text:
Family Birth Center
- Overview
- About the Family Birth Center
- Birthing Options
- Certified Nurse-Midwife Services
- Childbirth Education & Parenting Resources
- Choose a Doctor for Baby
- Incontinence and Bladder Health
- Infertility Clinic and Support
- Lactation Services
- For Baby
- Maternity Nurse Counseling
- Teleneonatology
- Meet the Providers
- OB-GYN Services
- Online Childbirth Education
- Pain Management Options
- Virtual Tour
- Wellness Clinic
Childbirth Education & Parenting Resources
Childbirth Education classes & parenting resources are offered at Barron, Eau Claire and Menomonie. See Classes & Events for local class dates, conference room locations and costs.
Registration is required for all prenatal and postpartum classes; class sizes are limited.
Big Brothers/Big Sisters Class
This class is designed for soon-to-be big brothers and big sisters, as well as their parents. Children will learn about diapering, swaddling and the important role of being a big brother or sister. Parents must accompany children. Siblings attending in Menomonie should bring a stuffed animal. Class geared toward siblings ages 3 to 9.
Class offered in Barron, Eau Claire and Menomonie.
Breast-feeding Education
This class is designed for women who are considering breast-feeding or those who have decided to breast-feed. It covers the benefits of breast-feeding and information needed to achieve breast-feeding goals. Support people welcome. Babies are encouraged to attend in Barron and Menomonie.
Class offered in Barron, Eau Claire and Menomonie.
Car Seat Safety Checks
Prior to baby's arrival, expectant parents receive an instructional car seat DVD that includes information on proper car seat size and installation. Additional education resources are available online.
Infant Massage Class
Parents or caregivers participate with their child in a class setting to learn massage techniques to soothe, support and communicate with their infants. Private, one-on-one sessions are also available for a fee by appointment in Barron and Eau Claire.
Class offered in Barron and Eau Claire.
Mom & Me...The Milky Way
New and expecting moms wanting to breast-feed are invited to a group discussion on breast-feeding. Those who have breast-fed in the past are invited to attend and share their experiences. Babies welcome.
Class offered in Barron.
Newborn Care
This one-session class is for women in the seventh to ninth month of pregnancy or those who have recently delivered. A support person is welcome. Topics include parenting, feeding baby, bath time, sleep patterns and signs of illness.
Class offered in Eau Claire.
Preparing for Delivery Classes
Support person is welcome at all classes.
- Birth Basics
This two-session or one-day class is designed for women in their seventh or eighth month of pregnancy. It includes a facility tour and information on labor, delivery, cesarean birth and pain management. See Prepared Birthing for a more in-depth class.
Class offered in Eau Claire.
- Childbirth Preparation Class
This four-session or one-day class is for first-time parents or those who need a refresher. Class includes a facility tour and information on labor, delivery, cesarean birth, pain management and newborn care. Bring two pillows and a blanket to class.
Class offered in Menomonie.
- Prenatal Workshop & Caring for Baby Class
This one-day workshop is designed to help parents-to-be prepare for their new baby. Learn about labor and delivery as well as caring for your newborn. Bring massage oil or lotion for practicing hand massage.
Class offered in Barron.
- Prepared Birthing
This five-week course is for women in their sixth or seventh month of pregnancy. Class includes a facility tour; discussions about labor, birth and early postpartum; and instruction in comfort measures, massage techniques and labor support.
Class offered in Eau Claire.


text:
Learn more about BLACKBURN & MURGATROYD LIMITED. Check the company's details for free and view the Companies House information, company documents and list of directors.
Know about every new company document that is added!
Take advantage of our watch this company feature free of charge and have notifications sent directly to your inbox. Whenever a new document appears on this website, or if their particulars change, you will be immediately informed about such changes. To monitor these changes, all you need to do is click on watch this company.
|Tangible Fixed Assets
|£ 32,880
|Current Assets
|£ 192,403
|Tangible Fixed Assets Depreciation
|£ 44,874
|Provisions For Liabilities Charges
|£ 2,082
|Share Premium Account
|£ 50
|£ 47,475
|Profit Loss Account Reserve
|£ 128,213
|Called Up Share Capital
|£ 550
|Net Assets Liabilities Including Pension Asset Liability
|£ 128,813
|Total Assets Less Current Liabilities
|£ 130,895
|Net Current Assets Liabilities
|£ 98,015
|Creditors Due Within One Year
|£ 94,388
|Cash Bank In Hand
|£ 142,728
|Stocks Inventory
|£ 2,200
|Share Capital Allotted Called Up Paid
|£ 550
|Par Value Share
|1631 each
|Number Shares Allotted
|£ 550
|Tangible Fixed Assets Cost Or Valuation
|£ 70,764
|Tangible Fixed Assets Depreciation Charged In Period
|£ 6,990
Information about the Private Limited Company BLACKBURN & MURGATROYD LIMITED has been prepared for information purposes only. It is not intended to be nor does it constitute legal advice. This is public information provided by the official company register.

subset: commoncrawl


text:
THE Saints say Brendon Goddard will just be another Essendon player on Saturday, but the bitterness over his departure isn't far below the surface.
Goddard quit the Saints at the end of last year to join Essendon as a free agent.
Asked if the two-time All-Australian was a big loss, St Kilda coach Scott Watters said: "That's up for conjecture.
"In Brendon's words, his last 40 games were mediocre and middle of the road."
For his part, Goddard has referred to his former coach a "hobbit" and a "dwarf", albiet tongue in cheek.
St Kilda defender Jarryn Geary said today the players would be treating all players in Essendon jumpers the same when the two teams meet for the first time since Goddard's departure on Saturday at Etihad Stadium.
"We'll be playing the jumper. You don't see too many faces out there any other time," he told the AFL website.
"He played here for a long time but this week we'll just be focusing on trying to beat Essendon and all that other stuff will take care of itself."
Goddard attended Nick Riewoldt's wedding in Texas in October and the Saints skipper says they will be "mates for life".
But off the field the wounds are still raw.
Club president Greg Westaway reopened them in a recent interview, when he put the issue of Goddard's money demands firmly on the table.
"He was a required player," Westaway told Fairfax media.
"But for four years, we wanted only three. That means we would be paying him $750,000 at age 32.
"I don't think so. It would have been derelict of our board to have sewn him up for that fourth year."
Goddard angrily rejected the claims on The Footy Show.
"That is totally fabricated and untrue," he said.
"So for Greg Westaway to come out and say that - a complete bunch of lies - is somewhat hurtful.
"Pretty much he's suggesting that I held the club to ransom for those figures and whatever and on those terms, well it's pretty hurtful."
Saints fans are sure to let their feelings be known in the stands, and while Goddard's former teammates might not hold a grudge, they won't have forgotten that Goddard could let his anger get the better off him on the field.
Don't be surprised if Clinton Jones goes straight to the Bombers' No.9 in an attempt to get under his skin.
Originally published as Goddard defection still raw


text:
A modular approach that allows those at General Practice and Hospital level to progress their accreditation is being considered by the Practice Standards Group (PSG).
The change in format aims to provide more flexibility, emphasise standards of care and provide a pathway for practices to improve.
The new proposals draw on comments made by the profession as part of the concept note consultation that took place towards the end of last year. Around 50 responses were received, and we are very grateful to those who took the time and trouble to respond.
It was considered that the new modular format would best be achieved through a graded system, where General Practice standards would consist of mandatory requirements plus additional optional standards, and the accreditation achieved (which may take the form of gold, silver or bronze) would depend on the percentage of additional requirements met.
In addition, there is a proposed new General Hospital category (roughly equivalent to the existing Veterinary Hospital) and additional new 'Referral Hospital' categories.
It was also considered that where practices focus on limited services there should be a mechanism to accredit what is being done though a similar system of grading.
The PSG also supports the introduction of a discussion forum for practices in the Scheme to share ideas and problems.
Members of the PSG will develop these proposals and a paper will be put to the Advisory Committee in due course. There will also be a meeting of RCVS Council on the afternoon of 6 June to discuss the proposals.
Refined proposals will be put out for consultation to the profession and the public before being adopted.
The Practice Standard (May 2013)


text:
Blackberry Grunt
Recipe by Xexe383
The recipe is from Alton Brown, it sounds amazing.
Top Review by Engrossed
GREAT recipe, Freddy Cat approves! I made this with white whole wheat flour and 3/4 cup Splenda Granular and 2T Splenda brown sugar blend. I cut the dry ingredients together with the butter with my pastry blender. I added 1T of cornstarch towards the end of cooking the blackberries to thicken it because of the Splenda subs. I cooked the blackberries in a medium pot and then poured it into an 8x8 baking dish since I didn't have a cast iron skillet. If you like biscuits and blackberries you'll love this! I do think this one would be better with real sugar but alas I was trying to make it more diet friendly. Thanks for inviting Freddy Cat by for a visit!
See Discussion:1 Review
Ingredients Nutrition
- 9 1⁄2 ounces all-purpose flour, approximately 2 cups
- 2 teaspoons baking powder
- 1 teaspoon kosher salt
- 1⁄4 teaspoon baking soda
- 2 ounces unsalted butter, cut into small pieces and chilled
- 1 cup buttermilk
- 19 ounces blackberries (fresh or frozen)
- 1 cup sugar
- 1 cup water
- 1⁄2 teaspoon ground ginger
Directions See How It's Made
- Preheat oven to 400 degrees F. Place a piece of foil on the bottom rack of the oven to catch any drippings.
- Place the flour, baking powder, salt and baking soda into the bowl of a food processor and process for 3 to 4 pulses.
- Pour the mixture into a large mixing bowl and, using your hands, work the butter into the flour mixture until about half of the fat disappears and the rest is left in pea-size pieces.
- Make a well in the center of the mixture and add the buttermilk and stir with a rubber spatula or wooden spoon just until it comes together.
- Turn the mixture out onto a piece of parchment or waxed paper that has been lightly dusted with flour, shape into a ball and wrap and store in the refrigerator while you prepare the filling.
- Combine the blackberries, sugar, water and ginger in a large mixing bowl. Pour the mixture into a 10-inch cast iron skillet and place over medium heat.
- Bring this to a simmer decrease the heat to medium low and continue to cook, stirring occasionally, for 15 minutes, or until the liquid is thick enough to coat the back of a spoon.
- Retrieve the dough from the refrigerator and gently drop it on the fruit mixture using a 1-ounce disher or large spoon, evenly distributing it over the top. Bake in the oven for 15 to 20 minutes, or until the top is just starting to brown. Remove from the oven and allow the grunt to cool for 15 to 30 minutes before serving.


