A lonely grandmother gazes at the photo of loved ones.
I’m William Beerman, author of the book, “Mary Regina’s Nursing Home.” In recognition of C. Diff Awareness Month (November), I am sharing the following from my personal life experience.
The disease C. Diff (Clostridioides difficile) is the most common healthcare-associated disease. It generates a half million infections a year and elderly persons in nursing homes are especially at risk.
I manage a Facebook page called Nursing Home Monitor, so of course, I’ve known for months that relatives of nursing home patients were banned from visiting their loved ones because of the COVID-19 virus.
But I didn’t expect to see the heartbreak of the nursing home personal visitation ban dramatized right before my eyes.
As I was delivering election information to a nursing home in Las Cruces, NM on October 27, 2020, a patient on a gourney and her daughter were checking in at the front desk. When they were finished, an attendant wheeled the patient away, and I heard the daughter say quietly, “I am so sad I cannot go with my mother.” The check-in host answered, “Yes, it is very sad.”
A transfer from a hospital to a nursing home is stressful enough these days. But it can be worse with the serious complication of C. Diff, an antibiotic-resistant bacteria that causes uncontrollable diarrhea.
The admission of the patient October 27 reminded me of the day I admitted my own mother to a nursing home in Pittsburgh in 2011 after she had a short stay in a hospital for repair of a broken hip. The nursing home turned out to be a bad one. But we could not get my mother transferred out because she came down with C. Diff.
C. Diff is contagious and requires the patient to have an isolation room. Medicare paid only a few dollars more for an isolation room than it paid for a semiprivate room. So any nursing home that accepted my mother would lose a lot of money because it would have to devote a room for two to just one patient. Nursing homes that we called while trying to transfer my mother said they had no isolation rooms available.
C. Diff played a big part in the death of my mother, who had been living independently before she broke her hip. She was an excellent candidate for rehab. But she died 30 days after being admitted to the nursing home, with C. Diff and a half dozen other afflictions.
The nursing home told me my mother had probably gotten C. Diff because the hospital had given her a heavy dose of antibiotics just before releasing her. The theory was that the dose wiped out benign bacteria and cleared the way for the antibiotic-resistant C. Diff to run rampant through my mother’s bowels without competition.
You can read about a lot of ways to fight C. Diff at the Peggy Lillis Foundation website https://cdiff.org, or https://peggyfoundation.org/ , or at the C. Diff Foundation website: https://cdifffoundation.org/ They are trying to raise awareness of C. Diff, and the fact that antibiotic use is the most common risk factor for C. Diff. The Peggy Lillis Website cdiff.org has a petition you can sign.
But one way to fight C. Diff that appeals to me is for the hospital patients being discharged to nursing homes to discuss the issue of antibiotics and C. Diff with the hospital staff.
This year the government Centers for Medicare and Medicaid Services — CMS — issued a rule that requires hospitals to provide discharge planning consultation for patients being released to nursing homes and other settings. You can discuss use of antibiotics with the hospital staff and select a nursing home that is appropriate for you. You are less likely to end up in a poorly rated one by accident.
Residents of Las Cruces, NM have a challenging job ahead of them if they need to choose a nursing home. Eighty-four percent of the city’s certified nursing home beds are in homes that are rated “Below Average” or “Much Below Average,” according to ratings current as of November 26, 2019 on the federal government’s web site, Medicare.gov.
Las Cruces, a city of 102,000, is the second largest city in New Mexico. (If you’re not from Las Cruces, you can learn how to find the ratings and other details about nursing homes in your area by clicking here.)
A recent rating drop from “Average” to “Below Average” for Good Samaritan Society, Las Cruces Village, means four of the six government-certified nursing homes in Las Cruces are now rated “Below Average” or “Much Below Average.” Further, a warning icon (a white palm-out hand in a red circle) has been added to the rating for Casa Del Sol Center to indicate that nursing home has been cited for abuse.
As of late-November, 434 of the city’s 514 government-certified nursing home beds are in homes rated “Below Average” or “Much Below Average,” so uninformed persons choosing a nursing home in Las Cruces have an 84 percent chance of finding themselves or a loved one in a below-average or much-below-average-rated nursing home.
Currently,
an estimated 339 people per day are staying in Las Cruces nursing homes that
are rated “Below Average” or “Much Below Average.”
In October, three of Las Cruces’ six nursing homes were rated “One Star,” or “Much Below Average,” by Medicare.gov, the federal website that rates nursing homes on a five-star scale. Two of the six were rated “Three Stars” (“Average”) and one was rated “Five Stars,” (“Much Above Average”). I posted details of the ratings prevailing in October in an October 22 article entitled Finding a Nursing Home When Half of the City’s Nursing Homes Are Rated Much Below Average. The article included comments by spokespersons for the New Mexico Department of Health, the management of four of the nursing homes, and one of the city’s two hospitals.
Generally, nursing home spokespersons said Medicare.gov ratings may reflect conditions that have already been corrected; the ratings do not include customer satisfaction data; and the overall ratings are composites of subcategory ratings on matters such as staffing and clinical outcomes that may be higher than the overall rating and particularly important to individual patients. They recommend consumers visit nursing homes as part of the decision-making process. They also recommend searching for customer satisfaction information on the internet rather than relying solely on Medicare.gov.
Regarding
the red Abuse icon that appeared on Casa Del Sol’s rating subsequent to the
October article, Lori Mayer, a spokesperson for three Las Cruces nursing
homes, said, “The Centers for Medicare & Medicaid Services (CMS)
recently began flagging skilled nursing centers cited for abuse, neglect, and
exploitation. We support making relevant, transparent information available to
make informed care decisions. However, we recommend prospective patients
review all information provided by CMS because the flag remains on the site
long after the relevant issue has been resolved.” Ms. Mayer is the spokesperson
for Casa De Oro and Casa Del Sol, which each have one star (much below
average), and for The Village
at Northrise, Desert Willow 1, which has five stars (much above average).
Speaking for the State of New Mexico Aging and Long-Term Services
Department (ALTSD), Sarah Jacobs, general counsel for ALTSD, provided the
following statement after reviewing an advance copy of this article.
“Improving the quality of our long-term care facilities is
a top priority for Secretary [Katrina] Hotrum-Lopez and the entire
administration. The Department of Health (DOH) licenses long-term care
facilities and oversees their compliance. ALTSD works closely with DOH, through
joint protocol to better serve our nursing home residents.
“Additionally, ALTSD runs the Long-Term Care Ombudsman Program,
which is a resident-centered advocacy program that assists residents by
protecting their health, safety, welfare, and rights. The Ombudsman Program is
also a way to push facilities to improve their quality of care.
“Residents of any long-term care facility in New Mexico also
have federally guaranteed rights, including the right to
present grievances, the right to be fully informed, and the right to dignity,
respect, and freedom. If residents or their families have concerns, they should
reach out to the Long-Term Care Ombudsman Program for assistance — the toll
free number is 1-866-451-2901.”
The October 22 article discussed how a rule change by CMS will require that hospitals discharging patients to nursing homes provide help with discharge planning and selection of an appropriate nursing home or other care provider. The change becomes effective November 29. Nevertheless, choosing will be problematic because the two nursing homes in Las Cruces not rated below- or much-below-average have only 50 and 30 beds respectively.
In October, the three Las Cruces nursing homes rated “One-Star” on the Medicare.gov Five-Star Rating System contained 66 percent of the 514 Medicare- or Medicaid-certified nursing home beds in the city. The three nursing homes continuing into November with a “One-Star” rating are Invigorate Post Acute of Las Cruces, Casa De Oro Center, and Casa Del Sol Center. Good Samaritan Society — Las Cruces Village, previously rated “Three Stars,” “Average,” dropped to “Two Stars,” “Below Average,” in November. Welbrook Senior Living, Las Cruces, LLC rose from “Three Stars,” “Average,” to “Four Stars,” “Above Average,” and The Village at Northrise, Desert Willow 1, continues to be rated “Five Stars,” or “Much Above Average.”
Regarding the abuse icon for Casa Del Sol, abuse is defined on Medicare.gov as the willful infliction of
injury, unreasonable confinement, intimidation, or punishment with resulting
physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse,
physical abuse, and mental abuse.
More information about nursing homes –
including how to look up information about nursing homes in your area –- can be
found in the article
from October mentioned above. Also, information about
nursing homes is available at my website www.wbeerman.com or at my Facebook page, Nursing Home
Monitor
Medicare.gov contains an explanation of its ratings and details about specific nursing homes, including the most recent inspection report.
Copies of this article were emailed in advance directly to selected entities listed in the following paragraph. The list only includes job titles, but the emails were sent to specific named individual office holders to enable them to be aware of the situation described in the articles.
Administrator, The Centers for Medicare and Medicaid Services; the two U.S. Senators for New Mexico; a U.S. Senator and a Congresswoman who sponsored the Quality Care for Nursing Home Residents Act of 2019; the U.S. Congresswoman for Las Cruces; the New Mexico Governor, and Secretaries of Health and Aging and Long-Term Services; the chairperson of the New Mexico House Committee on Health and Human Services; a New Mexico State Senator for Las Cruces; a New Mexico State Representative for Las Cruces; the Mayor, City Councilors, and City Councilors-elect for Las Cruces; the American Health Care Association; the New Mexico Health Care Association; the Las Cruces nursing homes mentioned in the articles; and the National Consumer Voice for Quality Long-Term Care.
William J. Beerman,
Sr., is the author of the book, “Mary Regina’s Nursing Home,” which is intended to help consumers prepare for a
possible nursing home stay for themselves or a loved one, and improve the
outcomes of their nursing home experiences.
That’s
how the U.S. Government rates three of the six government-certified nursing homes
in Las Cruces, a city of 102,000 and the second largest city in New Mexico.
Arriving at a nursing home after transfer from a hospital.
The three Las Cruces nursing homes rated One-Star on the Medicare.gov Five-Star Rating System contain 66 percent of the 514 Medicare- or Medicaid-certified nursing home beds in the city. (Not from Las Cruces? Look up your city with the steps outlined below.)
Frequently, hospitals abruptly tell families to find a nursing home right away when their loved one is being discharged. So, what if an unprepared family in Las Cruces who has just gone through a medical emergency — such as a parent or spouse breaking a hip — gets rushed to find a nursing home without receiving sufficient guidance? If that happens in Las Cruces there is about a two-out-of-three chance that the patient will end up in a “Much Below Average” nursing home.
