text: Tuesday, March 04, 2014 Obama Budget Would Eliminate Medicare Physician Self-Referral Loophole for Physical Therapy President Obama's federal budget proposal would close the loophole that allows physician self-referrals for physical therapy services—a change long supported by APTA that would improve quality of care and lower Medicare costs. If adopted by Congress, the FY 2015 budget would eliminate exceptions that now apply to physical therapy, radiation therapy, anatomic pathology, and advanced imaging. The Office of Management and Budget estimates that closing the loophole for these services would provide a savings of just over $6 billion over 10 years. APTA has held that in addition to fostering costly overuse, the exceptions compromise patient care and choice. In a press release, APTA President Paul A. Rockar Jr, PT, DPT, MS, said that APTA "fought long and hard" for the elimination of the exceptions. Rockar added that the Obama proposal "would save the country billions in unnecessary Medicare expenses and, more important, protect patients from being used as pawns for profit." APTA Private Practice Section President Tom DiAngelis, PT, DPT, was quoted in the same press release saying that self referral has an "abusive financial impact," and that "as health care providers we work and interact with patients every day. When physicians self-refer, patients feel as though they aren't in the driver's seat when it comes to their own care." The specific exceptions would be eliminated from the Stark self-referral law, a policy that was intended to prevent physicians from making referrals for certain health services payable by Medicare to an entity with which he or she, or an immediate family member, has a financial relationship. The exceptions to the law were carved out for in-office ancillary services (IOAS) that could be quickly administered for patient convenience, such as routine lab tests or x-rays. The problem, according to APTA and other groups, is that the exceptions have been broadly applied and now include self-referral for physical therapy services well beyond original intent. APTA has advocated for the elimination of physical therapy from the exceptions for years and is a founding member of the Alliance for Integrity in Medicare (AIM), a consortium of organizations focused on eliminating the IOAS loophole. In addition to APTA, the consortium includes laboratory, radiation oncology, and medical imaging groups. APTA strongly urges Congress to follow the recommendations laid out in the Administration's budget and pass legislation to remove physical therapy, advanced diagnostic imaging, anatomic pathology, and radiation therapy from the IOAS exception. Find out more about this issue at APTA's self-referral webpage, and take action now by asking your legislators to close the self-referral loophole. Contact the APTA advocacy staff for more information. Comments Hopefully we can get some leverage so the MD lobby doesn't get this aspect dropped off of the budget. Posted by dano napoli on 3/4/2014 5:28 PM As an OT looking in from the outside, this is a huge victory for not just PT (and OT/SLP as well), but especially the patient. Patients should be able to establish a long-term and sustained relationship with the PT of their choosing, much like how the very same patients do so with their MDs. Its comforting to know that this change could foster these relationships in the future. Posted by Dan Martin OTR/L, NMT on 3/5/2014 12:04 PM These are slanderous and incorrect assumptions. As a practicing orthopedic surgeon and hand surgeon for 20 plus years I am involved with both therapists that are independent and therapists that are employed by me. Our patients choose where they want PT or OT and their choice is respected. We find having therapist in our office that work side by side the MD is very efficient and benefits the patient. Immediate splinting, and immediate teaching of exercise protocols are available. Interaction and collaboration on patient care is more conducive when therapists and physicians are together. Independent physical therapist do a great job as well but the communication and timing is more difficult. Cost abuse is not just seen in a minority of physician owned therapy practices. Beware you may be biting the hand that feeds you. I would suggest you team up with physicians as providers of health care and together make changes in Obama care that truely help patients and are not for self interest. Respectively, Henry Backe,MD Posted by H Backe MD on 3/5/2014 11:11 PM There are a large number of "incident to" rehab services being done in MD offices with licensed PT staff. This would mean a large loss of jobs and opportunities to work side by side with MDs. I find that the team multidisciplinary approach works better in my practice. In my opinion and from many rehab articles I have reviewed PT services are very UNDER utilized, which makes sense since MDs do not have physical therapy courses or training (unless in DO school). From my experience most physicians/mid levels do not screen for rehab needs. I have first hand experience with this doing chart review in MD offices and working side by side with MDs. For the most part I find it difficult to get MDs to refer PT even when the need is strong. I have met and worked with hundreds of physicians and I do not know any trying to drive excessive and unnecessary rehab for profit. It seems that one bad apple spoils the whole country to this as being something common, when it is not. Posted by James Lee -> =IX^>M on 3/6/2014 10:07 AM This is excellent potential news; however, it is kind of like closing the barn door after the horse gets out. Currently the trend is less POPTS and more hospital ACO's where the hospital buys the physician practice then requires the physicians to refer to the hospital ancillary services. Just as severe of a problem for private practice PT as well as for patient choice and quality. Posted by Chris Goodwin on 3/6/2014 10:25 AM As a PT who has worked with a physician group for years, I find it interesting that self-referral is such a target when it stands to reason that if the IOASE goes away, you're going to see more ancillary services shifted to hospital settings where costs have shown to be higher. If ancillary services are no longer options for MDs, you'll see more physician practices selling out to hospitals or large networks. Good luck getting a referral out of a hospital or network system. You think POPTS is bad, just wait until you start fighting HOPTS. Our group gladly refers patients to outside PTs if patients request to follow-up with a PT outside of our practice. One other thing: at our location, we spend time focusing on patient care and patient outcomes. We haven't had to spend time on marketing efforts. If the IOASE is removed and we set up a private practice, I can guarantee we will not only continue to be supported by our former employer (the MD group), but we will also be aggressively establishing relationships with the other MDs in our area who we have heretofore not been able to market. A change to the status quo will have a ripple effect that I don't know if many have really considered. Posted by Robert on 3/7/2014 4:23 PM In response to the comments posted by James Lee and H Backe, I would be curious to know how many of the PT working in MD offices are really "incident to"? Many PTs working for physicians are individually enrolled with payers as PTs, billing under their NPI # and assigning payment to the physician or physician group. If this does finalize these PTs and those that do actually work "incident to" can continue to work collaboratively with physicians as private practitioners. I don't see this as a job killer. Posted by Sandra McCuen on 3/7/2014 6:03 PM As much as I see this as a win-win for both the therapist (based on a more level playing field) and patients (fewer visits based on the MedPac analysis from previous years), I believe that until unrestricted direct access occurs, we will still be treated as technicians instead of professionals. Regarding POPTS, I have many complaints regarding inequality, with the first being that the therapist employed in that specific setting does not have to be licensed in order to treat Medicare patients. Although the hand surgeon reports that his patients are free to attend therapy in a clinic of their choosing, this statement is not true for all physicians which own PT services. A former IPTA president once said that PT's are not allowed to own physician practices, but physicians are allowed to own PT practices. This again returns to the point that are profession, at this time, is still considered a paraprofession. Although the abolishment of POPTS is a step in the right direction, more has to be done to legitimize PT. Posted by Vince Gutierrez on 3/7/2014 6:20 PM Why can't a patient choose to go to a therapist associated with a physician? So long as the services are provided by a licensed PT, as a licensed PT I have no problem with it. I work in a medical practice. It is a primary/urgent care center with a strong walk-in population. I spend much of my time consulting with the other providers during their appointments. At times it results in a warm handoff to me. Other times it results in them being advised that they should seek out a physical therapy provider, and they are given a written referral to bring with them. At no time is anyone pressured to utilize me or my services. If I saw that happening, I would have to leave the practice. Patients' right to self-determination is very important to me and I am unable to participate in any situation I view as unethical. Posted by Leon Richard -> AJSa@O on 3/7/2014 6:31 PM Stop with the self serving nonsense? What do you MDs and PTs (working for MDs)who come on here think YOU are doing? MDs? Sorry. Your gravy train of self referall for profit is coming to an end. Threaten to bite the hand that feeds? Really? I suppose we'll find decreased referrals for PT services once you are cut out of it, but a good many of them were probably bogus, uneccessary referrals to your own service anyway. You know how many honest involved MDs there are in an MD/PT "incident to" setting? Near zero. I've heard this argument for 30+ years. "It's convenient", "we get to work in conjunction with the MD", yada, yada, yada. I know MDs who have had their own PT places for 10+ years with a connecting door, and have never ONCE set foot in them, let alone worked "side by side" with their PT in delivering care. And you PTs, fear not. You won't be out of jobs long. The decent private practices and other patient sites in your town will be hiring. You won't be out of work long, but you will probably take a cut in pay from your inflated trumped up salaries earned off the backs of patients and the Medicare program. The monopoly needs to end. The strict control over patients and the PT marketplace needs to end. These incidents are true and factual. I have personally had patints tell me that if they didn't go to their Mds PT department, they would have to find a new doctor!!!! I've seen MDs write out charge slips with $295.00 on them for a consult, they order PT then the patient says they have their own PT, the MD takes the charge slip back out of the patient's hand, crosses out $295 and writes in $395!!!! If that doesn't spell out the greed and nonsense that is going on, I don't know what does. Since when does an MD with his thriving PT practice need to order a double set of hand carved exotic rare wood doors for his home at a cost of $60,000? Answer: Anytime he wants, because he can. He has a thriving PT pracice with loads of MTs, OTs, PTs lavishing all kinds of uneccessary care on his patients. It's about as wasteful as wasteful can be. The true heroes here are the PTs who have successfully competed against this unethical and often times criminal behavior for years. Do you lazy PTs who work for MDs have any idea just how GOOD you have to be to survive and thrive as a PT in business under these circumstances? No, you wouldn't. You'd better start boning up though. And put a resume together, you're gonna need it. Posted by Mark1PT on 3/7/2014 6:45 PM I understand the concerns that drive APTA to pay attention to physician self referrals, but as a therapist employed by an orthopedic surgical group, my experience is that the autonomy in our practice is absolutely respected, patients are in no way disuaded from seeing any therapist they choose, and no unnecessary referrals have come to us. The quality of care patients receive and responsiveness of our referring providers to patient concerns are superior to any independently owned clinics I have worked in. Having a close working relationship with these providers improves outcomes and has improved the phsician's understanding of physical therapists' value and expertise, an added benefit to the profession Posted by Marla Crago on 3/7/2014 7:28 PM Physical therapists working for physicians or having offices in physician buildings etc. would not be a problem if patients had unrestricted direct access to physical therapy services. Take away the 3rd party payer's requirement for MD oversight of therapy plans of care and this would allow for fair business competition regardless of who employees the therapist or where the therapy practice is located. Posted by Ryan on 3/7/2014 8:31 PM I think it is great that some feel working for physician groups fosters a close working relationship with physician referrors. I would prefer a professional and collegial relationship with physicians and improve the communities' understanding of our knowledge and expertise. Be prepared to stand as a profession with your profession Posted by Bryan O'Halloran on 3/7/2014 10:23 PM To H Backe, MD Really?!! Slanderous?!! I compete against over 150 orthopedist physician owned physical therapists on a daily basis. They are spread between the three dominant Ortho surgeon groups in my area. On top of that I have to compete against the hand surgeon office, the neurologists, and the OB/GYN groups that all own, and like the Ortho surgeons, exclusively refer to their own PTs. Presenting your patients "a choice" of where they will go is a farce. As they will almost always choose to go where their doctor tells them that "they can keep an eye on the rehab". Now that the GPs are joining the hospital umbrellas to secure better reimbursement, they are contractually required to utilize only the services in their hospital groups. No referrals to be had from these folks either. I have watched my referrals from physicians decrease, as those same physicians derive profit from referring to PTs they employ. It no longer matters what the outcome is for the patient, rather only that the doctor's practice not suffer any "leakage" of lost revenue from referrals made to outside their organization. This budget proposal from President Obama will change nothing. His last was defeated 99-0 in the senate. This one will likely suffer a similar fate. The future of independently owned PTs is to make the case to the patients who fail our of the POPTS facilities. Thankfully, there are many. Direct your marketing to the public and away from the physicians. They stopped caring long ago about your patient results. Faced with decreasing reimbursements of their own, they decided to capitalize by earning profit on the backs if their employed PTs. Build a practice on capitalizing on their vast limitations. Jack Keller, MS, PT Posted by Jack Keller, MS, PT on 3/7/2014 10:26 PM As a physical therapist, I understand the challenges faced by those who work both in a private practice MD owned facility and those who work in the "real world", as Mark1PT boldly states "it isn't easy in the real world" and with the healthcare standards changing every year and mounting budget cuts I agree...it is important to make things more efficient. However, having worked in all of these different settings, I will say the unjust over billing issues are every where, to say that PT practices aren't based on monetary gain is ridiculous. I currently work at a MD owned private practice and feel it is a superior level of care and the communication is greatly enhanced. Our patients always have a say in the care they receive and may go elsewhere if they wish. That is part of providing accommodations and services to the community that is professional and respectable. The MD's in our clinic, as well as the MD's who refer to us are very reasonable and leave it up to the LICENSED physical therapist to determine the appropriate plan of care for each patient given the results of the initial evaluation. In my opinion I would agree that many MD's usually under refer in our practice, more so than I have seen elsewhere. Posted by Joshua on 3/8/2014 1:35 AM I take great offense at the comments made by Mark1PT. I have been a PT for 20 years. I have worked with a physician owned practice for the past 7 years. I am a Fellow in the American Academy of Orthopedic Physical Therapists, I have taught in graduate and post graduate courses, I take over 200 hours of con-ed annually. Many of my patients pay cash and wait 4 - 6 weeks to see me--by choice! There may be physicians and PT's who abuse the physician owned practice setting, no more I suspect, than PT owned practices who have aides teaching exercise, who add ultrasound and e-stim to pad bills, who see 3 or 4 patients per hour, etc. I am well paid, I am treated with respect, I practice autonomously regarding who I see, how I treat and for how long. Please save the insults. You're welcome to spend a day with me and observe how I practice. Posted by bob baumgarten on 3/8/2014 1:43 AM That's nice Marla but why do you have to be employed by the ortho group? Why can't the same set up work equally as well if you owned the therapy practice down the hall vs being an employee? Why can't PTs and MDs work together without one profession owning the other? Posted by Dean B on 3/8/2014 2:07 AM These individual positive experiences with referral for profit are not the norm. Repeated research has shown referral for profit is costly and not in the patients best interest. Use some logic & think about it..do you want your physician referring you for any reason other than you needing the care? Thank you APTA! Keep it up and let us all know what we can do to help Posted by Eric on 3/8/2014 7:37 AM To Bob B, If you have such a following, why settle to have a secure referral source? Take the risk like I have for 20 years and see what type of following you have. These are all excuses to get easy money. Maybe the reason they wait for weeks to see you is because you and the MD are telling them that they have to- by the way, those pts are paying cash to the MD, not you! Posted by Scott W on 3/8/2014 8:33 AM People, people, people. Please listen to yourselves. Anecdotal evidence is fine, but it is still anecdotal. I am SURE the are POPTS that are fine. But, the evidence is that it is NOT fine--in more cases than not, the referral process is corrupted and that is why insurance industry and OIG research demonstrates that these relationships increase the cost of care. I am seeing a patient on Monday who when to a POPTS--he questioned my office administrator for 10 minutes about what would happen when he was seen in our office because his experience was so bad. When he told the referring physician that he was told, "in that case, you should go to this clinic because they do a much better job." The patients complaint is "why didn't he send me to the 'better' clinic in the first place." Anecdotal, I know. As for communication--I get texts and phone calls from doctors that want to talk to me. In the 1990s before POPTS invaded Atlanta, it was 2-3 times/week. Today it is 2-3 times PER YEAR. I send notes regularly--never get read. I have closed 4 clinics because of POPTS. I have always been told our clinics offered superior value. So, why would I have to close clinics. Anecdotal, I know. In truth, I would love to work in conjunction with physicians in an Accountable Care Organization where the incentive would be a superior outcome, not increased revenue. I am waiting for that to happen as I believe I am the most cost effective provider in musculoskeletal care and in that