text:
1 to 1 Movement 1 to 1 Movement
Here's a sample of our volunteer opportunities:VIEW AS
Mission Statement
The 1 : 1 Movement, or "1 : 1" (pronounced one to one) is an organization focused on raising awareness and making change on the issues of sustainability. We believe in an approach in which we are empowering community members to realize the environmental, economic, and health benefits of making sustainable minded decisions instead of criticizing them for currently unsustainable behaviors. 1 : 1 believes in motivating our community to feel that they're part of the solution instead of chastising them for being part of the problem. Lastly, we at 1 : 1 feel that the most effective way to bring about change is through a combination of the people working towards their goals, and big business and government working down to meet us there. We call this the "Bottom Up, Top Down" approach.
One of the goals of 1 : 1 is to demystify the concept of sustainability. Currently, it's a word most often heard in liberal/progressive circles, most often associated with environmental issues. Ultimately, sustainability is a very simple term; it means whether or not we can continue to do things in a certain way. As mentioned earlier, it is also important for us to point out that sustainability is NOT only an environmental issue, but also one that affects our economy, our health, our cultural diversity, and that of surrounding wildlife.
We at 1 : 1 believe that people are good and want to do the right thing. Unfortunately, though, involvement and awareness is often complicated by the fact that issues are complex, and require multiple steps to bring about change. With sustainability though, the ratio is simple. Every plastic bag not used is one bag conserved. 1 : 1 ratio of your action to the desired outcome.
- Sarah Moersfelder
- 6192697047
- Need admin access?
This information
Might be out of date
Do you work for this organization?
Request administrator status and update its information!


text:
- Old Stuff
- Clearance Specials
- 1967 Gibson J-50
1967 Gibson J-50
You'd think that Gibson musta made about a zillion J-50s in the late-1960s and they prolly did, but they all seem to have that skinny little, pencil-thin neck. Not this one, or at least it doesn't feel that way. Has a nice comfy-feeling fullness around the back of it, just right. 100% original other than a strap button added at the heel, and not an issue to be found anywhere. Nice clean finish too; no scrapes, no dents, no belt-buckle rash, and 100% all there on the back of the neck; looks to me like it was barely ever played. Action easy and perfect of course, set up right here in our own workshop, frets and original solid rosewood adjustable bridge just fine all the way. Tone…… tons of it, the real 1960s Gibson, style, big and chunky. Original soft case as well of course. All The Way Home for
was $3195
save $200


