SPECIAL INVESTIGATION COMMITTEE ORANGE COUNTY LEGISLATURE VALLEY VIEW NURSING HOME AND REHABILITATION CENTER REPORT TO THE

LEGISLATURE September 5, 2012

Prepared By: Jacobowitz and Gubits, LLP 158 Orange Avenue Walden, New York, 12586

TABLE OF CONTENTS Executive Summary ....3 Physical Facility ...4 Operating Results ....5 Revenue ....6 Expenses ......9 Management ......13 Quality of Care ...18 Sale Impacts ..20 Supplement to Report....21 Breach of Contract by OAS .....21 Concerns as to RFP ..23 Proceedings: Witnesses ...26 Witness Appearances by Date 27 Documents and Exhibits...29

EXECUTIVE SUMMARY 1. Dedicated staff who appear to have adjusted to "doing more with less 2. OAS employees and County Commissioners did not testify, but Financial reporting was based upon Valley View Accountants reports and testimony 3. Taxpayer subsidy less than reported deficit a. No risk of bankruptcy from operations of Valley View 4. Management deficiencies, along with the lack of any county corrective measures taken at Executive level, at root of problems. 5. If sold and privatized, on-going health care legacy costs of at least $5 million per year will continue to be paid by the County. In addition unemployment insurance, workers compensation, accrued benefits and bonded indebtedness will have to be paid. 6. If Valley View is kept by the County conditions can be changed to reduce taxpayer subsidy to less than $6 million per year rather than the $20-$30 million publically stated. 7. There are a number of areas in which internal changes could be made, if County elected officials are willing to become more aggressive in endorsing and actively supporting a willingness to make changes that would help make Valley View more cost effective, while maintaining high quality standards.

PHYSICAL FACILITY The Valley View Center for Nursing Care and Rehabilitation is a 360-Bed Residential Health Care Facility, that provides baseline services, secured dementia care, as well as an expanding and successful short-term rehabilitation program. Sitting on approximately 29 acres, the subject propertys 342,248 square foot physical plant (273,839 is operational) was built in phases spanning nearly 40 years, 1959-1997. Valley View has been owned by Orange County since it was founded in 1831, but under third party management since the early 1990s. 1 For a complete physical description of the facility see Marcus & Millichap Marketing Memorandum. 2

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Marcus & Millichap Marketing Bates Document Number VVC001433 Marcus & Millichap Marketing Bates Document Number VVC001441

OPERATING RESULTS 1. Over the past 5 years, the following are the reported results of income and expense 3 : 2007 2008 2009 2010 2011 Revenue 36,208,219 35,419,295 35,812,437 33,939,109 37,919,869 Expense 55,951,085 55,785,017 55,141,558 57,756,906 57,103,887 Net 19,742,866 20,365,722 19,329,121 23,817,797 19,184,018 2. Valley View accountants demonstrated the current operating net is in the vicinity of $15.5 million. 4 3. The net is not the same as taxpayer subsidy a. Taxpayer subsidy has averaged $9.7 million over last 5 years (2007-2011) 5 because of I.G.T. Payments (see next page) 2007 2008 14,300,281 14,889,324 2009 15,186,000 2010 2,367,627 2011 1,809,013

Tax Levy Subsidy

4. Bankruptcy a. No likelihood i. 2010 year ending debt of County is $246.0 million ii. NYS Finance debt limit is $2.4 Billion iii. County is Triple A for Finance purposes

Financial Statements Year end 2008 (VV002297-2318) 2009 (VVC000537-547) 2010 (VVC000548-559) 2011 (VVC000560-571) 4 Morrone and Horan, 7/17/12, pages. 997-1022) 5 Financial Statements Year end 2008 (VV002297-2318) 2009 (VVC000537-547) 2010 (VVC000548-559) 2011 (VVC000560-571)

REVENUE 1. IGT 6 a. Governmental funding that arrives after fiscal year in two or three year cycles b. Averages $6 million per year over the past five years 7 2007 2008 2009 2010 2011 IGT 0 16,243,354 1,440,032 0 12,563,315 c. Has been approved to continue through 2019 on the federal level. d. I.G.T. funding has been budgeted by NYS at the same recent budget levels e. The $8.8 million in IGT matches made by the County between 2008 and 2009 resulted in release of IGT funding of over twice that amount that came directly to Valley View during the same period-funds that would not have been available to the Nursing Home without the County matches. Thus that IGT match portion of the County contribution to the Home can reasonably be viewed as an investment yielding a doubled return directly to Valley View, and therefore has value different from a subsidy that is limited to filling a gap between expenses and other available revenues. 8 2. Reimbursement & Payment Rate/Billing For Managed Care and Other Insurance: a. Currently the facility uses rates established in 2006. These rates have not been renegotiated with the insurance companies 9
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To support public facilities and help offset some of these added costs, the State enacted legislation in the form of Intergovernmental Transfer (IGT) payments to assist public or government funded nursing homes. ...Under the federal IGT program, local government tax funds generate federal matching payments. The amount of IGT payments available to county homes is determined by the State on an annual basis (although the actual cash payments have typically been made on a two- to three year lag). In order to receive lGT funds, a county has to "front" its 50% matching share of the funds through its General Fund. The nursing home then receives the total funding amount, i.e., the county share and the federal match. Thus all of the funds accrue directly to the Nursing Horne Enterprise Fund, as intended by the federal legislation, but" the concern from the perspective of County policymakers and taxpayers is that none of these matching funds are ultimately returned to a county's General Fund due to the underlying legislation which requires the IGT funds to be paid solely to the nursing home. CGR Report 7 Q. So, in effect, IGT payments from New York States lawmaking bodies and the Governor the Governor signed it in, we have authorized and set aside 300 million for IGT potential payments for the years 12 and even 13; is that a true statement? A. Yes. Q. Again, you hear people tell you we dont know if theres ever gonna be any more IGT, and you heard that statement from the Executive, there is no more IGT, its not coming, its over; clearly, it is there, potentially, to be gotten until the year 2013; correct? A. Correct. Q. So, we at some point, in theory, if we continue to own the nursing home would get payments for the years 11, 12 and 13, correct? A. Correct. (Morrone and Horan, 7/17/12, pages 1020-1021) 8 CGR Report 9 Q. Does the County have fully-executed contracts for insurance companies? A. There's a problem there. Um, obviously, we have the Medicare and Medicaid part

