Signature Healthcare is a national for-profit nursing home chain with more than two dozen facilities in Tennessee.  The government started an investigation in 2014 when two whistleblowers started collecting evidence on their own.  LeeAnn Holt and Kristi Emerson, both of whom are occupational therapists from Columbia, collected reams of anecdotes — in part, because they were concerned they might get in trouble themselves.  That evidence is the basis of the $30 million settlement in the Medicare fraud case between the federal government and Louisville-based Signature Healthcare, which operates more than 100 facilities in 17 states.

According to court documents, state and federal investigators discovered Signature was “knowingly submitting false claims to Medicare for rehabilitation therapy services that were not reasonable or necessary” at 115 of its facilities. Investigators said that led to a total of $232 million in false claims. The company also allegedly forged documents submitted to Tennessee’s Medicaid or Tenncare program, leading to another $12 million in fraudulent reimbursements.  So they stole $232 million but only had to pay a settlement of $30 million.  Who says crime doesn’t pay?

The complaint against Signature Healthcare (download here) accuses the company of systematically administering occupational, physical and speech therapy when it wasn’t warranted and withholding care when government reimbursements were already maxed out. According to the suit, the unnecessary therapy pushed patients into a category where the facility was reimbursed more per day for those patients, often hitting precisely the 720-minute per week threshold for maximum payment.  Holt and Kristi Emerson are the whistle-blowers who exposed a company-wide system of over-billing the federal government by Signature Healthcare.

“There were a couple of times when things happened with patients where we would just look at each other and say, ‘We can’t do this. We just cannot do this any more,'” LeeAnn Holt recalled.  Holt recalls a patient with advanced cancer who just wanted to spend time with her family rather than continue with therapy.

“She just put her hand on the therapist and said, ‘Honey, you need to go work with somebody that can really benefit from this.’ And you know, when you have a patient that is telling you that, you really have to stop and take inventory of what is going on here.”

Emerson says she hopes the case will still inspire other health care workers to push back when they feel pressured to do procedures they deem medically unnecessary.

“We can’t just blame these corporations for all of this,” she says. “We have to shoulder as therapists some of the responsibility because we’ve allowed this to get this bad.”

The women say before filing their suit, they repeatedly went to administrators all the way up to the corporate office.

“And no one was doing anything. And the more we reported, the more they came in and just started pushing back on us,” Emerson explained.

Emerson and Holt were let go amid the investigation and have found it difficult to find stable work. “No one really wants a whistleblower in their building,” Emerson says.

But now they will split roughly $6 million as their share of the settlement. Whistleblowers are entitled to 15 percent to 25 percent of the total.

 

Certified nursing assistants that bathe, dress and provide 95% of the care to residents at New Jersey nursing homes may get some help from Gov. Phil Murphy.  An identical bill cleared the state Legislature two years ago but was vetoed by former Gov. Chris Christie.

Legislation is progressing that will increase of staffing levels of these unlicensed caregivers.  Under the proposed law, nursing homes would have staffing ratios to meet: Facilities would be required at a minimum to having one certified nursing assistant on staff for every eight residents on a morning shift, no more than 10 per aide in the afternoon and no more than 16 per aide overnight.  This is great news for the residents and caregivers in New Jersey.

By the way, South Carolina only requires ratios of at least 1 CNA to 9 residents on first shift; 1 CNA to 13 residents on second shift; and 1 CNA to 22 residents on third shift.  This were established in the mid-1980s and are now considered insufficient and unsafe.  That is why the regulations include the following language:  “Additional staff members shall be provided if the minimum staff requirements are inadequate to provide appropriate care and services to the residents of a facility.”

The legislation would send a message to nursing home operators “that they need to staff adequately in their facilities,” given that the Garden State ranks among the bottom in the nation for average nursing aide staffing-hours per patient.

Several states have passed similar staffing ratio laws but they need to pay a living wage so the jobs are attractive to qualified and compassionate caregivers.  “Despite how difficult it is, it’s a very low paying job — with many (nursing assistants) only making $12 or $13 per hour,” CNA Lloyd-Bollard said. “It’s not right that caregivers have to do two or three jobs to make ends meet. These are the people responsible for caring for our state’s most vulnerable people; we should support them.”