About
278 people are staying in Las Cruces’s One-Star homes today, according to the
Federal Government.
Thanks
to a recent rule change by the Centers for Medicare and Medicaid Services (CMS),
the odds against a patient unintentionally ending up in a sub-par,
inappropriate, nursing home may be about to improve.
Effective
November 29, 2019, CMS will begin requiring hospitals to provide discharge
planning information to families about quality factors pertinent to their
nursing home choice.
CMS
issued a final rule September 26 that empowers patients preparing to move from
acute care (hospital) into post-acute care (PAC) (such as a skilled nursing
facility), to participate in “discharge planning.”
CMS
Administrator Seema Verma said: “Today’s rule puts patients in the driver’s
seat of their care transitions and improves quality by requiring hospitals to
provide patients access to information about PAC provider choices, including
performance on important quality measures and resource-use measures – such as
measures related to the number of pressure ulcers (bed sores) in a given
facility, the proportion of falls that lead to injury, and the number of
readmissions back to the hospital.”
Verma
added, “The Trump Administration is committed to empowering patients, and CMS
is getting it done. Today’s rule is a huge step to providing patients with the
ability to make healthcare decisions that are right for them, and gives them
transparency into what used to be an opaque and confusing process.”
As of October 21, 2019, according to Medicare.gov, Nursing Home Compare, an official U.S. Government website, the One-Star (Much Below Average) nursing homes in Las Cruces are Invigorate Post Acute of Las Cruces, Casa De Oro Center, and Casa Del Sol Center. The Three-Star (“Average”) homes are Good Samaritan Society — Las Cruces Village, and Welbrook Senior Living, Las Cruces, LLC. Rated five stars, or “Much Above Average,” is Village at Northrise (The) Desert Willow 1.
At
the present time, no Medicare- or Medicaid-certified nursing home in Las Cruces
is rated Four Stars, or “Above Average.”
Readers can infer what might be expected from a “Much Below Average” nursing home. But people who want the facts can get details ranging from health inspection results to staffing levels by going to Medicare.gov, selecting the Binocular icon, “Find Care,” then “Nursing Homes.” Then they can type in a Zip Code, such as Las Cruces 88011. For example, all six Las Cruces government-certified nursing homes will show up and then readers can compare up to three at a time. They can work down to the detail level, by selecting individual nursing home names from a list.
Comments about this article from nursing homes, MountainView Regional Medical Center, and the New Mexico Department of Health appear at the end of the article.
The
new rule change is long overdue. For decades, families of patients being
released from a hospital to a nursing home have faced a big problem. Hospitals
might tell the family their loved one was being released and tell the family to
find a nursing home as soon as possible, sometimes the same day, or the next
day. Some hospitals would tell the family that the hospital was not permitted
to recommend a nursing home. Others would provide a simple list with nursing
home name, address, and phone number, and an indication of whether the nursing
home accepted Medicare and Medicaid patients. Patients would not be told about
the government rating system.
The Commonwealth Fund reported on August 8, 2017 that most hospital patients who required care from a nursing facility following their discharge received no information about the quality of available facilities, according to interviews with patients and medical staff.
In the Commonwealth Fund study, a research team
interviewed 138 staff members at 16 hospitals and 25 nursing facilities across
eight U.S. markets. The team also interviewed 98 patients admitted to 14 of the
nursing facilities in five of those markets.
When researchers asked the 98 patients what
information they had been given by hospital staff members to help them select a
skilled nursing facility, only four patients said that they had received any
information about quality or instructions about where to find such data.
Instead, patients made comments such as this: “I got a two-page list of
different facilities that I could go to. It basically was the name, the
address, and a phone number.”
In the case of my mother, described in my book, “Mary Regina’s Nursing Home,” www.wbeerman.com, failure of the hospital to provide useful information about nursing homes had tragic consequences. She ended up in a poor-performing sub-par facility (Two Stars) and was dead within a month of admission. Before breaking her hip and being sent to a deficient nursing home for rehab, she had been very viable and was living independently in a senior citizen apartment building. That was in 2011. So the problem with lack of helpful hospital guidance about nursing homes has been around a long time.
Ironically,
a One-Star nursing home has the highest occupancy rate in Las Cruces: 94
percent. That’s higher than the 92-percent occupancy rate of the city’s
Five-Star “Much Above Average” nursing home.
After implementation of the rule change, there
may still be a lot of sub-par nursing home beds in Las Cruces, but patient
awareness of their options should be greatly improved.
Numbers of health citations reported in the most recent health inspections were 20 for Invigorate, 15 for Casa De Oro, and 24 for Casa Del Sol, for an average of 20 for the 1-star homes. The numbers of citations for the 3-5 star homes in Las Cruces were 22 for Good Samaritan, 10 for Village at Northrise, and 16 for Welbrook, for an average of 16. The average number of health inspection citations in nursing homes in New Mexico is 11.8, and the average for the U.S. is 8.1.
For the total of the 59 Las Cruces nursing home citations, the New Mexico Department of Health classified all but two as “minimal harm.” One was classified “immediate harm” and one was classified “actual harm.” Both of those involved pressure sores.
Family support for a nursing home patient can be limited
Comments from Nursing Homes
The Good Samaritan Society — Las
Cruces Village
Michelle Garrey, Administrator, wrote: “The Good Samaritan Society — Las Cruces Village is celebrating 40 years of providing high quality services for residents, giving family members peace of mind that their loved ones are in a safe and secure environment surrounded by a devoted staff. We align with CMS on helping families make the most informed decision when selecting a long term facility, and support public reporting and transparency of nursing center data. As changes to the Five-Star rating system are made in the future, we will continue to work with CMS to ensure clarity in how centers are ranked while including metrics such as customer satisfaction to improve the system. Thank you for the opportunity (to preview the article and comment).”
Casa Del Sol Center, Casa De Oro Center, and Village at Northrise
For Peak Medical Las Cruces, LLC, legal business name for Casa Del Sol Center, Casa De Oro Center, and Village at Northrise, Lori Mayer, Media Relations, wrote: “We support making relevant, transparent information available to patients, residents, and their families to make informed care decisions as provided by the Centers for Medicare & Medicaid (CMS) Five-Star Quality Rating System. This rating system is comprised of several factors – survey/inspection results, staffing levels, and clinical outcome ratings. We recommend that prospective patients review all three factors and not just the overall rating. For example, a significant component of the rating system is based on a center’s annual survey results over the last three years. As such, a survey score may not accurately reflect operations at the center today. In addition, CMS’s rating does not incorporate customer satisfaction scores. Our customer satisfaction ratings, conducted by an external research organization, are posted on our website by center at www.genesishcc.com. Additional reviews can also be found on Google. Finally, we recommend families take a tour of the facility so they can make an informed decision.”
Comments from Hospital
Las Cruces’s two major hospitals, MountainView Regional Medical Center, rated One Star on a Five-Star hospital rating scale by Medicare.gov, and Memorial Medical Center, rated Two Stars, are rated in part on customer satisfaction (called patient care experiences), unlike nursing homes, which are not rated on customer satisfaction by the government. In one of these customer satisfaction rating categories, only 47 percent of patients from MountainView and 50 percent from Memorial said they strongly agreed that they understood their care when they left the hospital. Other details about ratings are under “Find a Hospital” on Medicare.gov. Below is MountainView’s response to the article. Memorial did not provide a response.
MountainView Regional Medical Center
Ben Woods, Director of Business Development and Marketing, for MountainView, wrote: “We thank you for your outreach and for affording MountainView Regional Medical Center the opportunity to respond to your forthcoming article. We appreciate the time and effort you put into your piece and your concern for this issue at hand.
“MountainView Regional Medical Center is doing its due diligence to ensure we are planning discharges effectively, transparent in providing informed patient choice, and validating that our patients have access to the highest quality care our area has to offer.
“To support the continued healing of our patients post-discharge, in early 2018, MountainView Regional Medical Center formed our Post-Acute Collaborative (PAC) with the post-acute providers in our market – hospice, home health, skilled nursing, and inpatient rehab — revamped our patient choice list, educated staff and clinicians on quality data, and established new performance scorecards.
“Our case managers are kept appraised on post-acute performance and our patient choice list includes quality metrics for each facility and disclosure of our ACO; these tools are used by case managers to assist patients and families in making an informed choice.
“Discharge needs are anticipated through a needs assessment within the first two days of admission and transition planning is finalized prior to the day of discharge and ensures we are getting patients to the most appropriate level of care for their needs to reduce waste. We emphasize choice based on quality of care but there are times when a patient’s choice is limited based on their insurance/payer source and bed availability at the SNFs (Skilled Nursing Facilities).
“Each month we request and obtain standardized data metrics from each PAC entity in the ACO on our patients discharged and analyze data from CMS when it is released quarterly to drive change. We hold readmission collaboratives monthly with our PAC partners to review all 30-day readmissions from the month prior. In relation to SNF, per our latest CMS data, we have decreased the SNF average length of stay days from 22.5 to 20.8 and reduced overall SNF readmissions from 22 percent to 17 percent.
“The emphasis we have placed on this effort since January of 2018 has positively impacted patient understanding of their post-discharge care plan.”
Comments from New Mexico Department of Health
Below is a bulleted list of questions I submitted to the DOH, and
its replies, which were provided by David Morgan, Media and Social Media
Manager.
“Thank you for taking time to reach out to us with your questions. We’ve worked with our Division of Health Improvement to try to provide you some answers. If you have any follow-up, please let us know.”
Does NM DOH intend to check for compliance with the new rule on discharge planning as it surveys hospitals and/or nursing homes?
“The New Mexico Department of Health’s state survey agency complies with all required facility survey intervals. The Department of Health conducts onsite surveys to verify a facility’s compliance with all existing and/or newly implemented conditions of participation and regulations.”
Two thirds of the nursing home beds in the City of Las Cruces are rated One-Star and about 278 people are staying in those nursing homes. Does the NM DOH have any corrective action options to fix such situations in which residents of a city seem exceptionally likely to end up in One-Star nursing homes?