i. Subacute Network LLC (Carenext) is under contract to perform that function. ii. Inability to service short term rehabilitation clients limits revenue. 10 b. Managed care and other insurance revenue of $694,504 in 2011 may have been under billed by 50-100% because of outdated rates: i. Lost revenues of $347,252 to $694,504. c. Record Keeping i. Client care, medications, treatments, etc. must be documented in order to apply for reimbursement. (1) Staff inadequately trained to do so consistently. (2) Electronic system for monitoring is inadequate 3. CMI a. Client mix determines levels of financial support from government programs. i. State wide average 1.0314 ii. Valley View is 0.87 iii. If CMI were increased to state average could result in 14% revenue increase on Medicaid billings, which amounts to an additional $3.5 million. iv. Testimony indicated that revenue could be increased by $4 million. (Rosenberg testimony 7/14/12 p. 647) to $6.3 million (Chaiken testimony 7/17/12 p. 785) and (Horan testimony 7/17/12 p. 996). b. Attention to client needs at intake required to assure both quality of care needed and that mix is appropriate for maximizing revenue. c. Marketing has failed to secure higher reimbursable clients. 4. Collection a. No outside collection efforts since 2005 b. All work done in house c. Wrote off $200,000 in 2011 and also $200,000 in 2010 i. Some of the accounts are claimed to have been collectible d. Some bills allegedly written off by request of government officials 5. Admission/Marketing a. Competitive business 11
of that. Um, I have been in to Mr. Pascocello, a number of times here, recently, asking him about the contracts that we don't have. We don't participate in far more insurance companies than we participate in, um, and I have been told that the contracts are sitting in The County in County Legal. Um, this hurts us because, for starters, we can't accept a lot of patients from the hospital that have contracts or insurances that we don't participate in and, of the ones that we do participate in, some of those contracts are, at least, six years old . (Concepcion, 7/18/12, page 1202-1203) We do a lot of short-term rehab. Those are our money beds. Our 60 short-term rehab beds are where - where we can, actually, make the most of our - our money, and if we don't -- if we're not participating in the insurances, we can't do that. (Concepcion, 7/18/12, page 1204)
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. We, certainly, need to go back out and advertise. We - we, certainly, need to get somebody out there that's gonna, you know, P.R. for us and do what they need to do. I mean it's about selling the facility, and, you know, we, definitely, need to advertise and let people know that we're still here, we're still accepting residents to the facility. I mean the people that are entrenched within the surrounding areas of

b. Need for more insurance contracts to permit delivery of more comprehensive services. 12 c. Including Valley View there are currently 24 nursing homes within the 25-mile geographical radius around Valley View Center for Nursing and Rehabilitation. Valley View is the largest facility with its 360 beds. The existing homes provide 3,839 nursing home beds for the area's senior population (an average of 160 beds per facility). Of the 24 nursing homes, 10 (including Valley View) are within the borders of Orange County. These facilities have a total of 1,438 licensed nursing home beds. 13 d. Despite the existence of the beds, and despite the recent reduction of 160 beds at Valley View, the NYS Department of Health estimated a need by 2016 of 2,122 beds in Orange County, leaving a projected unmet bed need of 704 licensed beds in the area. e. Was done in house in past i. Cost estimate $70,000 per year using staff f. Currently under to contract to Care Next 14 i. Only facility in Orange County to use this vendor 15 ii. Cost of Contract - $50,000 to join & fixed fee of $7,000.00 per month (1) 60 days to terminate (2) William Pascocello is an owner 3% interest iii. Performance (1) Subject to criticism 16

Valley View, obviously, know we're there and they are, you know, they are loyal to Valley View, they have been there, they are repeat, you know, customers to us. They come back, time and time again. (Concepcion, 7/18/12, page 1209-1210) 12 (Concepcion, 7/18/12, page 1225) 13 CGR Report 14 OAS entered into a contract with CareNext to provide admissions coordination, screening and marketing services. Under the contract, CareNext staff assists in the identification of potential residents from hospitals needing skilled nursing services, especially of a specialized nature, and then performs the necessary pre-admission screening for the potential candidate and facilitates the patient's admission to the facility. This screening service is typically performed by most facilities in-house, and indeed this service may at least in part duplicate the existing in-house Admissions process. CGR Report 15 To my knowledge, Valley View is the only facility in this County that uses CareNext. Other facilities, for the most part, have an employed person by the facility that is out in the hospital, um, looking at potential admissions and contacts and doing the P.R. work that's required when you have an allegiance to whoever you work for. (Concepcion, 7/18/2012, page 1192-1195) 16 Currently, there is a person in that is employed by CareNext that spends 99 percent of his time at Orange Regional Hospital Orange Regional Medical Center. Um, he, to my knowledge, at some point in time, was going to other hospitals, such as St. Luke's and Good Samaritan. He does no longer do that. He doesn't find the need to do that. He has verbalized as much to me. Orange Regional is a main source of our admissions to the facility. (Concepcion, 7/18/2012, page 1195) but I find that in dealing with the other hospitals, they kind of forget we're here because there is nobody out there, um, talking to them, and, you know, I feel that a lot of questions, more recently, about the fact of whether or not we are still admitting to our facility and what the future of our facility holds and that kind of holds us back, sometimes. Q. Are you saying that person is, physically, at Orange Regional? A. Yes. (Concepcion, 7/18/2012, page 1196)

(a) Only one person (b) Only using Orange Regional Medical Center (c) No outreach to other facilities in County (2) 430 referrals in 2011 (a) Resulted in 42% being admitted (b) On track for 600 referrals in 2012 (3) Does have access to CareNext network in other geographic locations (4) 85% of referrals are short term admissions 6. No budget for 2012

I think he goes there every morning and he makes his rounds in the hospital and he - he sees what's out there and he faxes me what he calls "Contact Sheets" for people that he think might be suitable for admission to the hospital. (Concepcion, 7/18/2012, page 1196) Q. Why do you believe he would work in that manner, though? Why not other hospitals? I don't understand. A. He said to me, on more than one occasion, he doesn't feel that there are that there's any potential in St. Luke's or another hospital. He has never said to me a concrete reason why. (Concepcion, 7/18/2012, page 1196) Q. By working in the manner that he is, do you think it's hurting our, you know, our the number of residents that we take? A. I don't think it hurts it. I surely - I sure don't think it helps it. I - I don't think that -- I think that there is there's not a benefit to them. I get - I get more admissions from myself calling the hospital or the hospital sending me faxes. I mean a typical day will be this: You come into the - you come into the office and there are faxed paperwork faxes from the hospital from the different Caseworkers on the fax machine. This paperwork contains almost all the items I would need to screen for potential admission, what their diagnosis is, what they're in the hospital for, what they've had done in the hospital, the medication that they're on, which is key to us, because medication can be costly, especially, for a short-term rehab stay, um, and then their insurance and whether or not we participate, which is another problem for the facility, and, you know, then I would look at those and I would call -- I would either decline it based upon the various factors or I would call the Caseworker and I would say I can offer a bed. Um, a lot of times, we're the first choice. A lot of times, we're in the top two running. Um, a lot of times, we're not a choice at all. Um, I think that somebody, um, that has a vested interest in the facility could do a little bit more P.R. work out there and, you know, talk about -- talk the facility up a little bit because, you know, the bad press has hurt us in Admissions. Q. What advantage is this person to us then? A. None. Q. So, what advantage is CareNext? A. None. (Concepcion, 7/18/12, page 1198-1200)

