Princeton Daily Clarion had an article about Bryan Dillman, a certified nursing assistant at Good Samaritan Home and Rehabilitation Center in Oakland City, charged with choking and punching one of the facility’s vulnerable residents. He was arrested for a felony battery charge after police were called in reference to a battery with injury on a woman living at the home.

According to an affidavit for probable cause, a nurse at the home, Sharlet Sillz, found Dillman asleep in DeeAnn Hoffman’s recliner in her room.  Silz admitted in her affidaivt that she told Dillman she would not report him because "she knows that he is tired and that he has kids."  Hoffman, who had been undergoing a test, went back to her room.  Sillz then told police she heard Hoffman yelling "please don’t hurt me" and Sillz heard a smacking noise coming from Hoffman’s room.  Dillman then quickly walked away and Sillz went into the room. According to the affidavit, Hoffman said to Sillz that Dillman had tried to choke her and hit her numerous times in the face.

After police spoke with Hoffman, she said she had told Dillman she was ready for a shower when Dillman jumped out of a chair, got behind her and put both hands around her neck and choked her.  Dillman punched her in the face with his fist.  The affidavit says Dillman is 6-foot, 1-inch, and weighs 225 pounds. 

 

Center for Medicare Advocacy issued a bulletin about overpayments to nursing homes.  The bulletin explains the long history of nursing homes collecting more money than they deserve or are entitled to for services especially for nonexistent rehabilitation.  Changes have recently been made to rein in wasteful spending and overpayments.

In March 2009, as in previous years, Medicare Payment Advisory Commission (MedPAC) recommended that Congress not increase Medicare nursing home rates.   MedPAC reported that "the aggregate Medicare margin for freestanding" nursing homes was 14.5% in 2007; that for the seventh consecutive year, the aggregate Medicare margins exceeded 10%; and a one quarter of SNFs show profit margins of at least 24.8%.   That is a big profit margin paid for by taxpayers.

 

How overpayments occur:

SNFs are paid for services they do not provide. PPS pays SNFs a daily rate based on the assessed needs of the resident.  Although getting paid based on the assessment, most residents were not provided the therapy they required in order to be placed into those assessment categories.  SNFs did not provide the amount of rehabilitation services they were paid to provide and rehabilitation services actually provided to residents under PPS decreased.  Now it will pay only for services that are actually provided in the SNF. Billions of dollars in overpayments have been wasted.  CMS is not recouping the billions of dollars of overpayments from the previous four years.
 

The falsity of "concurrent" therapy.  SNFs shifted from one-on-one therapy to "concurrent" therapy, a method by which one professional therapist works with multiple residents on different therapy tasks at the same time, but SNFs still bill Medicare as if each resident received 100% of the therapist’s attention. For example, SNF Medicare reimbursement rules have allowed a therapist treating four patients concurrently during the course of one hour to bill Medicare for four full hours of therapy. CMS reports that more than a quarter (28.26%) of therapy provided in SNFs is now concurrent. CMS will close this loophole when it implements revisions to Medicare by requiring allocation of concurrent therapy time and by limiting concurrent therapy to two residents.  CMS is not recouping overpayments for the many past years of "concurrent therapy."

Greed.  When several large multi-state nursing home chains filed for bankruptcy protection in the late 1990s, Congress responded by increasing Medicare reimbursement rates for SNFs in multiple ways. Although Congress increased the nursing component of all SNF rates by 16.66%, SNFs did not spend the billion-dollar rate increase on nurse staffing, as Congress intended. The GAO found, "in the aggregate, SNFs’ nurse staffing ratios changed little after the increase in the nursing component of the Medicare payment rate took effect. Overall, SNFs’ average nursing time increased by 1.9 minutes per patient day."  The national for profit chains took the increase and put it in profits to increase their stock instead of using the money to increase staffing to provide proper and adequate care.