environment I would thrive. Posted by herb Silver on 3/8/2014 12:17 PM First I do not believe that the President's Budget will pass and all of this is an exercise in futility. I would like to share with you just few of the many incidents that I have experienced with a POPTS in my Private Practice. First one of my patients was told when she requested to see me that she had to see that groups PT practice. The patient then reluctantly went for her first treatment and was very unhappy deciding not to continue. On her follow up with her MD the next week she had her husband with her, who in the end had to step in to stop the MD from attempting to force her to go and continue with his PT. That MD then reluctantly gave her an Rx to take to us for treatment (Extra cost to Medicare for a second Evaluation). After her course of PT she was seen for a follow up by this MD who then asked the patient how I was doing prior to questioning her about her own condition and status. In another case we were referred a work comp. patient through a Therapy provider network. The patient was seen for an Evaluation and when the MD received the POC refused to sign it and raised a fuss with the referral network causing us to lose that patient to his own PT practice. If this is what I have experienced with my small practice I could only imagine to what scale this is actually going on. Posted by John on 3/8/2014 1:34 PM selfreferral just lubricates the physicians pockets since the restrictions in reimbursement continue to bemore and more restrictive-the bull that it enhances care due to proximity to the doctor does not exist-all it is is a well oiled money making machine to fund the pockets of the physicians -altruism does not enter into it.why would the doctors put up such a battle if it were for communicating with the therapist for better care.Also it leaves the therapist little prerogative to treat without charge if the patient needs the care and independent therapists do, NOT have quotas that they have to meet. Posted by harry m.brafmann,p.t. on 3/8/2014 1:36 PM To reply to Scott W...again I'd ask why go straight to insults. It does nothing to bolster your argument. My patients are not "told" anything, they are explicitly given a choice of PT's both by myself and my MD's , an entire page filled with options. Many are returning patients, many are patients who've failed rehab at other clinics, most remark on the amount of time I spend with them (45 minutes one on one) and the fact I don't have an inexperienced aide working with them (as I was forced to do in both private practice and in the hospital outpatient clinic. I don't find my money to be any "easier" now than when I worked either in private practice or in hospital based setting. I work hard for my patients and hard for my money. Perhaps you could refrain from slander when you present your side. I choose not to open a practice of my own out of desire to focus on patient care not on running a business Posted by bob baumgarten on 3/8/2014 8:51 PM I have worked in both the Private PT setting and the POPTs settings and the truth is there is a great potential for abuse in both settings. In the POPTs practice I worked for we chose not to see Medicare patients to avoid undue scrutiny. Medicare patients often begged us to come to our clinic because the poor care they perceived they experienced at privately owned clinics. The truth is I often was forced to see 4-6 patients at a time in private practice during prime times. Was that ethical? Was that good patient care? How many of those practices over utilize just the same as some POPTs. Why is the issue of POPTs so important to the APTA? Because the APTA has always been run and largely influenced by private practice ideology. Why is private practice pushing this so hard? Because at the end of the day its all profit driven. Don't think for second it's about the patients best interest. Those bonuses and incentive pay are directly tied to profit. The APTA has a double standard and if this was not the case why not go after HOPTs (who by the way are often owned by Physician Groups through investment or other means and directly benefit from those referrals) with the same passion as POPTs? You ask, why do you have work for a POPTs, and I will ask why can't I work for a POPTs when it was run more autonomously and ethical than the private practice I worked for? Stop being so self righteous and let patients decide where the best care is in their local area!!! It may surprise you! Posted by Jason on 3/8/2014 10:53 PM I am a PT. This is another bad decision by the APTA. Another bad decision by Obama. It won't save money, and will hurt more PT's, rehab professionals, and patients than they realize. Please stop pushing agendas and vote smarter people into all offices of government and professional governing bodies. Then maybe we can start fixing some problems. Posted by Tony C on 3/10/2014 3:04 PM Having previously worked for a POPTS facility, I can only use the example set forth during this course of employment. If the MDs tell their patients that they must see their owned PTs, then I have a problem with that. If PT is offered in a MD facility with no mention that they must perform these services in house, then by all means, carry on. In my experience where patients were told "go make your appointment right here" or "we want you to go here" and don't OFFER other alternatives, that is just plain WRONG. Reverse the situation ...If I hired a MD in my facility and told patients that they could only see my team of physicians, how would the rest of the independent MDs in the community react? I can guarantee they would be as unhappy as the PTs are now who deal with this on a daily basis. Can't quite understand why this is so debatable. Posted by Tracy Urvater on 3/10/2014 11:22 PM I have no respect for the APTA. Their only focus is pushing legislation for the benefit of private practice. There are just as many ethical issues related to providing physical therapy for profit (PT owned settings) as there are to referring physical therapy for profit. So, the only answer is regulation to the point that all PT services are controlled by ACO's. Our profession should focus more on ethical practices. Very skilled, ethical PTs work for large hospital organizations, physican owned practices and private practices. I'm also quite certain that PT is abused in private practices, hospital organizations and physican owned settings. I believe that the APTA should be fighting for the ability of every PT to be able to continue to choose the setting they prefer rather than lobbying for limited choices. Everyone for this policy should see that once for-profit referrals are limited, the next step would be for-profit services, right? Is more legistation, regulation and restriction really what you want? Posted by Kari on 3/11/2014 10:47 AM I have worked in an area with 2 large physician-owned practices for 6 years. If I had a dime for every patient who told my colleagues that they were told by their physician that they had to go to their therapists, I would be a very rich person. I have seen established patients in the middle of a course of care come in and say that their physician told them they would not continue to see them unless they started receiving care at the physician's practice. I have had family members and friends see a physician and during the visit they are strong-armed into scheduling a therapy appointment at the physician's own practice. Whenever I have inquired of the offices whether the patients are given a choice, I am told that the physician would never restrict patient choice, that it must be some rogue person in their front office. Nonetheless, it happens -- again, and again, and again. I have seen physicians who historically did not order therapy for their post-operative hip patients because they claimed it was not necessary, then suddenly begin referring the patients to their own practice once they employed therapists. I have also witnessed inpatient discharge notes written by physicians that specify that a patient must receive therapy at their practice. Meanwhile, case managers at the local hospital are required to present all community providers equally to patients when assisting them with discharge therapy planning. Many regulatory eyes are on hospitals and their affiliated practices. How many regul Posted by Jen on 3/12/2014 9:35 AM In more cases than not referral for profit is not good for patients, certainly not cost effective and reduces the professional status of Physical Therapists most of whom now have doctorate degrees. What is the point of long and very costly education, a DPT after your name and finally a law permitting direct access to our services. Doctors do not own drug stores and ownership in a physical therapy practice is no different. In my view Physical Therapy is a noble and independent Health care profession and should not be "owned" by any other profession. And to respond to Kari-we often need legilation to force us to do the right thing-example discrimination. Posted by Judith Hurley on 3/12/2014 4:16 PM In more cases than not referral for profit is not good for patients, Not cost effective and reduces the professional status of physical therapists most of whom now have doctorate degrees. What is the point of long and costly professional education resulting in a doctorate degree and why do we finally have a law permitting direct access to physical therapy if we are going to work in a POPTS? Doctors have never owned drug stores and they should not be able to self refer for physical therapy services. To answer Kari's post there are time when legislation is the only way to get us to do the right thing. Example "DISCRIMINATION". Posted by Judith on 3/12/2014 4:57 PM The only way to really fix this is to put everyone on a reasonable salary. PTs, MDs, hospital administrators, insurance execs, EVERYONE. The problem is fee for service, much more than the setting in which we work. Call me a socialist if you want, but sooner or later we need to take the "business" out of healthcare. Posted by Real fix on 3/14/2014 1:05 AM To Mark1PT, I must say you are painting with a very broad brush. Your comments are very narrow-minded. I will say this, though. It is therapists like you who we will target if and when our situation changes. Presently, we can't market other physicians in the community. Furthermore, our MDs give our patients a choice, although most prefer to come to us because, in our market, we have better outcomes than the private practice and hospital clinics. However, if for some reason the IOASE goes away, I can promise you our MDs will not be near as likely to refer to these other therapists and we WILL be marketing our services to the other referral sources in our market who, to this point, we have not even touched. You better be careful what you wish for or you just might be sending me YOUR resume. Posted by Robert on 3/14/2014 4:06 PM For 30 years I have heard and experienced all sides of this argument. To be clear there is good and bad care in all settings. The worst abuse I have seen however is from the private practice setting. The private practice setting has more motivation to see the patient longer and bill the patient more and at time for services that have not even been delivered. What the APTA should be doing is working with the AMA to have to Physicians and PTs work as colleagues and yes in the same offices. If you are an employed PT someone else is always going to be making or at times loosing money on your labor. That includes Physicians, other PTs ie owners of the private practice, hospitals, SNF, HH etc. PTs as a group sometime act like a bunch of entitled brats. Posted by Harry on 3/19/2014 1:05 AM I have worked in every setting possible and currently am in private practice. I left a physician owned group for the mere reason I was asked to see patients that did not require PT services. When I refused to do so, my salary was cut. I realize there are stories everywhere but I can assure you in the area I work ALL of the physician owned groups are excellent physicians but the therapy is lacking at best. If the laws do not allow for partnership, then there should be no employer-ship-period. There was a reason Stark laws were passed. The employer relationship does not change what used to be the partnership. Physicians need to keep being physicians, chiropractors being chiropractors and physical therapists being therapists. And according to the OIG the worst abuse on more than 1 occasion has been found in the physician ownership setting. This can not be disputed. Posted by Jeff on 3/31/2014 3:42 PM This is a truly stimulating debate. What amazes me is to see medical doctors responding on a PT article web page. This in addition to the numerous PT's who are employed by them and feel threatened by the potential change. The profession of PT is evolving into an autonomous practice based on the level of education and growth in our curriculum model. Consider it as the child who is now growing to a healthy responsible adult. We have established our own identity and should be allowed to pursue full independence without requiring oversight by a medical physician who often has no idea what physical therapists are capable of. If a medical doctor believes in the value of having a physical therapist onsite to improve communications and quality of care then why not establish a professional relationship and allow PT's to lease space or time in your office, and be independent practitioners who fully control the billing of their patients. This can be done without any financial gains from PT sessions going directly to the physician. It would merely be a professional referral . In a fantasy world this could be possible but the reality is physicians want full control of that pie and this is why they fight to maintain the billing power for providing these services in their office. To be continued... Posted by Matthew St.Aimee, PT, DPT on 4/7/2014 3:13 PM For those of you that enjoy being used as slaves , and like to be considered third class citizens in the hierarchy of healthcare delivery, enjoy this moment because it will end soon!! We will surgically remove the loophole that is keeping us from prospering. To Dr. Rockar and Dr. Diangelis thank you for pushing hard. Now let's focus on changing the verbiage of our practice act. Ultimately this is how Chiropractors won the battle against the AMA. Let's not re-invent the wheel let's learn from others that won this battle a while back. You never see a Physician owned Chiropractic practice due to the fact that they are recognized as Physicians. This is where our issue is! We raised the bar for the DPT level but didn't change the practice act to match the level of education. Let's push harder then ever before!! We have the numbers, drive and intelligence to beat this!!! The battle has just started!! Posted by Blair on 4/7/2014 9:02 PM I have been a physical therapist for 21 years and a private practice owner for 10. Some of the physicians owning therapy clinics in our area are to the point of rabid to keep "their" referrals. A nurse I know who worked for a large Neurology group told me if they didn't refer to their therapy clinic or dissuade patients from going to other clinics they would be fired. There is rampant abuse in our area by greedy physicians/groups. It is so bad one orthopods out right tells patients they will go to XYZ physical therapy owned by him. My practice is doing well. I built it on quality service and outcomes. Patients want results and happily tell others who get referrals for our services. But when physicians out right obstruct patients from going where they want it is time for the system to change. Posted by Charles on 5/29/2014 4:58 AM I have owned a private therapy clinic in Austin for 7 years and am an OT specializing in hands. I think that the stark laws were passed for a reason and I do think that we are not very well respected. Often the physicians see us as some sort of tech or replaceable office person (I have worked for a POPTS and when I questioned a very strange patient bill I was immediately let go by ironically one of the biggest opposers in the state of Texas to direct access to therapy). I do wonder why physicians don't worry about participating in businesses that are based on an abuse of a loop hole in a law that was simply meant to prevent the POPTs from even existing. Doesn't that put the therapists employed by the POPTS and the physician at risk? It's a house of cards and one law suit or mistake and everyone in that situation could LOSE THEIR LICENSES. I say this as someone who has talked to an OIG agent. Those POPTs are usually under investigation for something. PTs working for physicians really aren't very safe nor are the physicians that own their asses. Does no one even care about the stark laws? Incident two billing turns out to cost 1.5 times more than the bill for a stand alone clinic by the way. POPTs are very very expensive. The POPTs needs to end to protect all of us and the future of our professions. We need respect, we need to know our future is not one of abject poverty, and we need our licenses to be protected. Posted by Emily on 8/13/2014 4:32 PM Bob Baumgarten, I am impressed that PT's working at your POPTS clinic see patients for 45 minutes sessions with one-on-one. That's impressive and I am happy to see that, but just know that is definitely NOT the norm for POPTS. I have worked at some, interviewed at some, and talked with people who have worked at POPTS, and contrary to your situation, they are PT mills. I got the sense on my interview that they wanted a warm body that new how to make charges. When observed their clinic, patients were literally sitting around waiting to get there few minutes of 'hands on' time with the therapist. I'm sure there are some good PT's working at these clinics, but how good can you be when you have to see 30-40 patients a day. In one that I worked at, I couldn't remember who certain patients were at the end of the day in trying to finish documentation because I had seen so many; they spent most of the time with the tech while I was juggling and bouncing from patient to patient. I overheard patients asking the tech questions about their condition that should have been directed to me; I tried my best, but impossible with all the patients that I saw. I find it insulting that POPTS think that that is what PT is about. We are capable of so much more but it is impossible to give good therapy that way. I do not want to run myself into the ground just to make physicians more money. You don't even have time to use your manual skills that you have spent time and money to obtain. Billing for POPTS and hospital corporations is WAY more expensive than a private owned clinic. They get reimbursed significantly better than private clinics. Why do insurance companies do that? If they want to make some budge cuts, they might want to do away with some of that. I am excited to see those therapists who have made the leap and gone into cash-based practices. Massage therapists do it, personal trainers do it. Why can't we? To quote something I read that I felt makes a good point, "Historically, PTs have not aggressively entered the cash pay arena, preferring to maintain their long-established dependence on insurance reimbursement and MD referrals. As a profession, are we allowing other fitness and healthcare professionals to define us by marketing directly to the public with similar messaging to our own? Can we afford to stay in the cycle of referral-reimbursement, and now, what are our options?" Being a cash clinic that does not take insurance can be a solution, though it is not for everybody. But it can be answer for those who are sick of bouncing from patient to patient; there are therapists who are doing this successfully in states that do not have direct access as well. Patients pay more per hour for ~1 hour of quality one on one time and no time with a tech. As a result, patients are getting better quicker. Posted by Debbie on 10/21/2014 9:50 AM WHERE CAN I REPORT THREE DOCTORS THAT ARE REFERRING PATIENTS TO A THERAPY LOCATION RIGHT IN THEIR OWEN BUILDING. Posted by JOANNA on 7/25/2016 5:18 PM