EXPENSES 1. Staffing a. The County and thus Valley View must contribute to the New York State Pension Fund and the cost of both employee and retiree health insurance. 17 b. Unfunded Positions= 225 18 c. Vacancy filling process Witnesses expressed frustrations at such things as the need to "jump through hoops" to get approval to fill needed positions, even though the positions are already approved in the budget and even though the inability to fill the positions, or to fill them only after lengthy delays, will continue to increase the dollars that must be spent on overtime. 19 i. Need reported to OAS ii. OAS then reports to County Executive d. Per diem pool- did not exist for years and only recently reinstated with immediate savings in overtime. 20 e. CSEA Contract i. Contract expired 12/31/2011 ii. Substantive negotiations past ground rules begun 2/9/12 (1) CSEA Contract Proposals 21 (2) Negative impression created by County Executive letter of February 7, 2012 to NYS DOH announcing intent to close facility. 22 (a) Open mind questioned iii. Should there be a separate bargaining unit? f. Sick time (call in) abuse now results in penalty to employees i. In 2010 & 2011 an average of about three LPNs per day called in saying they would miss their scheduled shift. This represents about 7% of the LPN scheduled work force across all three shifts on a typical day. An average of 10.5 CNAs called in announcing non-scheduled absences each day-up almost 2.5 absences each day (a 28% increase) from the sample weeks in 2010.These unscheduled absences represent almost 10% of the entire scheduled CNA workforce each day. ii. If the CNA proportion of absences could be reduced to the same proportion of those of LPNs, there would be an average of 2.8 fewer call ins each day of the year-adding up to 1,022 missed shifts during the year that could be avoided, typically shifts that currently need to be covered by paying costly overtime. 23 iii. Caused by need for extended shifts and overtime 24 (1) No preapproval of time off hence only call in
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CGR Report Daniel Hart Vacancy Reports VVC002077-2095 19 (Pearson, 7/11/12, pages 545-546). 20 (Hart, 8/2/12, page 1471) 21 VVC001556-1560 22 VVC001562 23 CGR Report 24 (Pearson, 7/11/12, page 545-546).

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g. High turnover in nursing staff h. Advance Care Staffing i. Is in Brooklyn. Recently opened an office in Woodbury. 25 ii. No bid contract i. Limited success in filling per diems Not effective in terms of generating sufficient numbers of nurses who met Valley View's quality standards, purchase of backup staff coverage through this agency did generate $96,449 in additional costs to Valley View during the first nine months of the contract, over and above the $1.6 million in overtime costs in 2010. j. Employment levels higher than upstate Long Term Care Facilities 2. Administration Cost a. OAS contract 26 (i) Two year term (ii) Current cost is $700,000 per year (iii) $75,000 annual consulting fee (iv) Contract has been renewed four times 1. No substantive changes to agreement 2. No performance standards to hold OAS accountable (v) No efforts to open the process to request other proposals and to consider whether it might be possible to obtain the equivalent OAS services at less cost through either other contract arrangements or hiring County employees. Given more recent changes in the Orange County management pay schedules (and given the fact that there are experienced nursing home administrators currently available on the market, given other recent facility closings, who may be available at lower salary levels than previously assumed about the New York City market). 27 (1) Overtime (a) Cost (i) Cost in 2012 through 1st week in August is $1.5 million which projects out to more than $2.5 mill for the year. (Report to Mental Health Committee) (ii) 2011 was $2.1 million 28 (iii) 2010 = $1.55million
(Freedman, 8/16/12, page 1986) Continuation of the contract management arrangement has not been reconsidered by the Administration to determine if a qualified Administrator could be available under the new County salary rates. As a point of reference to provide additional perspective, the CGR team is aware of other temporary management contract arrangements that involve fewer administrative positions and considerably less costs than the Orange County contract. The terms of these contracts call for substantially less money, albeit, to be fair, neither of those contracts are in counties in the New York City metropolitan market. Those contracts also involve only the Nursing Home Administrator position, and not three separate positions as are included in the Valley View agreement. Comparable positions to the Deputy Administrator and Director of Operations are either not needed in those counties, or are provided by county employees, rather than as part of the management contract. CGR Report 27 CGR Report 28 Nursing Overtime VVC001492-1493
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(iv) 2009 = $900,000 (b) Results from reduced staffing 29 (i) If all such OT could be eliminated among CNAs, the differential savings between overtime pay and regular pay would equal almost $450,000 in 2011. 30 (c) 90% of overtime is attributable to nursing (d) Before OAS, OT was monitored 31 (1) Resident Food service 32 (a) Total Meals produced in 2011 455,625 meals (b) Total expense in 2011 was $5,266,450 (i) However 13.6% of all meals produced were for Meals On Wheels program of Office of the Aging. (ii) Service provides 61,773 meals per year to Meals on Wheels program (iii) Payment from Meals on Wheels was $175,751 33 (iv) Cost of meals to Meals on Wheels is $647,944 1. VV subsidizing cost of meals to Meals on Wheels $472,193 2. These costs are attributable to Valley View but reimbursement is only 27% of actual cost (v) If facility closed, those costs would be paid by county to others (2) Security (a) The facility utilizes a security service at the facility which also staffs the reception area. Costs for this service were $466,874 and $401,428 during 2009 and 2010, respectively. The costs are excessive since the facility is not located in a high crime area, and given that other options are available for locking down the facility at night. (3) Medical Records System 34 a) Valley View is paying eHealth Solutions $29,500 per month or $82 per month per bed. b) A private nursing operation is paying $17 per month per bed for a new medical records system. i. Facility may be overpaying for this service by about $280,800 per year.

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(Pearson, 7/11/12, page 545-546). CGR Report 31 (Pearson, 7/11/12, page 545-546). 32 VVC001574-1584 33 (Maher, 7/11/12, page 487) 34 Legislator RJ Smith research