“Provided below is the link to the CMS star rating system. A facility’s star rating is based on the factors listed in the link. The Health Facility Licensing and Certification department focuses on a facility’s compliance with licensing and regulations. The Department of Health provides facilities and their leadership with survey data and trends to assist in continual regulatory compliance. Both the New Mexico Health Care Association (an association of nursing home operators) and Comagine Health have a role in the mission to improve the quality of nursing care in New Mexico.”
Operators of One-Star nursing homes receive the same payments as higher-rated homes, yet the patients most likely receive inferior care, in some cases simply because bad luck landed them there. Can the NM DOH address such unfair situations?
“The Department’s Health Facility License and Regulations team is not involved in the reimbursement process. Residents have a right to choose the nursing home they want to be placed in.”
All but two of the 59 citations issued to Las Cruces nursing homes during the most recent round of inspections were categorized by the New Mexico Department of Health as “minimal harm with potential….” Is this a typical ratio (2 of 59)?
“Each facility survey is unique to that facility. The term “minimal harm with potential…” pertains only to scope and severity of the deficiency cited. All nursing homes are required to have available three years of survey history on site for consumer review. The statement of deficiencies report outlines each and every regulatory violation found during the survey cycle.”
Ironically, one of the One-Star nursing homes had the highest occupancy rate in town (94 percent), even a couple of points higher than the Five-Star nursing home (92 percent). Is there an explanation for why this situation would exist, since it would seem to be contrary to expectations?
“The Department of Health does not oversee the CMS Star rating system. Please see links below for how nursing homes are rated.
Considering her well-known expressions of concern about nursing homes, and the fact that she once went under cover in a nursing home, comments were sought from the Governor about this article. However, her spokesperson said: “I’ve read the article and I think it’s one the governor will be interested to read — but as she is out of town currently and through next week, and thus out of pocket, I am unable to confirm with her at present whether she’d like to comment or not. I appreciate, though, your reaching out and giving her the opportunity.”
(Note from William Beerman: This is very important. Be wary of your hospital care being referred to as “observation care.” The consequences can be severe. Reposted with permission from Kaiser Health News.)
by Susan Jaffe, Kaiser Health News, August 12, 2019
Medicare paid for Betty Gordon’s knee replacement surgery in March, but the 72-year-old former high school teacher needed a nursing home stay and care at home to recover.
Yet Medicare wouldn’t pay for that. So Gordon is stuck with a $7,000 bill she can’t afford — and, as if that were not bad enough, she can’t appeal.
The reasons Medicare won’t pay have frustrated the Rhode Island woman and many others trapped in the maze of regulations surrounding something called “observation care.”
Patients, like Gordon, receive observation care in the hospital when their doctors think they are too sick to go home but not sick enough to be admitted. They stay overnight or longer, usually in regular hospital rooms, getting some of the same services and treatment (often for the same problems) as an admitted patient — intravenous fluids, medications and other treatment, diagnostic tests and round-the-clock care they can get only in a hospital.
But observation care is considered an outpatient service under Medicare rules, like a doctor’s appointment or a lab test. Observation patients may have to pay a larger share of the hospital bill than if they were officially admitted to the hospital. Plus, they have to pick up the tab for any nursing home care.
Medicare’s nursing home benefit is available only to those admitted to the hospital for three consecutive days. Gordon spent three days in the hospital after her surgery, but because she was getting observation care, that time didn’t count.
There’s another twist: Patients might want to file an appeal, as they can with many other Medicare decisions. But that is not allowed if the dispute involves observation care.
Monday, a trial begins in federal court in Hartford, Conn., where patients who were denied Medicare’s nursing home benefit are hoping to force the government to eliminate that exception. A victory would clear the way for appeals from hundreds of thousands of people.
The class-action lawsuit was filed in 2011 by seven Medicare observation patients and their families against the Department of Health and Human Services. Seven more plaintiffs later joined the case.
“This is about whether the government can take away health care coverage you may be entitled to and leave you no opportunity to fight for it,” said Alice Bers, litigation director at the Center for Medicare Advocacy, one of the groups representing the plaintiffs.
If they win, people with traditional Medicare who received observation care services for three days or longer since Jan. 1, 2009, could file appeals seeking reimbursement for bills Medicare would have paid had they been admitted to the hospital. More than 1.3 million observation claims meet these criteria for the 10-year period through 2017, according to the most recently available government data.
Gordon is not a plaintiff in the case, but she said the rules forced her to borrow money to pay for the care. “It doesn’t seem fair that after paying for Medicare all these years, you’re told you’re not going to be covered now for nursing home care,” Gordon said.
No one has explained to Gordon, who has hypoglycemia and an immune disease, why she wasn’t admitted. The federal notice hospitals are required to give Medicare observation patients didn’t provide answers.
Even Seema Verma, the head of the Centers for Medicare & Medicaid Services, is puzzled by the policy. “Better be admitted for at least 3 days in the hospital first if you want the nursing home paid for,” she said in a tweet Aug. 4. “Govt doesn’t always make sense. We’re listening to feedback.” Her office declined to provide further explanation.
Patients and their families can try to persuade the physician or hospital administrators to change their status, and sometimes that strategy works. If not, they can leave the hospital to avoid the extra expenses, even if doing so is against medical advice.
The requirement of three consecutive days as a hospital inpatient to qualify for nursing home coverage is written into the Medicare law. But there are exemptions. Medicare officials don’t apply it to beneficiaries in some pilot programs and allow private Medicare Advantage insurers to waive it for their patients.
Concerned about the growing number of people affected by observation care, Medicare officials created a “two-midnight” rule in 2013. If a doctor expects a patient will be sick enough to stay in the hospital through two midnights, then it says the patient should generally be admitted as an inpatient.
Yet observation claims have increased by about 70% since 2008, to more than 2 million in 2017. Claims for observation care patients who stay in the hospital for longer than 48 hours — who likely would qualify for nursing home coverage had they been admitted —rose by nearly 159%, according to data Kaiser Health News obtained from CMS. Yet the overall growth in traditional Medicare enrollment was just under 9%.
Justice Department lawyers handling the case declined to be interviewed, but in court filings they argue that the lawsuit accuses the wrong culprit.
The government can’t be blamed, the lawyers said, because the “two-midnight” rule gives hospitals and doctors — not the government — the final word on whether a patient should be admitted.
The government’s lawyers argue that since Medicare “has not established any fixed or objective criteria for inpatient admission,” any decision to admit a patient is not “fairly traceable” to the government.
Like Gordon, some doctors also complain about observation care rules. An American Medical Association spokesman, who spoke on condition of not being named, said the “two-midnight” policy “is challenging and illogical” and should be rescinded. “CMS should instead rely on physicians’ clinical judgment to determine a patient’s inpatient or outpatient status,” he added.
HHS’ Office of Inspector General urged CMS to count observation care days toward the three-day minimum needed for nursing home coverage. It’s No. 1 on a list issued last month of the 25 most important inspector general’s recommendations the agency has failed to implement.
The Medicare Payment Advisory Commission, which counsels Congress, has made a similar suggestion.
However, Colin Milligan, a spokesman for the American Hospital Association, is more positive about the “two-midnight” rule. It “recognizes the important role of physician judgment,” he said.
Medicare isn’t dictating what physicians must do, said a physician who has researched the effects of observation care. “It’s a benchmark upon which to base your decisions, not a standard or a mandate,” said Dr. Michael Ross, a professor of emergency medicine at Emory University School of Medicine in Atlanta. He supervises observation care units at Emory’s five hospitals and was chairman of a CMS advisory subcommittee on observation care.
Other physicians claim that since HHS pays hospitals and doctors to treat Medicare patients, the agency’s policies weigh on their decisions.
“One of the hardest things to do is to get physicians to predict what will happen with patients — we like to hedge our bets and account for all possibilities,” said Dr. Tipu Puri, a physician adviser and medical director at the University of Chicago’s medical center. “But we’re being forced to interpret the rules and read between the lines.”
In the meantime, observation care patients who get follow-up care at a nursing home may soon receive a puzzling notice. A Medicare fact sheet issued last month “strongly encourages” nursing home operators to give an “advance beneficiary notice of non-coverage” to patients who arrive without the required prior three-day hospital admission.
But that notice says they can choose to seek reimbursement by submitting an appeal to Medicare — an option government lawyers will argue in court is impossible.
The following news release from the Department of Justice offers some insight in dollars-and-cents terms about doctor care for some nursing home residents. I wonder about the adequacy of doctor care at nursing homes, since I believe my mother would have benefited if she had received even the 5-minute visits described in the news release at critical times during her ill-fated nursing home stay. As I recall, doctors were a rare sight in her nursing home, which was not associated with the case discussed here.
Details about the nursing home experience of my mother and me are contained in my book, “Mary Regina’s Nursing Home.”
The Department of Justice news release follows.When called and invited to comment on the news release, Dr. Latella said, “There is no comment.”
A Webster City,
Iowa doctor who made false statements to the United States Attorney’s Office
about Medicare claims that the doctor had billed for his nursing home patients
pled guilty July 9, 2019 in federal court in Cedar Rapids.
Dr. Joseph X.
Latella, age 76, from Webster City, Iowa, was convicted of one count of making
false statements relating to health care matters. At the time of the offense,
Dr. Latella operated a private practice in Webster City, and he also was the
Hamilton County Coroner and the medical director for multiple nursing homes in
the Webster City area.
Dr. Latella
admitted in a plea agreement that, in June 2018, the United States Attorney for
the Northern District of Iowa was conducting a civil investigation about
concerns that Dr. Latella was “upcoding” claims submitted to Medicare and
Medicaid and billing for more intensive visits with patients at Webster City
area nursing homes than he had performed. The United States Attorney’s
investigation indicated that Dr. Latella was billing over 93 percent of his nursing
home visits to Medicare under the most intensive and expensive claim code. For
these claims to be valid, a doctor typically must spend 35 minutes at the
patient’s bedside and on the patient’s facility floor or unit. Medicare paid
more than $94 for these claims, but would only have paid no more than $32 if
the least expensive claim code, for routine 10-minute visits, had been billed.
In July 2016, a Medicare contractor sent Dr. Latella a letter warning him that
his billing patterns were significantly more expensive than other doctors.
In July 2018, Dr.
Latella submitted sworn written answers to the United States Attorney, in which
Dr. Latella falsely declared that, with respect to certain Medicare claims in
2017 and 2018, he had spent approximately 35 minutes for each of 12 patients’
care at two nursing homes. With respect to one particular date in October 2017,
Dr. Latella falsely swore he “started visiting the nursing home patients at
7:30 a.m. and completed my visits with each patient at approximately 5:30 p.m.”