CMS has taken strong steps to eliminate some of the waste and overpayments to SNFs that have been well-documented by MedPAC and the GAO for many years. In the final regulations published in August, CMS eliminated the look-back period; recalibrated the rates to maintain budget neutrality; revised the rules for concurrent therapy; and is considering development of a SNF-specific wage index. These changes and the changes included in H.R. 3200 should not result in reduced staffing and quality of care, as suggested by the nursing home industry. Instead, they will improve the integrity of the Medicare program by ensuring that SNFS are reimbursed accurately and fairly for the services they actually provide.

 

 

The New England Journal of Medicine recentl published a study on how to handle dementia in the elderly.  The conclusion was that dementia may lead to complications that may lead to death.  The problem with the study is that they did not determine the cause of the complications or the ability to prevent these foreseeable complicatons.  Could it be caused by abuse, self-neglect, negligent care?

The study’s conclusion is that pneumonia, febrile episodes, and eating problems are frequent complications in patients with advanced dementia, and these complications are associated with high 6-month mortality rates. Distressing symptoms and burdensome interventions are
also common among such patients. Patients with health care proxies who have an
understanding of the prognosis and clinical course are likely to receive less aggressive
care near the end of life.

The last line is scary.  It implies that if a residents’ "proxy" (which in many situations is the government) was aware of the study, they would decide not to provide care to someone with dementia.  Also, the study did not consider falls a significant complication in dementia residents.

Time Magazine had an article stating the study was "redefining" dementia as a terminal illness.  "Dementia is not a single illness but a collection or consequence of many, including Parkinson’s disease, vascular dementia and Alzheimer’s disease (which accounts for some 70% of all dementia cases). In the advanced stages of dementia, it is often impossible to tell which disease the patient had at the outset, as the end result is the same, according to Mitchell’s study: a syndrome of symptoms and complications — eating problems (86%), pneumonia (41%), difficulty breathing (46%), pain (39%) and fever (53%) — caused by brain failure. "Dementia ends up involving much more than just the brain," says Dr. Claudia Kawas, professor of neurology at the University of California, Irvine. "We forget the brain does everything for us — controls the heart, the lungs, the gastrointestinal tract, the metabolism."

 

Pittsburgh Live had a story about a resident who died as a result of a preventable fall.  Authorities are investigating the death of Loretta Benzel, a resident of the Presbyterian SeniorCare facility, who fell to her death.  Ms. Benzel was found shortly after 6 a.m. below the window of her third-floor room in the section of the facility known as The Willows.

Pat Kornick, spokesman for Presbyterian SeniorCare, said that when the incident occurred, "The staff was working with the residents, getting them breakfast and getting them showered."  She said the staff member who was working with Benzel was getting tea for her at the time she fell.  Kornick said Benzel, a former Plum resident, had lived at The Willows, which is a skilled nursing unit providing around the clock care.  Kornick said Benzel was not suffering from Alzheimer’s disease or dementia.  Kornick said the windows are equipped with safety features.  Kornick said the preliminary investigation indicated it was a suicide. She said she had no knowledge that Benzel had been despondent or suicidal.

As for the possibility that Benzel was suicidal, police responded, "That was never conveyed to us. She had health problems, but nothing like that was conveyed to us. "At this point, there is nothing indicative of any foul play," the chief said. "Now whether it was an accident or a suicide has yet to be determined."

 

 

The Madison Record had an article about a recent nursing home jury verdict.  The jury awarded Emons $5,000 his claim of wrongful death and $15,000 for what he claimed was a violation of the Nursing Home Care Act.   Clifford Emons sued the nursing home on behalf of the estate of Jane Schwartz.   According to court documents, Jane Schwartz fell while at the Alton facility, breaking her wrist and hip. It took the jury less than two hours to deliberate in a negligence suit against Rosewood Care Center of Alton.  The jury only had to consider what damages to award after Madison County Circuit Judge Andy Matoesian struck the defendant’s pleadings on the negligence issue and directed the verdict on the liability issues for the plaintiff.

It is the second verdict this year against the Rosewood Care Center chain in Madison County. Another negligence suit against the nursing home’s Edwardsville location went to trial earlier this year in Madison County Circuit Judge David Hylla’s courtroom.  That suit was also brought on behalf of an estate, by plaintiff Paul Graves on behalf of his deceased father. The jury in the Graves’ suit found for Paul Graves and awarded damages totaling about $150,000 over his father’s fractured hip.