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Advanced Search
Microsoft is looking to up the ante with its Windows Server HPC platform. The company released its third iteration yesterday and signaled it would like to see broader use of its high-performance computing platform.
"Think of this as one of the key shifts in our fleet for what we look at as this future of technical computing," said Bill Hilf, Microsoft's general manager for technical computing. Hilf made his remarks in his keynote address at the High Performance Computing Financial Markets conference in New York.
"It's a pretty wide initiative where we want to take the technical computing technologies and really make those available and accessible to a broader number of IT end users and developers," explained Bill Hamilton, Microsoft's director of technical computing.
In an interview right after his keynote address, Hilf said he believes HPC applications will drive usage of Windows Azure, thanks to Windows HPC Server's newfound support for Microsoft's cloud service.
"I believe the technical computing workload will be the killer Azure app because the nature of these workloads consume a ton of computer," he said. "We believe having an infrastructure with hundreds of thousands of servers is going to be very compelling."
Some notable facts about Windows HPC Server 2008 R2:
If you're among those that are testing it out, or intend to do so, share your thoughts with me at firstname.lastname@example.com.
Posted by Jeffrey Schwartz on September 21, 2010 at 11:59 AM
An Azure Active Directory outage that lasted for about 2.5 hours was caused by multifactor authentication challenges not working, according to Microsoft.
From the next major update to Windows 10 to the next generation of HoloLens, here's what's on tap from Microsoft this year.
Here's your guide to all the IT training sessions, partner meet-ups and annual Microsoft conferences you won't want to miss this year.
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subset: commoncrawl


