O P An Unwanted Winter Guest: How To Keep

in this issue
3. Marketing: Solving The
Motivation Mystery
February 2012
Vol. 18 No. 2
An Unwanted Winter
Guest: How To Keep
Norovirus Visit Short
Daniel Haimowitz, MD, CMD, a
utbreaks of noroviruses, a
long term care physician in Pennsylgroup of viruses that cause
vania, says, “Philadelphia Departstomach flu, can happen
ment of Public Health guidelines
in an instant and spread quickly in
suggest that the best way to reduce
a setting such as an assisted living
the risk or impact of an outbreak is
community. These illnesses are espefor facilities to
cially common
establish prein the cold
season preparaweather when
tion measures
people spend
and have a
more time
and widely
outbreaks can
rapid response
cause sigplan in place.”
nificant opThis plan
erational and
should address
financial burrisk factors that
dens in terms
increase the
of infection
possibility of a
norovirus outstaff sick leave
‘Staff, as well as residents,
break, the best
and overtime,
ways to identify
and additional
should know the signs of
an outbreak at
health care and
noroviruses so that they can
its onset, and
cleaning supnotify management when
plies and costs.
they see signs of the illness.’ interventions
that are most
likely to prevent
you don’t have
or contain outbreaks.
to just bite the bullet and accept
Staff, as well as residents, should
noroviruses as inevitable. There
know the signs of noroviruses so that
is much an assisted living facility
they can notify management when
can do to minimize the impact of a
they see or experience signs of the
norovirus outbreak and protect its
residents and staff.
>> pg 6
5. Finance: New Construction Possible
Casting A Vote For
Facility Election
rior to the Republican primary
in New Hampshire, at least one
facility was part of the hoopla
and excitement. Kendal at Hanover
hosted presidential candidate Jon
Huntsman for a visit.
“He was well received,” says Diana
Cox, the facility’s director of resident
health care services. She adds, “The
residents enjoyed the opportunity to
talk to the candidate about key issues
such as health care.”
Interestingly, Cox says, “Coming
so closely on the heels of the Iowa
primary, there wasn’t a lot of interest
in or activity surrounding the primary.” However, she adds, residents
want information about the candidates
and the issues. They take the right to
choose their candidates seriously.
As Cox explains, “Most of our
residents are women. When they were
younger—in the 1940s and ’50s, they
were expected to vote for the same
candidates their husbands did. Now
they make their own decisions and
The elections are discussed at community coffees and resident council
meetings. “Additionally, the activities
department does some historical programs about the election process and
plays memory games around political
issues. We also coordinate with our
social worker to coordinate absentee
T h e S o u rce fo r A ssi ste d L i v in g M a n a g e m e n t , N e w s , a n d P o lic y In f o r m a t io n
>> pg 4
Demonstrate Quality; Complete Two
Online Surveys
CAL encourages members to spend a few minutes to complete two online surveys as part
of its third annual Performance Measurement
Initiative. The two online surveys are the Performance
Measures Survey and the Employee Vacancy, Retention,
and Turnover (VRT) Survey. NCAL’s goal is to produce
reports that convey to consumers and policymakers the
assisted living profession’s commitment to delivering
quality care to residents.
The Performance Measures Survey was established
in 2010 to help the profession assess and improve the
quality of care and quality of life for residents in assisted living. It includes questions about how providers
evaluate their quality of care and services in nine areas
of operation. This year, NCAL’s Quality Committee
added nine questions about workforce. Most of the
questions require “yes” or “no” responses and should
take participants about 15-20 minutes to complete.
The VRT Survey focuses on one performance measure—staff retention. The VRT requires providers to
insert numbers related to staff vacancies, retention, and
Data collection for these two surveys will close on
Monday, April 2. NCAL will analyze the data and
produce reports to provide benchmarks for residents,
family members, state and federal policymakers, and
providers alike. Individual provider data submitted are
confidential. The data will be used in aggregate form
only, without any identifying information.
Access these surveys on NCAL’s website, NCAL.org,
under the “Be Heard” section. If you have any questions, contact Shelley Sabo at [email protected] 
4th Annual AHCA/NCAL
Quality Symposium
Westin Galleria » Houston, Texas
February 23–24, 2012 (pre-symposium session February 22)
Plan to
This intensive two-day symposium is designed to
maximize networking and peer-to-peer learning opportunities as well as offer sessions led by topic experts and Malcolm Baldrige National Quality Award
recipients. Earn up to 10 CEUs from the main symposium or 14 if you add a pre-symposium workshop.