In truth, a federal agent had conducted in-person surveillance of Dr. Latella
on that date, and Dr. Latella only was on site at the first nursing home for a
total of 47 minutes and did not visit the second nursing home at all on that
date. The administrator of the first nursing home estimated that Dr. Latella
spent approximately five minutes with each nursing home patient during his
visits to that nursing home.
Dr. Latella made
further false statements about claims in January and February 2018, which the
Medicaid Fraud Control Unit discovered through videotaped surveillance. For
example, Dr. Latella billed nine claims for services allegedly provided to nine
Medicare patients, on February 2, 2018, at a nursing home, but the surveillance
showed that Dr. Latella was only on site at the nursing home for a total of 14
minutes.
In total, Dr.
Latella admitted that, between January 1, 2014, and November 30, 2018, he
submitted 1,140 false claims to Medicare, which were not justified, and he was
paid $107,980.59 by Medicare for those claims. Dr. Latella also admitted that
he caused Medicaid to make unjustified payments in the total amount of
$9,218.73 for these claims. As a part of his plea agreement, Dr. Latella has
agreed to pay no less than $107,980.59 to Medicare and $9,218.73 to Medicaid
for economic losses caused by his commission of the offense.
Sentencing before
United States District Court Chief Judge Leonard T. Strand will be set after a
presentence report is prepared. Dr. Latella remains free on bond pending
sentencing. Dr. Latella faces a possible maximum sentence of 5 years’
imprisonment, a $250,000 fine, and 3 years of supervised release following any
imprisonment.
The case is being prosecuted by Assistant United States Attorney Tim Vavricek and was investigated by the Department of Health and Human Services, Office of the Inspector General, and the Iowa Medicaid Fraud Control Unit.
In 10 years, more than half of middle-income Americans age 75 or older will not be able to afford to pay for yearly assisted living rent or medical expenses, according to a study published Wednesday in Health Affairs.
The researchers used demographic and income data to project estimates of a portion of the senior population, those who will be 75 or older in 2029, with a focus on those in the middle-income range — currently $25,001 to $74,298 per year for those ages 75 to 84.
And it doesn’t look good for that group because of the rising costs of housing and health care. The researchers estimated that the number of middle-income elders in the U.S. will nearly double, growing from 7.9 million to 14.4 million by 2029. They will make up the biggest share of seniors, at 43%.
By 2029, more than half of the middle-income seniors will have annual financial resources of $60,000 or less, even if the equity in their homes is included. Projections put the average annual assisted living and medical expenses cost in 10 years at $62,000, meaning that a majority of the middle-income seniors then will not be able to afford an assisted living facility.
Middle-income seniors are a group that Beth Burnham Mace, one of the study’s authors, said has been often overlooked when policymakers and legislators think about housing and care for aging Americans.
“The low-income cohort has been taken care of by tax subsidies, while the high-income cohort is largely self-sufficient. But the middle-income seniors have been ignored,” said Mace, who is chief economist at the National Investment Center for Seniors Housing and Care, a nonprofit research group.
The study’s authors said they are probably underestimating the extent of the looming problem. They projected out-of-pocket medical costs of only $5,000 a year for seniors.
Deborah Carr, chairwoman of the department of sociology at Boston University who studies aging, noted that Americans “are able to live longer today than they have in the past because of medical technology.” The downside, said Carr, who was not affiliated with the study, is “if they’re living for years with dementia or mobility issues, then they have to pay longer for medical care for the additional years they live.”
Indeed, the researchers projected that 60% of the middle-income seniors will have mobility limitations, while 20% will be considered “high needs,” meaning they have three or more chronic conditions and one or more limitations in activities of daily living, such as bathing or dressing. Eight percent will have some form of cognitive impairment.
Seniors living with mobility limitations, chronic conditions or cognitive impairment are more likely to need care and support such as that offered by an assisted living facility.
But that’s not a reality for many.
In her written response to the Health Affairs study, Jennifer Molinsky, a senior research associate at the Joint Center for Housing Studies at Harvard University, addressed the needs of seniors who decide to stay at home as they age instead of going to an assisted living facility. She said these older Americans face a different set of challenges.
“One of the challenges is that most people don’t live in cities,” Molinsky said in an interview. “And most houses in these areas are single-family detached homes. The infrastructure is not set up for safe walking, so you have to drive. People often give up driving as they age. So these locations can be difficult to provide services to people.”
Molinsky said other issues to consider are making homes more accessible by adding ramps for wheelchairs or wall handles in the shower and the cost of these changes.
The other dire warning of the study: While spouses and middle-age daughters have historically provided the bulk of elder care, that is a less likely option in the future because of changing marriage patterns, lower birth rates and the increasing number of adult children who live far from their parents. Some seniors will need to seek paid care.
The study suggests that policymakers could expand Medicare benefits to include access to a wider range of supportive services, or create a new benefit, “Medicare Part E,” that funds long-term care. However, other attempts to set up such a program have run into resistance among lawmakers because of cost.
While Medicaid is the primary payer of long-term nursing home care, right now the program is available only to low-income seniors. Seniors may become eligible if they impoverish themselves. However, lawmakers could also broaden the Medicaid income eligibility requirements or expand options to include home-based care for those with higher-end incomes.
Some seniors are already turning to creative solutions to address their growing need for affordable housing.
Carr said one innovative option she has seen is the Village to Village Network, a community program that allows seniors to stay in their homes but have access to general support services, such as home repairs, transportation, health care and even social activities.
Co-housing, where seniors share a residence, like in the classic TV show, “Golden Girls,” is another solution, Carr said.
Mace said she hopes the study will spark more conversation between public and private sectors for creative ideas to address the issue of housing the growing number of Americans who will turn 75 or older in the next decade.
Her advice to both those seniors and their children is to openly discuss the issue.
“It is a good idea to sit down and talk about what your plan may be,” said Mace. “Talk about what the financial assets are and the housing options. It’s a worthy topic to talk about, though it can be hard, because it helps to avoid putting both children and parents in difficult situations in the future.”
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente. — April 24, 2019
I wanted to post the recent statement by Sen. Ron Wyden about nursing homes to help it get the widest circulation possible. It is self-explanatory.
The statement reads in part “…one of the challenges this country faces today is ensuring that seniors in nursing homes are safe and well cared-for. Our best nursing homes meet a high standard of care, but tragically, not all do.”
Help fight Clostridium Difficile (C. Diff) by supporting the Peggy Lillis Foundation. You can make a donation in honor of, or in memory of, a loved one.
C. Diff is a cause in 9,000 nursing-home deaths per
year, and the seventeenth leading cause of death in people 65 and over. It is responsible for 500,000 infections per
year.
The Peggy Lillis Foundation is building a nationwide C. Diff awareness
movement by educating the public, empowering advocates, and shaping policy.
One of the healthcare-associated superbug infections, C. Diff infections result in $8.2 billion in hospital costs annually, according to the Peggy Lillis Foundation. The average cost for a C. Diff hospital stay is $24,400 versus $18,200 for congestive heart failure, $10,500 for acute myocardial infarction, and $9,300 for pneumonia. American deaths from C. Diff (29,000) outpaced HIV/AIDS (17,000), and drunk driving deaths (10,000) combined.
California Advocates for Nursing Home Reform (CANHR)
said it remains concerned that the state’s Department of Public Health’s (DPH’s)
“excessive focus on waiving California’s minimum staffing requirements” is
harming residents’ ability to receive needed care.
In its latest newsletter at http://www.canhr.org/ CANHR noted that DPH has posted lists of the California nursing homes that it has approved to staff at levels below California’s minimum staffing requirements. Nursing homes with approved waivers are allowed to staff below the daily minimum 3.5 direct care service hours per resident requirement or the minimum 2.4 certified nursing assistant (CNA) hours per resident requirement, or both.
St. Louis, MO – Benjamin David Danneman, 37,
of Eureka, pled guilty on March 13, 2019 to federal charges of healthcare
fraud, social security fraud and aggravated identity fraud, the U.S. Department
of Justice announced. He appeared in federal court before U.S. District
Judge Ronnie White who accepted his guilty plea and set sentencing for June 12,
2019.
According to court documents, Danneman was not
a nurse, but used the name and nursing license number of an actual licensed
registered nurse to obtain work in the St. Louis area at Alexian Brothers
Sherbrooke Village, the Rehabilitation Institute of St. Louis, and Des Peres
Healthcare. Danneman was hired by Des Peres as the assistant director of
nursing at the Quarters of Des Peres at an annual salary of $68,000.
At these health care facilities, he was
responsible for the day to day care of patients needing skilled nursing care.
Further, according to court documents, during 2017 and 2018 in at least six
states, Danneman used the names, Social Security account numbers, nursing
license numbers, and other personal identifying information of several persons
to rent apartments and to obtain a driver’s license, loans, credit cards, and
insurance.
“Ensuring that our beneficiaries are provided quality care by
appropriately licensed providers is a top priority of our office,” said Steven
Hanson, Special Agent in Charge of the Kansas City Region of the United States
Department of Health and Human Services, Office of Inspector General.
“Individuals who steal the identity of licensed providers and then seek to provide
services to Medicare beneficiaries will be aggressively investigated by our
office.”
DES MOINES, Iowa, March
6, 2019 – United States Attorney Marc Krickbaum announced that six nursing home
employees have been indicted for controlled substance offenses committed in the
course of their employment at nursing home facilities.
The defendants from various nursing homes are accused of diverting
drugs from nursing home residents. The drugs included Oxycodone, Hydrocodone,
and Tramadol pills. In one case an employee allegedly removed fentanyl patches from nursing home residents and
diverted the medication for her own use.
The public is
reminded that an indictment is merely an accusation, and defendants are
presumed innocent unless and until they are proven guilty, the Department of
Justice said.
The possible penalties for acquiring a controlled
substance by misrepresentation, fraud, deception, and subterfuge is up to four
years in prison and up to a $250,000 fine.
Over the decades, bad nursing homes have hemorrhaged
a ceaseless stream of scandals and lawsuits alleging neglect and serious harm
to patients.
