in Performance Measure Areas. Clcik here for guidelines. This is a great opportunity for Quality Award Winning Facilities to share their journey.

Earn up to 10 CEUs
Earn additional 4 CEUS by attending the Pre-Symposium Workshop

Returning for its fourth year, the symposium continues to offer comprehensive programming to quality practitioners at all levels. We have developed session designations that aid in measuring and assessing where you are in implementing quality improvement. These include:

•    Transition Sessions – for those professionals new to the quality journey

•    Commitment Sessions – for those professionals who have examined their organizations and begun the process of implementing policies and practices to advance their quality goals.

•    Advanced Sessions – for professionals who have achieved performance excellence and are looking for ways to sustain their accomplishments.

This conference is designed to be highly interactive with idea sharing and networking opportunities built upon the tenets of Continuous Quality Improvement, and features 14 individual sessions, two general sessions featuring keynote speakers and two networking lunch sessions -- comprise this intensive, two-day conference. Learning tracks have been developed from the framework of the Malcolm Baldrige National Quality Award program.
 
Earn four additional CEUs by attending one of two pre-symposium sessions*  on February 22.

Housing Reservations
You can complete your online registration, make housing reservations and get education information, plus download your conference brochure on this exciting event by visiting the AHCA/NCAL Quality Symposium website.
 
*Pre-symposium sessions are a separate ticketed event.

 Applicants for the 2012 AHCA/NCAL National Quality Award program are required to submit a non-refundable $75 Intent to Apply fee by January 12, 2012. Get started today with the Intent to Apply Process by visiting the Quality Award website to learn more about the program.
Questions about submitting the Intent to Apply?
Send an e-mail by clicking here.

AHCA/NCAL has designed a series of educational webinars for 2012 National Quality Award applicants, each presented by program staff or Quality Award Examiners. There are two webinars devoted to the Bronze Quality Award process and a six-part webinar series focusing on the Silver/Gold application process. The webinars are free and can be accessed at any time, by visiting the Quality Award website. Quality Award applicants are required to participate in an educational program in the year they apply for the award; participating in these webinars will meet that requirement.

Questions? Please click here.
 

An independent analysis projects nursing home margins will slide into negative territory if Congress makes further reimbursement cuts to the Medicare and Medicaid programs, underpinning the argument of long term care advocates that enough is enough in the way of reductions to providers serving the nation’s frail and elderly.

The American Health Care Association (AHCA) commissioned The Moran Co. to perform an independent analysis of national nursing facility margins to show the most recent performance of the nursing home industry. The analysis is based on the most recent Medicare cost reports for fiscal years ending in 2009 filed by nursing facilities that participate in the Medicare program and includes revenue from all payers for nursing facility services and total expenses.

The data show slight 0.75 percent overall aggregate margins in 2009 for nursing facilities, which is a lower number than those published by the Medicare Payment Advisory Commission (MedPAC), although within MedPAC’s margin of error. The commission has backed a market basket freeze for nursing homes, assuming margins for freestanding facilities for 2009 to be 3.5 percent.

Moran’s analysis projecting into 2012 and beyond shows a bleaker outlook. When factoring in a two-year zero market basket update and a possible new requirement for nursing homes to limit bad debt to 25 percent, among other factors, margins would dip into negative ground in 2012 at minus 0.1 percent and deflate further to a negative 2.9 percent in 2013, the report said.

“Our baseline suggests that going forward from 2009, nursing facility operating margins would be mildly positive, bolding current payment policies constant,” the report said.

However, if reimbursement policy changes, then the slide to negative margins would be impacted, Moran said. These changes include the aforementioned two-year suspension of market basket adjustments and limiting bad debt to 25 percent, as well as imposing 5 percent coinsurance on days one through 20 of skilled nursing facility care and capping Medicaid provider taxes at 3.5 percent of total payments.

“If reimbursement policy changes of the magnitude of those now under discussion are implemented, our point of estimate of the outcome suggests that nursing facility overall margins would turn consistently negative,” the report said.