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I have built a custom options panel which allows site owners to enter their social profiles. I then use the second code to make the links appear in the theme.
When no link is entered in the options panel, I would like there to be no link called on the page where the code is being called. Currently, it provides me with a link to the homepage of my site.
Take a look: http://themeforward.com/demo2/ - the green box is the facebook link, the purple is the google link
I know what you're thinking - why not just leave it the way it is? Because, I'm styling each link with a background image rather than using normal text links... so if I just leave it this way we will still have an image showing up advertising a social site presence, but it won't be linked. The styling can be found here: http://pastebin.com/m3PrBDae I think that may be affecting this.
In my functions
array( "name" => "Facebook Page",
"desc" => "Enter your Facebook address. (Must include http://)",
"id" => $shortname."_facebook",
"type" => "text",
"std" => ""),
array( "name" => "Google Plus",
"desc" => "Enter your Google Plus address. (Must include http://)",
"id" => $shortname."_google_plus",
"type" => "text",
"std" => ""),
How I call them
<a href="<?php echo get_option('to_facebook'); ?>">
<a href="<?php echo get_option('to_google_plus'); ?>">


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Adelphi Paper Hangings
Welcome to Adelphi Paper Hangings, producer of the finest quality, block-printed wallpapers available on the market today. Our wallpapers are meticulously reproduced from original documents and hand-printed by skilled artisans using the same methods and materials employed in the eighteenth and nineteenth centuries.
Owned and operated by Chris Ohrstrom and Steve Larson, Adelphi Paper Hangings LLC is a small, artisanal producer of historically accurate block printed wallpapers for museums and historic institutions, as well as for period designers and those involved in contemporary design projects.
Founded in 1999, Adelphi Paper Hangings grew out of a symposium of some of the world's foremost experts and researchers on block printed wallpapers. While the symposium demonstrated that interest in these historic papers and techniques remains extremely high, it was also clear that the art of producing these unique papers had been in sharp decline since the early 20th century.
To help insure that the art and craft of traditional handmade wallpapers would survive, Adelphi established the only commercial production facility for block printing historic papers in the United States.
Adelphi Paper Hangings offers wallpapers that are reproduced using the same hand-printing methods and materials employed circa 1720-1860, after which machine printing methods began to dominate the industry. Our work is based on exhaustive and continuing research into methods, materials, techniques and styles. Each order is individually hand printed by skilled artisans without compromises in quality, historical accuracy or consistency.
Working from original documents that range from an entire wall's worth of antique wallpaper to a modest box of faded, water damaged scraps still attached to chunks of plaster, Adelphi Paper Hangings has successfully reproduced wallpapers which date from the 1740s through the 1930s. By understanding the nature of historic paints, the muting effect of time, as well as the historic context and fashions, Adelphi Paper Hangings can successfully interpret documentary evidence and accurately reproduce the style, character and look of original period documents.
In addition to historic American, French and English patterns from its own extensive collection of original wallpaper documents, Adelphi offers patterns licensed from the archives of Historic New England, The Smithsonian Institution, The Colonial Williamsburg Foundation, Old Sturbridge Village, the New York State Historical Association, the Musée du Papier Peint (Rixheim, France), and from many other historic institutions and private collections.
Our commitment to quality, historical accuracy and uncompromised production values are our assurance to customers that Adelphi products are the finest quality block printed papers available on the market today.
Some of what Adelphi Paper Hangings does best ….


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Cincinnati, OH. – Antonelli College will offer transfers for students affected by the sudden closing of ITT Technical Institute.
Antonelli College has been approved by the State of Ohio as a school who is willing to assist these displaced students to transition from their program at ITT Technical Institute to Antonelli College. ITT Technical Institute's sudden closure displaced more than 35,000 students from their programs nationwide.
Displaced students who want to explore their educational transition options should call our Antonelli College Community Relations Specialist, Michele Anderson, at (513) 824-7004 or send a text message to (513) 300-0669. She will be able to answer questions about the application process, financial aid and other special situations students may have.
ITT Technical Institute announced Sept. 6 it was shutting down all of its campuses, citing sanctions from the U.S. Department of Education that barred the school from obtaining federal student loans and grants for ITT students. This decision came from findings that ITT was out of compliance with its accreditation standards.


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Feb. 10, 1934 – July 19, 2013
Roy Joseph Fowler, of West Seneca, former owner of Fowler's Chocolates, died July 19 in Father Baker Manor, Orchard Park, after a long illness. He was 79.
In 1963, after the death of his father, Mr. Fowler joined his uncle Ray in the family business, which had been founded by his grandfather in 1910 on Jefferson Avenue and was widely known for its sponge candy. They moved the business to a larger location on Union Road in West Seneca in 1968, which enabled them to double their sales.
He became sole owner upon the retirement of his uncle in 1978 and retired in 1994 after selling the company to a group of investors.
In retirement, Mr. Fowler operated a small candymaking firm, R.J.'s Olde English Chocolates.
Born in Buffalo, Mr. Fowler was a graduate of Amherst High School, where he established several records as a basketball player. He later was inducted into the Amherst High School Athletic Hall of Fame.
He went on to play basketball for Arizona State University and the University of Buffalo, where he earned a bachelor's degree in accounting. Before joining Fowler's, he was an accountant for Peat, Marwick and Mitchell.
A lifelong sportsman, he enjoyed handball and bowling, and once rolled a perfect 300 game.
He also was an avid golfer and a longtime member of Springville Country Club.
Survivors include his wife, the former Irene Carr; his former wife, the former Jacqueline Brockto; two sons, Royce and Joel; four daughters, Dawn Holenski, Sheryl Gerard, Saima Horab and Kim Worgren; and a brother, Bruce.
A private service was held in Kazmierczak Funeral Home, West Seneca.