Online registration will be available October 20, 2011.
Mark your calendars now to join us in Houston.
February 2012
Solving The Motivation
Mystery For Sales
inding, keeping, and motivating sales staff that can fill
assisted living communities
and keep them filled is an art and
a science. When you get the right
people on the job, it enhances the
facility’s profitability and reputation. When someone is a bad fit,
the cost to replace him or her is
According to Russ Watson, EdD,
president of Illinois-based Target
Consultants, a bad hire can cost
from $150,000 to $450,000 in business revenue, or two to six times
wages and benefits.
The key is to use proven means
of assessing applicants and
determining their motivations
before they come on board. This
can help employers identify those
individuals who are most likely to
succeed in this sales setting.
Watson gathered data from
participants at a recent sales and
marketing summit for seniors
housing sales staff from numerous
organizations to conduct a statistical study of the top and lowest
performers. “We looked at where
they were common, where they
were different, and how we can
move the lower performers more
toward the middle of the curve,”
says Watson.
“The first thing we found was
that top performers were slightly
more decisive than lower performers, and this was accompanied
by a higher sense of urgency,”
Watson says.
For example, when a prospect says that he wants to wait
and see how his illness progresses,
the sales person
helps the prospect
imagine how important it is to make a
decision while he is
able to take the time
and effort to examine
all options.
The sales person
also makes the prospect envision how
waiting until a move
is necessary can result in an impulsive
decision that he may regret later.
Conversely, Watson says, when
prospects say they want to wait, a
lower performer is more likely to
say, “Okay, I’ll talk to you again in
six months.”
Knowing how top performers
think and function can help you
improve the results of low performers. However, Watson says,
“you don’t turn low performers
into top performers, but you can
bring them closer to the middle.”
To do this, he suggests a number
of useful exercises and activities.
For example, “Ask lower performers to make two more calls
How Head, Heart,
And Money Drive
nother type of assessment
Watson used identifies
a person’s drives and
motivators. It addresses six types
of values: theoretical (drive for
knowledge), utilitarian/economic
(drive for money and materials),
aesthetic (drive for harmony and
form), social/altruistic (drive
to help others), individual/
political (drive for uniqueness
and influence), and traditional/
regulatory (drive for order and
Watson used this assessment with
the same study group, and “some
things emerged in a robust way,” he
says. “There was a huge difference
in theoretical drive between high
and low performers. Top performers were much better at learning
about the industry, properties, and
customers. They were naturally inquisitive.” Economic drive also was
stronger in top performers. Interestingly, while they were more driven
by money than lower performers,
the difference between the two
wasn’t extreme, and top performers’ drive for the dollar was “appropriate and not extreme.”
Top performers were much less
driven by aesthetics. Watson says
that this generally translates into
more personalized and effective
facility tours. Top performers are
more likely to encourage prospects
to explore the grounds and features
that are of greatest interest to them.
Low performers, on the other hand,
give tours based on what they think
are the property’s strongest, best
>> pg 4
>> pg 4
February 2012
Motivation Mystery
every day for two weeks. These can
be prospect calls or follow-ups to a
visit or question. This might make a
difference in getting a prospect into
their pipeline.”
Role playing exercises can help
sharpen their decisiveness, says
Watson. For example, pair up low
and high performers. Ask the low
performers to throw out a role
objection they’ve encountered at
the high performer. Then discuss
the possible answers. “I always
encourage sales people to role play
with others when they are stumped
or have a problem. This can be
done informally, and it helps them
envision solutions they hadn’t seen
before,” he says.
By partnering strong sales people
continued from page 3
with weaker ones, low performers can learn to be less dependent
on structure. “Low performers
often use structure—processes and
paperwork—as a safety blanket to
avoid asking for money. They may
be a little afraid to close a deal or
ask for a contract,” he says. “Lower
performers can be encouraged to
let go a little bit by learning how
to manage structure without being
consumed by it,” he says.
Another way to help low performers is have the two top sales
people in the organization stand in
front of the sales team, and have
people call out actual objections
they have heard in the past month.
