The Center for Medicare Advocacy recently published a press release on the failure of nursing homes participating in the "Advancing Excellence in America’s Nursing Homes"–an industry program to self-police and improve quality of care.  Below are excerpts of the press release:

Many nursing facilities that are identified by the federal government as among the facilities providing the poorest quality of care to residents in the country – the Special Focus Facilities (SFFs) – participate in the nursing home industry’s voluntary quality improvement campaign, Advancing Excellence in America’s Nursing Homes.  Forty-three percent of all facilities identified by the Centers for Medicare & Medicaid Services (CMS) as SFFs have participated in Advancing Excellence for more than two years.

Participation in Advancing Excellence has neither prevented facilities from being identified as SFFs nor helped them improve the quality of care they provide to residents to warrant removal from the SFF list.  That nursing facilities participating in a quality improvement campaign are nevertheless identified by the federal government as among the most poorly performing facilities in the country demonstrates, once again, that voluntary quality improvement efforts by the nursing home industry do not guarantee high quality of care for residents and cannot replace a strong public regulatory system.

Each month, CMS identifies nursing facilities that are providing the poorest care to their residents, as determined by federal deficiencies cited in the prior three years. There are 15,568 nursing facilities in the United States. Only 150 facilities (less than 1%) were identified by CMS as SFFs that were either newly added to the SFF list or had not shown improvement as of December 15, 2011.

Advancing Excellence in America’s Nursing Homes
Advancing Excellence is a voluntary quality improvement initiative implemented by the nursing home industry and others in October 2006.   When Advancing Excellence was implemented in 2006, facilities chose at least three goals from among eight available goals. Four goals were clinical goals – reducing high risk pressure ulcers, reducing the use of daily physical restraints, improving pain management in long-stay residents, and improving pain management in short-stay residents.  Four goals were non-clinical – setting individualized quality improvement targets; assessing resident satisfaction, family satisfaction, or both; measuring and reducing staff turnover; and consistent assignment of staff to residents.

Participation in Advancing Excellence has neither prevented nursing facilities from being identified as SFFs nor helped them improve the quality of care they provide to residents so that they are removed from the SFF list.  SFFs are defined as among the 1% of worst performing nursing facilities in the country, yet they participate in Advancing Excellence at high rates. Many facilities appear to have participated in Advancing Excellence when they were first identified as SFFs. Participation in the Campaign clearly has not improved their performance.
These findings give little reason to believe that Advancing Excellence is making a difference in improving quality of care and quality of life for residents. And they provide no reason to believe that voluntary quality improvement campaigns can be a substitute for an independent, objective, public regulatory system

The Center for Medicare Advocacy reported that allowing facilities to self report key data on staffing, quality of care, and complaints does not work.  See report here. The Centers for Medicare & Medicaid Services (CMS) identifies nursing facilities that are providing the worst care to their residents. These facilities, called Special Focus Facilities (SFFs), receive extra attention from the survey agency – at least two surveys each year and enhanced enforcement activities.

The Center concludes that facilities’ self-reported staffing and quality measure data cannot be relied on to provide an accurate picture of a nursing facility. This conclusion refutes the nursing home industry’s claim that facilities can effectively regulate themselves.  In light of SFFs’ "over-reporting" [read lying] of their staffing levels and quality measures, the Center for Medicare Advocacy recommends that:

Staffing and quality measures not be reported on Nursing Home Compare for any SFFs;

 No SFF be given more than one star on their composite scores unless and until it graduates from the SFF program;

 Pain not be used as a quality measure for any facility on Nursing Home Compare.

 The Center for Medicare Advocacy study shows that SFFs often report high staffing and high quality measures, despite their extremely poor performance on publicly-conducted, objective surveys. The study did not evaluate whether all other nursing facilities’ self-reported staffing levels and quality measures are similarly inconsistent with their survey results.

 

The Washington Post had an article about the political attack against Mitt Romney because of his  involvement and connection to a company that paid a multimillion-dollar fine for Medicare fraud.  The clip is labeled “Mitt’s Blood Money.”   It looks at the acquisition by Romney’s private equity firm, Bain Capital, of the medical testing company Damon Corp. which was fined more than $35 million and eventually went bankrupt.

Another article from The Washington Post discusses the facts concerning Damon Clinical Laboratories.  The article states that attack "is relevant because 1) Romney was a director of the firm while the fraud took place; 2) the fraud appears to have ended only after Bain sold the firm; 3) Romney earned nearly $500,000 from the sale of Damon; and 4) Romney’s statements about what he knew and when he knew it have been inconsistent".