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For those of you who don't yet
know, Good Housekeeping is now on Facebook and Twitter! Get timely updates ranging from what to get
your dad for Father's Day to how togrill like an expert. The Good Housekeeping Research Institute
(GHRI) is showcased with its own Twitter account. You can find out about the latest product
testing and blog posts through these sources, as well as other interesting GHRI
tips and tricks. These forums provide
you with the ability to talk directly to the scientists,
engineers, nutritionists, and researchers and give us valuable feedback
on how to better serve your needs.
Follow us to keep up with the latest Good Housekeeping has to offer! Remember, it's not your Grandmother's Good
Housekeeping anymore!
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Has Shakespeare's inspiration for Ophelia – one of literature's most tragic heroines – finally come to light? A 1569 coroners report published in The Guardian tantalizing suggests maybe so.
In 1569 – when Shakespeare was five years old – a small girl named Jane Shaxspere was reported as slipping and drowning whilst collecting flowers only 20 miles form Shakespeare's home. Shakespeare's Ophelia character in Hamlet fell with her garlands of "crow-flowers, nettles, daisies and long purples" into a brook, singing "snatches of old tunes" until her waterlogged clothes dragged her to a watery grave.
Historians are now speculating that Shakespeare could have heard of the event, and even that Jane could even have been a relative of William: the spelling of his surname was irregular at the time, with variations even in his own signature.
A nice reminder that though Shakespeare's plays often draw on well-attested literary sources, they also have roots in gossip and everyday life.


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Paul Joynson-Hicks isn't very good at giving money to beggars at traffic lights. He finds it "awkward and slightly demeaning," he says. Instead, he finds out who they are and where they're from, and treats them like real human beings.
Then he starts a group to help them.
That's how Mr. Joynson-Hicks founded Wonder Welders, a welding-and-crafts workshop in Dar es Salaam, the largest city in the East African country of Tanzania.
Since 2004, the organization has trained and employed one of Tanzania's most disadvantaged populations – people with physical disabilities – who have few alternatives to begging at intersections for spare change.
At Wonder Welders they make "hip, recycled art" out of everything from donated bottles and cans to scrap metal. It provides income and a sense of purpose for the disabled people, whom most employers in Tanzania consider "unhireable" because of their physical limitations.
Magdalena Kombe, one of the workshop's 35 employees, says the work has given her hope. "I am able to support my family, pay school fees for my nephew and niece, and I've learned valuable skills – how to recycle waste and turn it into something that people want to buy."
Joynson-Hicks's history of finding creative solutions to empower and improve lives doesn't end with Wonder Welders. In 15 years he's gone from being just another commercial photographer to having a second career as a serial social entrepreneur.
Driven by a "deep sense of injustice when people are being treated badly through no fault of their own," as one friend of his puts it, Joynson-Hicks has founded three other charities, earned a Member of the British Empire medal from Queen Elizabeth II, and changed thousands of lives across East Africa.
Born in London in the early 1970s, Joynson-Hicks grew up the only boy among four children. His mother was raised in Kenya. Led by her Christian faith, she helped build AIDS hospices across Britain and Uganda, earning an award from Queen Elizabeth II for her work. His father, a lawyer, served on the boards of several nonprofit groups.
After a "relatively normal upbringing," as he puts it, Joynson-Hicks skipped college and landed a job as a photographer's assistant in London, where he built a successful career in commercial photography.
In 1993 he moved to Uganda to work on his first book of photos. After its successful publication, he went on a safari with his parents, who gave him a new perspective.
"So now that you're here, you've got your book, you've got a nice life ... what are you doing for Uganda?" they asked.
"They opened my eyes to the possibility that I had an opportunity to make a difference, and saw in me characteristics I didn't realize I had," Joynson-Hicks recalls.
He spent several nights on the streets of Kampala, Uganda – sleeping curled up behind trash cans and talking with street children – to see how he could help.
The answer turned out to be simple.
"We'd like to eat and play football [soccer]," the kids said.
A week later, Joynson-Hicks, a friend, and 10 "boisterous, smelly" street kids piled into his Land Cruiser and headed out with a soccer ball and a feast packed.
"They still had glue and gasoline sticking to their clothes ... but they were full of great character!" Joynson-Hicks says.
The Tigers Football Club became a weekly occurrence, growing to serve hundreds of street children and providing entertainment, empowerment, and even basic health care to disadvantaged youths.
The ragtag group managed to win Kampala's Kadya Youth Trophy, beating established youth groups and schools while playing barefoot. "It's still my proudest sporting trophy," Joynson-Hicks says.
Andrew Williams, a social worker who helped support the organization financially from Belgium, agreed to move to Kampala and take it over full time. Under Mr. Williams, it grew to become Retrak, which today serves thousands of disadvantaged youths across Kenya and Uganda.
Joynson-Hicks has "a big heart, and a big vision," Williams says, "but he also had humility and wisdom, realizing that he wasn't the best person to run it full time."
Joynson-Hicks later moved to Dar es Salaam and formed another charity, the Goat Races. This annual event (which does involve racing goats) has raised hundreds of thousands of dollars for local charities.
"There's so much need, so many people who need help in [Tanzania], it's a bottomless pit," says Adam Fuller, general manager of the Southern Sun, a luxury hotel in Dar es Salaam, who has helped at Joynson-Hicks events over the years. "Yet Paul just always seems to pull all the right people together to become cheerful givers.... He's got the right recipe for doing good."
Joynson-Hicks now is on his fourth endeavor, a company called Molly's Network that helps accredit small nonprofits and connect them to resources, networks, and local and international donors.
But Molly's Network won't be a full-time job either.
Photography, still his passion, continues to fuel his charitable work, both emotionally and financially. "I love this kind of altruistic work ... but I don't think I'd be good at it full time," he says.
Part time seems to be good enough.
[Editor's note: The original version of the headline on this story misidentified the countries that Mr. Joynson-Hicks works in.]


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Our Mission
Our goal is to minimize or eliminate need for medications, reconditioning of body function, return patient to a productive work life and enjoyable personal leisure activities. We are dedicated to provide the highest quality of pain care. ~ Dr. Xia
While occasional pain or ache is a controllable and almost considered a normal occurrence, living with pain for long periods of time such as several months or years is an unbearable experience. 1 in every 10 Americans has reported experiencing pain that lasted for a year or more. This kind of pain
is can alter an individual's life and affect their daily life activities in a negative way. Most people are left incapacitated to handle basic tasks in their lives and most will depend on other people resulting in a complicated situation
The good news is that anyone suffering from this kind of pain or ache can get relief at Integrated Pain Management clinic. For a good number of years, Integrated Pain Management trained and experienced specialists have assisted multiple patients dealing with chronic pain using effective treatment methods and medications. Today, our pain management clinic utilizes modern techniques in evaluating and treating acute and chronic pain. Through keen listening, our highly trained clinicians and physicians will get all the necessary details from the patient and create a treatment plan that will meet the patient's needs and manage the pain.
Integrated Pain Management clinic offers modern resources through a comprehensive program that is aimed at effectively managing different pains and restoring the patient's quality of life. We specialize in treating different types of pain and anyone who feels as though pain is interfering with their daily life activities is welcomed for check up and treatment. Pain can be as a result of different conditions and at Integrated Pain Management; we focus on relieving pain caused by different conditions such as,
The main goal of Integrated Pain Management clinic is to assist patients suffering from pain in managing the pain through decreasing the intensity and frequency, increasing function and restoring the quality of life. After a patient goes through the evaluation process our specialists work together with multidisciplinary teams consisting of orthopedic surgeons, occupational therapists, cancer specialist, anesthesiologists, physiologists and physical therapist to create a pain management plan that is specifically aimed at managing the patient's pain.
Patients treated by our specialists benefit from a number of therapies such as,