The top people then say how they
would overcome these objections. 
continued from page 3
features. Lower performers are more
altruistically aimed. While this may
seem like a positive, it often means
that they are overly, inappropriately
involved with prospects and may
get too involved with them or dig
too deeply into their problems and
concerns. “The top performers are a
nonanxious, reassuring presence,”
says Watson.
“This study surprised me, and I’ve
been doing research for 30 years,”
says Watson. There was only a sixpoint spread between the top three
motivators for leading performers.
“What drives top performers is a
combination of business, heart, and
head.” 
Casting A Vote, continued from page 1
ballots and get residents who are
able out to the polls,” says Cox.
As few facilities are completely homogenous, it
is important to invite
candidates from both
parties. These invitations
can be extended through
local Democrat and
Republican headquarters,
congressional representatives’ local offices, and
organizations such as the
League of Women Voters.
Alec Pruchnicki, MD,
medical director of Robert Lott Assisted Living Facility in New York
City, adds that his facility’s recreational therapist invites speakers
and arranges political programs. He
says, “We are Medicaid-supported,
so we have to be attuned to policy
February 2012
changes and legislative issues.
We try to keep in close touch with
politicians. We often invite them
to come in and
speak with staff
and residents.”
Political infighting could cause
problems in the
assisted living
this doesn’t
seem to be an
issue. Cox and Pruchnicki agree that their residents are
respectful of each other’s political
viewpoints and opinions. “People
with minority views are respected.
Debates or arguments have never
risen to the level where we needed
to address this,” says Cox.
While the facility can help make
sure residents have access to information about issues and candidates,
they have to be careful to remain
neutral. Nonetheless, making sure
residents have accurate information
is important. As Pruchnicki says,
“Sometimes residents will complain
about government programs, and
I gently tell them that they’re in
the facility because of one. If I hear
someone say something factually
incorrect, I try to give them the facts
as objectively as possible.”
Why should facilities make the
effort to put politics on the front
burner? According to Cox, “For
people in their 70s, 80s, and 90s,
voting was one of their first opportunities to speak their mind. It is a
hallmark of their values. It is very
important to people.”
New Construction: More Possible
Than You Might Think
n this fragile economy when budget cutting is the
norm and banks are tightening their purse strings,
new assisted living construction or expansion may
seem like a pipedream. However, some innovative
owner/operators have found creative ways to make
their dreams come true.
Gerald Hamilton, partner in Beehive Homes of Albuquerque, N.M., opened two small (15-bed) facilities in
2006 and 2008. Even then, financing was a challenge. “I
started with a Small Business Association [SBA] loan for the first building.
I was able to convert to a commercial
bank loan in a couple of years.”
Establishing a track record made
a difference when he went back for
funding to open a third building in
April. “I found that it works well to
use a bank where I have an established relationship with people,”
Hamilton says. Bank personnel who
have witnessed a business’ success
and seen the fruits of the owner’s
labor can be strong allies.
In contrast, Hamilton is working
on a project in another state where he
lacks such relationships, and he says,
“It’s been slow going—with lots of
paperwork and meetings.”
When dealing with strangers,
research and preparation can make
a huge difference. As Hamilton says,
“When you’re dealing with people who don’t know
you, they want to know you’ve done a good needs
analysis. They want to know precisely what kind of
money you’ll be putting in, what you need, and when
cash flow will start. They want to see your marketing
plan and where your customers will be coming from.”
He adds, “There’s an old saying: ‘Banks don’t lend
you money unless you can prove you don’t need it.’
There is some truth to that. Banks want to see a track
record and a proven product.”
Financing isn’t the only challenge, says Hamilton. He
had to learn to be a diplomat, educator, and student. He
explains, “The people we deal with for permits, inspections, and so on know their business, but they don’t
know assisted living. They don’t know the kind of
building we’re constructing. We have to educate them
in a diplomatic way.” As these individuals hold the key
to zoning and approval processes, assisted living facility owners can’t afford to offend them.
Especially if you’re a one-person operation, you can’t
always get what you want when dealing with inspectors and other officials. “I don’t have a lot of time and
money to sit around and wait for approvals. Sometimes
it’s easier to compromise and do what they want me to
do,” Hamilton says.