Yet the world of nursing homes comes close to looking
like single-payer health care. The American Health Care Association (AHCA)
reports that 71 percent of nursing home revenues come from the government: 57
percent from Medicaid and 14 percent from Medicare. Some nursing homes get
virtually ALL of their revenue from Medicaid.
So, in light of our experience with nursing
homes, should single-payer health care advocates be more careful about what
they ask for?
AHCA is a non-profit federation of state health
organizations, together representing more than 13,500 non-profit and for-profit
nursing facilities, assisted living facilities, and other facilities that care
for approximately 1 million elderly and disabled individuals each day.
AHCA says the payments the nursing home industry
gets from Medicaid fall short of what the nursing homes need to fully comply
with regulations by $25 per Medicaid-patient-day, or collectively by $7 billion
a year.
The nursing home operators say they are plagued
by excessive and inappropriate regulations and costly questionable lawsuits
that consume money that could be better spent at the bedside.
Hundreds of thousands of people have filed
formal complaints about nursing homes, while in recent years, as the number of
complaints rose, the number of government enforcement actions declined.
There are many good nursing homes, and many poor ones. Medicare.gov rates nursing homes on a scale, with one star equating to “much below average” and five stars meaning “much above average.” The rating for “average” is three stars. For example, a search I did in 2016 for nursing facilities in Pennsylvania belonging to the Golden Living chain, which is the subject of a contested Pennsylvania Attorney General consumer-protection lawsuit, turned up 36 Golden Living nursing homes. Two had five stars, seven had four, 10 had three, seven had two, and 10 had one star. So, 47 percent were below average (one or two stars). Some below-average nursing homes stay open for years and continue to receive government funds.
Critics say nursing homes can game the Five-Star
rating system and that the system does not consider the opinions of the residents.
Nursing home workers told investigators in multiple states that managers knew
when state inspectors were coming. A Florida state nursing home regulator,
Bertha Blanco, was sentenced in December 2017 to prison for selling confidential
inspection schedules and copies of patient complaints to nursing home operators
for $100,000 in bribes.
The overseer of nursing homes is the would-be
single payer: the government. The inspectors generally are state health
departments, which in turn follow regulations issued by the Centers for
Medicare & Medicaid Services (CMS), a part of the Department of Health and
Human Services (HHS).
On the west coast, the California Advocates for
Nursing Home Reform released a white paper in December that the organization
says summarizes major problems in long-term care in California. It begins: “The
quality of nursing home care in California has never been worse.”
On the east
coast, New York State Senator Rob Ortt (R-North Tonawanda) announced in a
televised news conference December 27 that he was introducing new nursing home
regulatory bills because: “Since I have been in office, the quality of care in
the nursing homes across our state has been a persistent issue and it has
continually gone unaddressed.”
U.S.
Senator Bob Casey (D-PA) has been criticizing government oversight of nursing
homes for decades. When he was Pennsylvania’s auditor general in 1998, he
issued a scathing audit report about the state health department’s oversight of
nursing homes. It was entitled “Residents in Jeopardy.” In a 1998 news release
Casey said the Pennsylvania Department of Health had “failed miserably” in its
oversight of nursing home care. Casey followed up with another audit report
entitled “Residents Still
in Jeopardy.”
More recently, current Pennsylvania Auditor
General Eugene DePasquale issued a report critical of the health department’s
oversight of nursing homes in 2016, and ongoing state attorney general lawsuits
in Pennsylvania and New Mexico describe horrendous conditions that AG investigators
found in nursing homes.
Last year, about 20 years after his “Still
in Jeopardy” audit, Casey was among a group of 12 U.S. senators who sent a
letter to HHS Secretary Alex Azar and CMS Administrator Seema Verma saying in
essence that they were alarmed that proposed easing of nursing home regulations
was putting nursing home residents “at greater risk.”
The senators cited a report by the HHS Office of
Inspector General (OIG) from 2014 that found that, during a Medicare-covered
stay, nearly a third of nursing home patients experienced an adverse event or
an incident that led to temporary harm, with 59 percent of these events being
considered preventable. “More alarming,” said the senators, “is that during the
one-month period that OIG reviewed, Medicare incurred a cost of $208 million
due to hospitalizations (of nursing home residents) alone and found that
adverse events contributed to 1,538 deaths, most of which had not been
anticipated.”
So, one
must wonder, is the government system that oversees and largely funds our
nursing homes ready to take over all of our health care?
William J. Beerman, Sr., is a retired former journalist whose mother’s nursing home experience motivated him to write Mary Regina’s Nursing Home, a book about nursing homes and government oversight of nursing homes (www.WBeerman.com). Besides his home page, William maintains a Facebook Page, Nursing Home Monitor.
Tampa,
Florida, Tuesday, February 12, 2019–U.S. District Judge
Steven Merryday has sentenced Lisa McLaren Janick, 48, Port Charlotte, to 16
months in federal prison for healthcare fraud.
According to court records, while employed as a
marketer at a home health agency, Janick falsified documents relating to
patients from her husband’s medical office and created referrals for these
patients to receive home health services from her employer, when Janick knew
that the patients were not entitled to such services.
Janick’s husband, Dr. John Janick (73, Port
Charlotte), was previously sentenced to five months in prison for obstruction
of a federal audit.
This case was investigated by the FBI and the U.S.
Department of Health and Human Services – Office of Inspector General. It was
prosecuted by Assistant United States Attorney Rachel Jones.
The organization, Justice in Aging,
issued a guide January 30, 2019, that is must reading for persons going through
or anticipating a nursing home experience for themselves or a loved one.
In response to a request for a reply, an Orlando, FL nursing home issued a statement pushing back against a Department of Justice news release.
On January 28, 2019, U.S. Attorney Maria Chapa Lopez
announced that Conway Lakes skilled nursing facility, several entities
associated with Conway Lakes, and an Orlando-area orthopedic surgeon, Dr.
Kenneth Krumins, agreed to pay $1.5 million to resolve allegations that they
engaged in a kickback scheme related to the referral of Medicare and TRICARE
patients.
The settlements resolve allegations that Conway Lakes,
through associates, conspired to pay Dr. Krumins under a sham “medical
director” agreement to induce him to illegally refer Medicare and TRICARE
patients to Conway Lakes for rehabilitation services that were billed to the federal
government, the U.S. Attorney said. Dr. Krumins’ settlement agreement also
resolves allegations that he engaged in a similar kickback scheme with a
related home health agency, the U.S. Attorney said.
On February 1, Conway Lakes issued a statement saying,
“First and foremost, Conway Lakes is a Five-Star, Governor’s Gold Seal
recipient, whose quality of care surpasses both state and national averages. “
Conway Lakes pointed out that it had not admitted any
wrongdoing, but “determined that it would be less disruptive to its business
and its patients to negotiate a settlement with the government.”
The government alleged that financial arrangements
violated the physician self-referral law, commonly known as the “Stark Law,”
and the Anti-Kickback Statute, giving rise to liability under the False Claims
Act. Under two separately executed settlement agreements, Dr. Krumins has agreed
to pay $500,000, and Conway Lakes and associates have agreed collectively to
pay $1 million to the federal government, the DOJ said.
“Disguising intricate kickback arrangements through
directorships and other misrepresented positions corrupts physician
decisionmaking and undermines the public’s trust in the healthcare system,”
said Special Agent in Charge Shimon R. Richmond of the U.S. Department of
Health and Human Services’ Office of Inspector General.
The allegations resolved by the settlement agreements
were originally brought in a lawsuit filed by a former employee of Conway
Lakes, under the qui tam, or
whistleblower, provisions of the False Claims Act, the government said. The act
permits private citizens with knowledge of fraud against the government to
bring an action on behalf of the United States and to share in any recovery. The
whistleblower will receive $267,000 of the proceeds from the settlements, the
government said.
Conway Lakes said the whistleblower is a former
employee who was dismissed for failing to show up to work, never reported any
of his concerns, nor did he inform a supervisor of any of the claims. Conway Lakes said the whistleblower lodged
accusations against multiple individuals “without any evidence.”
The claims settled by the agreement are allegations
only, and there has been no determination of liability, the original DOJ news
release pointed out.
Long-term-care hospitals (LTCHs) are inpatient hospitals that treat patients who are very ill—often with several acute and/or chronic conditions—and require care for an extended period. LTCHs provide continued, acute-level care for patients following their stays in traditional acute-care hospitals.
The HHS Office of Inspector General (OIG) found that 21 percent of Medicare patients in LTCHs experienced adverse events, which are particularly serious instances of patient harm resulting from medical care, according to a November 2018 OIG report.
The four categories of adverse events include outcomes such as prolonging a patient’s LTCH stay or necessitating transfer to another facility; requiring life-saving intervention; resulting in permanent harm; and contributing to death. (Five percent of Medicare patients in LTCHs experienced adverse events that contributed to or resulted in their deaths.)
An additional 25 percent of patients experienced temporary harm events, which are patient harm that required medical intervention but did not cause lasting harm.
The overall percentage of patients in LTCHs who experienced either type of harm (adverse events or temporary harm events) is 46 percent, higher than OIG found in hospitals (27 percent), skilled nursing facilities (33 percent), and rehabilitation hospitals (29 percent).
Patient stays in LTCHs present more opportunities for harm events because the stays are longer, but the number of harm events per patient day was similar between LTCHs and other post-acute-care settings and lower than in non-LTCH acute-care hospitals.
Over half of these adverse events and temporary harm events (54 percent of harm events) were clearly or likely preventable. Preventable harm events were often related to substandard care (58 percent) and medical errors (34 percent).
Forty-five percent of harm events were found to be clearly or likely not preventable, often because the patients were highly susceptible to harm due to other health conditions or poor overall health.
In response to prior OIG work, the Centers for Medicare & Medicaid Services (CMS) and Agency for Healthcare Research and Quality (AHRQ) took important steps to raise awareness of adverse events and temporary harm events and to reduce harm in several inpatient settings. OIG said AHRQ and CMS should tailor their ongoing efforts to improve patient safety to address the specific needs of LTCHs. OIG recommended that AHRQ and CMS collaborate to create and disseminate a list of potential harm events in LTCHs and that CMS include information about patient harm in its outreach to LTCHs. CMS and AHRQ concurred with the recommendations.