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Replies to This Discussion
Great Angela, please write me to [edit by Moderator] and let us plan something next week!
Hi, I just moved to Cambridge. Let me know if you would like to play sometime. Thanks,
Jay, I am currently overseas and will be back in January. Let's get in touch in January for a hit,
Still up for a hit (this weekend)? Kind of want to rip it up this spring / summer and need a few peeps to train with. By rip it up I mean entering some of the tennis northeast matches.
hope all is well,
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"Our Labradors love their freedom and so do we. We feel we have happier, safer, healthier, well-mannered dogs since installing the fence. We cannot thank you enough, except to say that we will tell anyone that has a pet to get Invisible Fence Brand!"
You know from experience: owning a pet is a big responsibility. But he's not your only responsibility. That's why, at Invisible Fence, we created innovative solutions that allow you to enjoy all the love your pet has to give — without all the stress and mess. But that's not the only thing that sets us apart from all those other guys. With Invisible Fence, you get:
Invisible Fence pioneered the pet containment industry. So we understand the technology — and how to make it work for your pet — better than any of our imitators.
Choose from exclusive systems like our GPS 2.0 Ultimate Wire Free Pet Fence™ Solution, Doorman™ Pet Door, and more. Or put them together to create the integrated solution that's customized just for you.
Our exclusive Perfect Start™ Plus Training ensures a safe, stress-free adjustment to your pet's new boundaries.
When it comes to keeping your pets out of trouble, a cookie cutter approach won't work. With our exclusive Different Rules for Different Pets™ Technology, each of your pets can be themselves and still be one big, happy family.
Designed to be the best power source available, our reliable Power Cap® Batteries ensure that your pet's Computer Collar® Receiver works at full power, consistently, for longer periods of time, and in all types of weather.
Your pet is part of your family. That's why the professionals at your neighborhood Invisible Fence promise to improve the way you live with your furry family members.
Invisible Fence Brand's advanced technology is important. But it's only part of the picture. It all comes together when we pair those innovations with our Perfect Start™ Plus Training Protocol. Together, they change the way your pet understands (and remembers) his boundaries.
This training protocol was developed in collaboration with leading animal behaviorists from around the country, ensuring that your dog learns his boundaries without fear or distress. Our trainers become certified in Perfect Start™ Plus Training after intensive coursework in animal behavior, both in the classroom and in the field. And they're able to customize the training and the technology to each of your pets' individual needs and behaviors. Invisible Fence also provides expert training for cats.
All training is conducted on your schedule, at your home, at the pace that's right for you and your four-legged friend. And that's important. Because our training ensures that your dog or cat will be taught on your Invisible Fence system, in a way that makes their safety and well-being a priority. Because, like you, we love pets. And it's our mission to make their lives—and yours—better than ever.
One house and three dogs later, Invisible Fence Brand is still the best solution for keeping my dogs safe and healthy. They can run free in the yard and get the exercise they need to stay healthy and strong.
Webster, NY
I never thought the fence would work for Luke, Lenny and Buddy. Now I tell everyone Invisible Fence Brand is the real deal. These three stay in the yard even when the school bus unloads.
Cuyahoga Falls, OH
Leo, our 4 year old Bernese Mountain Dog/Rottweiler rescue, has had his Invisible Fence Brand solution for 3 years. We changed the layout recently and with training he quickly learned his new boundaries and never leaves his yard
Aurora, OH
I certainly made a big mistake trying another electronic containment system. Now that I have switched to Invisible Fence Brand, I am very satisfied and will continue to highly recommend Invisible Fence to my clients.
Newell Hickory Grove Animal Hospital
We had immediate success with the training. We love the freedom of just letting them out into our yard with no worries.
Would like to thank invisible fence for the job they did at my house today! All the young men who came out to my home were very polite and clean cut! Also took the time to explain how to train and use all the equipment! They are highly recommendable and very professional! They also went above and beyond! They have the best customer service I have seen in years!
Tampa, FL
I am a satisfied customer. I have two large dogs and they are extremely content having the freedom to roam with the Invisible Fence® Brand system boundaries. I feel very comfortable with the system and have recommended it often to my clients at my veterinary hospital.
Past President, North Carolina Veterinary Medical Association
Not only are many of our clients satisfied customers of Invisible Fence® Brand, but we can rest assured that our personal dogs are safely contained on our property.
Twin Lakes Veterinary Services
Have questions? Here are a few that other pet owners have asked. And we're happy to help answer your questions you may have about Invisible Fence Solutions. Just click here, or give us a call at 1-866-804-1250.
Every dog, family and property is unique, which is why we customize every system to meet your specific needs. Size of property, type of equipment purchased, number of professional training sessions purchased and number of pets on the system are all factors that must be considered when determining the final price.
We'll help you determine a solution that will fit your needs and your budget. To get an exact price, schedule a FREE, no-obligation, consultation in the convenience of your home by calling us at 866-804-1250 or click here to schedule online.
At Invisible Fence of the Upstate we're passionate about protecting pets — so you can focus on fun! So, let's talk. And we'll find the gentle, effective, affordable solution that's right for you and your pet. Guaranteed.


text: Written by Geraldine Granahan, CLIR project cataloger The Patricia D. Klingenstein Library of The New-York Historical Society has several items in its collections that were printed in the Cherokee language. One example is the above almanac, Cherokee Almanac 1861, which is written in Cherokee (or Tsalagi), an Iroquoian language used by the Cherokee people. The…Read More


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9ct Gold Mini Gemstone Bangle Amythest
9ct Gold Mini Gemstone Bangle Amythest
We understand the many different aspects which come into play when choosing your perfect piece of jewellery.
ach of our pieces radiates a passion for exceptional quality, craftsmanship, personality and sophistication.
Shop our collection and begin your love affair with jewellery.


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When Presidents Lie
For the first time, most Americans don't trust Obama. Can he recover?
For Richard M. Nixon, it was "I am not a crook," for George H. W. Bush it was "Read my lips: no new taxes" and for Bill Clinton it was "I did not have sexual relations with that woman."
Big presidential lies take many forms. What they all share is the potential to sever the bond of trust between a president and the people he was elected to serve—and therefore to destroy a presidency.
Story Continued Below
And while it may lack the intrigue of Watergate or the Monica Lewinsky imbroglio, "If you like your plan, you can keep it" may very well have a similar effect on Obama: effectively ending his presidency more than three years before it officially concludes.
In August 1964, Congress passed the Gulf of Tonkin Resolution, which authorized President Lyndon B. Johnson to use " all necessary measures" to protect U.S. service members abroad without having to secure a formal declaration of war by the Senate. The resolution was prompted by the Gulf of Tonkin incident, which Johnson described to Congress and the American people as two unprovoked attacks by North Vietnamese warships against U.S. vessels in the Gulf.
Only it was untrue. Johnson used the incident first to promise the American people that "We still seek no wider war," which helped him defeat the hawkish GOP Sen. Barry Goldwater in the 1964 election, then, later, to escalate the war in Vietnam.
It is often said that Vietnam was LBJ's undoing. But it was his lies about Vietnam that really did him in. A 1967 Harris poll found that Americans' most serious criticism of Johnson was that "he was not honest about sending troops to Vietnam." Johnson's approval ratings never recovered, and he was forced to scale back his ambitious domestic agenda. Ultimately, he reluctantly withdrew from the 1968 presidential race.
At the 1988 Republican National Convention, George H.W. Bush accepted the Republican nomination for president by emphatically stating, "Read my lips: no new taxes." The pledge was seen by the Bush campaign as a way to unite the GOP around the moderate candidate. Once in office, Bush ultimately raised taxes at the behest of a Democratic Congress dead set on balancing the budget through tax increases. The backlash was strong. A New York Post headline read: "Read my lips: I lied."
Bush's popularity plummeted, and Pat Buchanan, who challenged Bush in the 1992 Republican primaries, constantly reminded voters of Bush's lie, insisting it was proof of Bush's lack of honesty. Clinton also seized on Bush's broken promise, producing ads late in the campaign that attacked Bush's character. Bush's repeated apologies only made him look weak, and they became fodder for late-night comedy shows. When Bush lost, many political pundits said they believed he would have won had he not raised taxes.