For example, contrary to his own wishes, he put a
commercial lid over the range in one home. “It cost
money and took away from the residential look and feel
of the place. But it enabled us to get the construction
done in a reasonable time frame,” he says.
Rosalene Black, owner of Midland Meadows Senior
Living in West Virginia, avoided some of the challenges
Hamilton faced by going the prefab route. “When I had
an opportunity to be an owner, I went with a prefab
building because that’s all I’ve known. The quality is
good, set up is fast, and cold weather doesn’t delay
>> pg 8
February 2012
Limiting The Spread
Of Norovirus
orovirus is easily transmitted and
hard to remove from the environment,” says Haimowitz. It can
survive temperatures from freezing to 60 degrees
Centigrade. “Some outbreaks have been traced
to contaminated computer keyboards and sinks
where food service workers first washed their
hands and then rinsed vegetables,” he says. Surfaces soiled with vomit or contaminated hands
can “sustain an uncontrolled epidemic,” he says.
In fact, contaminated fingers could transfer norovirus to up to seven consecutive clean surfaces.
According to Haimowitz, among the common
ways noroviruses are
transmitted in an assisted
living facility are through:
■ Eating food prepared
by contaminated hands
of food handlers who are
■ Eating shellfish or
water contaminated by
raw sewage;
■ Oral contact after
exposure to contaminated
body fluids or skin or
contaminated environmental surfaces; and
■ Oral exposure to droplets of vomit.
Although preventing person-to-person transmission can be difficult, the Centers for Disease
Control and Prevention (CDC) recommends the
following measures:
■ Frequent hand washing with soap and water;
■ Wearing masks (for people who clean areas
substantially contaminated by feces or vomitus);
■ Minimal handling of soiled linens and
clothes. Laundering these with detergent at the
maximum available cycle length and then machine dried; and
■ Clean soiled surfaces with an appropriate germicidal product (for example, 10 percent solution
of household bleach). 
February 2012
Norovirus Visit Short
continued from page 1
illness. Norovirus symptoms include nausea, diarrhea,
and stomach cramps. Additionally, some people experience a low-grade fever, chills, headache, muscle aches,
and fatigue. Symptoms can appear as soon as 12 hours
or up to 48 hours after infection.
Identifying incidences of norovirus early is important, because prevention is difficult and treatments are
limited. There is no vaccine to prevent infections. There
are no antiviral medications that work for noroviruses,
and the illness cannot be treated with antibiotics.
Treatment includes keeping people well-hydrated
with fluids containing electrolytes. Over-the-counter
antidiarrheal medications may be helpful, except for
patients with severe abdominal pain or
For most people, the illness lasts for a
day or two. However, the elderly, especially those with impaired immune
systems, are more likely to experience a
longer duration of diarrhea and vomiting
and complications such as dehydration,
electrolyte disturbances, aspiration, and
even death.
To limit the spread of the norovirus,
says Haimowitz, “it is important to
restrict symptomatic and recovering
patients from leaving the residence other
than for care or treatment.”
This can be challenging in an assisted
living community where residents are
used to being active and moving freely throughout the
“This is one reason education is so important. When
residents and their families understand how staying in
their units can prevent the spread of the illness, they
are more likely to comply,” says Haimowitz. 
In March 2011, CDC released its “Updated Norovirus Outbreak Management and Disease Prevention
Guideline.” The guideline includes recommendations
regarding infection and control, updates on diagnostic methods, information about transmission and
outbreaks, and guidance on reporting and assistance.
For more information, visit www.cdc.gov/mmwr/preview/mmwrhtml/rr6003a1.htm.
RegisteR today !
Home Visits: A View Of The Present
e a R Ly
Shapes The Future
NCAL 2012
i sout
magine this scenario.
if youd
it isn’t a good
C othat
Mrs. Jones, a prospect
fit or e
that the person
for your community,
can’t afford the
has come for visitsMarch
twice.13-14, 2012 New Orleans, Louisiana Royal Sonesta Hotel
don’t waste their time or yours.
She seems to like what she’s
You can give him or her other
seen, and her adult children
options,” she adds. 
earn up
are encouraging
the to
How can you10.25
find out what
is holding
her credits.
back? ConCeu
sider a visit to her home. It
can speak volumes about
issues or concerns she can’t
or won’t express.
“The main benefit is to
be able to see them in their
comfortable environment.