 

The Sun News had an article about the SLED unit called Vulnerable Adults Investigative Unit that is responsible for investigating abuse and neglect of vulnerable adults but only in state-run facilities.  For some unknown reason, they do not investigate incidents in private for profit nursing homes.  SLED investigates deaths and complaints about abuse at state-run facilities, such as those operated by the state Department of Mental Health. Call 866-200-6066. 

The lieutenant governor’s office on Aging/Long Term Care ombudsman has the duty to investigate all other residential facilities, including private nursing homes and assisted living centers, but they hardly ever do and do not have the necessary resources. Call 800-868-9095.

The S.C. Department of Social Services investigates abuse or neglect of vulnerable adults in private or foster care homes. Call 803-898-7318. S.C.

Attorney General’s Medicaid Fraud Control Unit investigates misuse of Medicaid funds. Call 888-662-4328.

Last November, Dwayne Walls was living in the Alzheimer’s wing at Veterans’ Victory House, a state-owned nursing home in Walterboro, when another patient beat him unconscious with a cane. Walls died a week later.   Despite the beating, the Colleton County coroner ruled that Walls, 76, died of natural causes. But the death also triggered an investigation by the state Law Enforcement Divisions Vulnerable Adults Investigative Unit.

In place for two years, the unit was created to investigate abuse, neglect, exploitation and deaths in government nursing homes, such as Veterans Victory House.   So far the unit has received more than 2,500 reports and complaints.  "A patient might be 105, but maybe he wasn’t supposed to die that day," said Matt Brown, a SLED agent who works in the unit. "He has the same right to live as 5-year-olds with their whole lives ahead of them."

Lawmakers established the unit in 2007 after a nonprofit group, Protection and Advocacy for People with Disabilities, issued a report that showed the departments of Mental Health and Disabilities and Special Needs had long ignored or covered up abuse cases. The new unit is a more neutral investigative body for these agencies, said SLED Capt. Patsy Lightle, who runs the Vulnerable Adults Investigative Unit and a separate one that investigates child deaths.

One of the unit’s responsibilities is to investigate suspicious deaths at state-run facilities. In the unit’s first two years, agents received reports about 725 deaths.

 

McClatchy Washington Bureau recently had an article about a panel discussion on curbing medical malpractice litigation. Below are some interesting points:
"Health policy myths become convenient truths," said Gregg Bloche, a graduate of the medical and law schools at Yale and a former visiting fellow at the Brookings Institution. Bloche has written extensively on the implications of policy for doctors and patients.  Bloche said that costs associated with medical malpractice accounted for "a small and steady fraction" of health care costs — 2 to 3 percent at most — and couldn’t be blamed for the continuing increase in those costs.  For example, while Bloche put costs due to medical malpractice at roughly $55 billion for 2007, total health care spending estimates for that year topped $2.2 trillion.

Bloche was joined by other experts in the legal, medical and economics fields.
"The bottom line is that (malpractice) tort reforms don’t work as well as proponents say they do," said Kathryn Zeiler, a professor of law and economics at Georgetown and a widely published author on the subject of malpractice revisions.   Zeiler, citing studies spanning four decades, said that findings were conflicting and at most indicated only meager cost savings as a result of restricting medical malpractice litigation.

The panelists said politicians made points that were anecdotal rather than statistical and tended to make bloated claims about the negative impact of medical malpractice litigation on health care costs.  Hyman said that most costs surrounding malpractice suits were associated with those cases that went beyond pretrial settlements. As a result, mechanisms such as "review panels" that curb lawsuits would have a limited effect on reducing costs.
"Tort reform is not a magical solution to the problems with our health care system," Hyman said. "There are dysfunctions in our system, and they ought to be addressed. But we ought to be modest in our expectations."