In 1996, Damon had agreed to pay a $35.3 million criminal fine — one of the largest corporate fines in U.S. history — and an additional $83.7 million to settle whistle-blower lawsuits. The company admitted that from 1988 to 1993 it had bolstered its earnings by submitting false claims to Medicare and other federal programs. Essentially, the firm billed for blood tests that doctors had not ordered.

Romney was on the board of directors, which had a fiduciary duty to oversee company executives.  The film correctly notes how Romney’s story changed about his knowledge of the investigation. It also airs of clip of him denying at a GOP debate this month — to Gingrich — that Bain Capital did any Medicare business. It ends with a plea to report Medicare fraud to the government.

 

"The Damon case is certainly a valid subject for scrutiny of Romney’s business record. He was on the company’s board at the time criminal fraud was taking place, and his statements about his knowledge of the federal investigation have been inconsistent."

I wonder how this will play in Florida?

 

Kaiser Health News reported the disturbing but all too common story of Medicare fraud involving hospice and nursing homes.  A whistleblower accuses AseraCare of improperly cycled patients through nursing homes and hospice with a goal of making as much profit as possible from Medicare.  Federal attorneys also sued alleging it milked Medicare’s hospice benefit by pressuring its employees to enroll people into hospice who weren’t dying and resisted discharging them despite evidence they weren’t deteriorating. 

Critics of Medicare’s hospice benefit have said that the way the government pays providers gives them financial incentives to abuse the system. AseraCare, a Fort Smith, Ark.-based hospice company operating in 19 states.  The company is owned by Golden Living, a national for profit chain that operates nursing homes.

The whistleblowers contend that AseraCare first recruited patients eligible for skilled nursing care –also provided by Golden Living— for 20 days, for which Medicare pays the entire bill. After 20 days, when Medicare requires patients pick up a part of the tab, AseraCare had the nursing homes send the patients to hospice, according to the lawsuit. In hospice, AseraCare would collect a flat payment from Medicare for each day they are enrolled.  AseraCare sent employees to “patrol hospitals,” ride along with “Meals-on-Wheels” and go “door-to-door” in housing run by the Department of Housing and Urban Development, according to the lawsuit brought by the whistleblowers, who are represented by Birmingham attorney, Jim Barger. In a separate suit settled in 2009, Barger won the largest settlement in a hospice care case against SouthernCare, and is also representing whistleblowers suing Vitas HealthCare.

“Typically, a patient admitted into Defendant’s web of operations will be referred and re-referred until that patient has received—and Medicare has been billed for—the maximum number of days of skilled nursing care, including rehabilitative therapy … home health care, and hospice care,” says the lawsuit, brought by Dawn Richardson, an AseraCare nurse manager, and Marsha Brown, who ran several AseraCare offices in Alabama.

 

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World News Report reported the study in the Annals of Surgery showing that nursing home residents suffer more compplications after surgery than people who remain at home, leading to questions about possible neglect by caregivers in nursing homes.  Researchers reviewed records from over 70,000 nursing home residents and one million non-institutionalized Medicare recipients over the age of 65. The research team focused on people who died following routine abdominal surgery, which included removal of the appendix, colon and gall bladder as well as surgery to treat bleeding ulcers.

The study showed that deaths following those surgeries were consistently higher for nursing home residents despite the fact that certain surgeries are considered "low-risk."  For example, after surgery for bleeding ulcers, 42 percent of nursing home residents died compared to just 26 percent of elderly people not in nursing homes. For colon surgery the study found 32 percent for nursing home resident deaths and 13 percent for their non-nursing home counterparts. The figures for those who died within a month after appendix removal were 12 out of 100 compared to just 2 out of 100.

 

The New York Times had a great article written by Paula Span about the many benefits of nonprofit nursing homes.  Her article discussed a recent study in The Gerontologist that showed employees of nonprofits are happier at their jobs than those at national for profit chains.

"For years, researchers have reported that ownership status is one of the factors related to quality care. “Most studies show that nonprofits do a better job of caring for patients,” said JiSun Choi, a postdoctoral fellow in nursing and long-term care at the University of Kansas Medical Center School of Nursing. “But we’re not sure why that happens.”

A nonprofit nursing home doesn’t have to worry about paying shareholders dividends or keeping stock prices high. But we also know that staff members’ feelings about their jobs appear to play a significant mediating role. Past studies have shown that in commercially operated homes, for instance, the certified nursing assistants who provide the bulk of the hands-on care are less satisfied with their jobs than those in nonprofits. Directors of nursing in commercial homes are less satisfied as well, and more likely to be planning to leave. In general, such homes are associated with higher — in some cases, shockingly high — staff turnover.