text:
Gordon & Rees Ranked Among 50 Largest U.S. Law Firms by Law360
Here's a little unabashed, yet well-deserved honor my firm recently obtained. Number 48!! Go Team G&RSM! #Medicaidatty #Medicareatty
"Gordon Rees Scully Mansukhani now ranks as the 48th largest law firm in the United States per Law360 in its annual rankings of the 400 largest law firms in the nation. The firm attained this distinction by moving up five spots from the prior year's rankings and 23 positions from the 2015 list, and currently comprises some 733 attorneys and 304 partners throughout the U.S.
"This distinction represents an important milestone for the firm," commented Firmwide Managing Partner Dion N. Cominos. "We continue to have good fortune in growing our platform with outstanding lawyers; most importantly, however, the growth has not occurred for its own sake but instead to allow us to best service our clients on a national stage."
During the last three years, the firm has expanded its U.S. headcount by more than 26 percent and, since 2000, Gordon & Rees has added more than 30 new offices, and now has a major outpost in eight of the 10 largest cities in the United States. In 2017 alone, the firm has opened five new offices: Cincinnati and Columbus, Ohio; Oklahoma City, Oklahoma; Salt Lake City, Utah; and Milwaukee, Wisconsin.
Gordon & Rees is a national litigation and business transactions firm with more than 700 lawyers in 43 offices across the United States. Our lawyers provide full service representation to public and private companies ranging from the Fortune 500 to start-ups. Founded in 1974, Gordon & Rees is recognized among the fastest growing and largest law firms in the country and continues to climb the ranks of both The Am Law 200 and The National Law Journal."
Merger of Cardinal and Eastpointe: Will [Should] It Go Through?
What if, right before your wedding day, you discover a secret about your betrothed that changes the very fabric of your relationship. For example, you find out your spouse-to-be is actually gay or a heroin addict. Not that there is anything bad about being gay or a heroin addict, but these are important facts to know and accept [or reject] about your future mate prior to the ringing of the wedding bells. The same is true with two companies that are merging to become one. The merged entity will be liable for any secrets either company is keeping. In this hypothetical, Eastpointe just found out that Cardinal has been cheating – and the wedding is set for July 1!
Cardinal Innovations and Eastpointe, two of our managed care organizations (MCO) charged with managing Medicaid behavioral health care funds plan to merge, effective July 1, 2017. Together the monstrous entity would manage Medicaid behavioral funds for 32 counties.
Last week the State Auditor published a scathing Performance Audit on Cardinal. State Auditor Beth Wood found more than $400,000 in "unreasonable" expenses, including corporate retreats at a luxury hotel in Charleston, S.C.; chartering planes to fly to Greenville, Rocky Mount and Smithfield; providing monthly detailing service for the CEO's car; and purchasing alcohol, private and first-class airline tickets and other items with company credit cards.
Cardinal's most significant funding is provided by Medicaid. Funding from Medicaid totaled $567 million and $587 million for state fiscal years 2015 and 2016, respectively. In other words, the State Auditor found that Cardinal is using our tax dollars – public money obtained by you and me – for entertainment, while concurrently, denying behavioral health care services and terminating providers from its catchment area. Over 30% of my salary goes to taxes. I do not accept Cardinal mismanaging my hard earned money – or anyone else's. It is unacceptable!
"The unreasonable spending on board retreats, meetings, Christmas parties and travel goes against legislative intent for Cardinal's operations, potentially resulting in the erosion of public trust," the audit states.
Eastpointe, however, is not squeaky clean.
A June 2015 Performance Audit by the State Auditor found that its former chief financial officer Bob Canupp was alleged to have received kickbacks worth a combined $547,595. It was also alleged that he spent $143,041 on three agency vehicles without a documented business purpose. Canupp, chief executive Ken Jones and other employees also were determined to have used Eastpointe credit cards to make $157,565 in "questionable purchases." There has not been an audit, thus far, on Eastpointe's management of public funds. One can only hope that the results of the Cardinal audit spurs on Beth Wood to metaphorically lift the skirts of all the MCOs.
Given the recent audit on Cardinal, I would like to think that Eastpointe is hesitant to merge with such an entity. If a provider had mismanaged Medicaid funds like the State Auditor found that Cardinal did, without question, the authorities would be investigating the provider for Medicaid fraud, waste, and abuse. Will Eastpointe continue with the merger despite the potential liability that may arise from Cardinal's mismanagement of funds? Remember, according to our State Auditor, "Cardinal could be required to reimburse the State for any payroll expenditures that are later disallowed because they were unauthorized." – Post-payment review!!
Essentially, this is a question of contract.
We learned about the potential merger of Cardinal and Eastpointe back in January 2017, when Sarah Stroud, Eastpointe's chief executive, announced in a statement that the agency plans to negotiate a binding agreement within weeks. The question is – how binding is binding?
Every contract is breakable, but there will be a penalty involved in breaching the contract, usually monetary. So – fantastic – if Eastpointe does back out of the merger, maybe our tax dollars that are earmarked for behavioral health care services for Medicaid recipients can pay the penalty for breaching the contract.
Another extremely troubling finding in Cardinal's State Audit Report is that Cardinal is sitting on over $70 million in its savings account. The audit states that "[b]ased on Cardinal's accumulated savings, the Department of Health and Human Services (DHHS) should consider whether Cardinal is overcompensated. For FY 2015 and 2016, Cardinal accumulated approximately $30 million and $40 million, respectively, in Medicaid savings. According to the Center for Medicaid and Medicare Services (CMS), Cardinal can use the Medicaid savings as they see fit."
As Cardinal sees fit??!!?! These are our tax dollars. Cardinal is not Blue Cross Blue Shield. Cardinal is not a private company. Who in the world thought it a good idea to allow any MCO to use saved money (money not spent on behavioral health care services for Medicaid recipients) to use as it sees fit. It is unconscionable!
Because of my blog, I receive emails almost daily from mothers and fathers of developmentally disabled or mentally handicapped children complaining about Cardinal's denials or reductions in services. I am also told that there are not enough providers within the catchment area. One mother's child was approved to receive 16 hours of service, but received zero services because there was no available provider. Another family was told by an MCO that the family's limit on the amount of services was drastically lower than the actual limit. Families contact me about reduced services when the recipient's condition has not changed. Providers contact me about MCO recoupments and low reimbursement rates.
Cardinal, and all the MCOs, should be required to use our tax dollars to ensure that enough providers are within the catchment areas to provide the medically necessary services. Increase the reimbursement rates. Increase necessary services.
According to the report, "Cardinal paid about $1.9 million in FY 2015 employee bonuses and $2.4 million in FY 2016 employee bonuses. The average bonus per employee was about $3,000 in FY 2015, and $4,000 in FY 2016. The bonuses were coded to Cardinal's administrative portion of Medicaid funding source in both years." Cardinal employs approximately 635 employees.
Good to know that Cardinal is thriving. Employees are overpaid and receive hefty bonuses. Executives are buying alcohol, private and first-class airline tickets and other items with company credit cards. It hosts lavish Christmas parties and retreats. It sits on a $70 million savings account. While I receive reports from families and providers that Medicaid recipients are not receiving medically necessary services, that there are not enough providers within the catchment area to render the approved services, that the reimbursement rates for the services are too low to attract quality providers, that more expensive services are denied for incorrect reasons, and that all the MCOs are recouping money from providers that should not be recouped.
If I were Eastpointe, I would run, regardless the cost.
NC State Auditor Finds Cardinal Expenditures Unreasonable!!(Finally) #Wastedtaxdollars
The NC State Auditor Beth Wood released an audit report on Cardinal Innovations yesterday, May 17, 2017. Here are the key findings. For the full report click here.
Cardinal is a Local Management Entity/Managed Care Organization (LME/MCO) created by North Carolina General Statute 122C. Cardinal is responsible for managing, coordinating, facilitating and monitoring the provision of mental health, developmental disabilities, and substance abuse services in 20 counties across North Carolina. Cardinal is the largest of the state's seven LME/MCOs, serving more than 850,000 members. Cardinal has contracted with DHHS to operate the managed behavioral healthcare services under the Medicaid waiver through a network of licensed practitioners and provider agencies.
• Cardinal spent money exploring strategic opportunities outside of its core mission
• $1.2 million in CEO salaries paid without proper authorization
• Cardinal's unreasonable spending could erode public trust
• Cardinal should consult and collaborate with members of the General Assembly before taking any actions outside of its statutory boundaries
• The Office of State Human Resources should immediately begin reviewing and approving Cardinal CEO salary adjustments
• The Department of Health and Human Services should determine whether any Cardinal CEO salary expenditures should be disallowed and request reimbursement as appropriate
• Cardinal should implement procedures consistent with other LME/MCOs, state laws, and federal reimbursement policy to ensure its spending is appropriate for a local government entity
My favorite? Recoup CEO salaries. Maybe we should extrapolate.
Appealing Adverse Decisions: Should We Reconsider the Medicaid Provider Reconsideration Review?
What if you had to appeal traffic citations through the police officer who pulled you over before you could defend yourself before an impartial judge? That would be silly and a waste of time. I could not fathom a time in which the officer would overturn his/her own decision.
"No, officer, I know you claim that I was speeding, but the speed limit on Hwy 1 had just increased to 65. You were wrong when you said the speed limit was 55."
"Good catch, citizen. You're right; I'm wrong. Let's just rip up this speeding ticket."
Not going to happen.
The same is true when it comes to decisions by the Department of Health and Human Service (DHHS) to sanction or penalize a Medicaid provider based on alleged provider abuse (otherwise known as documentation errors). If DHHS determines that you owe $800,000 because your service notes are noncompliant, I am willing to bet that, upon its own reconsideration, the decision will be upheld. Asking for reconsideration review from the very same entity that decided the sanction or penalty is akin to doing something over and over and expecting different results (definition of insanity?).
But – are informal reconsideration reviews required by law to fight an adverse decision before you may appear before an administrative law judge?
The reason that you should care whether the reconsideration reviews are required by law is because the process is time consuming, and, often, the adverse determination is in effect during the process. If you hire an attorney, it is an expensive process, but one that you will not (likely) win. Generally, I am adverse to spending time and money on something that will yield nothing.
Before delving into whether reconsideration reviews are required by law, here is my caveat: This issue has not been decided by our courts. In fact, our administrative court has rendered conflicting decisions. I believe that my interpretation of the laws is correct (obviously), but until the issue is resolved legally, cover your donkey (CYA), listen to your attorney, and act conservatively.
Different laws relate to whether the adverse decision is rendered by the DHHS or whether the adverse decision is rendered by a managed care organization (MCO). Thus, I will divide this blog into two sections: (1) reconsiderations to DHHS; and (2) reconsiderations to an MCO.
Appealing DHHS Adverse Determinations
When you receive an adverse decision from DHHS, you will know that it is from DHHS because it will be on DHHS letterhead (master of the obvious).
10A NCAC 22F .0402 states that "(a) Upon notification of a tentative decision the provider will be offered, in writing, by certified mail, the opportunity for a reconsideration of the tentative decision and the reasons therefor. (b) The provider will be instructed to submit to the Division in writing his request for a Reconsideration Review within fifteen working days from the date of receipt of the notice. Failure to request a Reconsideration Review in the specified time shall result in the implementation of the tentative decision as the Division's final decision."
As seen above, our administrative code recommends that a Medicaid provider undergo the informal reconsideration review process through DHHS to defend a sanction or penalty before presenting before an impartial judge at the Office of Administrative Hearings (OAH). I will tell you, having gone through hundreds upon hundreds of reconsideration reviews, DHHS does not overturn itself. The Hearing Officers know who pay their salaries (DHHS). The reconsideration review ends up being a waste of time and money for the provider, who must jump through the "reconsideration review hoop" prior to filing a petition for contested case.
Historically, attorneys recommend that provider undergo the reconsideration review for fear that an Administrative Law Judge (ALJ) at OAH would dismiss the case based on failure to exhaust administrative remedies. But upon a plain reading of 10A NCAC 22F .0402, is it really required? Look at the language again. "Will be offered" and "the opportunity for." And what is the penalty for not requesting a reconsideration review? That the tentative decision becomes final – so you can petition to OAH the final decision.
My interpretation of 10A NCAC 22F .0402 is that the informal reconsideration review is an option, not a requirement.
Now, N.C. Gen. Stat. 150B-22 states that "[i]t is the policy of this State that any dispute between an agency and another person that involves the person's rights, duties, or privileges, including licensing or the levy of a monetary penalty, should be settled through informal procedures. In trying to reach a settlement through informal procedures, the agency may not conduct a proceeding at which sworn testimony is taken and witnesses may be cross-examined. If the agency and the other person do not agree to a resolution of the dispute through informal procedures, either the agency or the person may commence an administrative proceeding to determine the person's rights, duties, or privileges, at which time the dispute becomes a "contested case.""
It is clear that our State's policy is that a person who has a grievance against an agency; i.e., DHHS, attempts informal resolution prior to filing an appeal at OAH. Notice that N.C. Gen. Stat. 150B-22 is applicable to any dispute between "an agency and another person." "Agency" is defined as "an agency or an officer in the executive branch of the government of this State and includes the Council of State, the Governor's Office, a board, a commission, a department, a division, a council, and any other unit of government in the executive branch. A local unit of government is not an agency."
Clearly, DHHS is an "agency," as defined. But an MCO is not a department; or a board; or a commission; or a division; or a unit of government in the executive branch; or a council. Since the policy of exhausting administrative remedies applies to DHHS, are you required to undergo an MCO's reconsideration review process?
Appealing an MCO Adverse Determination
When you receive an adverse decision from an MCO, you will know that it is from an MCO because it will be on the MCO's letterhead (master of the obvious).
For example:
There is a reason that I am emphasizing the letterhead. It is because DHHS contracts with a number of vendors. For example, DHHS contracts with Public Consulting Group (PCG), The Carolina Center for Medical Excellence (CCME), HMS, Liberty, etc. You could get a letter from any one of DHHS' contracted entities – a letter on their letterhead. For example, you could receive a Tentative Notice of Overpayment on PCG letterhead. In that case, PCG is acting on behalf of DHHS. So the informal reconsideration rules would be the same. For MCOs, on the other hand, we obtained a Waiver from the Center for Medicare and Medicaid Services (CMS) to "waive" certain rules and to create the MCOs. Different regulations apply to MCOs than DHHS. In fact, there is an argument that N.C. Gen. Stat. 150B-22 does not apply to the MCOs because the MCOs are not an "agency." Confusing, right? I call that job security.
Are you required to undergo the MCO's internal reconsideration review process prior to filing a petition for contested case at OAH?
Your contract with the MCO certainly states that you must appeal through the MCO's internal process. The MCO contracts with providers have language in them like this:
Dispute Resolution and Appeals: "The CONTRACTOR may file a complaint and/or appeals as outlined in the LME/PIHP Provider Manual promulgated by LME/PIHP pursuant to N.C. Gen. Stat. 122C-151.3 and as provided by N.C. Gen. Stat. Chapter 108C."
I find numerous, fatal flaws in the above section. Whoever drafted this section of the contract evidently had never read N.C. Gen. Stat. 122C-151.3, which plainly states in subsection (b) "This section does not apply to LME/MCOs." Also, the LME/PIHP does not have the legal authority to promulgate – that is a rule-making procedure for State agencies, such as DHHS. The third fatal flaw in the above section is that the LME/MCO Provider Manual is not promulgated and certainly was not promulgated not pursuant to N.C. Gen. Stat. 122C-151.3, does not apply to LME/MCOs.
Just because it is written, does not make it right.
If N.C. Gen. Stat. 150B-22 does not apply to MCOs, because MCOs are not an agency, then the State policy of attempting to resolve disputes through informal methods before going to OAH does not apply.
There is no other statute or rule that requires a provider to exhaust an MCO's internal review process prior to filing a petition for contested case.
What does that mean IN ENGLISH??
What it means is that the MCOs contract and provider manual that create an informal one or two-step reconsideration process is not required by law or rule. You do not have to waste your time and money arguing to the MCO that it should overturn its own decision, even though the reconsideration review process may be outlined in the provider manual or your procurement contract.
OAH has agreed…and disagreed.
In Person-Centered Partnerships, Inc. v. NC DHHS and MeckLINK, No. 13 DHR 18655, the court found that "[n]either the contractual provisions in Article II, Section 5.b of the Medicaid Contract nor MeckLINK's "Procedures for implementation of policy # P0-09 Local Reconsideration Policy" states that reconsideration review is mandatory and a prerequisite to filing a contested case."
In another case, OAH has held that, "[c]ontract provisions cannot override or negate the protections provided under North Carolina law, specifically the appeal rights set forth in N.C. Gen. Stat. Chapter 108C. Giesel, Corbin on Contracts § 88.7, at 595 (2011) (When the law confers upon an individual a right, privilege, or defense, the assumption is that the right, privilege or defense is conferred because it is in the public interest. Thus, in many cases, it is contrary to the public interest to permit the holder of the right, privilege, or defense to waive or to bargain it away. In these situations, the attempted waiver or bargain is unenforceable.")" Essential Supportive Services, LLC v. DHHS and its Agent Alliance Behavioral Healthcare, No. 13 DHR 20386 (NCOAH) (quoting Yelverton's Enrichment Services, Inc., v. PBH, as legally authorized contractor of and agent for N.C. Department of Health and Human Services, 13-CVS-11337, (7 March 2014)).
However, most recently, OAH ruled in the opposite way. A provider was terminated from an MCO's catchment area, and we immediately filed a preliminary injunction to cease the termination. As you can see from the above-mentioned cases, OAH had not considered the reconsideration review mandatory. But, this time, the Judge found that the "contractual provision in [the MCO's] contract with Petitioner, which provides for a local reconsideration review, is a valid and binding provision within the contract."
So, again, the law is as clear as two and two adding up to five.
For now, when you are disputing an adverse determination by an MCO requesting a reconsideration review before going to OAH is a good CYA.
Going back to the traffic example at the beginning of the blog, my husband was pulled for speeding a few weeks ago. I was surprised because, generally, he does not speed. He is a usually conscientious and careful driver. When the officer came to his window, he was genuinely confused as to the reason for the stop. In his mind, he was driving 73 mph, only 3 miles over the speed limit. In fact, he had the car on cruise control. Turns out he confused the sign for HWY 70, as a speed limit sign. The speed limit was actually 55 mph.
We did not appeal the decision.
Legislative Update For May 10, 2017
I am a member of the Health Law Section's Legislative Committee, along with attorneys Shawn Parker, and Scott Templeton. Together we drafted summaries of all the potential House and Senate Bills that have passed one house (crossed over) and have potential of becoming laws. We published it on the NC Bar Association Blog. I figured my readers would benefit from the Bill summaries as well. Please see below blog.
On behalf of the North Carolina Bar Association Health Law Section's Legislative Committee, we are providing the following 2017 post-crossover legislative update.
The North Carolina General Assembly has been considering a substantial number of bills of potential relevance to health law practitioners this session. The Health Law Section's Legislative Committee, with the help of NCBA staff, has been monitoring these bills on virtually a daily basis.
The General Assembly's rules provide for a "crossover date" during the legislative session, which this year was April 27. The importance of that date is essentially that, with certain caveats, unless a bill has passed one chamber (House or Senate) by the crossover date, the bill will no longer be considered by the legislature. The following listing provides brief descriptions of current proposed legislation, in two categories.