December 3, 2018, St. Louis, MO – Demagio Smith, 28, of St. Louis, Missouri, pled guilty to conspiracy to make false statements to Medicaid, the U.S. Department of Justice reported. In his plea agreement, Smith admitted that he repeatedly submitted false time sheets to Medicaid that suggested that he was working as a home healthcare aide during 2013-17, and was taking care of two women inside their homes. In reality, Smith was actually working at another job or traveling outside of Missouri on the dates and times indicated in his time sheets. Smith’s out-of-town trips included travel to California, New Jersey, the Virgin Islands, and a voyage on a Caribbean cruise ship. Sentencing for Mr. Smith is set for March 6, 2019.
San Francisco, CA – Calling for an overhaul in the Department of Public Health — the agency responsible for oversight of California’s nursing homes — California Advocates for Nursing Home Reform (CANHR) released a white paper that it says summarizes major problems in long term care in California, and offering suggestions as to what needs to be done to improve nursing home and residential care for elders and persons with disabilities.
The paper, titled “California’s Broken Long Term Care System,” outlines problems in oversight, enforcement, and funding in nursing homes, residential care, home and community-based services, and elder abuse prevention and prosecution.
In a November 3 email of the CANHR newsletter, CANHR listed the following issues:
A need for replacing the leadership at the Department of Public Health and the Center for Health Care Quality with “visionary consumer protection leaders who will reform the Department and directly address a crisis in nursing home care that residents face.”
The need for funding for the Department of Social Services that is adequate to meaningfully inspect and oversee California’s 7,200+ residential care facilities for the elderly (RCFEs), which house more than 152,000 frail elders, and oversight of 66,000+ other facilities in California.
Increase availability and access to cost-saving home and community-based alternatives for those who do not wish to die in a nursing home.
Increase remedies for victims of residents’ rights violations and elder abuse, including a private right of action.
CANHR called on the newly elected Governor, Gavin Newsom, and legislators “to address this crisis in long term care and to create new models of care where the health and safety of residents takes priority and where elder abuse becomes a distant memory.”
The article reproduced below, by Jordan Rau of Kaiser Health News, is an excellent one in which Rau adds some perspective for a directive issued by Centers for Medicare & Medicaid Services (CMS) about monitoring of weekend nursing home staffing.
Lack of a nurse on duty on weekends, night shifts, or otherwise, raises a sometimes overlooked question: In the absence of a nurse, who is administering medications?
In my book, Mary Regina’s Nursing Home, I discuss a situation in which I visited my mother’s nursing home at 5:30 one morning in 2011 in an attempt to find out why my mother was being heavily drugged, or “zonked.” It appeared that possibly a nurse assistant, who would not be allowed to administer medication in a nursing home setting in Pennsylvania, had been doing so, with serious adverse consequences for my mother. I suspect this situation occurred because a nurse or nurses called off for the night shift on a weekend, or possibly no nurse was scheduled at all to administer medications.
When I complained in writing about this situation to the nursing home’s director of nursing, she confirmed in a phone call to me that the staff person should not have administered the medications — morphine and klonopin — and should have consulted a supervisor. When the state health department conducted an abbreviated onsite investigation of my complaint, the director of nursing was not present that day, and the health department refused to follow-up by revisiting the nursing home or even calling the director of nursing. The DOH instead declared that no medication error had occurred.
During the year of their investigation of my complaint, 2012, the DOH took only two enforcement actions statewide against nursing homes, compared to a high of 171 in 2003, and an average of 63.5 for the period 2002-2015.
Feds Order More Weekend Inspections Of Nursing Homes To Catch Understaffing
The federal government announced plans Friday to crack down on nursing homes with abnormally low weekend staffing by requiring more surprise inspections be done on Saturdays and Sundays.
The federal Centers for Medicare & Medicaid Services said it will identify nursing homes for which payroll records indicate low weekend staffing or that they operate without a registered nurse. Medicare will instruct state inspectors to focus on those potential violations during visits.
“Since nurse staffing is directly related to the quality of care that residents experience, CMS is very concerned about the risk to resident health and safety that these situations may present,” the agency said in a notification to state inspection offices.
The directive comes after a Kaiser Health News analysis found there are 11 percent fewer nurses providing direct care on weekends on average, and 8 percent fewer aides.
Residents and their families frequently complain the residents have trouble getting basic help — such as assistance going to the bathroom — on weekends. One nursing home resident in upstate New York compared his facility to a weekend “ghost town” because of the paucity of workers.
Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group in Manhattan, welcomed the new edict but said it was only necessary because state inspectors have not been properly enforcing the rules already on the books.
“The basic problem is the states don’t take this seriously,” Mollot said. “How many studies do we have to have, year after year, decade after decade, saying it all comes down to staffing, and there are very few citations for inadequate staffing and virtually all of them are identified as not causing any resident harm?”
CMS said it will identify potential violators by analyzing payroll records that nursing homes are now required to submit. Those records, which became public this year, showed lower staffing than what facilities had previously told inspectors during their visits, according to the KHN analysis.
“CMS takes very seriously our responsibility to protect the safety and quality of care for our beneficiaries,” CMS Administrator Seema Verma said in a statement.
The nursing home industry criticized the heightened scrutiny.
“Unfortunately, today’s action by CMS will enforce policies that makes it even more difficult to meet regulatory requirements and hire staff,” said Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, an industry trade group, in a written statement. “Rather than taking proactive steps to address the national workforce shortage long-term care facilities are facing, CMS seems to be focusing on a punitive approach that will penalize providers and make it harder to hire staff to meet the shared goal of increasing staffing.”
Currently, a tenth of inspections must occur during “off hours,” which can be either a weekend, or during a weekday before 8 a.m. or after 6 p.m. But for facilities that Medicare identifies as having lower weekend staffing, half of those off-hour inspections—or 5 percent of the total — must be performed on Saturdays or Sundays.
Medicare requires nursing homes to have a registered nurse on site for at least eight hours every day, but according to the payroll records, a quarter of nursing homes reported no registered nurses available at least one day during a three-month period. Since July, Medicare’s Nursing Home Compare website for consumers has highlighted homes that lack sufficient registered nurses and lowered their star ratings. Nursing Home Compare has downgraded ratings for 1,402 of 15,600 facilities for gaps in registered nurse staffing, records show.
The new directive instructs inspectors to more thoroughly evaluate staffing at facilities Medicare flags. The edict does not mean a flurry of sudden inspections. Instead, Medicare wants heightened focus on those nursing homes when inspectors come for their standard reviews, which take place roughly once a year for most facilities.
But what may appear to be staffing scarcities in payroll records may instead be clerical problems in which nurse hours are not properly recorded, say some nursing home officials.
Katie Smith Sloan, president of LeadingAge, an association of nonprofit providers of aging services, said in a statement that some homes are still struggling to adapt to the new data collection rules.
“We’ve been voicing our concerns to CMS and will continue to do so,” she said.
PITTSBURGH, Pa. – Ten residents of Western Pennsylvania, a resident of Georgia, and a resident of South Carolina were charged by a federal grand jury in a 22-count indictment related to a years-long conspiracy to defraud the Pennsylvania Medicaid program, United States Attorney Scott W. Brady announced November 27, 2018.
According to the indictment, between January 2011 and April 2017, multiple home health care companies owned and operated by the conspirators received more than $87 million in Medicaid payments. During that time, all 12 of the defendants, along with other individuals, participated in a wide-ranging criminal conspiracy to defraud the Pennsylvania Medicaid program which resulted in the payment of millions of dollars in illegal Medicaid payments. The indictment sets forth dozens of fraudulent acts by the defendants, including making false claims for services that were never provided, creating fake employees, improperly using consumers’ personal identifying information, and falsifying documentation during state audits of the companies. In some instances, the indictment alleges that the defendants were actually working at other jobs or living out of the area. In other instances, Medicaid claims were submitted for services for consumers who were actually hospitalized, incarcerated, or deceased.
“Home health care programs are critical to the ability of patients with serious physical limitations, especially the elderly, to receive the care they need while remaining independent. Those who provide home health care are expected to deliver services honestly,” said U.S. Attorney Brady. “When criminals cheat and steal from these programs, they not only steal from the taxpayers, but they steal from the most vulnerable members of our community.”
An indictment is an accusation. The defendants are presumed innocent unless and until proven guilty.
Assistant United States Attorneys Eric G. Olshan and Special Assistant United States Attorney Edward Song are prosecuting this case on behalf of the government. The Federal Bureau of Investigation, Pennsylvania Office of the Attorney General – Medicaid Fraud Control Unit, Internal Revenue Service – Criminal Investigation, U.S. Department of Health and Human Services – Office of Inspector General, and United States Postal Inspection Service conducted the investigation of the defendants.
Some baby boomers are worrying about the financial costs of caring for their aging parents, and whether they’ll be able to live close to them as they age.
That’s one of the insights contained within a new survey commissioned by Capital Senior Living (NYSE: CSU) about baby boomers’ attitudes as they juggle taking care of their parents and living their own lives. The survey, which was conducted by market research company OnePoll, was sent to 2,000 baby boomers.
While the survey focuses only on boomers who are still caring for their parents, it could provide new insight into what the crucial demographic will ultimately want when they, too, age into senior housing settings. Just 12% of the respondents reported parents who lived in a senior living setting, while 19% said their parents still live at home.
“Baby boomers will be the largest generation entering the senior care system over the next few years and are currently the decision-makers for many of their parents,” Capital Senior Living COO Brett Lee told Senior Housing News. “It’s important that we, as an industry, understand their feelings and concerns about aging — like how prepared they feel — so that we can better answer their questions, help them plan their futures and put their minds at ease.”
About half of the surveyed baby boomers felt like they were “parenting their parents,” with overall concerns related to costs (41%), providing part- or full-time care (38%) and living close to them (32%). And baby boomers fretted that their parents might struggle with staying active (39%), feeling isolated (39%) or keeping up with medications (38%).
The survey also asked boomers about how they felt about their own aging. Boomers responded they worried about being a burden (52%), managing their own health (49%) and staying active (42%). More than three-quarters (79%) of boomers thought more about their own aging since taking care of their parents, according to the survey.
“I think the challenge for us now, as an industry, is to make sure we’re educating boomers on the services that senior living communities provide, and that communities do more than just care for seniors’ physical health,” Lee said. “They help boomers and their parents live a better life.”
Read the rest of the survey online.