 

The Tampa Bay Times reported the $200 million jury verdict in a case where the Defendant was in default.  The case stemmed from the 2004 death of Elvira Nunziata, a resident with dementia at Pinellas Park Care and Rehab Center. Her bloody body was found at the bottom of a stairwell after she toppled one story while strapped to a wheelchair. Former aides at the home testified that the door to the stairwell was supposed to be locked, but that staffers often disabled the alarm so they could go smoke.  The home had a history of deficiency citations and abuse complaints and the aides said it was frequently understaffed.

The defendant was Trans Health Management Inc., who had sole authority to operate the home at the time, but has since gone defunct. Its parent company, Trans Health, Inc., is in receivership in Maryland.  The Tampa law firm of Wilkes & McHugh, which represented Nunziata’s estate, alleged that the true owners were private equity investors who shuffled the assets of Trans Health Management into affiliated entities to avoid liability and then chose not to mount a defense.

 

 

The Knoxville News reported Maryland’s Colonial Hills Nursing Center will likely lose its status as a Medicare service provider and take only private-pay patients for at least the next six months effective Jan. 7.  CMS has determined that the nursing home "is not in compliance" with its regulations.   More than six months ago, Colonial Hills was added to a national list of "special focus" facilities in danger of losing certification, and as of October, the list said, conditions at Colonial Hills had not improved enough for it to be removed from the list.  Medicare will not pay for the care of any residents admitted after Jan. 7 and will pay only for 30 days’ care, through Feb. 6, for residents admitted before Jan. 7.

Beecher Hunter is president of Cleveland, Tenn.-based Life Care Centers of America, which manages Colonial Hills and more than 100 other nursing homes. Hunter blames previous administrator, Rick Sharp, who was "dismissed". Director of Nursing Donia Amburn is serving as interim administrator while Life Care looks for the "best person" to fill the position full time. 

So they blame everything on the Administrator–I would like to hear his side of the story.

 

The University of Alabama at Birmingham is currently studying the relationship between the sale, purchase, and operation of nursing homes by private firms and the quality of care provided by those facilities. The study will compare quality and financial performance data of both private and public nursing homes. The study will show a decreased quality of care in the facilities owned by private firms.

 

UCSF ran an article on the recent study that proved the nation’s largest for-profit nursing homes deliver significantly lower quality of care because they typically have fewer staff nurses than non-profit and government-owned nursing homes. It is the first-ever study focusing solely on staffing and quality at the 10 largest for-profit chains.  The 10 largest for-profit chains operate about 2,000 nursing homes in the United States, controlling approximately 13 percent of the country’s nursing home beds.

Poor quality of care is endemic in many nursing homes, but we found that the most serious problems occur in the largest for-profit chains,” said first author Charlene Harrington, RN, PhD, professor emeritus of sociology and nursing at the UCSF School of Nursing. Harrington also is director of the UCSF National Center for Personal Assistance Services“The top 10 chains have a strategy of keeping labor costs low to increase profits,” Harrington said. “They are not making quality a priority.”

Low nurse staffing levels are considered the strongest predictor of poor nursing home quality.  The researchers compared staffing levels and facility deficiencies at the for-profit chains to those at homes run by five other ownership groups to measure quality of care. The 10 largest chains were selected because they are influential in the nursing home industry and are the most successful in terms of growth and market share.  The study found that for-profit homes strive to keep their costs down by reducing staffing, particularly RN staffing.

The 10 largest for-profit chains in 2008 were HCR Manor Care, Golden Living, Life Care Centers of America, Kindred Healthcare, Genesis HealthCare Corporation, Sun Health Care Group, Inc., SavaSeniorCare LLC, Extendicare Health Services, Inc., National Health Care Corporation, and Skilled HealthCare, LLC.

From 2003 to 2008, these chains had fewer nurse “staffing hours” than non-profit and government nursing homes when controlling for other factors. Together, these companies had the sickest residents, but their total nursing hours were 30 percent lower than non-profit and government nursing homes. Moreover, the top chains were well below the national average for RN and total nurse staffing, and below the minimum nurse staffing recommended by experts.

The 10 largest for-profit chains were cited for 36 percent more deficiencies and 41 percent more serious deficiencies than the best facilities. Deficiencies include failure to prevent pressure sores, resident weight loss, falls, infections, resident mistreatment, poor sanitary conditions, and other problems that could seriously harm residents.

The study also found that the four largest for-profit nursing home chains purchased by private equity companies between 2003 and 2008 had more deficiencies after being acquired. The study is the first to make the connection between worse care following acquisition by private equity companies.

UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.