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MANAGEMENT 1. Chain of Command 35 Orange County is one of very few counties in New York, if not the only one, to have a history of a county-operated nursing home administered under a management contract. Other county-owned and operated nursing homes are typically managed by an Administrator who is a county employee. But going back to the previous Orange County Executive in 1998, Valley View has consistently been administered since then under a management contract. The current contract, with Orange Administrative Services (OAS), represents the second management company to have been under contract with Orange County to operate the Valley View facility. OAS assumed the administrative and oversight responsibilities in 2003. 36 a. Administrator (OAS) b. Assistant Administrator (OAS) c. Director of Plant Operations (OAS) 2. Need for the Management Company is questionable. a. Do you believe that Valley View could be, effectively, run by ourselves without a management company? A. Oh, yes. 37 3. Authority a. Inability to improve contract services. We we have to go with who we have a contract with whether the person can repair it or not repair it. Um, I wish I could just call somebody else in and get something done, but, unfortunately, we're stuck with the contract that, um, that the whole County has for certain things, likes air conditioning. Um, our current person we use now, um, you know, I don't have a choice in, you know, whether they're doing the job or not. I still have to keep calling the same company in whether they can fix it or not. 38 4. Accountability Monitoring a. Concerns are frequently raised about the perceived accessibility of the Administrator, who is also portrayed as having other business interests that sometimes limit his time at the facility, and about the level of ongoing communications with staff, and the level of openness to suggestions from employees other than the OAS team. b. Troubling to many, especially in the context of the perception that the County may be seriously considering selling Valley View, is the provision in the OAS Administrative Services Agreement that, "In the event [the County] intends to sell or lease the Facility," OAS would have the "right of first refusal" to purchase or lease the facility and/or surrounding property. . Nonetheless, that explicit provision in the contract has raised suspicions among many, and has raised questions about the actual motivations and role of OAS in carrying out its administrative function. 39
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VVC000214 CGR Report 37 (Hart, 8/2/12, page 1481) 38 (Beam, 7/18/12, page 1145) 39 CGR Report

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c. In that context, many suspect that OAS, while concerned about the residents and the quality of care provided at Valley View, is also primarily focused on positioning the facility for sale, rather than looking aggressively for ways to make Valley View more viable as a public entity. Questions surfaced from various sources concerning whether the primary OAS staff loyalty and responsibility, in the final analysis, is to OAS interests or to the interests of its employer, the County. 40 41 d. Experience issues. i. Not all OAS employees are sufficiently trained for their position. 42 e. Systems not operable i. Smartlink System purchased but never implemented ii. Frustrations were expressed of the fact that software purchased a year ago to help expedite, rationalize and monitor staff scheduling remains uninstalled and of no value, even though the money has been spent for its purchase, and even though the number of staff devoted to scheduling has been reduced. Staff at Valley View express frustration that no one at the County seems to have made this a priority for implementation support by the IT office, leaving the software "unopened in a box in the basement." iii. Card Swipe system never operational. 43 f. Subcontractor performance i. Laundry (i) Contract not bid 44 (ii) Complaints of poor service 45 ii. eHealth (Sigma Care) Electronic Medical records (i) Contract not bid (ii) Review reveals overpayment for services rendered. (See expense paragraph 6 as to overpayment) iii. Advance Care staffing (i) Contract not bid iv. Carenext (i) Contract not bid (ii) Promised clinical programs not initiated. 46 1. Specifications written but not used 5. Staffing
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CGR Report And you have to understand that, um, something like that would only be done by an Administrator who would benefit from the facility doing better. If he's not gonna benefit from the facility doing better, then to what point would that be in his best interest? (Concepcion, 7/18/12, page 1232 42 (Beam, 7/18/12, page 1113, 1114) 43 (Beam, 7/18/12, page 1130, 1131)
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Burley, 7/10/12, page 306

With the full Laundry staff, the complaints were, actually, not as great. It's during I believe October of 2009 is when or 2010 is when the - is when the entire staff was laid off. That's when we had more complaints then. I mean our complaints may have gone from 3 percent to 93 percent. (Burley, 7/10/12, page 301 46 (Concepcion, 7/18/12, page 1216-1217)

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a. Present staff 397 47 b. Morale not good c. There are a disproportionate numbers of grievances filed by employees, in part because of the fact that the employees are represented by the overall CSEA employees union and therefore operating under practices that do not take into adequate consideration the uniqueness of the demands of a 24-7 facility such as Valley View. 48 d. Staffing strained 49 i. Functions Most Affected by the Layoffs (i) No layoffs were experienced by nurses or CNAs (ii) The Housekeeping unit, (housekeeping and laundry) lost 19 positions (iii) Dietary, lost six positions (iv) Activities, lost four positions (v) Maintenance and Plant Operations Lost four positions 50 . Maintenance response time delayed which can present dangers to residents from predictable maintenance issues from heating and cooling systems (vi) Pharmacy , lost two positions (vii) Beauty/Barber lost two positions (viii) The unit that handles Staffing/Scheduling of nurses across the three shifts each day has been reduced from four or five positions working on staffing at various times to 2.5 persons (scheduling functions have typically been combined with other functions). The process of doing the scheduling is strictly a manual process, and with fewer people responsible, scheduling errors are perceived to have increased as a result, with consequent reported increases in scheduling-related grievances and added overtime costs needed to cover the shortages resulting from scheduling errors. 51 e. More injuries and workers compensation claims under OAS 52 i. Inconsistent use of Lifts. 53
The vast majority of Valley View staff (almost 62%) are nursing staff or nursing administrators. Almost 55% of the positions are either Certified Nursing Assistants (CNAs) or LPNs. There are few part-time nursing or CNA staff, thereby limiting flexibility in staffing shifts. In addition to the mostly full time staff, there are additional nursing per-diem staff -who are on call to supplement regular nursing staff, but at this point the County has no provision for per-diem CNAs. CGR Report 48 CGR Report 49 Um, well, when you're - when you're used to having 20 or 19 or 20, you would say it's - it's - it's not adequate, but, um, can we get the job done with what we have? Yes. (Beam, 7/18/12, page 1150) 50 (Beam, 7/18/12, page 1120-1121) 51 (Pearson, 7/11/12, page 545-546). 52 (Maher, 7/18/12, page 1279-1280) 53 . Well, let me -- I - I'm not an aide, I don't know, but, um, the Maintenance Department's job is to do work orders. We get work orders for beds cause they use beds every day, tubs, cause they use tubs every day. I never got a work order for a lift. I've never ordered a part for a lift. My opinion, they're not using them or I'd be fixing them. (Beam, 7/18/12, page 1134)
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f. Overtime essential to meet schedules 54 i. Discussed as part of budget 55 ii. Anger with Pascocello as to big budget issues 6. Cost of Administration a. $700,000 for three positions 56 i. Premium pricing ii. Premium service not provided b. Facility contracts with third party to provide staffing 7. Planning a. HEAL Grant in place. The $7.8 Million grant is earmarked for the following improvements to Valley View: $1,060,000 in demolition of a 68,000 square foot (s.f.) building on the campus; $1,015,000 for the creation of a 20-bed ventilator dependent unit in 8,000 s.f.; $3,430,000 for the creation of a 60-slot Adult Day Care unit in 8,222 s.f.; $1,625,000 for a Physical Therapy Addition in 3,690 s.f.; and $650,000 for Design and Construction Contingencies. By implementing improvements to the facility made possible through the HEAL Grant, the facility will be able to expand services which should result in a substantial increase in Revenue. 57 8. Professionalism 58 a. No safety committee 59 b. No goals or objectives for staff or facility c. Insufficient training d. Lack of communication 60 61 e. No management meeting minutes since OAS f. No budget variance reports g. No evaluations in years h. No current job specifications and duties i. No meetings to discuss efficiency, cost cutting, equipment problems, etc. 62
(Pearson, 7/11/12, page 545-546). Overtime and Nursing Assistant Per Diems VVC001490-1491 56 Orange County was totally different situation. Year ago they created a management contract with a company out of New York City. One of the players is an attorney with deep pocket and the other person is an administrator and a proprietary owner. The way the contract was written they were actually given the right of first refusal should the County ever decide to go out of the business. Costs skyrocketed and when asking questions you find out that the guy is never there and things arent happening. It was a bad management situation and they had lost a lot of money, the building and campus is aging. The dollar value of the contract was astronomical. I looked at that and I almost fell of my chair. It was inconceivable that you could pay three people that kind of money to run a nursing home. 57 Marcus & Millichap VVC001433 58 This has been 10, 12 years of this facility being neglected, management- wise. (Bisone, 7/17/12, 901). 59 (Bisone, 7/17/12, 866) 60 (Sprately, 7/10/12, page 269) 61 And I was made aware of that, roughly, five minutes before it occurred. I was called into the Executive Office and they pointed out a pile of paper and said that these were 39 people that were - that were going to be laid off and that we would need to take care of it. (Hart, 8/2/12, page 1489-1490) 62 Were you given guidance by Administrator on how to reassign your staff? A. No. (Burley 7/10/12 page 298)
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Electronic systems not detailed as to medications and a percentage of claims are rejected k. No training as to maximizing billing and reimbursements 9. Capital Improvements a. Improvements to the piping and HVAC systems are over due. Project was planned in phases, went out to bid but contract not let. Flooring and Windows in part of the facility require replacement. 63 10. Competition a. St Theresas Middletown i. 99% occupancy (i) 98 beds ii. Case Mix Index 1.16 (i) Valley View is .87 iii. Staffing (i) Industry standard = 1.01 1.02 x # of beds (ii) St Theresa at 103 FTE iv. Safety (i) Training v. Laundry (i) Personal items in house- greater satisfaction