NOVEMBER 20, 2018–The Centers for Medicare & Medicaid Services (CMS) announced upcoming efforts to support better care and outcomes for nursing home residents under the Civil Money Penalty Reinvestment Program (CMPRP). This three-year initiative aims to improve residents’ quality of life by equipping nursing home staff, administrators and stakeholders with technical tools and assistance to enhance resident care, CMS said.
“CMS is committed to ensuring nursing home residents are safe and receive quality care,” said CMS Administrator Seema Verma. “We are pleased to offer nursing home staff practical tools and assistance to improve resident care and positively impact the lives of individuals in our nation’s nursing homes.”
As part of the CMPRP, CMS said it will develop a variety of work products for nursing home professionals, such as staff competency assessment tools, instructional guides, training webinars and technical assistance seminars. These supports aim to help staff reduce adverse events, improve dementia care and strengthen staffing quality, including by reducing staff turnover and enhancing performance, CMS said.
This initiative is one of several CMS has underway to strengthen safety and health outcomes for nursing home residents, the agency said. For example, the Nursing Home Compare website and facility Star Ratings are resources CMS provides to help consumers and their caregivers make informed healthcare decisions. These resources are updated and expanded frequently, recently with the addition of payroll-based data on nursing home staffing, which can serve as one indicator of the quality of care, CMS said. In addition to the CMPRP, CMS also operates the National Partnership to Improve Dementia Care in Nursing Homes, which helps reduce the rate of inappropriate prescribing of antipsychotic drugs in this population.
The CMPRP is funded by federal civil money penalties, which are fines nursing homes must pay CMS by law when they are noncompliant with certain regulations and there are serious concerns about the safety and quality of care they provide. Most penalties collected are returned to states to fund state-based projects that benefit nursing home residents, and CMS retains a portion of the funds for similar federal initiatives.
Under the new program, CMS will collaborate with industry experts to develop an ongoing series of toolkits and technical assistance intended to help nursing home staff and management improve care delivery and thereby residents’ quality of life.
On November 20, CMS released its first toolkit in the CMPRP series, the Nursing Home Staff Competency Assessment and its supporting materials. The competency assessment is designed to help nursing home frontline and management staff evaluate their skills. It includes several questions to gauge staff knowledge about behavioral, technical and resident-based capabilities. Additional toolkits will follow under the series heading “Building on a Culture of Quality: Your Guide to Resident-Centered Care.”
Under stress of illness and hospitalization, patients and family caregivers are not well-positioned to make informed decisions about post-acute care (including nursing homes).
NEW YORK, NEW YORK November 15, 2018—As hospital stays shorten, continued care following hospitalization is now a common part of recovery for many patients who undergo major surgery or experience serious illness. Each year, approximately one in five hospital patients in the United States, including some 300,000 New Yorkers, require such care—in rehabilitation centers, in nursing homes, at home, or in their communities. Yet too often, patients and their families do not have the critical information and support they need to carefully assess their options and make the best possible decisions.
United Hospital Fund (UHF) conducted a year-long inquiry, supported by the New York State Health Foundation (NYSHealth), to better understand why hospital discharge planning can fall short despite well-intentioned efforts by hospital staff, and today released the first in a series of reports based on that work. The report, Difficult Decisions About Post-Acute Care and Why They Matter, spotlights the many factors that can hinder informed decision-making and limit care choices.
The stakes are high—patients who receive care from lower-quality providers have higher rates of complications and worse outcomes. But patients and family caregivers may not be aware that quality of care varies, and they must choose a provider when they are stressed and under pressure. While most patients and families ask their care team for help with decision-making, many discharge planners will not offer direct advice because of concerns about complying with federal regulations that limit hospitals from recommending specific providers.
Information on post-acute care that is available online also has many limitations. It can be hard to gather and interpret, much of it is too technical, and there are gaps and barriers for those with limited English proficiency, literacy, numeracy or research skills. Mistrust of information on the Internet is an issue as well.
“There’s simply too much at stake to leave sick patients and their families on their own to research and evaluate post-acute care options,” said Lynn Rogut, director of quality measurement and care transformation at UHF and co-author of the report. “They need assistance from health care professionals to identify the best possible choices.”
Today’s report is the first in a four-part series on the Difficult Decisions project, which combined inputs from patients and their families, health care providers, researchers, policymakers, and other stakeholders with UHF’s own research to identify promising approaches for supporting decision-making at discharge. Forthcoming reports will focus on the experiences of patients and family caregivers and the perspectives of health care providers; they will also identify strategies and policy levers that could help make a difference.
“Arranging for post-acute care can be among the hardest decisions patients and their families have to make, especially when emotions are running high and they’ve been under the stress of dealing with an illness,” said David Sandman, Ph.D., President and CEO of NYSHealth. “Although there are resources available, many families are unaware of their options. These are tangible solutions to help patients and their families make the best care choices for themselves.”
“Our goal with these reports is to bring attention to this significant issue, which affects the health and well-being of many vulnerable New Yorkers,” said UHF president Anthony Shih, MD, MPH. “But, as with all our projects, the larger aim is continuous improvement of our health care system overall.”
The report can be downloaded from UHF’s website here.
About United Hospital Fund Foundation
United Hospital Foundation works to build a more effective health care system for every New Yorker. An independent, nonprofit organization, we analyze public policy to inform decision-makers, find common ground among diverse stakeholders, and develop and support innovative programs that improve the quality, accessibility, affordability, and experience of patient care. For more on our initiatives and programs, please visit our website at www.uhfnyc.org and follow us on Twitter.
The California Advocates for Nursing Home Reform (CANHR) reports that the California Department of Public Health (DPH) has posted lists of the California nursing homes that have sought its approval to staff below the minimum staffing requirements the Legislature adopted last year in SB 97.
Thus far, 344 skilled nursing facilities have applied for “workforce shortage” waivers, while 391 facilities applied for “patient needs” waivers. The massive numbers of waiver requests expose the rampant understaffing in California nursing homes, CANHR said. Moreover, the waiver process is having the perverse effect of DPH endorsing understaffing at California’s most poorly staffed nursing homes rather than enforcing the (highly inadequate) minimum staffing requirements, CANHR said.
The federal government’s requirement for nursing homes to electronically report their staffing levels is a step in the right direction but obviously does not resolve staffing problems. The federal government does not have numerical minimum staffing requirements.
The US Attorney’s Office for the Northern District of Texas announced thatPatricia Armstrong, 32, of Coppell, TX pleaded guilty on November 1 to conspiracy to commit health care fraud.
The U.S. Attorney said Armstrong admitted to participating in a scheme to defraud Medicare and Medicaid of over $60 million by causing those programs to be billed for hospice beneficiaries who were ineligible for hospice care, were fraudulently recruited to hospice care, or who were not provided billed-for services.
She now faces up to 10 years in prison and a fine of up to $250,000, the U.S. Attorney said. The FBI, the Department of Health and Human Services Office of the Inspector General, and the Medicaid Fraud Control Unit investigated the case.
William J. Beerman, Sr. has been invited to appear on the “All About Books” radio show on KTAL-LP, 101.5 FM in Las Cruces, NM from 12:30-1 p.m., Friday, November 9. He will talk about his book, “Mary Regina’s Nursing Home,” with host Lynn Moorer.
The book is a journalistic novel that wraps a human-interest story around factual information about nursing homes and the government oversight systems for nursing homes. The wide-ranging book includes coverage of New Mexico Attorney General Hector Balderas’s lawsuit against a New Mexico nursing home chain. Details about the book are presented on the website https://www.wBeerman.com
Acting as a member of the Peggy Lillis Foundation’s Advocates Council, I presented Congresswoman Michelle Lujan Grisham (D-NM) with an information packet about the superbug Clostridium Difficile (C. Diff) and other healthcare-associated infections (HAIs).
by William J. Beerman, Sr.
I recently had an opportunity to present gubernatorial candidate and New Mexico Congresswoman Michelle Lujan Grisham (D-Albuquerque) with an information packet about an anti-superbug campaign being waged by the Peggy Lillis Foundation (PLF). Rep. Lujan Grisham responded that she would “take a personal interest” in the matter.
Rep. Lujan Grisham expressed concern about superbug Clostridium Difficile (C. Diff) and other healthcare-associated infections (HAI) during a brief meeting with me in Las Cruces, NM, where she took part in a public forum for New Mexico Democratic gubernatorial candidates on May 1.
The PLF is named for Peggy Lillis, a teacher and mother who died from C. Diff in 2010 at age 56.
A former cabinet-level state health official, Rep. Lujan Grisham said she is familiar with the problem of antibiotic-resistant bacteria such as C. Diff and other healthcare-associated infections.
“I am a care-giver myself,” she commented. She co-founded the bipartisan Assisting Caregivers Today (ACT) Caucus in Congress. Her experience with caregiving for her mother was outlined in a November 2017 article published on Forbes.com.
Once went undercover in a nursing home
Formerly the New Mexico Secretary of Health and the Director of the New Mexico Agency on Aging, Lujan Grisham went undercover in a nursing home in 1997, posing as a stroke victim, to investigate conditions there. A 2016 campaign ad about her 3 days undercover in the nursing home, where she saw abuse and she herself was neglected, is archived on You Tube.
The information packet I presented to Rep. Lujan Grisham contained information about Senate Bill 2469, which was introduced by Senator Sherrod Brown (D-Ohio) on February 28. Brown’s bill, named the STAAR Act (Strategies to Address Antibiotic Resistance), calls for various actions to address the growing crisis in which an estimated 2 million people get sick each year with antibiotic-resistant infections.
Besides the human suffering, antibiotic resistance takes a toll on the U.S. economy estimated at $20 billion a year in excess healthcare costs and as much as $35 billion in lost productivity.
Another New Mexico member of Congress, Ben Ray Lujan (D-Santa Fe), sits on the Energy and Commerce Committee’s Subcommittee on Health. He helped develop the 21st Century Cures Act, which overwhelmingly passed Congress and was enacted in December 2016. The law allocates $4.8 billion in funding to the National Institutes of Health (NIH) for cutting-edge scientific research on treatments and cures. The STAAR Act would complement the 21st Century Cures Act by improving the existing surveillance, data collection, and research work to prevent bacteria from developing resistance to current and future antibiotics.
PLF is concerned that many cases of C. Diff go unreported, and the organization wants to make reporting of C. Diff mandatory, including on death certificates.