The analysis tapped cost reports from a wide range of 12,641 providers, which is a good number of the 15,068 nursing facilities counted by MedPAC in 2009, based on survey and certification from the Centers for Medicare & Medicaid Services.

There is also the matter of the current debate in Congress on another “doc fix,” which AHCA is battling to keep from turning into another reduction in Medicare reimbursement to long term care providers.

The Medicare physician fee schedule encompasses a formula known as sustainable growth rate (SGR), which was developed to control the cost of Medicare spending related to physician services. The SGR formula sets a yearly budget for Medicare spending on physician services. If this budget is exceeded by actual spending then the annual update in following years is reduced to control cumulative spending.

Due to original miscalculations in the true effect of the formula, Congress has issued an annual legislative fix, commonly known as the “doc fix,” to allow for an increase in Medicare funding related to physician services to avoid a cut in reimbursement to physicians.

This increase in Medicare spending must be funded from other areas of the Medicare program, and so skilled nursing facilities will likely be targeted as a “pay for” for the 2011 doc fix bill, observers say.

AHCA is pushing for no more reimbursement reductions for the long term care sector under a multi-media advocacy campaign featuring the slogan, “Care Not Cuts.” The argument being made by providers is that Medicare reductions that started Oct. 1, 2011, under the skilled nursing prospective payment system of 11.1 percent, and substantial reductions in many states for Medicaid, are stretching the limits of providers.

”

American Health Care Association and National Center for Assisted Living (AHCA/NCAL) members can now benefit from several member service programs designed to help cut costs on products and services that you use every day. Start saving money now with our exclusive member benefit discounts only available to AHCA and NCAL Members!!! Click here for more details.

•General and Professional Liability Insurance
•Employee Screening Services
•Discounted Shipping Program
•Communication Services
•Flowers & Specialty Gifts
•Incident Notification
•Lands' End Apparel
•Credit Card Processing

The popular Centers for Medicare & Medicaid Services Skilled Nursing Facilities/Long-Term Care Open Door Forums will be moving to a web-streaming format. CMS representative Gregory Price said via conference call at Thursday's SNF forum that the next forum — on Thursday, Jan. 19 — would be web-streamed. There will be a registration process for participants.

In January, CMS also anticipates publishing an update to the MDS manual. A CMS official said that update does not have “a whole lot of significant changes” and that the agency will not be switching the page numbers.

For those looking for guidance on the MDS, CMS will hold its 2012 MDS National Conference twice. The first session will be March 6 and 7, and the second one March 8 and 9, both at the Hyatt Regency St. Louis at the Arch in St. Louis. Conference registration will close Dec. 30. For more info, click here.

In September 2011 CMS made significant changes to the RAC Scope of Work.  The purpose of the Scope of Work is to give the RAC contractors guidelines for how to conduct business with CMS and providers. While many changes were made to the scope of work, here is a synopsis of changes that affect SNF providers:

RAC—RACs are now called Recovery Auditors (RAs).

Semi-Automated Review--  this two part review includes both automated and complex reviews.
 
Allowance for Discussion Period—Shall be in writing to the RAC.  In addition, the provider may elect to have their claim escalated to a physician review.  This can be done only if the provider’s physician or one employed by the provider requests that the RAC physician reviews the claim.    Furthermore, if the provider files an appeal with the MAC, the discussion period must be stopped.  
 
Share information— CMS may share this information to other approved CMS entities which may include, but not limited to other MACs, CERT contractors, and ZPICs.

RAC and MAC’s roles—How the MAC and the RAC will work together and their roles.

Please be sure to check out the AHCA RAC website, which is updated each Friday with the latest RAC issues that affect SNF providers.
 

In response to significant input from multiple stakeholders, expert testimony, and countless hours of review, analysis and deliberation, HHS announced its intention to delay the start of Stage 2 meaningful use for the Medicare and Medicaid EHR Incentive Programs for a period of one year for those first attesting to meaningful use in 2011.  CMS intends to propose such a delay in the Stage 2 meaningful use Notice of Proposed Rulemaking (NPRM), which is scheduled to be published in February 2012.