Jeanitha Louigene, a certified nursing assistant of 27 years, is certain it’s having an effect on the quality of care provided by nursing facilities. “I really feel sorry for the residents,” she said. “With the amount of residents we have at once, we really don’t have time for them — they may want to talk, but we can’t do that. We have one person taking care of sometimes 15 or more residents, who are needing the bathroom, water or are in pain. We have multiple people calling for us. But we can only be in one place at one time.”

LoHud.com had an article about the ten questions to ask before admitting a loved one to a nursing home.

What follows are questions to get answered before picking a nursing home.

1. How long has the nursing director worked there? High staff turnover can be a sign of problems while staff retention and longevity is a good sign.

2. How many registered nurses work there, and what is the ratio of licensed nurses to certified nursing assistants? Studies show strong positive relationships between registered nurse staffing levels and quality in nursing homes.

3. Is the staff friendly? Get a sense of how long they’ve worked there and if they like it by talking to them.

4. How good is the food? Visit on a Saturday or Sunday around lunch or dinnertime to see if you would eat what is served and maybe have a meal yourself.

6. Do you see good activities listed on the home’s calendar and are they really going on? Determine how staff works to engage residents.

7. How do residents look? If residents don’t appear clean, comfortable and neat, this could be a red flag.

8. What do state inspectors say? Ask to see the most recent inspection report and research other reports on your state regulatory agency’s website; in New York, it’s the New York Department of Health.

 9. What do federal regulators say about the home? Go to the Medicare.gov Nursing Home Compare website to review the nursing home’s star rating and other information.

10. Is the home a member of a reputable trade association in your state such as Greater New York Health Care Facilities Association? Membership requires meeting certain standards, and members are kept up-to-date on best practices and regulations.

For more, go to Medicare.gov.

Sources: USA TODAY Network, AARP, Medicare.gov, National Institute on Aging, New York Department of Health, Aging Life Care Association, Agency for Health Care Administration

Newson6 reported on a resident’s family seeking answers in a lawsuit against Grace Living Center. Twila Knight was 57 when she checked in at Grace Living Center to recover from a fall.  At the facility, Twila suffered from falls, custodial neglect, and a pressure ulcer injury.  The family of a former resident is suing Grace Living Center claiming the staff failed to monitor, treat, diagnose and care for their loved one.

The center’s Medicare health inspection rating is one out of five stars.  The health inspection report shows the rating is the lowest possible score. And it’s rate of long-stay patients developing pressure ulcers is 12.6 percent more than double the national average.

Knight’s family is suing the nursing home for negligence claiming the staff also failed to properly treat bed sores she got in their care. The family is also claiming the staff was verbally abusive and failed to address her dietary needs, weight loss, and medication needs.

“There has to be special mattresses put in place, there has to be turning that’s done, you have to make sure that people are getting up,” said the family’s attorney Mark Edwards.

“We rely on these places to take care of our most fragile. And what’s happening is we have businesses that are putting profits over people,” said Edwards.

 

New York Magazine had an article about Trump’s decision to withdraw protections from people with pre-existing conditions claiming their are “unconstitutional”.  Republicans kept versions of the Affordable Care Act’s protections for people with preexisting conditions in all of their health-care bills last year.  Now Trump and Sessions are attempting to take them away.

“Specifically, the Justice Department announced that it would not defend the Affordable Care Act from a challenge brought by a group of red states, which claims that Congress’s repeal of the individual mandate renders the rest of the law unconstitutional — as that provision is not severable from the rest. This is a legal claim so radical and ill-supported it made the National Review blush. The notion that Congress is not constitutionally allowed to eliminate the ACA’s insurance mandate — unless it also repeals the law’s other regulations of the health-care market — is not some sacred principle of constitutional originalists. Rather, it’s a transparently ad hoc rationalization for the judiciary to veto a duly-passed expansion of the safety net. And yet, Attorney General Jeff Sessions concluded that his department could make no honest argument against the plaintiffs’ case.”

“Out-of-pocket health-care costs are rising for virtually everyone in the United States. Drug prices are resolutely high, premiums on the individual market are skyrocketing (thanks to the GOP’s tireless efforts to sabotage said market), and the average deductible for those with employer-provided insurance has increased by nearly 400 percent since 2006. The Democratic Party’s prescription is for the government to impose price controls, while further subsidizing ordinary Americans’ health-care costs by raising taxes on the rich (the party is internally divided over the details of its policy, but united on its general direction). The Republican Party, by contrast, is beholden to reactionary interests who want the government to cut public spending on health care, so as to finance ever-lower taxes on the wealthy and corporations.”