The first category includes bills that passed either the House or Senate by the crossover date, and therefore remain in consideration by the legislature. The second category includes bills that did not pass either chamber before the crossover date, but because the bills contain an appropriation or fee provisions, they may continue to be considered pursuant to legislative rules.
In addition to the bills listed below, a number of bills did not make crossover and do not meet an exception to the crossover rule, and are likely "dead" for this legislative session. We recognize, however, that the legislature is capable of "reviving" legislation by various mechanisms. The Legislative Committee continues to monitor legislation during the session, and in addition to this update, we may provide further updates as appropriate, and also anticipate doing a final summary once the legislature has adjourned later this year.
Bills That Passed One Chamber by the Crossover Date.
House Bills
HB 57: Enact Physical Therapy Licensure Compact
Makes North Carolina a member of the Physical Therapy Licensure Compact, upon the 10th member state to enact the compact. Membership in the compact would allow physical therapists who hold licenses in good standing in any other compact state to practice physical therapy in North Carolina. Likewise, physical therapists holding a valid license in North Carolina would be able to practice physical therapy in any of other the compact member states.
HB 140: Dental Plans Provider Contracts/Transparency
Provides that insurance companies that offer stand-alone dental insurance are subject to the disclosure and notification provisions of G.S. 58-3-227.
HB 156: Eyeglasses Exemption from Medicaid Capitation
Adds the fabrication of eyeglasses to the list of services that are not included as part of transitioning the State Medicaid program to a capitated system.
HB 199: Establish Standards for Surgical Technology
Creates standards for surgical technology care in hospitals and ambulatory surgical facilities, specifically prohibiting employing or contracting with a surgical technologist unless that technologist produces one of four enumerated qualifications.
HB 206: N.C. Cancer Treatment Fairness
Requires insurance coverage parity so orally administered anti-cancer drugs are covered on a basis no less favorable than intravenously administered or injected anti-cancer drugs.
HB 208 : Occupational Therapy Choice of Provider
Adds licensed occupational therapists to the list of providers for whom insurers are required to pay for services rendered, regardless of limitations to access of such providers within the insurance contract.
HB 243: Strengthen Opioid Misuse Prevention (STOP) Act
Requires, among other things, practitioners to review information in the state-controlled substance reporting system prior to prescribing certain targeted controlled substance and limits the length of supply that a targeted controlled substance may be prescribed for acute pain relief.
HB 258: Amend Medical Malpractice Health Care Provider Definition
Includes paramedics, as defined in G.S. 131E-155, within the definition of health care provider for the purposes of medical malpractice actions.
HB 283: Telehealth Fairness Act
Requires health benefit plans to provide coverage for health care services that are provided via telemedicine as if the service were provided in person.
HB 307: Board Certified Behavioral Analyst/Autism Coverage
Adds board certified behavioral analysts as professionals that qualify for reimbursement for providing adaptive behavioral treatments under North Carolina's mandatory coverage requirements for autism spectrum disorder.
HB 403: LME/MCO Claims Reporting/Mental Health Amendments
Requires Local Management Entities/Managed Care Organizations (LME/MCOs) to use a state-designated standardized format for submitting encounter data, clarifies that the data submitted may be used by DHHS to, among other authorized purposes, set capitation rates. Also modifies multiple statutory requirements and references related to LME/MCOs. Limits the LME/MCOs' use of funds to their functions and responsibilities under Chapter 122C. Also limits the salary of an area director unless certain criteria are met.
HB 425: Improve Utilization of MH Professionals
Allows licensed clinical addiction specialists to own or have ownership interest in a North Carolina professional corporation that provides psychotherapeutic services. Allows licensed professional counselors or licensed marriage and family therapist to conduct initial examinations for involuntary commitment process when requested by the LME and approved by DHHS.
HB 550: Establish New Nurse Licensure Compact
Repeals the current nurse licensure compact codified at G.S. 90-171.80 – 171.94 and codifies a substantially similar compact, which North Carolina will join upon adoption by the 26th state, allowing nurses to have one multi-state license, with the ability to practice in both their home state and other compact states.
HB 631: Reduce Admin. Duplication MH/DD/SAS Providers
Directs DHHS to establish a work group to examine and make recommendations to eliminate administrative duplication of requirements affecting healthcare providers.
Senate Bills
SB 42: Reduce Cost and Regulatory Burden/Hospital Construction
Directs the N.C. Medical Care Commission to adopt the American Society of Healthcare Engineers Facility Guidelines for physical plant and construction requirements for hospital facilities and to repeal the current set of rules pertaining to such requirements under the current hospital facilities rules within the North Carolina Administrative Code.
SB 161: Conforming Changes LME/MCO Grievances/Appeals
Provides a technical change to North Carolina LME/MCO enrollee grievance statutes by renaming "managed care actions" as "adverse benefit determinations" to conform to changes in federal law.
SB 368: Notice of Medicaid SPA Submissions
Directs DHHS to notify the General Assembly when DHHS submits to the federal government an amendment to the Medicaid State Plan, or decides not to submit a previously published amendment.
SB 383: Behavioral Health Crisis EMS Transport
Directs DHHS to develop a plan for adding Medicaid coverage for ambulance transports to behavioral health clinics under Medicaid Clinical Coverage Policy 15.
SB 384: The Pharmacy Patient Fair Practices Act
Prohibits pharmacy benefits managers from using contract terms to prevent pharmacies from providing direct delivery services and allows pharmacists to discuss lower-cost alternative drugs with and sell lower-cost alternative drugs to its customers.
SB 630: Revise IVC Laws to Improve Behavioral Health
Makes substantial revisions to Chapter 122C regarding involuntary commitment laws.
Bills That Did Not Pass Either Chamber by the Crossover Date, But Appear to Remain Eligible for Consideration.
House Bills
HB 88: Modernize Nursing Practice Act
Eliminates the requirement of physician supervision for nurse practitioners, certified nurse midwives, clinical nurse specialists and certified registered nurse anesthetists.
HB 185: Legalize Medical Marijuana
Creates the North Carolina Medical Cannabis Act. Among many other provisions, it provides that physicians would not be subject to arrest, prosecution or penalty for recommending the medical use of cannabis or providing written certification for the medical use of cannabis pursuant to the provision of the newly created article.
HB 270: The Haley Hayes Newborn Screening Bill
Directs additional screening tests to detect Pompe disease, Mucopolysaccharidosis Type I, and X-linked Adrenoleukodystrophy as part of the state's mandatory newborn screening program.
HB 858: Medicaid Expansion/Healthcare Jobs Initiatives
Repeals the legislative restriction on expanding the state's Medicaid eligibility and directs DHHS to provide Medicaid coverage to all people under age 65 with incomes equal to or less than 133 percent of the federal poverty guidelines. Appropriates funds and directs the reduction of certain recurring funds to implement the act. Additionally the bill creates and imposes an assessment on each hospital that is not fully exempt from both the current equity and upper payment limit assessments imposed by state law.
HB 887: Health Insurance Mandates Study/Funds
Appropriates $200,000 to fund consultant services to assist the newly established Legislative Research Commission committee on state mandatory health insurance coverage requirements.
HB 902: Enhance Patient Safety in Radiological Imaging.
Creates a new occupational licensure board to regulate the practice of radiologic imaging and radiation therapy procedures by Radiologic Technologists and Radiation Therapists.
Senate Bills
SB 73: Modernize Nursing Practice Act
Eliminates the requirement of physician supervision for nurse practitioners, certified nurse midwives, clinical nurse specialists and certified registered nurse anesthetists.
SB 290: Medicaid Expansion/Healthcare Jobs Initiative
Repeals the legislative restriction on expanding the state's Medicaid eligibility and directs DHHS to provide Medicaid coverage to all people under age 65 with incomes equal to or less than 133 percent of the federal poverty guidelines. Appropriates funds, directs the reduction of certain recurring funds to implement the Act. Additionally the bill creates and imposes an assessment on each hospital that is not fully exempt from both the current equity and upper payment limit assessments imposed state law.
SB 579: The Catherine A. Zanga Medical Marijuana Bill
Creates the North Carolina Medical Cannabis Act. Among many other provisions, it provides that physicians would not be subject to arrest, prosecution or penalty for recommending the medical use of cannabis or providing written certification for the medical use of cannabis pursuant to the provision of the newly created article.
SB 648: Legalize Medical Marijuana
Creates the North Carolina Medical Cannabis Act. Among many other provisions, it provides that physicians would not be subject to arrest, prosecution or penalty for recommending the medical use of cannabis or providing written certification for the medical use of cannabis pursuant to the provision of the newly created article.
Please contact a member of the Health Law Section's Legislative Committee should you have any questions regarding this report. The Committee's members are Knicole Emanuel, Shawn Parker, and Scott Templeton (chair).
EHR: What's In YOUR Contract? Legal Issues You Need to Know.
Electronic health records or EHR have metamorphosed health care. Choosing a vendor can be daunting and the prices fluctuate greatly. As a provider, you probably determine your EHR platform on which vendor's program creates the best service notes… or which creates the most foolproof way of tracking time… or which program is the cheapest.
But…what's in YOUR contract can be legally deadly.
Regardless how you choose your EHR vendor, you need to keep the following legal issues in mind when it comes to EHR and the law:
Regulatory and Clinical Coverage Policy Compliance
Most likely, your EHR vendor does not have a legal degree. Yet, you are buying a product and assuming that the EHR program complies with applicable regulations, rules, and clinical coverage policies – whichever are applicable to your type of service. Well, guess what? These regulations, rules, and clinical coverage policies are not stagnant. They are amended, revised, and re-written more than my chickens lay eggs, but a little less often, because my chickens lay eggs every day.
Think about it – The Division of Medical Assistance (DMA) publishes a monthly Medicaid Bulletin. Every month DMA provides more insight, more explanations, more rules that providers will be held accountable to follow.
Does your EHR program update every month?
You need to review your contract and determine whether the vendor is responsible for regulatory compliance or whether you are. If you are, should you put so much faith in the EHR program?
Document Accessibility
You are required to maintain your records (depending on your type of service) anywhere from 5-10 years. Let's say that you sign a four year contract with EHR Vendor X. The four years expires, and you hire a new EHR vendor. You are audited. But Vendor X does not allow you access to the records because you no longer have a contract with them – not their problem!
You need to ensure that your EHR contract allows you access to your documents (because they are your documents) even in the event of the contract expiring or getting terminated. The excuse that "I don't have access to that" does not equal a legal defense.
This is otherwise known as the "Blame Game." If there is a problem with regulatory compliance, as in, the EHR records do not follow the regulations, then you need to know whether the EHR vendor will take responsibility and pay, or help pay, for attorneys' fees to defend yourself.
Like it or not, the EHR vendor does not undergo audits by the state and federal government. The EHR vendor does not undergo post and pre-payment reviews for regulatory compliance. You do. It is your NPI number that is held accountable for regulatory compliance.
You need to check whether there is an indemnification clause in the EHR contract. In other words, if you are accused of an overpayment because of a mistake on the part of the vendor, will the vendor cover your defense? My guess is that there is no indemnification clause.
HIPAA Compliance
HIPAA laws require that you minimize the access to private health information (PHI) and prevent dissemination. With hard copies, this was easy. You could just lock up the documents. With EHR, it becomes trickier. Obviously, you have access to the PHI as the provider. But who can access your EHR on the vendor-side? Assuming that the vendor has an IT team in case of computer issues, you have to consider to what exactly does that team have access.
I recently attended a legal continuing education class on data breach and HIPAA compliance for health care. One of the speakers was a Special Agent with the FBI. This gentleman prosecutes data breaches for a living. He said that hackers will pay over $500 per private medical document. Health care companies experienced a 72% increase in cyberattacks between 2013 and 2014. Stolen health care information is 10 times more valuable than your credit card information.
Zombie Apocalypse
Obviously, I am exaggerating here. I do not believe that The Walking Dead is real and in our future. But here is my point – You are held accountable for maintaining your medical records, even in the face of an act of God or terrorism.
Example: It was 1996. Provider Dentist did not have EHR; he had hard copies. Hurricane Fran flooded Provider Dentist's office, ruining all medical records. When Provider Dentist was audited, the government did not accept the whole "there was a hurricane" excuse. Dentist was liable for sever penalties and recoupments.
Fast forward to 2017 and EHR – Think a mass computer shutdown won't happen? Just ask Delta about its August 2016 computer shutdown that took four days and cancelled over 2000 flights. Or Medstar Health, which operates 10 hospitals and more than 250 outpatient facilities, when in March 2016, a computer virus shut down its emails and…you guessed it…its EHR database.
So, what's in YOUR contract?
Hospital May Lose Its Medicare Contract, Threatens CMS
Hospital is shocked to learn that its Medicare contract with Health and Human Services may be terminated by April 16, 2017. Medicaid services may also be adversely affected. The hospital was notified of the possible Medicare contract termination on March 27, 2017, and is faced with conceivably losing its Medicare contract within a month of notification. Legal action cannot act fast enough – unless the hospital requests an emergency temporary restraining order, motion to stay, and preliminary injunction and files it immediately upon learning that its Medicare contract is terminated.
The Center for Medicare and Medicaid Services (CMS) threatened Greenville Memorial Hospital, part of Greenville Health System, in South Carolina, that Medicare reimbursements will cease starting April 16, 2017. According to CMS, Memorial's emergency department is not compliant with Medicare regulations.
A public notice in the Greenville News says: "Notice is hereby given that effective April 15, 2017, the agreement between GHS Greenville Memorial Hospital, 701 Grove Road, Greenville, S.C. 29605 and the Secretary of Health and Human Service, as a provider of Hospital Services and Health Insurance for the Aged and Disabled Program (Medicare) is to be terminated. GHS Greenville Memorial Hospital does not meet the following conditions of participation. 42 CFR 482.12 Governing Body, 42 CFR 482.13 Patients' Rights and 42 CFR 482.23 Nursing Services."
"The Centers for Medicare and Medicaid Services has determined that GHS Greenville Memorial Hospital is not in compliance with the conditions of coverage. The Medicare program will not make payment for hospital services to patients who are admitted after April 16, 2017."
The findings came after an onsite audit was conducted on March 13, 2017. Memorial was notified of the report on March 27, 2017.
Memorial must have submitted a corrective action plan by April 3, 2017, but it has not been released.
The emergency department at Memorial treats about 300 patients per day. An employee of Memorial estimates that the termination would lose net revenue from Medicare and Medicaid could potentially reach around $495 million. Greenville Memorial received $305 million in Medicare funding and $190 million from Medicaid in the most recent fiscal year, accounting for nearly six in 10 patients, officials said.
While CMS and Memorial refuse to discuss the details of the alleged noncompliance, CMS' public notice cites three CFR cites: 42 CFR 482.12 Governing Body, 42 CFR 482.13 Patients' Rights and 42 CFR 482.23 Nursing Services.
42 CFR 482.12 requires that hospitals have governing bodies and plans to follow Medicare regulations. Subsection (f) specifically requires that if a hospital has an emergency department that the hospital must follow 42 CFR 482.55 "Conditions of Participation," which states that "The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice.
(a) Standard: Organization and direction. If emergency services are provided at the hospital –
- The services must be organized under the direction of a qualified member of the medical staff;
- The services must be integrated with other departments of the hospital;
- The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff.
(b) Standard: Personnel.
- The emergency services must be supervised by a qualified member of the medical staff.
- There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility."
The Memorial audit stemmed from a March 4, 2017, death of Donald Keith Smith, 48, who died as a result of traumatic asphyxiation. After an altercation, the patient was placed on a gurney, supposedly, face-down. South Carolina's Department of Health and Environmental Controls Site Survey Agency investigated the hospital after the death and the audit found that hospital security officers improperly restrained Smith, strapping him face down to a gurney during an altercation, rendering him unable to breathe. The death was ruled a homicide.
Memorial terminated the security officers involved in the death.
Now the hospital is faced with its own potential death. The loss of Medicare and, perhaps, Medicaid reimbursements could financially kill the hospital. Let's see what happens…
Health Care Fraud Liability: With Yates Fired – What Happens to the Memo?
"You're fired!" President Trump has quite a bit of practice saying this line from The Apprentice. Recently, former AG Sally Yates was on the receiving end of the line. "It's not personal. It's just business."
The Yates Memo created quite a ruckus when it was first disseminated. All of a sudden, executives of health care agencies were warned that they could be held individually accountable for actions of the agency.
What is the Yates Memo?
The Yates Memo is a memorandum written by Sally Quillian Yates, former Deputy Attorney General for the U.S. Dept. of Justice, dated September 9, 2015.
It basically outlines how federal investigations for corporate fraud or misconduct should be conducted and what will be expected from the corporation getting investigated. It was not written specifically about health care providers; it is a general memo outlining the investigations of corporate wrongdoing across the board. But it is germane to health care providers.
See blog.
January 31, 2017, Sally Yates was fired by Trump. So what happens to her memo?
With Yates terminated, will the memo that has shaken corporate America that bears her name go as well? Newly appointed Attorney General Jeff Sessions wrote his own memo on March 8, 2017, entitled "Memorandum for all Federal Prosecutors." it directs prosecutors to focus not on corporate crime, but on violent crime. However, investigations into potential fraud cases and scrutiny on providers appear to remain a top priority under the new administration, as President Donald Trump's proposed budget plan for fiscal year 2018 included a $70 million boost in funding for the Health Care Fraud and Abuse Control program.
Despite Sessions vow to focus on violent crimes, he has been clear that health care fraud remains a high priority. At his confirmation, Sessions said: "Sometimes, it seems to me, Sen. Hirono, that the corporate officers who caused the problem should be subjected to more severe punishment than the stockholders of the company who didn't know anything about it." – a quote which definitely demonstrates Sessions aligns with the Yates Memo.
By law, companies, like individuals, are not required to cooperate with the Justice Department during an investigation. The Yates Memo incentivizes executives to cooperate. However, the concept was not novel. Section 9-28.700 of the U.S. Attorneys' Manual, states: "Cooperation is a potential mitigating factor, by which a corporation – just like any other subject of a criminal investigation – can gain credit in a case that otherwise is appropriate for indictment and prosecution."
Even though Trump's proposed budget decreases the Department of Justice's budget, generally, the increase in the budget for the Health Care Fraud and Abuse Control program is indicative of this administration's focus on fraud, waste, and abuse.
Providers accused of fraud, waste, or abuse suffer extreme consequences. 42 CFR 455.23 requires states to suspend Medicaid reimbursements upon credible allegations of fraud. The suspension, in many instances, lead to the death of the agency – prior to any allegations being substantiated. Just look at what happened in New Mexico. See blog. And the timeline created by The Santa Fe New Mexican.
When providers are accused of Medicare/caid fraud, they need serious legal representation, but with the suspension in place, many cannot afford to defend themselves.
I am "all for" increasing scrutiny on Medicare/caid fraud, waste, and abuse, but, I believe that due process protection should also be equally ramped up. Even criminals get due process.
The upshot regarding the Yates Memo? Firing Yates did not erase the Yates Memo. Expect Sessions and Trump to continue supporting the Yates Memo and holding executives personally accountable for health care fraud – no more hiding behind the Inc. or LLC. Because firing former AG Yates, did nothing to the Yates Memo…at least not yet.
Work Requirements for Medicaid?
Under the Trump Administration, some Republican governors may look to move their Medicaid programs in a more conservative direction. In his latest column for Axios, Drew Altman discusses the arguments about Medicaid "work requirements" and why few people are likely to be affected by them in practice.
via Don't Expect Medicaid Work Requirements to Make a Big Difference — The Henry J. Kaiser Family Foundation