The STAAR Act facilitates national Center for Disease Control partnership with state health departments through CDC’s Prevention Epicenters Program. Lujan Grisham said her interest will continue if she is elected governor and she foresees roles in fighting HAIs for government agencies and institutions in New Mexico.
PLF points out that C. Diff is the most common cause of infectious diarrhea in healthcare settings. It caused nearly 500,000 infections in one year, and 29,000 deaths. Seventeen percent of C. Diff cases occur in nursing homes and 22 percent in hospitals. Only 7 percent are completely unrelated to health care. In nursing homes, the infection interferes with residents’ rehabilitation therapy and recovery as it causes uncontrollable diarrhea, fever, nausea, abdominal cramping, dehydration, loss of appetite, and death in some cases. Ninety percent of Americans who die from a C. Diff infection are 65 or older.
More information is available in blog posts on my website about nursing homes, https://wbeerman.com and at the following PLF websites:
Recent court actions determined that two major lawsuits by state attorneys general (AGs) against nursing home chains will continue.
In one case, the Pennsylvania Supreme Court on September 24, 2018 reinstated a suit that the state’s Commonwealth Court had dismissed. In the second case, a court-administered status conference September 27, 2018 in New Mexico determined that an AG suit against a nursing home chain will remain alive — but stayed (suspended) — pending legal determinations in separate bankruptcy court proceedings. A spokesman for the New Mexico AG Office in Santa Fe said the office expects that another status hearing on the stayed case will be held in about 6 months.
The Pennsylvania case involves the Golden Living/Golden Gate senior care chain, and the New Mexico case is about the Preferred Care chain. Both cases are covered extensively in my book, Mary Regina’s Nursing Home, and the Pennsylvania Supreme Court’s September 24 opinion is posted on my website, https://wbeerman.com under the index listing “Litigation-Related Documents.” Also posted there is the earlier Commonwealth Court decision, a dissenting judge’s minority opinion, and the AG’s complaint in the Preferred Care case.
Both the New Mexico and Pennsylvania cases essentially alleged that the nursing homes had not provided all the care for which they billed. My book includes the arguments presented by the nursing home chains as well.
A statement by Preferred Care, Inc., of Plano, Texas, said it filed Chapter 11 bankruptcy proceedings in November 2017 to allow it to remain in business as it defended against 163 personal injury cases. A lawyer for Golden Living did not respond to my request for comment on the Pennsylvania Supreme Court decision.
When the Pennsylvania Commonwealth Court dismissed the Golden Living case, concerns were raised that attorney general lawsuits might no longer be a viable tool to enforce standards of care in nursing homes. The various reasons why are contained in the Commonwealth Court opinion and in a dissenting minority opinion by one of the Commonwealth Court judges.
“The Supreme Court’s decision allowing our lawsuit against this nursing home chain to continue is a significant victory for Pennsylvania seniors and their families,” said Attorney General Josh Shapiro.
Under the Supreme Court ruling, the state can recover public funds charged for services not provided – “a win for taxpayers,” Shapiro said.
“This ruling allows my team to hold businesses accountable for deceptive, misleading practices under our Commonwealth’s consumer protection law,” Shapiro said.
Mary Regina’s Nursing Home reports on state AG lawsuits and AG research that encompass 65 nursing homes and more than 1 million patient-days of nursing home care. The investigations for the AG lawsuits elicited reports on nursing home operations from former employees such as certified nurse’s assistants (CNAs) who became confidential witnesses for the AGs. Their insider view of nursing home operations is reported in the book. The investigations looked not only at how residents were treated, but at how the nursing homes interacted with oversight agencies and with their parent corporations.
Three whistle-blowers who reported false claims allegations about nursing homes where they provided care are to get $2 million of a $10 million settlement of the case, the U.S. Department of Justice announced July 18.
Meanwhile, the Government Accountability Office (GAO) reported in July that whistle-blowers in the Department of Veterans Affairs (VA) were much more likely than their peers to receive disciplinary action within a year of reporting misconduct, and they were much more likely to drop from VA employment rolls.
In the nursing home case, two consulting companies and nine affiliated skilled nursing facilities (SNF) agreed to pay $10 million to resolve False Claims Act allegations related to allegedly medically unnecessary rehabilitation therapy services.
Under the agreement, Southern SNF Management, Inc., Rehab Services in Motion, doing business as Dynamic Rehab, and nine affiliated SNFs in Florida and Alabama agreed to resolve allegations they violated the False Claims Act by submitting or causing the submission of false claims to Medicare for medically unnecessary rehabilitation services. They agreed to pay to the United States a total of $10 million.
The federal government alleged that they submitted false claims during 2009-2013 based on inflated Resource Utilization Group (RUG) levels.
The allegations resolved by this settlement arose from a whistle-blower lawsuit filed under the False Claims Act by La-Wanda Davis, Tramecier Donald, and Megan Dinkins, former employees of one of the skilled nursing facilities. Under the False Claims Act, private citizens can sue on behalf of the government for false claims and share in any recovery. The whistleblowers will receive $2 million of the recovered funds.
The case is captioned United States ex rel. Davis, et al. v. Southern SNF Management, Inc., et al., Case No.13-000384-WSM (S.D. Ala.). The claims resolved by the settlement are allegations only; there has been no determination of liability.
Regarding the VA, GAO reported in Report GAO-18-137 that individuals who filed a disclosure of misconduct with the Office of Special Counsel (OSC) received disciplinary action at a much higher rate than the peer average for the rest of the VA in fiscal years 2010–2014. Additionally, GAO’s interviews with six VA whistle-blowers who claim to have been retaliated against provided anecdotal evidence that retaliation may be occurring. “These whistle-blowers alleged that managers in their chain of command took several untraceable actions to retaliate against the whistle-blowers, such as being denied access to computer equipment necessary to complete assignments,” GAO said.
For 129 nonanonymous whistle-blowers, GAO found that only approximately 2 percent received an adverse action in the fiscal year prior to their disclosure, while 10 percent had received an adverse action in the fiscal year of their disclosure, and 8 percent received an adverse action in the year subsequent to this disclosure. “While the fact that nonanonymous whistle-blowers faced higher rates of adverse action subsequent to their disclosure than the VA population as a whole is consistent with a pattern of retaliation for nonanonymous whistle-blowers, it is only an indication that retaliation could be occurring,” GAO said.
GAO’s analysis also showed that among employees who could be matched to the end-of-year roster, attrition rates were higher for those individuals who filed a nonanonymous disclosure with the OSC. On average, only approximately 9 percent of all VA employees on the end-of-year roster in one fiscal year were not on the subsequent year’s roster. In contrast, 66 percent of the 129 nonanonymous whistle-blowers did not appear in the subsequent year’s roster. Attrition rates were higher among employees who had filed a disclosure than among their peers who had not filed disclosures, for all fiscal years in GAO’s review.
PLF Executive Director Christian Lillis, left, at a recent C. diff Summit in Washington, D.C. with Dr. Michael Mansour, MD, PhD, infectious diseases, Massachusetts General Hospital.
By William J. Beerman, Sr.
The Peggy Lillis Foundation (PLF) has kicked off a “Make C. diff Count” campaign to increase surveillance and public reporting of the superbug Clostridium Difficile (C. diff), and other healthcare-associated infections (HAIs).
“Everyone should count,” contend PLF co-founders Christian John Lillis and Liam Lillis. Their mother, Peggy Lillis, died of a C. diff infection 8 years ago at age 56. “When it comes to monitoring and combating healthcare-associated infections, like C. diff, counting the people who are harmed, and die, from these infections is critically important.”
“Tens of thousands of C. diff infections go uncounted every year due to our patchwork system of infectious disease reporting,” according to PLF.
Seventy-seven percent of Americans have not heard of C. diff. One reason is that the federal government and 49 states do not mandate reporting of C. diff infections (CDIs) on death certificates. A 2014 study showed 17 percent of deaths attributed to chronic diseases like heart disease actually were likely due to infection.
The 2011 death certificate for my mother, Mary Regina Beerman, showed “respiratory failure due to pneumonia due to a bed ridden state,” and “congestive heart failure” as causes of death. I wonder whether the cause of the “bed-ridden state” should have been mentioned. The death certificate did not mention C. diff although a hospital record showed a diagnosis of “Intestinal infection due to Clostridium Difficile” among my mother’s diagnoses. Mary Regina was diagnosed with C. diff 6 days into a 21-day stay in a nursing home. She died 10 days after the nursing home sent her to a hospital emergency room. Prior to breaking her hip and being sent to the nursing home for rehabilitation, she had been living independently.
PLF points out that C. diff is the most common cause of infectious diarrhea in healthcare settings. It caused nearly 500,000 infections in one year, and 29,000 deaths. Seventeen percent of C. diff cases occur in nursing homes and 22 percent in hospitals. Only 7 percent are completely unrelated to health care. In nursing homes, the infection interferes with residents’ rehabilitation therapy and recovery as it causes uncontrollable diarrhea, fever, nausea, abdominal cramping, dehydration, loss of appetite, and death in some cases. Ninety percent of Americans who perish from a CDI infection are 65 and over.
PLF points out that underreporting of C. diff cases results in fewer resources being allocated to combat C. diff. For example, the National Institutes of Health budgets $3 billion for HIV/AIDS, but only $438 million for C. diff and other antibiotic-resistant infections.
The “Make C. diff Count” campaign follows the PLF’s C. diff Summit and Lobby Day in Washington, DC April 8-10. Twenty-five PLF advocates met at 42 legislative offices on Capitol Hill, sharing their personal experiences and providing facts to an array of senators, congressmen, and staffers. They urged action on Senator Sherrod Brown’s STAAR Act (Strategies to Address Antibiotic Resistance).
About 30 PLF advocates from 14 states participating in the Summit were joined by another 40 stakeholders and leading experts in the fields of medicine, healthcare policy, aging, epidemiology, and grassroots organizing. Summit participants attended learning sessions on C. diff clinical and practice guidelines from the Infectious Disease Society of America and Society of Healthcare Epidemiologists of America; an overview of the Centers for Disease Control and Prevention healthcare-associated infection surveillance and reporting systems; and a preview of the Alliance for Aging Research’s forthcoming report on HAIs in nursing homes.
November 18, 2018 by Tim Regan
By William J. Beerman, Sr.
By William J. Beerman, Sr.