 

We are happy to share a guest post from Cohen & Cohen, P.C., who are great trial lawyers in Washington D.C.  

One of the main factors employers look at before deciding on whether or not to grant workers’ compensation benefits is if the injury is work related or not. In order to qualify for benefits, you have to show that you sustained the injury while doing a work-related task. Let’s take a closer look at some common scenarios:

Lunch Breaks 

If you got injured while on your lunch break, you may or may not qualify for benefits. For instance, if you were walking to a restaurant and fell on the sidewalk, you generally won’t be eligible for benefits. However, if you were eating lunch in the employee break room and got hurt, the injury will typically be considered work-related and you will qualify for benefits.

Travel 

Typically, workers’ compensation won’t cover injuries that were sustained while traveling to and from work. However, there are some exceptions. For example, if you were driving a company vehicle, running errands for your boss or going on a business trip and suffered an injury, you may be entitled to benefits.

Injuries that Developed Over Time 

Not all work injuries happen all of a sudden. Some of them, including repetitive stress injuries, occur over a long period of time. While these injuries do qualify for workers’ compensation benefits, they can be difficult to prove. You will have to have evidence that these injuries did indeed occur at work and not somewhere else.

Company Outings 

Many companies nowadays hold events for their employees throughout the year, including baseball games, picnics and barbecues. These events are typically considered work-related and any injuries sustained during those events qualify for workers’ compensation benefits.

Improper Conduct 

Employees who got injured while breaking a safety rule or doing something else that their employer disapproves may not be eligible for workers’ compensation. For instance, if you got hurt while under the influence of drugs or alcohol or while trying to hurt another person, you won’t qualify for benefits. You may also be ineligible to receive benefits if you got injured while you were engaged in horseplay. However, if your employer condoned that kind of behavior, it might be a different story.

Hiring a Workers’ Compensation Lawyer 

If you are having trouble that your injury is work related, it may be a good idea to consult with a workers’ compensation attorney Washington D.C. residents trust. He or she has dealt with these kinds of situations in the past and will know if you qualify for benefits or not. If you do qualify, your lawyer can help you file a timely claim.

During your initial meeting with a workers’ compensation lawyer, be prepared to answer several questions about your case, such as where your injury took place what kind of injury you sustained. If you have any evidence, such as medical records or witness statements, bring them with you.

Many workers’ compensation lawyers offer free initial consultations, so there’s no risk to speaking to one.

Thanks to our friends and contributors from Cohen & Cohen, P.C., for their insight into workers’ compensation.

PennLive is taking a hard look at nursing homes that were formerly operated by Golden Living.  The Texas-based chain-long battered by lawsuits and accusations of poor care (and rightly so!)- sold all 35 of its Pennsylvania homes between 2016 and 2017.

However, there are signs that problems remain in many of those homes.

If you or your loved one has any experience with these facilities – whether good or bad – please take a moment to fill out the form for PennLive on the link above, making sure to include accurate contact information. PennLive states that No information that you provide will be published without your permission.

If you’re unsure whether you or your loved one is in a former Golden Living nursing home, take a quick look at the list on the link above.

If you prefer, you can also reach PennLive reporter Daniel Simmons-Ritchie at simmons-ritchie@pennlive.com or at 717-255-8162.

McKnight’s had an article about FDA concerns over the use of Nuedexta as a chemical restraint.  Nuedexta is the only drug approved to treat uncontrolled laughing and crying due to pseudobulbar affect.  However, some nursing homes are using it for residents without pseudobulbar affect.   It’s a rare condition yet the U.S. government is cautioning private insurers to look for suspicious off-label use there because officials fear the drug is being misused to control behavior.

A CNN investigation published in October found Nuedexta’s maker had been “aggressively targeting frail and elderly nursing home residents for whom the drug may be unnecessary or even unsafe.”   CNN unearthed what seems to be a concentrated effort to keep the increasingly controversial drug in nursing home’s formularies.  The station obtained complaints sent to the Food and Drug Administration from insurers and nursing home physicians who questioned the maker’s marketing and advertising tactics.

In a follow-up article published Monday, the news organization said the Centers for Medicare & Medicaid Services issued a March memo asking Medicare Part D providers to monitor prescriptions for appropriate use.