j.

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Beam, 7/18/12, page 1161, 1162

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QUALITY OF CARE 1. Dementia Patients a. Increased cost, lower reimbursement 2. Patient Mix 3. Future Patient Load a. Trend will be greater demand for services 64 b. About 20% to 25% of County Nursing Home Residents would not be served by other nursing homes if the county home were be sold. CGR Report September 2007 Page 11 4. Public vs Private level of service a. Fulton County Public to Private experience of 210 existing staff reduced to 40 raises questions as to ability to maintain proper levels of care. 65 Substantial changes in terms of employment as recited in the Marcus & Millchap Marketing Memorandum page 6. 5. Create the same potential quality care risks. a. Projected operation under new owner: 66 i. 81.7% Reduction in benefits, ii. 30% Reduction in Nursing Salaries, iii. 66% Reduction in activities and social services for residents confirm similar results from Fulton County. iv. 32% Reduction in activities and social services for residents v. Quality of Care may suffer
Demographic trends suggest that the aging of the "baby boom" generation and increases in life expectancy will lead to growing numbers, and higher proportions, of elderly in the Orange County population over the next 20 years. Based on population projections developed at the Cornell Program on Applied Demographics, by 2015, that segment of the population will have increased by another 20%, and in just 20 years, by 2030, the 65+ population will have expanded by an additional 88%, from just under 41,000 in 2010 to almost 77,000 residents, or 16% of the projected total population in 2030. Cornell Program on Applied Demographics (Projected 2015, 2020 and 2030 population; produced April, 2009) http://pad.human.comell.edu/cQunties/projeclions.cfm CGR Report (VVC001573) 65 (Compani 8/8/12, pages 1646 1647) : Q. If you were going into a facility to get health care, would you be comfortable if the people that were providing that health care, getting paid eight and a half dollars an hour with no insurance and no retirement, essentially, a McDonalds type worker Im not trying to disparage any one company, but we understand what we mean when we say McDonalds type worker would you be comfortable going into an institution with healthcare provided by McDonalds type workers? Mr. Compani: A. Absolutely Not. Theres no incentive for a worker to do his best when he is making a fraction above minimum wage. Mr. Compani: Um, you should, also be aware that I dont know how closely you follow what is declared in this state. Gloversville, New York, is officially the poverty capitol of New York State. People quit those jobs in the poorest city in this state. Thats a message loud and clear. These are workers that have been in those positions for 20, 25 years and had a dedication to the facility and to the patients in that facility and they just found it unbearable to the point where they quit in a city where there are no jobs. 66 Marcus & Millichap Marketing Memorandum page 6.
64

18

vi. Process in very difficult on everyone (See Footnote 64.) 6. Lack of consistent reporting as to quality care points 7. Patient Safety issues a. Fire equipment b. Heater units 67 c. Safety committee now non-existent

67

..Do you find there's a concern for, say, public safety with any incident because -A. Sure. (Beam, 7/18/12, page 1120) Sure. We have, um, what's called "PTAC units." They're in the newer building, which is the Glenmere Building." They - they're, directly, piped with heating and cooling. They have coils, and there's one of those units, sometimes, two in each resident room. In the winter, if it gets too cold, say, minus 2 degrees, those coils could split, and what's in those coils is 160 to 180 degree water. Um, sometimes, that sprays out into the resident rooms or up in the air. You got to get somebody there, quickly, to shut that water off. Q. You've had that happen? A. Every year, every winter since 1998. (Beam, 7/18/12, page 1120) Q. In the residents' rooms? A. Yes. (Beam, 7/18/12, page 1121) At night, you know, we have to wait to be called, and, you know, you have to shut the valve off. (Beam, 7/18/12, page 1121) [I]f somebody - if a resident got up and walked over to see what was going on, it is possible she could get or he could get hurt. Q. That's hot water? A. Very hot water. (Beam, 7/18/12, page 1121) Q. When they cut back the shift, did you tell them that this was a foolish thing to do? A. Absolutely. We -- I've been telling them for the last seven years. I mean I need a night shift. (Beam, 7/18/12, page 1121)

19

SALE IMPACTS 1. Health care legacy costs - $5million per year 68 a. Uncertainty causes workers to worry about job security and look for other work i. Results in distortion of current financial picture b. Rush out the door increases retirements c. Fulton County privatization resulted in loss of employment of 81%. 2. Additional legacy obligations would include: i. Unemployment Insurance: If as many as 10% of Nursing Home employees were to become unemployed as a result of a sale or implementation of some other restructuring option, and remained unemployed for as much as 26 weeks (utilizing a midpoint of 26 weeks of average unemployment), the cost to the County for that time period could be as much as about $650,000 ii. Accrued Employee Benefit Time: This could potentially cost the facility in the neighborhood of $1.6 million, based on accrued sick and vacation time recorded on the Facility's balance sheet. iii. Workers' compensation or $2 million or more . iv. Debt service: As of 2011, the Nursing Home will have a remaining debt service bill of about $8.7 million to be paid in annual installments between 2011 and 2029. This will of course have to be paid, whether the County remains in the Nursing Home business or decides to divest itself of its interest in one way or another. 3. Capital expenses committed a. $2.46153M 69