 

Public Citizen wrote a letter to Max Baucus regarding the same issue signed by various consumer and professional groups such as Alliance for Justice, Center for Justice & Democracy, Center for Medical Consumers, Consumer Watchdog, National Consumers League, National Research Center for Women & Families, National Women’s Health Network, and NCCNHR: The National Consumer Voice for Quality Long-Term Care.

They oppose any provisions that would encourage states to adopt “alternatives” to medical malpractice litigation. Medical malpractice is at epidemic levels in this country. The Institute of Medicine has estimated that up to 98,000 people die every year from medical errors in America’s hospitals. Diminishing medical providers’ accountability for wrongful acts conflicts with Congress’s stated intent to provide affordable and quality health care to Americans. Congress should focus on improving patient safety and reducing deaths and injuries, not insulating negligent providers from accountability and saddling taxpayers with the cost.

The Facts:

Medical malpractice litigation has fallen to less than 0.6 percent of all health care spending – the lowest level on record. At the same time, health care costs have soared.

Three to seven people die from preventable medical errors for every one who receives compensation for any malpractice, including those resulting in injury or death.

States with the most draconian “tort reform” measures have seen little or no reduction in their health care costs. That isn’t surprising. The Congressional Budget Office found that “Malpractice costs account for less than 2 percent of [health care] spending.” Medical malpractice cases also account for only about four percent of tort cases.

Doctors in many states have seen dramatic rate increases after “tort reform” measures were approved. Rates were only held down in states with strong state insurance rate regulation.
States with the most severe “tort reform” have seen insurance rates for medical providers rise and fall at similar levels as other states, according to a recent study by Americans for Insurance Reform, a coalition of nearly 100 consumer and public interest groups that examined the insurance industry’s own data.

States with the most severe “tort reform” measures have often left patients without any remedy regardless of the severity of their injuries or the degree of negligence that may have occurred.

“Tort reform” laws shift the costs away from those who should pay -– insurance companies or health care providers who have committed malpractice – onto the taxpayer.   We are aware of families with children severely injured by medical malpractice who had to seek government assistance to survive because “tort reform” reduced their compensation, burdening state Medicaid systems funded by federal and state taxpayers.

Total medical malpractice payouts for injuries and deaths caused by medical negligence in the nation, have recently hovered between $5 billion and $6 billion annually. This is less than half of what Americans pay for dog and cat food each year.

Government studies, from the Congressional Budget Office to the Government Accountability Office, that have examined so-called “defensive medicine” have found little or no substantiation for it, particularly in this age of managed care.

Real Malpractice Reform Should Include:

A physician’s registry that tracks doctor records in all 50 states. As Public Citizen’s examination of the National Practitioners Data Bank found, 5% of doctors commit 54% of the malpractice. Such a registry would be transparent and ensure that incompetent dangerous physicians would be unable to move from state to state – as they do today – and injure more patients. In addition or in the alternative, simply open the National Practitioners Data Bank to the public.

Enact the federal bill creating a registry of hospital infection rates nationally.  Infections are a significant source of morbidity and mortality for nursing home residents and account for up to half of all nursing home resident transfers to hospitals. Infections result in an estimated 150,000 to 200,000 hospital admissions per year at an estimated cost of $673 million to $2 billion annually. When a nursing home resident is hospitalized with a primary diagnosis of infection, the death rate can reach as high as 40 percent. Consumers Union’s “StopHospitalInfections” has successfully helped to pass state laws requiring hospitals to publish their infection rates. When such state laws are enacted, hospital infection rates go down markedly.

Encourage health care providers – doctors, hospitals, nurses – to adopt full disclosure programs when malpractice occurs, but without coercive measures like some Sorry Works/Early Offer programs. The provider must commit to discovering the cause of the injury and to ensuring it won’t happen in the future.

Encourage the implementation of patient safety reforms to reduce preventable medical errors. Public Citizen’s “Back to Basics” report listed simple measures, such as best practices to eliminate patient falls and prevent pressure ulcers, that would save 85,000 lives and $35 billion a year in health care delivery.