text:
It can be tough to keep a house clean—clutter piles up on coffee tables, dust settles in corners, and families of possums don't move out of cupboards without heavy sedation. Evict the mess with this Groupon.
Choose Between Two Options
- $49 for one two-hour housecleaning session (a $100 value)
- $89 for two two-hour housecleaning sessions (a $200 value)
Using environmentally friendly cleaning products, dust blasters run through each homeowner's personal to-do list, with services that include vacuuming, mopping, and dusting ceiling fans. Other complimentary add-ons include folding clothes or making beds, depending on each client's needs. This Groupon is valid anywhere in Savannah, along with Tybee Island, Rincon, and Richmond Hill.
Great Expectations Cleaning Service
The conscientious housecleaners at Great Expectations Cleaning Service make their clients' schedules top priority, sending out courtesy calls before arriving promptly at homes. Once they've ferreted out the lay of the domestic land, they un-bag a slew of green cleaning supplies to scour living spaces from top to bottom. With their phalanx of earth-friendly cleaning products, they sleuth out dirt hiding in every nook, cranny, and dust-bunny safe deposit box, polishing everything from the tops of ceiling fans to the floorboards.


text:
Addiction to opioid drugs has become a substantial public health problem due to the large number of Americans who use opioids for chronic pain, and the increased use by teenagers and adults of opioid prescription painkillers for nonmedical purposes. In this application, we describe development of a behavioral paradigm that models 'addiction-like'behavior for opioid drugs, we link this behavior with the expression of key molecular components, and we outline a novel strategy to translate this knowledge into potential therapeutic interventions. Specifically, using this behavioral paradigm, we linked 'addiction-like' behavior for heroin in rats following a one month test period to expression of several key regulators of the mu-opioid receptor (MOR), the primary mediator of the analgesic and rewarding properties of opioid drugs. One of these regulatory proteins is Wntless (WLS), a transport protein necessary for Wnt protein secretion. Wnts are ubiquitous glycoproteins with trophic properties for neurons, including dendritic spine maintenance and increased hippocampal neurogenesis, properties that are normally inhibited by opioid agonist drugs such as morphine, heroin, and fentanyl. Binding of morphine to the MOR enhances the interaction between MOR and WLS, resulting in the inhibition of Wnt protein secretion. Changes in WLS expression were also found to occur in the prefrontal cortex of rats demonstrating addiction-like behaviors for heroin. These results lead to the hypothesis that the opioid-induced MOR/WLS interaction is a critical molecular component contributing to the development of opioid addiction. Experiments proposed in this application are designed to challenge the MOR/WLS hypothesis by testing whether blockade of the MOR/WLS interaction in the prefrontal cortex can prevent acquisition of heroin 'addiction-like'behaviors in rats and/or rescue heroin-experienced rats from 'relapse'.
Specific Aim 1 will test whether the disruptive effects of morphine on Wnt secretion can be prevented in vitro via administration of MOR/WLS blocking peptides expressed in a lentiviral vector.
Specific Aim 2 will use a viral vector to test whether blockade of the MOR/WLS interaction in the prefrontal cortex will disrupt the development of addiction-like behavior for heroin in drug nave rats, while Specific Aim 3 will use a viral vector to test whether blockade of the MOR/WLS interaction in the prefrontal cortex will disrupt drug-induced reinstatement of heroin-seeking behavior in heroin-experienced rats. If successful, results from the experiments proposed in this application will reveal a novel avenue for the pharmacotherapy of opioid addiction in humans.
Treatment of pain in the US is an enormous public health problem, with over 240 million prescriptions written for opioid drugs in 2012. However, opioid drugs have substantial risks for dependence and addiction. This project is designed to utilize a behavioral model that assesses heroin addiction-like behaviors and novel compounds that will effectively prevent and treat addiction-like behaviors for heroin in rats. In so doing, novel avenues for the pharmacotherapy of drug addiction will be opened.
|Jenney, Christopher B; Petko, Jessica; Ebersole, Brittany et al. (2016) Early avoidance of a heroin-paired taste-cue and subsequent addiction-like behavior in rats. Brain Res Bull 123:61-70
|Ebersole, Brittany; Petko, Jessica; Woll, Matthew et al. (2015) Effect of C-Terminal S-Palmitoylation on D2 Dopamine Receptor Trafficking and Stability. PLoS One 10:e0140661