Diana Letter to NYS DOH VVC001562-1566 RFP page 13 there is a $9.5M expense for ventilator and adult day care units of which $7.8M will be grant funded if received. That leaves $1.7M to be spent for that project by the County. In addition, a sprinkler system is required for $746,153.00. These are both expenses that appear to be the responsibility of the County. Therefore, the cost to the County with respect to these items if it is sold will be $2.46153M.
69

68

20

SUPPLEMENT TO REPORT OTHER ISSUES TO BE EXPLORED BY LEGISLATURE It came to the attention of the Committee during the course of the investigation which while not directly relevant to the issue of the future of the Valley View Nursing Home and Rehabilitation Center, are important substantive matters that are of concern to the interests of the County of Orange: I. Breach of contract by OAS: A. The contract provides for an obligation by the contractor to information and reports to the County upon request. Requests were made via various communications including subpoena for OAS employees to provide information to the special Investigation Committee. In addition, Subpoena Duces Tecum was served requesting certain specific documents that would have been in their care, custody and control. There were numerous email and letter communications to OAS requesting their providing information and reports. They totally failed and refused to provide any of the reports and information and documents that were requested. Every contract includes an implied obligation of good faith and fair dealing. OAS is a contractor with the County under contract that was directly affecting the Valley View facility. There have been serious questions with respect to the level of competence and performance provided by OAS with the reasonable inference that the County has suffered financial losses as a result of their breach of the performance obligations under the contract. Those have included but are not limited to the failure to have a per diem pool for CNAs and other employees, the failure to fill positions in a reasonably timely fashion, the failure to put into place an operation to systems that were purchased by the County, failure to take reasonable steps to improve the CMI, improve the reimbursement rates; failures to secure reasonable performance of contracts by subcontractors involving staffing, laundry and other services; failure to institute and administer an accounts receivable collection system.

B.

C.

II.

The agreement with OAS in paragraph 7.02 purportedly provides for a right of first refusal. The validity of that provision is suspect and more than not is unenforceable by OAS. In view of the recalcitrance and failure of OAS to cooperate, there can be a finding of non responsibility on their part and such a determination could be pursued. Such a determination of prior non responsibility would require

III.

21

disclosure in the future under New York State Finance Law Section 139-k(2) and Section 139-j.

IV.

The testimony of Robin Ahrens raised questions with respect to the bad debt collection practices engaged in by OAS which can prompt a further review of those practices and determinations as to whether or not special considerations were provided to any patients or their families. The subcontractor eHealth was requested to attend and testify. They did not do so based on excuses of scheduling. In response to a specific letter inquiry as to whether there was any relationship between that company and any of its principals with OAS or its principals, to the company refused to respond. In the course often investigation and review of the E-Health contract, analysis reveals contract charges are excessive compared to the usual and customary industry charges for such services. Whether that is a violation of a County Code of Ethics, the General Municipal Law or otherwise can be further considered. In the course of testimony, there was disclosure that the administrator of Valley View owned a minority interest in one of the subcontractors that had entered a contract with the County to provide services at Valley View. Whether that is a violation of the County Code of Ethics, the General Municipal Law or otherwise can be further considered. The County Executive and Executive Branch employees failed to testify in response to lawful Orange County Legislature Committee subpoenas issued pursuant to express powers set forth in the Orange County Charter 2.02, Orange County Administrative Code 2.02, NYS County Law Section 209 and the Legislatures Resolution #160 of 2012, for which no valid legal excuse was provided.

V.

VI.

VII.

22

CONCERNS AS TO RFP

I.

Sewage treatment facility. The terms are to transfer ownership and operation of this to the buyer. However, the facility is to continue to serve other users. Also, the remaining vacant land value in part is dependent upon the availability of utility services. A. No provision has been made for protecting the remaining properties with respect to adequacy and quality of service. Inadequate provision has been made with respect to servicing other County lands with respect to future use or value. A transfer of the SPDES permit would be required. There are only certain entities that can obtain a permit. Those are governments, districts and sewer transportation corporations. If a sewer transportation corporation, it needs approval for its incorporation from the municipality in which it is located. The charges to be made for sewage treatment services are subject to approval by the municipality that has given approval for a sewer transportation corporation.

B.

C.

D.

II.

The notice states that one of the objects of the disposition is to provide services at reduced costs to County residents and taxpayers. This creates different issues. A. The reduced costs are not consistent with the information obtained at the Investigation Committee hearings where the overall testimony has been that the rates charged are below rates that could otherwise be charged. If there are reduced costs, that inures to the operator, not the County residents. With respect to the taxpayers, there will be tax revenue from real property taxes, but continuing costs as a result of employee benefits with respect to medical and retirement benefits. These expenses will continue even after disposition of the facility.

B.

III.

One of the standards for awarding the contract is that there are sufficient assets to operate for five years. Based on the purported losses of $20,000,000 for the current year, the successful proposer would have to show financial ability of $100,000,000. If in arriving at the amount that is sufficient assets to operate, there are significant changes in the operations, staffing and expenses, that raises matters as to:
23

A. B.

Level of care. Employee transitions.

IV.

One of the terms in paragraph 10 provide that the proposer will consider employment of full-time employees. Also on page 14, item 1 is the expressed intent to retain employees. Since there is an obligation to continue operation for only five years, the retention of employees can have great difficulty. Also, if the level of compensation is to be drastically altered, that is a contrary force to retention of employees, the level of care, providing excellent, high quality skilled nursing care, continuation of employment, continuation of services, all of which are listed as the basis of making an award. The proposer is only required to consider the employment of full-time employees.

V.

The retention of residents at the facility is to the extent practicable. The standard is whether someone is in good standing financially and otherwise. These are both significant potential exceptions to the general rule and extent practicable makes an obligation weak. The five year limit is a disconnect with the demographics that are described on page 10. There can only be a greater need for these services based on the demographic analysis provided to the proposers. By limiting to five years their commitment, places vacancy availability at risk. On page 12 there is reference to a $7.8M grant. It creates a five year obligation. It must be implemented by March 31, 2014. Hence the obligation presumably starts then. Since the proposer is only obligated to operate five years, the mandated program would not be in operation for five years based on the date the sale and takeover takes place. On page 13 there is a $9.5M expense for ventilator and adult day care units of which $7.8M will be grant funded if received. That leaves $1.7M to be spent for that project by the County. In addition, a sprinkler system is required for $746,153.00. These are both expenses that appear to be the responsibility of the County. Therefore, the cost to the County with respect to these items if it is sold will be $2.46153M. On page 13, Organization, subparagraph b, there is discussion of the right of first refusal that is in the OAS contract. There is no language that in any way indicates the right of first refusal may not be enforceable and therefore would not be involved in the decision process. Since a large part of the proposers submission involves as to the residents, level of care, sufficiency of assets,

VI.