Real Insurance Reform Should Include:

Repeal of the McCarran-Ferguson Act’s exemption of the health and medical malpractice insurance industry from anti-trust laws. Congress must prohibit insurers from cooperating in collusion and price fixing, behavior that costs doctors and consumers a tremendous amount.
 

Philadelphia Daily News had an article about the Veteran Administration trying to conceal system wide neglect at a VA nursing home.  In a directive, VA officials informed local agency officials that inspection reports are no longer to be released to the public including family members of residents.  The directive came after the Tribune-Review disclosed details of a 2008 report on the nursing home that concluded the VA "failed to provide a safe and sanitary environment for their residents."   Such reports from the Long Term Care Institute – which the VA hired to inspect its facilities – are considered "protected" documents under the provisions of a federal law designed to promote improved quality, the directive states.  The Wisconsin-based institute, according to VA officials, conducted similar inspections of more than 100 VA facilities nationwide. Under last week’s order, none of those reports will be made public.

The report cited by the Tribune-Review was released by VA officials in Philadelphia under a public records request.   It described how one veteran had to have his leg amputated after a serious infection had gone untreated for so long that it attracted maggots. It also described blood-stained floors, a fly infestation and life-threatening treatment of veterans dependent on tube feeding.

 

 

Coastal Courier had an article about another nursing home employee stealing from residents.  Demetria Denise Williams, an employee of Coastal Manor Long Term Care Facility, was arrested after Elise Stafford, the home’s chief long-term care officer, reported the center had information showing an employee had been stealing.   Williams was then taken to the police station where she was charged with theft by deception, theft by taking and exploitation of the elderly.
Williams has been charged with stealing more than $4,000 and that he anticipates as many as 25 more theft warrants.  Williams stole from residents by taking money for their families, but not depositing it into appropriate accounts.

Williams also stole from the facility by taking payment of services not provided to residents.
“The majority of the money that was stolen was from payment for services,” Stafford said. “There was a minimal amount taken from the residents.”
 

McKnight’s had an article about salary increases in Administrator and Director of Nursing positions.  CNA pay appears to be static.  Nursing home management salaries rose at a healthy rate this year, despite the recessionary environment, according to the recently released “2009-2010 Nursing Home Salary & Benefits Report” from Hospital & Healthcare Compensation Service. The publication is created in association with the American Association of Homes and Services for the Aging, and the American Health Care Association, the nation’s largest nursing home associations.  National median salaries for both nursing home administrators and assistant administrators rose by 4.8% in 2009, according to the HCS survey. Administrators’ salaries climbed to $89,606, up from from $85,464 last year.   Nurse management who typically do not provide direct care enjoyed an overall pay bump. Directors of Nursing matched last year’s pay increase of 3.9%, putting the national median at $77,921. The assistant DON median rose by a bigger margin–4%–putting it at $62,400 per annum.

The article points out that the economic stability of the long term care industry is doing well despite the cuts in Mediciad and the economic recession.    Although resident numbers are down and, particularly in the not-for-profit sector, fund-raising efforts are down as well. Still, administrators at not-for-profit facilities averaged an almost 7% pay rise over last year. (The 4.8% average is for administrators from the both for-profit and not-for-profit sectors.)

The unsustainable trajectory of current healthcare spending is one of the big reasons healthcare reform is necessary, although it remains to be seen what will happen under a new plan.   The Employee Free Choice Act contains three major provisions that would help make it easier for unions to organize: a card-check provision, allowing a union to form if a majority of workers (50% plus one) sign a card in support of organizing; a mandatory arbitration clause that would impose a working contract on both the new union and management if those parties cannot agree with each other within 90 days; and a provision that would alter the rules governing union elections, reducing the amount of influence management can exert on union voters.   Conventional wisdom says that if EFCA passes, organizing in healthcare will go up, and with it, employee wages.  

The healthcare discussion has perked up the ears of many long-term care accountants and various executives, who are struggling to prepare for possible Medicare reimbursement cuts and market basket eliminations. When you consider that even small changes in a facility’s payroll, especially in larger metropolitan facilities that employ thousands of workers, can add up to millions of dollars.