text:
Change Your Image
Upload An Image
Crop And Save
IMDb member since December 2010
Best Christmas Movies.
a list of 4 titles
Best Worst Movies!
a list of 10 titles
I want it to be known, that i will be seeing all of these movies in my life time.
My favorite movies of 2010
a list of 12 titles
Showing all 3
Sucker Punch (2011)
For the fans of previous Zack Synder films.
29 June 2011 - 20 out of 37 users found this review helpful.
2007 he brought us "300" and in 2009 he brought us the comic book adaptation "Watchmen". Now we are blessed with "Sucker Punch".
Im not going to explain the movie in this review, but I am going to point out the good and the bad points.
PROS: I love the action sequences. Sure, they're a bit cliché, but who gives a flying f**k. I love the way Synder makes his movies. The story is deep and great. and the graphics? This is Blu-ray material, ladies and gentlemen.
CONS: the PG-13 rating. It holds this movie back a lot. It could have been better if they had released it as an R rated movie. (this is the only reason keeping me from giving this movie a 9)
If you enjoyed 300 And Watchmen, You'll love this, If not, go watch Battle: Los Angeles.
See more▼See less▲


text:
PALMco Joins Autism Services and Resources Connecticut's Annual Walk for Autism as a Silver Sponsor
Raised Funds to Support ASRC's Statewide Work and Promote Autism Awareness
BROOKLYN, NY and WALLINGFORD, CT -- (Marketwired) -- May 01, 2015 -- PALMco, a family owned and operated energy supply company, announced today its sponsorship of Autism Services and Resources Connecticut's (ASRC) Walk for Autism on May 3, 2015. As a silver sponsor, PALMco is helping ASRC, the state leader in advocacy, training, and family supports, create a day to remember at its 17th annual Walk for Autism.
Drawing over 3,000 families, the Walk for Autism raises funds to support the statewide work for ASRC and promotes autism awareness on a broader scale. Located in Wallingford, CT, this year's walk features raffles, awards, food trucks, and new events like Touch-A-Truck.
"As a family owned and operated company, we are proud to support ASRC's efforts to help families on the daily journey of autism," said Robert Palmese, President of PALMco. "The 17th annual Walk for Autism is a great opportunity for the broader Connecticut community to learn about ASRC's creative activities, support groups, and recreational opportunities. ASRC's mission to support these families echoes our commitment to helping the local communities in which we operate."
"We are so grateful to have wonderful, community-minded corporate sponsors like PALMco, partner with us in providing the financial resources required for us to make much needed programs and services available to Connecticut's families," stated Kim Newgass, ASRC Director of Outreach & Special Projects.
The Walk for Autism on May 3rd is the year's largest fundraiser for ASRC, providing resources for all statewide advocacy efforts, programs, and services. Funds raised will also support the new Housing and Employment initiatives, which will address these issues as individuals on the spectrum grow into adulthood.
This new partnership is part of "PALMco Cares," a larger effort to give back to the communities in which PALMco operates. Launched in December 2013, PALMco Cares' inaugural campaign donates $1 per month for each participating gas and/or electric account to the American Childhood Cancer Organization (ACCO). In January 2014, PALMco announced that it had surpassed the initial goal of $10,000 but is continuing to offer the opportunity for customers to opt into donating to ACCO. Now in its third year, PALMco Cares has contributed over $30,000 to ACCO.
To learn more about PALMco Cares, visit www.palmcoenergy.com/palmco-cares/.
About PALMco
PALMco is a family owned and operated energy supply company (ESCO) that supplies electricity and gas in Connecticut, Illinois, Maryland, Massachusetts, New Jersey, Ohio, and Pennsylvania. Our family has been in the energy business since 1938, and we dedicate ourselves to providing quality service, customer satisfaction, dependable energy, and competitive prices. For more information, please visit www.palmcoenergy.com.
About ASRC
The vision of Autism Services & Resources Connecticut -- ASRC -- is two-fold: to prepare those with an autism spectrum disorder (ASD) for the world, as we prepare the world for those with an ASD. ASRC believes that everyone deserves to live their best life possible. This belief guides ASRC's mission as a non-profit organization, to provide lifelong access to opportunities for persons on the autism spectrum with the goal of being fully-included and participating members of their communities.
Contact Profile
NewsMaker is an Australian Press Release Distribution and Social Media Marketing service founded in 2004. The company today represents over 22,000 brands who seek to share their content with journalists, bloggers and the community.
Newsmaker Editors
W: www.newsmaker.com.au


text:
Drag Racing Hack
In Drag Racing you can drive over 50 officially licensed cars, upgrade them and show your skills in races. Would you select an iconic Skyline GT-R, a classic 69′ Mustang, or a brand new BMW M3 as your ultimate driving machine? With our Drag Racing Hack Apk you can get them all with a few clicks. Drag Racing Hack was made to help players get unlimited cash, respect points and unlock all cars. Drag Racing Hack Apk made by tooldownload.net doesn't require root or jailbrake to run. Our developers have done amazing job when they created this hack. It has never been easier to accumulate cash, rp points or get all cars.
Download button is just below and you will recieve some amazing features with our Drag Racing Online Hack such as unlimited cash generator, unlimited respect points generator and all cars unlocker. Go online and race for strips, you can win every car with our hack tool. Unlock every car you want and upgrade it to the maximum. It's like they say, push the pedal to the metal! Get your own hack and beat everyone in the game, beat all of your highscores and take down anyone you like. Drag Racing Cheat is updated daily to work perfectly for a long period of time.
Drag Racing Hack Features:
Unlimited Cash/Money
Unlimited Rp (Respect Points)
Unlock all Cars
Works with PC, Mac OS, all browsers, all mobile devices
No Jailbrake or Root Required
Auto update
To hack Drag Racing, download the hack tool or use our online generator:
Drag Racing Game Trailer:


text:
Picnic Salad Skewers Recipe
"These make-ahead kabobs are a fun way to serve a chilled salad," says Iola Egle of McCook, Nebraska. A homemade vinaigrette complements the tender potatoes, crisp peppers, cherry tomatoes and sliced zucchini.
- 8 unpeeled small red potatoes
- 8 fresh pearl onions
- 1 tablespoon water
- 1 medium sweet red pepper, cut into 1-inch pieces
- 1 medium green pepper, cut into 1-inch pieces
- 16 cherry tomatoes
- 1 small zucchini, cut into 1/4-inch slices
- 2/3 cup olive oil
- 1/3 cup red wine vinegar
- 2 garlic cloves, minced
- 1 tablespoon dried oregano
- 1 teaspoon salt
- 1/4 teaspoon pepper
- 4 ounces crumbled feta cheese, optional
- 1. Place potatoes in a saucepan and cover with water; bring to a boil. Cook for 10-13 minutes or until tender; drain. Place onions and water in a microwave-safe bowl. Cover and microwave on high for 1 to 1-1/2 minutes or until crisp-tender; drain.
- 2. On metal or wooden skewers, alternately thread potatoes, onions, peppers, tomatoes and zucchini. Place in a large shallow plastic container or large resealable plastic bag.
- 3. In a bowl, whisk together the oil, vinegar, garlic, oregano, salt and pepper. Pour over vegetable skewers. Marinate for at least 1 hour, turning frequently. Sprinkle with feta cheese if desired. Yield: 8 servings.
Reviews for Picnic Salad Skewers
Average Rating
Reviewed Mar. 8, 2010
"I substituted mushrooms for the potatoes. My husband said it was very good."
© 2017 RDA Enthusiast Brands, LLC


text:
HAMAMELIS 6DH HOMEOPATHIE Boiron Drops 60ML
Boiron souches homéopathiques toutes dilutions
HAMAMELIS 6DH HOMEOPATHIE Boiron Drops 60ML
The advice of your pharmacist
Partners with: LEMON TOOTHPASTE HOMEODENT CARE SENSITIVE GUMS 2 x 75ML
In stock
Warning: Last items in stock!
Availability date: 01/19/2013Preview the Shipping Fees - Free Shipping from 99€*
HAMAMELIS 6DH HOMEOPATHIE Boiron Drops 60ML
Authorized medicinal product: Aut. 0678
Enrolled in the pharmacopoeia
Refundable 30% by Social Security
Origin: Plant
Mode of administration of Hamamelis virginiana
Oral drops, solution for oral administration. The drops are diluted in a little water.
Composition of Hamamelis virginiana
Precautions of Hamamelis virginiana
Keep out of reach of children. Due to the presence of alcohol, tell your doctor if liver disease, epilepsy or pregnancy. If symptoms persist, consult your doctor.
Caution with Hamamelis virginiana
This medicine contains alcohol. Its alcohol content is 55% V / V, 0.45 g of alcohol 50 drops.
Instructions Hamamelis virginiana
Hamamelis virginiana 6 DH Drops
Authorized medicinal product: Aut. 0678
Enrolled in the pharmacopoeia
Refundable 30% by Social Security
Origin: Plant
Drops in 30 ml:
- CIP Code: 1353491
- CNAM Code: 7135349100024600
- Public price: € 2.46
Drops in 60 ml:
- CIP Code: 0353454
- CNAM Code: 7035345400043000
- Public price: € 4.3
The Laboratory Boiron has acquired unique know-how in the production of homeopathic medicines, the result of more than half a century of experience and innovation. The manufacture of homeopathic medicines meet pharmaceutical requirements and specific regulations.
Discover our new range of homeopathic drops and oral ampoules in alternative medicine within bio pharmacy vote online.
Save time by using the quick order form. With a few clicks , you can easily order your favorite references.
Be fan of our Facebook page and get 5 % discount!
If you are not logged in to Facebook, please first log in and then refresh this page before clicking the Like button. Otherwise, you will not get your voucher.


text:
What is JotForm?
JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
At JotForm, we want to make sure that you're getting the online form builder help that you need. Our friendly customer support team is available 24/7.
We believe that if one user has a question, there could be more users who may have the same question. This is why many of our support forum threads are public and available to be searched and viewed. If you'd like help immediately, feel free to search for a similar question, or submit your question or concern.
Please use the W9 form of our payment processor BlueSnap (former Plimus): https://home.bluesnap.com/files/W9%20BlueSnap_0.PDF
By PO, I assume you are talking about a Purchase Order. Please note that the minimum payment for Purchase Order is $100, as manual handling is involved. So, the cheapest available option for you would be to buy the Premium bi-yearly subscription.
Upon choosing any of the links at the bottom, make sure you choose "Purchase Order" at the Method of Payment field. Fill everything in that page, including your JotForm Login Name (which would be your JotForm Username, not the email address)
Once you are done, it will redirect you to another page where you will actually see the Address where you must send the check for payment. This is our Payment Gateway's, Plimus. You can hit on "Back" in order to correct anything, then you can print it. Also check the terms at the bottom of the page.
Make sure to SAVE the Reference Number and/or Quote Numbers and include it when sending the payment. That is important so our payment processor will be able to determine that the payment was made for your account.
It takes standard 15 days processing - excluding non-working days.
Premium Bi-Yearly ($139 USD): https://www.plimus.com/jsp/buynow.jsp?contractId=1851946
Economy Yearly ($199.95 USD): https://www.plimus.com/jsp/buynow.jsp?contractId=3173680
Economy Bi-Yearly ($349.50 USD): https://www.plimus.com/jsp/buynow.jsp?contractId=3176742
Professional Yearly ($499.95 USD): https://www.plimus.com/jsp/buynow.jsp?contractId=3135328
Professional Bi-Yearly ($799.95 USD): https://www.plimus.com/jsp/buynow.jsp?contractId=3176746
Please let us know if you need any further clarifications or assistance, and we will be happy to help.


text:
One shot, one stabbed in Dorchester incidents
Two men were injured last night in a stabbing and a shooting in Dorchester, police and witnesses said.
It was unclear last night of the two were injured in related incidents, both within a two-block area, police said.
Neighbors said there was a large gathering of teens near the intersection of Harvard Street and Ripley Road. The teens there were fighting and one was stabbed, said a group of neighbors gathered near the scene, all of whom said they called 911. They said shortly after the teen was stabbed another man was shot.
|The article you requested has been archived
- More On:
- Dorchester


text:
Services >> Dedicated Team > Dedicated Team
Dedicated Team
Resource Hiring ProcessNeosoft Technologies is a leading offshore software development company in India that offers dedicated team's services. If you are looking for cost effective resource solutions and would also like to have full control over development team, this is a perfect solution. For your needs. Under this model, Neosoft will reserve infrastructure and resources exclusively for the customer for a predefined time frame. The customer will have total access, control and transparency over the team to manage and monitor his software development process.
- We send 3 Competitive Resumes after getting your requirement.
- We run through the interview process and technical test if required, over Phone/Internet.
- On Selection, we immediately offer the services of the dedicated IT Staff for your organization.
- Tremendous Cost Savings
- Increase in Efficiency and Productivity
- To expand their service offerings
- Easy Project Execution
- No Long-term Investments
- No more Business Risks
- Full Operational Control
- Dedicated Development Team will work as per client's
time zone
- No IT Infrastructure setup required
- Access to Best IT brains handpicked from Indian IT
- High ROI (Return on Investment)
Hire Now
What we offer
- Hire 1 or more developers
- At least 9 hours a day, 5 days a week of working.
- A favorable development environment.
- Guaranteed timely communication through emails, phone and instant messengers.
- Daily and weekly reporting.
- Easy coding style.
- Highly skilled staff.
- Hardware and software infrastructure
- Multiple High Bandwidth Internet connection : Broadband & Leased Line


text:
Author Tags: Advice, Poetry
Having grown up in Newfoundland, UBC Language and Literacy professor Carl Leggo has repeatedly returned home in his imagination since he moved to British Columbia near the turn of the century. He also wrote a book about reading and teaching poetry, Teaching to Wonder: Responding to Poetry in the Secondary Classroom.
Teaching to Wonder: Responding to Poetry in the Secondary Classroom (Pacific Educational Press).
Mother's House (Killick, 1999). poetry.
Growing Up Perpendicular on the Side of a Hill. poetry.
Come-By-Chance (Breakwater Books, 2006)
[BCBW 2007] "Poetry" "Advice"


text:
Why rob a bank when you can dupe someone into doing it for you?
Lately, crooks have been fooling businesspeople into forking over their corporate funds this way. "CEO fraud" or "business email compromise," as the scam is known, has become a popular trick: Send an email (from a hacked employee account or spoofed domain) pretending to be an executive, and con the recipient (preferably an unquestioning subordinate) into transferring some amount of money.
In the U.S. alone over the past two years, as much as $750 million has been lost to wire fraudsters, reports the Federal Bureau of Investigation.
Tom Kemp, CEO of computer security firm Centrify, says his company is often targeted with these kinds of attacks. "I now regularly experience various forms of sophisticated attempts to get us to transfer money to crooks," he writes in a blog post on his company's website. "We are now getting one of these scam emails per week."
The first attempt happened in Feb. 2014, he says, when his vice president of finance received a wire transfer request, apparently from the company's chief financial officer. "Process a wire of $357,493.41 to the attached account information," read the message, which contained a PDF attachment purporting to contain further instructions. "Let it be coded admin expense. Send me the confirmation when completed."
"Thanks," the message continued, ostensibly bearing a sign-off from Centrify CFO Timothy Steinkopf: "Tim."
Below that, the email contained an apparently forwarded note, what might have seemed like an original request from Kemp. "Per our conversation, attached is the wiring instructions for the wire," the note, allegedly authored by the CEO, said. "I'll send the documentation later on. Let me know when done."
The VP of finance, whose inbox had been targeted, looped in other people at the company for approval. When the request made its way to the real Kemp and Steinkopf, it became obvious that something fishy (well, phishy) was going on. "After squinting our eyes a few times, we immediately deduced that the email was sent from a look-alike domain called 'centrilfy.com' which looks a lot like 'centrify.com,'" Kemp writes. So they called the FBI.
Meanwhile, the imposter became impatient. "Whats happening with the wire? I need to know," a follow-up email read.
Kemp relished the irony: "It was somewhat amusing to have an attempted crime playing out while we were on hold with the FBI trying to report that crime."
"That was the first of many attempts to scam us," Kemp writes before detailing a handful of other examples, all drawn from personal experience this year. Common phrases in the fraudulent emails include "urgent payment," "needs to go out today," "need you to take care of," "process," "now." The requests are typically short, informal, and pressing.
Kemp's tips for avoiding wire traps? He's got a few: Get approvals, cross check with accounting, use multi-factor authentication (a service his company offers, of course, as do rivals such as Duo, Okta, RSA, and Authy), and take domain names similar to the one used by your organization off the market by snatching them up. For example: the marketing or IT teams at Fortune.com might choose to buy "F0rtune.com," where the "o" has been replaced by a zero.
By the way, dear reader: Your CFO asked me to tell you to wire money to my personal bank account. No rush, though—whenever you get a chance.
Subscribe to Data Sheet, Fortune's daily newsletter on the business of technology.
For more on email cybersecurity, watch this video.