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Operation Thunderbolt
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DescriptionOperation Thunderbolt is the exciting sequel to Operation Wolf. An airliner is hijacked by terrorists en-route from Paris to Boston, who threaten to kill all hostages on board if their mates aren't released from jail. Instead of reaching its destination, the airliner makes a landing in Kalubya, Africa, and all the hostages are hidden in various locations. The authorities have asked the hero from Operation Wolf to rescue the hostages, but only this time, the hero brings his friend along for the ride.
There are eight missions to complete in Operation Thunderbolt, and each one has you shooting down soldiers, choppers, and tanks. The gameplay varies every one or two missions. In some missions, you are driving a jeep or controlling a boat, while in others, you are walking while you're shooting. You have a limited supply of ammo, and a limited supply of rocket bombs, but you can always stock up by shooting down crates falling from the sky, or by killing a cat or dog that get in the line of fire. Also from crates, you can get special items like bulletproof vests, rocket bombs, and different weapons.
You also have a life bar to worry about. If you're shot at by soldiers, or if rocket bombs or grenades are thrown at you, you 'll lose energy, and once you're energy is depleted, you lose one of your three lives. You can lose a lot of energy by killing hostages on purpose, and you can't easily avoid killing them if you decide to use rocket bombs to wipe out enemies. The eighth mission, the mission that involves you fighting terrorists on a plane, proves to be difficult because a woman in a blue dress stands up and gets in the line of fire, and you have to very careful when you're going to use rocket bombs.
There are two endings to this game, and which ending you can watch will depend on the number of hostages you've saved, and whether or not you shot the pilot instead of the mission eight boss.
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Part of the Following Groups
- BPjS / BPjM indexed games
- Genre: Light Gun Shooter
- Operation Wolf / Thunderbolt series
- Setting: African
User Reviews
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Critic Reviews
|Commodore User
|Jan, 1990
|94 out of 100
|ZX Spectrum
|Dec, 1989
|91 out of 100
|Sinclair User
|ZX Spectrum
|Jan, 1992
|88 out of 100
|Feb, 1990
|85 out of 100
|Commodore Format
|Commodore 64
|Jan, 1992
|83 out of 100
|The Games Machine (UK)
|Commodore 64
|Jun, 1990
|71 out of 100
|ASM (Aktueller Software Markt)
|Jan, 1990
|7.4 out of 12
|Power Play
|Feb, 1990
|56 out of 100
|Retro Game Reviews
|Jul 01, 2015
|ASM (Aktueller Software Markt)
|Commodore 64
|Jul, 1990
|3.2 out of 12
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TriviaAs well as the obvious 9/11 parallel of Arab terrorists hijacking planes, the plot is spookily close to the Lockerbie tragedy of 1988, in which Pan-Am flight 103 (just 1 number away from the plane in the game) was blown up over the Scottish town of Lockerbie. Lybian agents were responsible - which probably explains the change Black Wolf mentions.
Contributed to by Trypticon (11039), Martin Smith (66827), Dan K (200) and Katakis | カタキス (41060)
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A new Oxfam report released in time for the World Economic Forum spells out just how vast the inequality divide has become and the urgent need to act. It's just not good for anyone
The annual meeting of the ultimate insider's club has begun in Davos, Switzerland today. The World Economic Forum attracts the rich, powerful and seriously cool from all over – the opening day has seen speeches from Mario Monti, David Cameron and Larry Summers, an award for Charlize Theron and reports of Prince Andrew drifting around for some reason. What's surprising are some of the comments from the IMF.
Its chief Christine Lagarde has been stressing the importance of long-term thinking by the world's leaders, with one of her key points being concerns about inequality. Not what you'd expect from the IMF really, but crucial in the light of a new report by Oxfam released just prior to the forum.
According to the report, 'The cost of inequality: how wealth and income extremes hurt us all', the world's richest 100 billionaires made US$240 billion last year, which would be enough to end global poverty four times over. Oxfam says baldly that "Extreme wealth and inequality are reaching levels never before seen and are getting worse", continuing:
"It is now widely accepted that rapidly growing extreme wealth and inequality are harmful to human progress, and that something needs to be done. Already this year, the World Economic Forum's Global Risk Report rated inequality as one of the top global risks of 2013. The IMF and the Economist agree...
In the last decade, the focus has been exclusively on one half of the inequality equation - ending extreme poverty. Inequality and the extreme wealth that contributes to it were seen as either not relevant, or a prerequisite for the growth that would also help the poorest, as the wealth created trickled down to the benefit of everyone.
There has been great progress in the fight against extreme poverty. Hundreds of millions of people have seen their lives improve dramatically – an historically unprecedented achievement of which the world should be proud. But as we look to the next decade, and new development goals we need to define progress, we must demonstrate that we are also tackling inequality- and that means looking at not just the poorest but the richest... That is why we are calling for a new global goal to end extreme wealth by 2025."
Which, for an organisation reliant on donations, often from rich people, is a ballsy critique to be offering. My first response is to wonder at the research. I mean, in all reality, how can they identify the richest 100 people and know their income. Who knows what this Russian oligarch or that tin-pot dictator is worth? But allowing for those numbers being a half-decent guess, my other response is to feel like weeping.
For me, that kind of wealth in the hand of a few is hand-wringing stuff. There's nothing good about it. As Oxfam points out, in a finite world that can only mean many, many others are missing out. The emotional, psychological and physical detachment created by that kind of wealth, and lack of care it must create for your fellow man, cannot be healthy. It's a dehumanising, destructive amount of money, both for those who have it and those who don't.
Sure, some use their mega wealth well. But Oxfam estimates that as much as a third of the world's wealth is hidden in tax havens. In other world, the Buffets and Gates are the exceptions, not the rule.
I'm always wary of claims that things are 'worse than ever', but the great concern is that the Global Financial Crisis, despite its name, has actually been very good business for the very rich. Oxfam points out that:
"Globally the incomes of the top 1% have increased 60% in twenty years. The growth in income for the 0.01% has been even greater. Following the financial crisis, the process has accelerated, with the top 1% further increasing their share of income."
In China the top 10 percent take home 60% of the income. And in the US it's worse. The New Yorker reported last year that billionaires were lining up against Barack Obama because he was spelling out the dangers of extreme wealth – they called it class warfare and felt persecuted. But the numbers said otherwise. The Obama years have been good to the uber-rich, according to the magazine:
"At the end of September, the S. & P. 500, the benchmark U.S. stock index, had rebounded to just 6.9 per cent below its all-time pre-crisis high, on October 9, 2007. The economists Emmanuel Saez and Thomas Piketty have found that ninety-three per cent of the gains during the 2009-10 recovery went to the top one per cent of earners... the top 0.01 per cent captured thirty-seven per cent of the total recovery pie"
Many of the billionaires the New Yorker discussed were the hedge-fund managers, Wall St titans and the very buggers who got us into this mess in the first place. It's obscene that they have profited from the damage done by their hubris and greed. Meanwhile, this week the ILO reported that global unemployment was up by 4.2 million last year, with a global unemployment rate for 15-24 year-olds standing at 12.4 percent.
This is unsustainable and shows just how fragile the talk of a recovering global economy really is. Economies simply function better if wealth distribution is more even and the middle classes have some cash in their pocket and skin in the game. Look at how countries like the US and New Zealand grew in the '50s and '60s, how Brazil is growing now. Cutting inequality is good business.
President Obama seems to be recognising that at last – or at least speaking more openly about it. One of the best things about his election win last year was that those billionaires didn't get their way – great organisation trumped great wealth. I just hope Obama repays that debt with action.
Inequality is not new, the poor will always be with us, and coming back from a financial disaster is a decade-long task. I don't want to be Pollyanna-ish about this. But justice demands action on narrowing this obscene gap in wealth – and all the comes with it. And not just justice. If we want a safer world. If we want an economy where the masses have enough to spend and build and save. If we want something left for our kids, this is something to take seriously. Really, there's nothing more important.


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Climategate revisited
The BBC Radio 4 programme revisiting Climategate is on tonight at 9pm. Here's the blurb:
Climategate was the term quickly applied in 2009 to the mysterious appearance on the internet of large numbers of emails and documents belonging to some of the world's leading climate scientists.
This happened just a month before the Copenhagen climate change conference, which failed to meet the expectations of many for agreement on international action. The timing may not be coincidental.
For some climate change sceptics, the emails were a disturbing revelation of the real thoughts and manoeuvrings of scientists at the University of East Anglia's Climatic Research Centre and their international colleagues. The scientists argue that while some of the phrasing may have been unfortunate, there is nothing in the documents to undermine the validity of mainstream climate science.
Climategate certainly inflamed the debate over climate change, in the UK, the US and elsewhere.
In 2012 the Norfolk Police announced they were abandoning their investigation into who hacked into the university's computer and then distributed what they found.
But what have been the longer-term consequences of this incident, for public opinion, media reporting and international policy-making on climate change? Chris Vallance investigates, asking if this was it a political crime, and, if so, how effective has it been?
As readers here know I was interviewed for the show as were Steve M, Tallbloke and Benny Peiser I think. CRU refused to take part, although Mike Hulme was involved.


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By Lisa Capobianco
Staff Writer
Honest, Organic, and Pesticide-Free Eats. These are the words that describe HOPE Kitchen and Marketplace, a community supported kitchen establishment that has served Connecticut for more than five years.
For Chef Cathy Blanchette, being the owner of HOPE Kitchen and Marketplace, LLC means sharing her passion for health, food and cooking with the local community in every food preparation she makes. Recently, the professional chef expanded her business to 26 North Main Street, sharing a space with the Sixpence Pie Company.
"I want this to be Southington's Community Supported Kitchen—it's their kitchen now," said Blanchette, a long-time resident of Southington who initially started her business at home. "Nothing is processed here."
A Community Supported Kitchen (CSK) is a weekly or bi-weekly box of locally grown and raised food for individuals to cook. The box varies each week, and includes a variety of food selections, including meats, vegetables, soups, salads and other items. From hormone and antibiotic-free meats to wild caught seafood to farm-fresh fruits and vegetables, HOPE Kitchen provides natural and organic food to the community, committed to supporting local farms.
Blanchette has provided produce and poultry from a variety of local farms, including Lewis and Karabin Farms in Southington as well as other ones throughout the state including Bethlehem and Morris.
"It's really easy to develop those relationships cause I'm in a commercial setting," said Blanchette, adding that she learned a lot from local farmers. "We have so many farms right here available to us."
A typical week for Blanchette involves creating a menu and sending it out to clients, preparing the food on Mondays and Tuesdays after ordering ingredients and produce, then cooking on Wednesdays. Clients order their food in advance, and pick up their "box" on Thursday evenings from 5-7 p.m. and Friday mornings from 9 a.m. to 12 p.m. HOPE also offers curb-side pick-up.
Offering vegan and gluten-free items, the menu at HOPE provides a diverse selection, as Blanchette cooks everything from scratch. The menu offers clients breakfast, lunch, salads, dressings, soups, entrees and vegetables. The professional chef said some popular items include her lemon and herb crusted cod, granola and frittatas.
"Our granola is flying off the shelf," she said.
After working for 30 years in financial accounting, Blanchette decided to pursue her passion in 2007 with inspiration from her family. While working full-time, Blanchette completed training in Advanced Culinary Arts at the Connecticut Culinary Institute in Hartford, where she graduated as valedictorian in 2009. She became a professional personal chef after completing the Culinary Business Academy's course and then opened her first business, Peppercorns Personal Chef Service, LLC. Two years later, Blanchette started working with her sister, Julie Wallace, the owner of Bloom Yoga Studio, preparing meal options for participants of the studio's weight loss program.
"When I started doing this, I wanted to be healthy," said Blanchette, who conducted research on the health effects of packaged food in the supermarket chains. "A lot of the foods in there are pesticides and food colorings—we really weren't seeing what we thought we were seeing there."
Blanchette said some her clients from the weight loss program are also her current clients at HOPE Kitchen.
"What I'm cooking is helping people heal," said Blanchette, adding that her own health has improved overall after changing her lifestyle. "I love being able to do this for the community."
Dawn Leger was (and still is) one of Blanchette's first clients, who now serves as a marketing consultant and grants writer for HOPE Kitchen. She joined HOPE Kitchen after attending the Integrative Weight Loss classes at Bloom Yoga, and successfully changed her lifestyle. Through Blanchette's cooking, Leger said she lost 50 pounds over the course of a year, reporting health improvements in previous stomach issues she experienced. Leger's daily diet now consists of eggs, quinoa, salad and chicken.
"I wouldn't survive without her food," said Leger, adding that her previous lifestyle consisted of diet Coke. "What she's giving us is the best she can give us in the state of Connecticut—it really shows."
Now that Blanchette's business has expanded to downtown Southington, the chef said she hopes her business will continue to grow. Blanchette added that she plans to have a retail section her business, in which clients can purchase items.
"We're Connecticut's first CSK," Blanchette said. "I want to bring this out there because I believe folks want it."
For more information, visit http://hopekitche-nandmarketplace.com.
Local chef looks to bring HOPE to community
By Lisa Capobianco