VII.

VIII.

IX.

24

consideration of employment of full-time employees, safety and well being of residents and employees, and numerous other material matters, the ultimate decision standard is largely subjective. What are the terms to be as to which there could be a right of first refusal asserted? X. The Parry building is going to be used from 2-4 years for County purposes for which a lease agreement will be necessary. The terms and conditions of the lease are being negotiated as part of the purchase and sale agreement. This can be a material financial matter that would alter the financial consideration the County receives which can significantly alter the high bid. Since the bid of $18.5M undertakes to carry the operating losses of the facility from the time they undertake operation and before closing and the purported losses are $20M per year, how does the financial pressure for that proposer plan to be addressed and particularly with respect to level of care and matters of staffing and compensation? How does quality of care and the expressed importance of employment retention get honored when a proposer is going to be under pressure to reduce costs so as to keep them within whatever was their anticipated bid? On the other hand, the bidders who bid more than $18.5M if the basis of their bids are that the County is going to continue to sustain losses in the interim, their higher bids are really lower.

XI.

Based on the evidence adduced at the Investigation Committee hearings with respect to operational matters and staffing, level of care, etc., the standards that are part of the RFP are too vague and lack certainty so that an evaluation can be made with respect to one bidders level of commitment over another. While the RFP contains numerous references to no liability by the County, a decision that is arbitrary, capricious or unreasonable is subject to being challenged. The absence of definitive standards can create issues.

25

PROCEEDINGS 1. Witnesses a. The following witnesses attended and provided testimony under oath: (ii) Mary Sprately (iii) Jonathan Burley (iv) Pat Matero (v) Richard Kaplan (vi) Roberta Neidhardt (vii) Barbara Maher (viii) Michele Pearson (ix) William Oliphant (x) Ken Rozenberg (xi) Annmarie Fitzpatrick (xii) Michael Chaiken (xiii) Christine Naylor (xiv) Vanessa Bisone (xv) David Bonk (xvi) Anthony Morrone (xvii) Nick DeSantis (xviii) Connie Tracy (xix) Wayne Beam (xx) Donna Concepion (xxi) William Oliphant (xxii) Barbara Maher (xxiii) Daniel Hart (xxiv) Robin Ahrens (xxv) Robert Compani (xxvi) Steve Alviene (xxvii) Camilo Otalvaro (xxviii) Leo Friedman b. The following witnesses refused to attend and provide testimony under oath: (i) Edward Diana (ii) David Jolly (iii) Donna Strecker (iv) Joel Kleinman (v) Neil Blair (vi) William Pascocello (vii) John Chobar (viii) Sherri Cassidy (ix) Janet Calnan (x) William DeProspo (xi) Hon. Katherine Bartlett (xii) Steve Paccicco

26

WITNESS APPEARANCES BY DATE June 19, 2012 No appearances June 25, 2012 No appearances June 27, 2012 No appearances July 10, 2012 Mary Sprately, Senior Clerk, Admissions Department Jonathan Burley, Executive Housekeeper Pat Matero, Director of Admissions and Human Services Richard Kaplan, CaseNext Roberta Neidhardt, Director of Nursing July 11, 2012 Barbara Maher, Director of Dietary Service Michele Pearson, Staffing Manager William Oliphant, President of Orange County Bargaining Unit/ Senior Social Caseworker, Department of Social Services Ken Rozenberg, Bruce Gendron & Jeff Sicklick, Northern Nursing Facility July 13, 2012 Annmarie Fitzpatrick, Resident of Valley View Dr. Michael Chaiken, Executive Director at St. Theresas Nursing Home Christine Naylor, Reimbursement Analyst July 17, 2012 Vanessa Bisone, Ward Clerk, Medical Records David Bonk, Director of Healthcare Practice Group, Toski & Company Anthony Morrone & Michael Horan, Valley View Accountants Nick DeSantis & Scott Oling, Orange County Accountants Connie Tracy, Principal Clerk July 18, 2012 Wayne Beam, Maintenance Supervisor Donna Concepcion, Licensed Practical Nurse, Admissions Department William Oliphant, President of Orange County Bargaining Unit/ Senior Social Caseworker, Department of Social Services Barbara Maher, Director of Dietary Service

27

July 25, 2012 No appearances August 2, 2012 Daniel Hart, Director of Staff Resources Robin Ahrens, Principal Account Clerk August 8, 2012 Robert Comparni, CSEA (Private Division) Assistant Director of Field and Member Services Steve Alviene, CSEA (Private Division) Director of Field and Member Services Camilo Otalvaro, Maximum Staffing Solutions August 10, 2012 No appearances August 16, 2012 Leo Friedman

28

Documents and Exhibits Bates Stamp No. (1) Collective Bargaining Agreement between OC and CSEA VVC000001 - 66 (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) HEAL grant contract 7.8 mill - Berger Commission HEAL NY 21 Grant Application Hearthstone Letter of Compliance Staff History Valley View Organizational Chart Valley View Maps and Floor plan HEAL - Berger CON Modification TOWERS Legal Description Valley View Legal Description Valley View Map Showing Property Included in Sale 12-01-174 Response Letter 2010 Fixed Asset Reconciliation - Final VVC000067-111 VVC000112-207 VVC000208-209 VVC000210-213 VVC000214 VVC000215-219 VVC000220-369 VVC000370 VVC000371 VVC000372 VVC000373 VVC000374

2011 Budget Revenues December 2011 #2 as of 02-02-12 VVC000375-376

(15)

2011 Budget Revenues 2011 #4 as of 04-20-12 VVC000377-379

(16) (17) (18) (19)

2011 Reliable Trial Balance as of 4-19-2012 - Darwin VVC000389-394 2012 Propose Capital 2012 Rate Sheet Active Employee Listing - Valley View 05 15 12 VVC000395 VVC000396 VVC000397-403

29

(20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31)

Admissions by Payor Source 2009-2011 Capital Projects as of 02-27-12 Current Wage and Benefit Report Facility Equipment Final 03-16-12 Feb 2012 Financial Financial Projections for 2011-2013 from Mgmt Co. Financial Statement year end 2003 Financial Statement year end 2004 Financial Statements year end 2009 Financial Statements year end 2010 Financial Statement year end 2011

VVC000404-405 VVC000406 VVC000407-419 VVC000420-474 VVC000475-480 VVC000481-488 VVC000489-512 VVC000513-536 VVC000537-547 VVC000548-559 VVC000560-571

Independent Auditors Report on Supplementary Data 6-15-12 VVC000572-581 Medicaid Capital Worksheet 07/07/2011 as of 9-12-11 VVC000582

(32)

(33) (34) (35) (36) (37) (38) (39)

Payor Source and Occupancy 09-11 Rate Sheet (07/07/2011) RHCF 2010 Valley View Center Notes RHCF 2011 Valley View Center Cost Supplementary Data year end 2009 Supplementary Data year end 2010