You can get a clear picture of
their living conditions and how they function,” says Jill
Sproul, vice president of operations, Harmony Senior
Services, Roanoke, Va. She adds, “You can look around
and see pictures. You find out about their families
and how much interaction they have with them and
what—if any—support they get.” You get a sense of
how dependent they are on
others and who is influential
in their lives. By observing,
asking questions, and listening, you can “see things you
couldn’t see if they come to
your community.”
The visit can help
■ Bring a little gift that you know the prospective resident will like. For exdetermine what services
ample, if they love gardening, bring a little plant. “The gift says, ‘Thank you for
the prospective resident
letting us into your home.’ It also shows that you cared enough to get to know
needs and if assisted living
something about them,” says Sproul.
is the best setting for this
■ Take someone else with you on the visit. Also, tell the prospect to invite a
individual. “A lot of times
family member to join you. This is a risk issue. For example, if a prospect with
people come to use and
mild dementia got upset and confused and later made an unfounded accusation
say that their mom needs
against the facility representative, it is important to have a witness.
assisted living, but we see
■ Gently ask questions to give you insight into the person’s living situation.
that independent living
What challenges do they face by living alone? Do they cook their own meals?
n Operations n Legal
would be more appropriate.
What would make their life easier? How do they get around (to the store, for
n Public Affairs/Customer Relations/Media
If you find that the person
example)? Who helps them?
is a good fit for your facility,
■ Observe details in the environment. Is the home clean? Is there evidence of
Learn best practices and real world actions you need
you’ll be better able to sell
hoarding? Are there pets? Are there signs of the person’s hobbies or interests?
to understand to fully manage risk in your community.
it,” says Sproul. Conversely,
keys to ensure a successful home visit
in Assisted
thRee tRacks:
For the agenda and to register, visit
February 2012 NCAL FOCUS
1201 L Street, NW Washington, DC 20005
New Construction
continued from page 5
construction,” she says. While prefab has advantages, Black
says, it doesn’t affect financing. However, Black hasn’t had
trouble with financing, mainly because of her diligence and
“We have a wonderful relationship with the local branch
of our bank. The bank president knows us personally and
believes in our project.”
Black also has the advantage of a good track record she
established several years ago. She explains, “We’ve been
able to show that we pay our bills on time, we’ve been
successful, and we have 45 people on a waiting list.”
In planning her buildings today, Black considers features
and expenses that would have seemed foolish 10 or 15
years ago. “I wouldn’t have dreamed about installing
exercise rooms and equipment or wireless Internet access.
Today, residents expect that,” she says.
One thing that hasn’t changed is the desire to make
residents happy. “You can have the best building in the
world, but you won’t keep or attract residents if you don’t
provide a home and life that make them happy.” 
NCAL is the assisted living voice of the American Health Care
Association. NCAL Focus (ISSN: 1095-5585) is published monthly by
the American Health Care Association (AHCA), 1201 L Street, NW,
Washington, DC 20005. Copyright © 2012 by AHCA. Reproduction
in whole or in part is prohibited without written
authorization from the copyright holder. NCAL or AHCA
members’ subscription fees are included in membership
dues. AHCA is the nation’s largest federation of assisted
living, nursing facility, and subacute providers. AHCA has 47
affiliated organizations, together representing more than 10,000
individual facility members.
Editor: Lisa Gelhaus
Manager, Focus Production: Shevona Johnson
NCAL Board of Directors: Michael Shepard (Chair), Ashley
Blankenship, Deb Choma, Vickie Cox, Helen Crunk, Marcia
Hamilton Dooner, Patricia Giorgio, Howie Groff, Jeffrey Hyatt,
Brad Klitsch, Deborah Lowe-Meade, Cindy Luxem, Christian
Mason, Nicolette Merino, Rich Miller, Joe Perkin, John Poirier, Neil
Pruitt Jr, Leonard Russ, Laurie Shepard, Jan Thayer, Dee Thieme,
Brett Waters, Kristin West, Roderick Wolfe.
Your suggestions and feedback about NCAL Focus are welcome.
Contact Lisa Gelhaus by e-mail ([email protected]), by phone (202898-2825), or by writing to the address above.
T h e S o u rce fo r A ssi ste d L i v in g M a n a g e m e n t , N e w s , a n d P o lic y In f o r m a t io n