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Trial begins for 4 sisters who allege Eli Lilly pill caused their cancers
BOSTONEli Lilly and Co. failed to test a drug's effect on fetuses before promoting it as a way to prevent miscarriages, a lawyer charged Tuesday in opening statements in a trial over whether four sisters' breast cancer was caused by medication their mother took during pregnancy.}
A lawyer for Eli Lilly told the jury there is no evidence the synthetic estrogen known as diethylstilbestrol, or DES, causes breast cancer in the daughters of women who took it. No medical records show the mother of the four women in the Boston case took DES, he said, or that if she did take it, that it was made by Eli Lilly.
The sisters' case is the first to go to trial out of scores of similar claims filed in Boston and around the country. A total of 51 women, so called "DES Daughters," have lawsuits pending in Boston against more than a dozen companies that made or marketed the drug.
DES was prescribed to millions of pregnant women between the late 1930s and early 1970s to prevent miscarriages, premature births and other problems. Studies later showed the drug did not prevent miscarriages.
The Centers for Disease Control and Prevention estimates between 5 and 10 million pregnant women and children were exposed to the DES.
The Melnick sisters, who grew up in Tresckow, Pa., say they all developed breast cancer in their 40s after their mother took DES while pregnant in the 1950s. They say their mother did not take DES while pregnant with a fifth sister, and that sister has not developed breast cancer.
"I'm sad for my mother who took this because she wanted to have us and wasn't explained the risks of what she took," Andrea Melnick Andrews told CBS Boston last week.
The sisters allege Eli Lilly urged doctors to prescribe DES without proof that it prevented miscarriages and other reproductive problems. They are seeking unspecified damages.
The companies that make DES argue that no firm link has been established between breast cancer and the drug. It was eventually taken off the market after it was linked to a rare vaginal cancer in women whose mothers used DES.
Indianapolis-based Eli Lilly argues in court documents there is no evidence that the Melnick sisters' mother even took DES. She and her doctor are dead, and the drug company says there are no medical records documenting her treatment. A company spokesman said Eli Lilly believes the claims are without merit and is prepared to defend against them vigorously.
All four Melnick sisters had miscarriages, fertility problems or other reproductive tract problems long suspected of being caused by prenatal exposure to DES. They were diagnosed with breast cancer between 1997 and 2003 and had treatments ranging from lump-removal surgery to a full mastectomy, radiation and chemotherapy.
Then in 2008, one sister read about a study reporting an increased incidence of breast cancer in the daughters of women who took DES during pregnancy.
Lawyers for the Melnick sisters cite a study published in 2011 that suggests the risk of breast cancer is nearly double in DES daughters over 40. The study, led by a researcher at the National Cancer Institute, found that the chances that a DES daughter will develop breast cancer by age 55 are about 1 in 25. For the average woman, it is about 1 in 50.
Thousands of lawsuits have been filed alleging links between DES and vaginal and cervical cancer, as well as fertility problems. Many of those cases were settled.
The Boston trial is expected to last several weeks.


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Paul Roberts, the best-selling author of The End of Oil, turns his attention to the modern food economy and finds that the system entrusted to meet our most basic need is failing.
In this carefully researched, vivid narrative, Roberts lays out the stark economic realities behind modern food and shows how our system of making, marketing, and moving what we eat is growing less and less compatible with the billions of consumers that system was built to serve.
At the heart of The End of Food is a grim paradox: the rise of large-scale food production, though it generates more food more cheaply than at any time in history, has reached a point of dangerously diminishing returns. Our high-volume factory systems are creating new risks for food-borne illness, from E. coli to avian flu. Our high-yield crops and livestock generate grain, vegetables, and meat of declining nutritional quality. While nearly one billion people worldwide are overweight or obese, the same number of people—one in every seven of us—can't get enough to eat. In some of the hardest-hit regions, such as sub-Saharan Africa, the lack of a single nutrient, vitamin A, has left more than five million children permanently blind.
Meanwhile, the shift to heavily mechanized, chemically intensive farming has so compromised soil and water that it's unclear how long such output can be maintained. And just as we've begun to understand the limits of our abundance, the burgeoning economies of Asia, with their rising middle classes, are adopting Western-style, meat-heavy diets, putting new demands on global food supplies.
Comprehensive in scope and full of fresh insights, The End of Food presents a lucid, stark vision of the future. It is a call for us to make crucial decisions to help us survive the demise of food production as we know it.
Paul Roberts is the author of The End of Oil, which was a finalist for the New York Public Library's Helen Bernstein Book Award in 2005. He has written about resource economics and politics for numerous publications, including the Los Angeles Times, the Washington Post, Harper's Magazine, and Rolling Stone, and lectures frequently on business and environmental issues.
"synopsis" may belong to another edition of this title.
Paul Roberts is the author of The End of Oil, which was a 2005 New York Public Library Helen Bernstein Book Award finalist, and he is a regular contributor to Harpers Magazine. A long-time observer of both business and environmental issues, he is an expert on the complex interplay of economics, technology, and the natural world. He lives in Washington State.From AudioFile:
Paul Roberts critiques the current system of food production, both domestic and international, and it is a scary world. Roberts shows how seemingly disparate problemsfirst-world obesity, third-world hunger, food-borne pathogens, rising fuel costs, pollution, and climate changeare connected and are logical responses to an unsustainable large-scale, hyperefficient food system. William Dufris employs an energetic and lively manner to hold the listener's interest while maintaining a note of matter-of-factness that adds to the grimness and peril. He is adept at delivering the mix of seriousness and astonishment clearly intended by Roberts. Dufris's pacing is also entirely appropriate for material that is often complex. A faster pace could leave the listener behind; a slower one could dull the impact of the material. A.B. � AudioFile 2008, Portland, Maine
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Book Description Houghton Mifflin Harcourt, 2008. Hardcover. Condition: New. Seller Inventory # DADAX0618606238
Book Description Houghton Mifflin Harcourt, 2008. Condition: New. book. Seller Inventory # M0618606238
Book Description Houghton Mifflin Harcourt. Hardcover. Condition: New. 0618606238 New Condition. Seller Inventory # NEW33.1698885
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There are three kinds of backup documentation required for the data that is entered into the CAR:
1. Backup Data Sheets Campuses are required to upload a backup spreadsheet or report on the basis of which data on each student in each program can be verified. ACICS strongly recommends use of the ACICS Backup Data Spreadsheet available on the ACICS website. If that spreadsheet is not used, the data and formulas in the spreadsheet should be replicated in the spreadsheet or report utilized by the campus, and the graduation data that is provided should include program norms to ensure that the data on completers, grads and withdrawals has been normalized.
Please forward all questions and requests for assistance with Backup Data Sheets to Ms. Terron King, Senior Manager, Policy and Accountability Systems at (202) 336-6771. 2. Waiver Requests due to Mitigating Circumstances Campuses are required to upload documentation for data and a program improvement plan for any waiver that is requested through the CAR due to mitigating circumstances. Waivers are requested at the program level or the campus level by entering data as described in the question. Documentation for how the data were collected and calculated must be uploaded along with a program improvement plan to address the mitigating circumstance and raise the retention, placement or licensure pass rate to or above the relevant benchmark standard. Please upload survey results or other documentation and a program improvement plan in the "Upload Backup Document" section of the CAR. Include the program name, credential level, standard to be waived, and either "data" or "plan" in the file name. For example, "Business_AA_Retention_Data."
Please forward all questions and requests for assistance with Waiver Requests due to Mitigating Circumstances to Ms. Emily Jacobs, Research Coordinator at (202) 336-6852. 3. Student Placement Verification Campuses are required to keep appropriate backup data to verify the placement data entered into the ACICS Campus Accountability Report (CAR). Data on whether each completer or graduate has been placed, is working but not placed, is unavailable for placement or is not working should be included in the Backup Data sheet. For those graduates and completers who are working, the campus should maintain back-up data that includes the employer's name and telephone number, job title, and any other pertinent information to assist verification by evaluation teams. This information should be easily accessible at the institution, because during all scheduled and unscheduled evaluations, campuses will be asked to produce this information In addition, ACICS is currently developing an in-house placement verification program which will involve additional backup data in the form of a Placement Data Record as well as documents to be maintained by the campus relating to the basis by which each student is classified as placed or unavailable for placement and relating to the student's program.
If the backup documentation for enrollment data, waiver requests or placements and placement waivers does not appear to be consistent with the data published in the CAR, an area of noncompliance will be noted in the team report and the campus will be required to submit a revised CAR, corrected backup documentation, or both, along with a revision fee.
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