VVC000583 VVC000584-605 VVC000606-615 VVC000616-725 VVC000726-735 VVC000736-745

Trial Balance 2011 Detail 04-13-12 to OC General Services VVC000746-76

Contracts (40) Advanced Care VVC000763-786

30

(41) (42) (43) (44) (45) (46) (47) (48) (49) (50) (51) (52) (53) (54) (55) (56) (57) (58) (59) (60) (61) (62) (63)

Allgas exp 8-31-12 Allstate exp 5-31-12 Bioreference exp 11-30-12 Boro Audiology exp 10-31-12 Crystal Run Healthcare 6-30-12 Dentserv exp 6-30-12 EA Morse exp 6-28-12 Earthcare exp 2-17-12 eHealth solutions exp 12-31-12 Fresh Maint exp 3-18-12 Greenman-Pedersen Sprinkler exp 4-30-13 Hearthstone Contract HMM exp 6-30-14 Long Term Solutions exp 6-30-12 Medworld exp 8-31-12 MMCAP no exp. Patient Care exp 4-30-12 Praxair exp 8-31-12 Stericycle exp 10-31-12 VVC Contract Listing 3-6-12 CareNext 1 CareNext 2 OAS Contract exp 12-31-12

VVC000787-811 VVC000812-824 VVC000825-848 VVC000849-864 VVC000865-881 VVC000882-913 VVC000914-943 VVC000944-965 VVC000966-981 VVC000982-1008 VVC001009-1031 VVC001032-1037 VVC001038-1068 VVC001069-1088 VVC001089-1115 VVC001116-1126 VVC001127-1132 VVC001133-1153 VVC001154-1170 VVC001171-1194 VVC001195-1224 VVC001125-1279 VVC001280-1322

Notice of Sale (64) Agreement of Sale FINAL-DRAFT - 3-19-12 VVC001323-1355

31

RFP (65) (66) RFP FINAL RFP - Site Visit Addenda VVC001356-1385 VVC001386

Photos - Boiler Room & Sewage Area (67) (68) (69) (70) (71) (72) (73) (74) (75) (76) (77) (78) RFP Q&A (79) (80) (81) (82) Exhibits (83) (84) (85) Valley View Payroll Week Overtime & Nursing Assistant Per Diems Nursing Overtime VVC001468-1489 VVC001490-1491 VVC001492-1493 RFP CE001 12D RFP CE001 - 12D Q&A RFP CE001 - 12D Q&A part 2 Valley View - Marketing Memorandum 3-19-12 VVC001399-1421 VVC001422-1425 VVC001426-1428 VVC001429-1467 Photo Photo 2 Photo 3 Photo 4 Photo 5 Photo 6 Photo 7 Photo 8 Photo 9 Photo 10 Photo 11 Photo 12 VVC001387 VVC001388 VVC001389 VVC001390 VVC001391 VVC001392 VVC001393 VVC001394 VVC001395 VVC001396 VVC001397 VVC001398

32

(86) (87) (88) (89) (90) (91) (92) (93) (94) (95) (96) (97) (98) (99)

Overtime & Nursing Assistant Per Diems Letter from Anthony Morrone 7/19/12 Horace NYE Design Committee Message from Diana re: VVC NY Senate Enacted Budget Summary NYSDOH Re: Medicaid UPL NYSDOH to Kleiman Re: Medicaid UPL IGT Funding Health and Mental Health Committee Operating Protection CSEA Contract Proposals Average Salary and Benefit Cost Diana to NYSDOH Re: Sale of Facility Medicaid and Medicare billing

VVC001494-1495 VVC001496 VVC001497-1518 VVC001519-1520 VVC001521-152 VVC001523-1525 VVC001526-1531 VVC001532 VVC001533 VVC001534-1555 VVC001556-1560 VVC001561 VVC001562-1566 VVC001567-1569 VVC001570 VVC001571-1572 VVC001573 VVC001574-1584 VVC001585 VVC001586-1587 VVC001588-1589

(100) THR Article Sale of VVC (101) Chronicle This Week in OC (102) CGR Re: Population (103) Mahar Documents and Statement (104) Contact at Environmental Services (105) Letter from Diana to Donnery (106) Naylor Report re: Facility Overtime 2008-2012 (107) Naylor Reports Overtime/Full Time Employee Reports

VVC001590-1631 (108) Appraisal of Real Property Report (109) CGR Preliminary VV Draft Report 6.3.11 VVC001632-1749 VVC001750-1871

33

(110) NYSID 10.1.11-9.30.12 (111) eHealth Solutions 7.1.08-12.31.12 (112) Valley View Marketing Memo 3.19.12

VVC001872-1896 VVC001897-1946 VVC001947-1985

(113) Valley View Prop. Town of Goshen 2012 Assessment VVC001986-1988 (114) SOI Cover Letter 7.9.12 (115) Statement of Interest (116) IGT Worksheet VVC001989-1990 VVC001991-1996 VVC001997

(117) Bonk Testimony from Rockland County Legis. 6.18-20.12 VVC001998-2076 (118) Daniel Hart Vacancy Reports VVC002077-2095

(119) Emails btw Jacobowitz & Golden re: List of County Employees VVC002096-2101 (120) Benton Request for Evidence 7.23.12 (121) Valley View Property Assessment 2012 (122) Darwin to Donnery re: Foil 8.7.12 (123) Average Salary and Benefit Cost 6.12 (124) Valley View Operating Projection 11 & 13 (125) Valley View Projections 7.26.12 (126) Abbott to Kleiman re: UPL 8.16.11 (127) Long Term Care Services (128) Fulton County: Evaluation Report-Bates (129) County Nursing Facilities September 2007 VVC002102 VVC002103-2104 VVC002105 VVC002106 VVC002107-2114 VVC002115-2116 VVC002117-2122 VVC002123 VVC002135-2174 VVC002175-2183

(130) Notice of Special Meeting Rockland County Legis. 6/18/12 VVC002184-2188 (131) Restructuring Local Govt Options for County Nursing Homes

34

VVC002189-2199 (132) Options for Fulton County Nursing Home July 2009 (133) Fulton County: Evaluation Report March 2010 (134) Horace NYE Design Committee 12/13/06 (135) Notables on Horace NYE Design Committee VVC002200-2218 VVC002219-2258 VVC002259-2271 VVC002272-2273

(136) E-mail Reed to Jacobowitz Re: Legislature Approving OAS VVC002274-2275 (137) Social Services Committee Minutes VVC002276-2290

(138) Donnery to Ostrer Re: Bartlett Decline of Invitation 8/13/12 VVC002291-2293 (139) Notes to Financial Statements 12/31/11 VVC002294-2295

(140) Elant Application Instructions for Health Care Service VVC002296 (141) Financial Statements 2007-2008 (142) Medicaid & Medicare Monthly Billing 7/30/12 VVC002297-231 VVC002319-2322

35