text:
This is a timed quiz.
You have 1 hour to complete the 6 questions in this quiz.
Click the button below to start the quiz.
What is the tagline of Project 1095? Answer:
What are the four domains of Project 1095?
SIM Global Education Scholarship and Bursary
Career Development & Professional Internship
Global Learning
Student Care
Peer Assisted Learning
Student Development
Student Support and Services
Which of the following is NOT a monthly activity at Student Wellness Centre (SWC)?
How many International Student Clubs are there?
7 clubs
8 clubs
9 clubs
10 clubs
Which country is the Service Learning Project 2016 based in? Answer: .
How many sectors are there in Career Chapters? Answer: (use numerals only)


text:
Have you ever felt confused when you are ready to start a woodworking project? You are not alone, but It is not as hard as it seems. Woodworking really can be easy and a whole lot of fun. Let's start with the most basic element... wood. Lowe's is happy to provide this information as a service to you.
In Canada, there are over 1,000 species of trees. Of these, only about 100 are used for constructing and manufacturing wood products. From this group, it's best to pick the ones that are easiest to work with and most appealing to you.
There are basically two kinds of wood from which to choose - hardwoods and softwoods. In addition, there are certain characteristics that are common in all wood types. Here are some common terms and definitions you should know:
These are the trees that lose their leaves in the fall (deciduous). Among an abundant variety, only 200 are plentiful and pliable enough for woodworking. Much like our skin, hardwoods have microscopic pores on the surface. The size of these pores determines the grain pattern and texture. Because of this, hardwoods are classified by pore openings as either: Closed Grained (smaller pores) - Most popular examples: cherry and maple; Ring Porous (larger pores) - Most popular examples: oak, ash or poplar.
Softwoods come from "evergreen" trees (coniferous). Only 25 percent of all softwoods are used in woodworking. All softwoods have a closed grain (small pores) that is not very noticeable in the finished product. The most popular softwoods are cedar, fir, pine and spruce.
Heavy woods like oak are identified by their weight and tight grain pattern, and resist wear, dents and scratches better than softwoods.
This is the wood property that determines the condition of the surface and stability. It plays an important role in deciding how a wood can be finished.
Defects in wood are natural and are appreciated by many woodworkers for the unique character they contribute.
Colour contributes to the personality of wood. For example, red cedar will give you a very different look and character than white pine.
Grain is the most well-known wood characteristic. Grain pertains to the wood-cell fibres' orientation. The project you are undertaking dictates the most suitable type of grain.
Lumber grades are determined by the number, location and size of defects in the board, not its strength. The clearer the wood, the higher the grade.
This is the wood's ability not to shrink or expand before or after it has been worked.
Durable woods better resist excess moisture and exposure to the earth, where there's a greater chance of decay. Remember, no wood will decay if it's kept dry.
Two boards of the same species can look very different. Each tree has its own grain pattern. This is the direction in which the wood cell fibres grow. These variances in grain direction can have a significant impact on your project.
The grain direction is important to consider when building either structural projects or decorative projects such as furniture or crafts. For instance, when working on a structural application, a straight-grained board is generally the strongest. In more decorative projects, grain with varying characteristics can add beauty and personality to the project.
There are six general types of grain:
Diagonal Grain
When a straight-grained log is not sawn along its vertical axis, diagonal grain is the result.
Spiral Grain
When trees grow twisted, spiral-grained logs and subsequent boards are produced. Fibres follow a spiral course with a twist that is either left- or right-handed.
Straight Grain
The board's fibres run approximately parallel with the vertical axis of the log from which it originated.
Wavy Grain
This type of grain results when the direction of wood fibres has constantly changed.
Irregular Grain
Boards of this type have fibres at directions that are varying and irregular from the log's vertical axis (for example: fibres around knots).
Interlocked Grain
Boards with this grain result from trees whose fibres lined up in opposite directions in each growth year.
Grain pattern density determines strength. As you'd expect, a piece of lumber with a tight pattern is stronger than one with a loose grain pattern. And when building, a board's strength is maximized when other pieces run across the grain pattern - not parallel to it.
When you are choosing lumber, do you know what the stamp on the wood actually means? Fear not! We've deciphered those hieroglyphics for you. So the next time you go to the lumber yard, you'll sound like a pro.
Grading designation depends on the number of defects in a given length and width of hardwood boards. As with softwoods, a lower grade can be perfectly acceptable, depending on placement and usage. Hardwoods are graded by the National Hardwood Lumber Association. Here's a chart to help explain the grading system. Grades are listed from highest to lowest.
Grade Name
Minimum Board Size
% Usable Material On One Face
Firsts and Seconds
6" x 8'
4" x 6'
#1 Common
#1 Com
3" x 4'
#2 Common
#2 Com
3" x 4'
There are grades below #2 Common, but they are typically not suitable for woodworking.
Softwoods are divided into two categories: dimensional lumber, with a grade based on strength, and appearance boards, which are typically used for woodworking projects. Grading of softwoods is overseen by a number of different agencies, so you will be more likely to find some variations in terminology. Grades listed here are from highest to lowest.
What It Means
C Select
Almost completely clear of defects. Widely used for interior trim and cabinets.
D Select
Fine appearance, similar to C Select. May have dime-sized knots.
1 Common
Best material for high quality pine with a knotty look. Knots will be tight, meaning they won't fall out and are generally small.
2 Common
Tight knots, but larger than found in 1 Common. Often used for panelling and shelving. Very suitable for general woodworking projects.
3 Common
Knots larger than in 2 Common. Also used for panelling and shelving, but especially well-suited for fences, boxes, and crates.
TWIST: Multiple bends in a board.
CUP: Hollow across the face of a board.
CROOK: Warp along the edge line, also known as crown.
KNOT or KNOTHOLE: A tight knot is usually not a problem. A loose or dead knot, surrounded by a dark ring, may fall out or may have already left a hole.
SPLIT: Crack going all the way through the piece of wood, commonly at the ends.
WANE: Missing wood or untrimmed bark along the edge or corner of the piece.
CHECK: Crack along the wood's annual growth rings, not passing through the entire thickness of the wood.
SHAKE: Separation of grain between the growth rings, often extending along the board's face and sometimes below its surface.
BOW: Warp on the face of a board from end to end.
Typical grade stamp
While lumber of the same species and size is still at the mill, it is designated and separated by grade. It is then identified by a stamp and often inventoried by its grade and species. When selecting wood, be sure you look for its grading stamp because different lumberyards sometimes use different names for the same grade. (And remember, if you are having trouble figuring it all out, ask for help.) Grade designations depend on particular defects such as knots or wane. Keep your project final results in mind when selecting the grade of wood. Grade does not indicate consistency of colour or grain patterns.
Manufacturer: Mill's number, name, or symbol. (ex. 12)
Certification mark: Symbol of agency providing quality-control supervision. (ex. WWP®)
Grade: Often abbreviated. 1 Common shown. (ex. 1COM)
Moisture content (MC): Abbreviation for MC when board surfaced. MC 15 is 15 percent or less; KD or S-DRY is 19 percent or less; S-GRN is green wood with more than 19 percent MC. (Ex. S-DRY)
Species mark: Symbol or abbreviation for types of tree. Example shown is Ponderosa pine. (Ex. PP)
Tools, products, materials, techniques, building codes and local regulations change; therefore, Lowe's assumes no liability for omissions, errors or the outcome of any project. The reader must always exercise reasonable caution, follow current codes and regulations that may apply, and is urged to consult with a licensed professional if in doubt about any procedures. Please visit our terms of use.


text:
Radioactive isotopes, also called radioisotopes, are atoms with a different number of neutrons than is usual, making them unstable. A radioisotope's nucleus decays, emitting alpha, beta and gamma rays until the isotope reaches stability. Once it's stable, the isotope may become another element entirely, such as when uranium decays into lead. The random nature of radioactivity means it's impossible to know exactly when an individual atom will decay.
How Many?
At present, about 200 radioactive isotopes are used on a regular basis, and while some are long-lasting and easily obtained, others are very unstable and decay into other isotopes in a few hours or less.
How Are They Manufactured?
Radioactive isotopes can be manufactured in several ways; most commonly, by bombarding a substance with neutrons in a small nuclear reactor; an excess of neutrons makes the substance radioactive. Some isotopes are produced in a cyclotron in which protons are added to the atomic nucleus, resulting in an excess of protons; this also produces radioactivity.
Radioactive isotopes are useful because they produce alpha, beta and gamma rays. The radiation's penetrating power depends on its energy, particle mass, and the object's density. These properties lead to many practical applications in science, medicine and industry. The type and strength of radiation needed as well as an isotope's lifetime determine its uses in various fields.
Medical Uses
Radioactive isotopes are powerful tools used to diagnose and treat a variety of illnesses. For example, chromium-51, which produces gamma rays, helps in classifying blood cells and measuring protein loss in the human body. Cobalt-60, a substance that gives off both gamma and beta radiation, is often used in cancer treatment. Oxygen-18 and technetium-99 are used as biological tracers, helping doctors find hidden tumors in various parts of the human body; as the diseased tissue absorbs the tracer substance, the telltale radiation marks the tumor's location.
Uses in Archaeology and Industry
Scientists use radioactive isotope elements such as carbon-14, used to establish the age when a living organism died; lead-210, used to date ice and sediments under 150 years old, and potassium-40 to establish the age of rocks and minerals. Chlorine-36 helps measure the age of ground water up to about a million years. In industry, radioisotopes are used as fuel for nuclear power plants, in the manufacturing of smoke alarms, tracing factory waste that may cause pollution, and predicting the behavior of heavy metals in water. Sodium-24 and magnesium-27, for example, are used to locate leaks in water pipes, while iridium-192 is used in radiography devices.
Other Uses
Radioisotopes are used to study biological processes in plant life for agriculture, and to treat and preserve food, making it safer for consumption and prolonging its shelf life.