Why Did HHS Make this Decision?
Input from the vendor community and the provider community makes clear that the current schedule for compliance with Stage 2 meaningful use objectives in 2013 poses a challenge for those who are attesting to meaningful use in 2011. 

The current timetable would require EHR vendors to design, develop, and release new functionality, and for providers to upgrade, implement, and begin using the new functionality as early as October 2012.

What are the Benefits to the Proposed Delay?
HHS believes that a proposed delay will be beneficial for several reasons: 
They hope that this will give vendors added time to develop certified EHR technologies for Stage 2, as well as give providers additional time to implement new software and meet the new requirements of Stage 2. 
They also intend to propose maintaining the current expectation for those first attesting to meaningful use in 2012, so that all providers attesting to meaningful use in 2011 or 2012 will begin Stage 2 in 2014. 
HHS believes this provides an added incentive for providers to attest to meaningful use in 2011 and rewards early participants.

Under the Medicare and Medicaid EHR Incentive Programs, providers who attest early receive greater incentives.  And now those providers who first attest in 2011 are eligible for three payment years for meeting the Stage 1 criteria, while those first attesting in 2012 can only have two payment years under Stage 1 criteria.

Are Medicaid Program Participants Affected?
Because Medicaid providers can receive an incentive payment for adopting, implementing, or upgrading to certified EHR technology in their first year of Medicaid EHR Incentive Program participation, Medicaid providers will still be able to attest to Stage 1 meaningful use for the next two years (first for a 90-day period, then for a 365-day period). 

Therefore, most Medicaid providers do not attest to Stage 2 requirements until 2014 at the earliest.

Want more information about the EHR Incentive Programs?
Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

A claims processing issue was identified that has affected payment of some Part B claims for SNF patients for dates of service from Saturday, October 1, 2011 through Monday, November 21, 2011. 

Some Part B claims for SNF patients submitted to Medicare during Oct and Nov 2011 have been erroneously denied by Medicare’s claims processing system.  In other instances, the claims processing system has paid and then identified a Medicare “overpayment” on these claims in error. 

If you submitted a Part B claim for a SNF patient, you may receive a system-generated Demand Letter from Medicare, or you may see a notification for a payment offset on your Remittance Advice. 

Your Medicare Claims Administration Contractor is working with CMS to remedy this problem in the claims processing system so that appropriate payment adjustments can be made.

CMS is asking providers not to appeal these claims at this time.  Because these are erroneous adjustments in Medicare’s claims processing system, submitting an appeal may slow down the correct adjustment of your claim. 

Your Medicare Claims Administration Contractor will notify you when the adjustment process for these claims is initiated and keep you updated so that you can anticipate when your claims (along with any notifications for payment recovery) will be adjusted.  CMS apologizes for any inconvenience.

While technology can help to provide better and safer patient care, hardware used can be involved in the transmission of infection between staff and patients. 

Computer hardware, especially keyboards, can be contaminated with microorganisms when touched by contaminated hands. Clostridium difficile can survive on inanimate surfaces for months. Gram positive bacteria, including vancomycin-resistant enterococcus (VRE) and methicillin-resistant staphylococcus aureus (MRSA) can survive days to months on dry surfaces. Many gram-negative species, such as E. coli and P. aeruginosa can also survive for months on equipment. All it takes is one provider who is over-worked and in a hurry. Computer access without proper hand hygiene can deposit organisms on the keyboard for the next provider. Recent studies support this, showing that keyboards can become significant reservoirs for organisms because of the increased use of computers in patient care areas. 

This is why hand hygiene is critically important after touching surfaces that may be contaminated and before contact with another patient or with the environment. Unfortunately, hand hygiene compliance across the U. S. is about 40% and multi-drug resistant organisms are on the rise in the community and in other health care settings.