The CMS memo told plan sponsors that Nuedexta is only approved to treat pseudobulbar affect, and that they are legally required to ensure the drug is only covered for medically-accepted prescriptions. Neudexta’s maker, Avanir Pharmaceuticals, has said that dementia patients may suffer from PBA.  No medical research supports that contention.  Since the drug launched in 2011, CNN reports Avanir has generated millions of dollars in annual sales in nursing homes.

McKnight’s had an interesting article regarding the arrests of operator-owner Joseph Zupnik and Daniel Herman, a top-level manager.  The men ran Focus Ostego, which was operated by CCRN, which was owned almost entirely by Zupnik, according to The Daily Star.  They were arraigned May 31 on three counts of first-degree endangering the welfare of an incompetent or physically disabled person, a felony; two counts of second-degree endangering the welfare of an incompetent or physically disabled person, a class A misdemeanor; and three counts of willful violation of health laws, an unclassified misdemeanor.

In 2014, the Ostego County nursing home had 298 employees. By 2016 — under new, private ownership — that number was down to 225, despite immediate jeopardy findings and plenty of other regulatory and staff warnings about quality of care.  Short-staffing always affects the quality of care.

“Upon taking ownership and control of the home’s operation in October 2014, Zupnik, Herman and CCRN cut staff payroll, cut staffing and cut other necessary services and supplies needed to provide safe and adequate care to more than 200 individual residents who were in the care of Focus through at least November 29, 2016, when Focus was designated as a Special Focus Facility by the Centers for Medicare & Medicaid Services,” read the state’s complaint.

The Attorney General’s office said CCRN disregarded communications from local and federal officials and senior staff “that residents were at risk for harm.”   Those missed opportunities for improvement included:

  • State health inspection surveys and reports that contained immediate jeopardy findings in 2015 and 2016.
  • Warnings from senior managers about the defendants’ 50% cuts in payroll and staffing and required double shifts.
  • Six arrests between May 2015 and August 2016 of Focus staff for crimes at the facility involving healthcare offenses. These included neglect of a 91-year-old fall victim and a 94-year-old woman who developed a pressure sore after 41 hours in a recliner.

Otsego County owned and operated the nursing home in question before selling it to Focus for $18.5 million. Focus has since been resold to Centers Health Care, which renamed it Cooperstown Center for Rehabilitation and Nursing.

McKnight’s had another great article on the ongoing use of anti-psychotics in nursing homes.  Approximately 20% of nursing home residents — more than 250,000 nationwide — are still receiving antipsychotic drugs as part of their long-term care treatment despite the well known dangers of off-label use of these medications.  The Long-Term Care Community Coalition claims only 2% of the population will ever have a diagnosis for a condition which the government uses when it risk-adjusts for potentially appropriate use.

Despite concerted industry and government efforts to phase out the use of certain drugs, nursing homes are still placing residents at risk of known dangerous side effects. The use of antipsychotics has been watched closely since at least 1987, when a sweeping new nursing home reform law prohibited inappropriate drugging and the use of chemical restraints. In 2005, the Food and Drug Administration issued a “Black-Box Warning” on serious risks of atypical antipsychotic drugs for elderly patients with dementia.  Several patient advocacy organizations have continued to criticize their prevalence in long-term care.

“Too many residents and families are not even made aware of the dangerous potential side-effects of these drugs, or the fact that they are not clinically indicated for so-called dementia ‘behaviors,’” said Richard Mollot, executive director of LTCCC. The New York State based coalition of consumer, community, civic and professional organizations says its goals including raising quality and accountability of care.

The analysis, based on first-quarter information for 2018, provides usage rates for “every” U.S. nursing home and provides state breakdowns.

In February, Human Rights Watch issued “‘They Want Docile’: How Nursing Homes in the United States Overmedicate People with Dementia,” a scathing report that estimated 179,000 U.S. nursing home residents are given antipsychotics without an appropriate diagnosis each week.

At the time, providers and a national association representing them said the report ignored the improvements made in nursing homes since the Centers for Medicare & Medicaid Services set a 15% reduction target in 2012.

In March, AHCA announced its latest round of quality initiatives would push providers nationwide to reduce their off-label use of antipsychotics by another 10%.

CMS has also linked financial outcomes to quality improvements and prescription management.