Computer cleaning guidelines have been developed which can help reduce the risk of transmission of organisms. A keyboard/mouse cover can be one strategy used. Covers are easily removed and disinfected with a low or intermediate-level hospital approved disinfectant. Also washable/sealed keyboards may be employed. Rutala's studies indicate that keyboards can be as easily disinfected with or without covers using 5 seconds of friction and a wide range of low level disinfectant solutions. Gloves should not be worn during computer use. And hand hygiene should be performed before using the computer. Keyboards and mice need to be disinfected daily or when visibly soiled or contaminated with blood. 

11 Infection Prevention and Control Guidelines for Computers in Patient Care Areas 

• Use waterless alcohol degermer for non-soiled hands; soap and water for soiled hands prior to computer use, and prior to touching patients. 

• No gloves should be worn during computer use. 

• Hands must be de-germed after accessing the computer, before touching patients in multi-bed rooms. 

• Roving computers must be cleaned before moving to another patient room. 

• Clean/disinfect computer surfaces including keyboards using germicidal wipe containing a hospital disinfectant by wiping surface with friction for 5 seconds once a day and when soiled.

• Keyboards in patient rooms should be cleaned and disinfected with same process as the other horizontal surfaces and equipment in the patient room, i.e. at least daily and when soiled. 

• Touch-screen computer monitors should be cleaned and disinfected with same process as the other horizontal surfaces and equipment in the patient’s room, i.e., at least daily and when soiled. 

• Non-touch screen monitors should be cleaned per manufacturer’s instruction and/or when visibly soiled. 

• Whenever possible install computer at least 3 feet from sink. 

• Splashguard can be used between computer and sink and should be made of clear plastic that can be cleaned using disinfectant products compatible with the plastic. 

• Splashguard should be cleaned with same frequency and process as all other horizontal surfaces in the patient care environment, i.e., daily and when soiled.
 
The preceeding article was originally published in Preventing Infection in Ambulatory Care, the quarterly e-publication from the Association for Professionals in Infection Control and Epidemiology (APIC). To learn more about receiving this resource and joining APIC, visit www.apic.org/ambulatorynewsletter. To learn more about APIC, visit www.apic.org.

The U.S. Supreme Court has agreed to hear the challenges to the Affordable Care Act (ACA). The Court will combine the petitions filed by the 26 states, the National Federation of Independent Business, and the US Department of Justice (DoJ) to settle several of the issues in the law that are currently being challenged.

In March 2012, the Court will allow at least 5.5 hours of oral argument to discuss the issues, including the constitutionality of the individual mandate and Medicaid program expansion; whether ACA must fail if the insurance mandate is struck down; and whether the Anti-Injunction Act bars some of all of the challenges to ACA. The US Supreme Court is expected to rule on this matter in late June 2012. In the meantime, while challengers start preparing for these US Supreme Court arguments, lower courts are still hearing challenges to the provisions in the ACA. In early November, the D.C. Circuit Court of Appeals, the fourth appeals panel to hear arguments, upheld the individual mandate in the ACA. We will continue to keep you apprised of this matter continues to unfold.

The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) today released the first of 11 short video and audio presentations for health care providers on top health care compliance topics.

“We know that the overwhelming majority of health care providers are working hard to comply with Federal laws and regulations,” said Daniel R. Levinson, HHS Inspector General.  “These videos are designed to guide them in further enhancing their compliance efforts.”

Today’s video and audio podcast discusses OIG exclusion authorities, which are the legal means by which OIG may bar certain individuals and entities from participating as providers in Federal health care programs, including Medicare and Medicaid. This presentation also includes a discussion of the impact of exclusion on providers and the types of activities and actions that may lead to exclusion.

Subsequent videos and audio podcasts will be released at the beginning of each week over a 3-month period (with no release the week of December 26).

You can see the news release at http://go.usa.gov/5nA  
Health Care Fraud Prevention and Enforcement Action Team (Heat) Procider Compliance Training Initiative.