Ken Powers
Media Relations Manager

The Joint Commission Announces 2009 National Patient Safety Goals
for Long Term Care Organizations

(OAKBROOK TERRACE, Ill. – June 17, 2008) The Joint Commission today announced the 2009 National Patient Safety Goals and related requirements for accredited long term care organizations. The National Patient Safety Goals promote specific improvements in patient safety by providing health care organizations with proven solutions to persistent patient safety problems. These Goals apply to the more than 15,000 Joint Commission-accredited and -certified health care organizations and programs.

Major changes include a new requirement related to preventing deadly central line-associated bloodstream infections. This addition builds on an existing National Patient Safety Goal to reduce the risk of health care associated infections, and recognizes that patients continue to acquire preventable infections at an alarming rate while receiving health care. The new infection-related requirement has a one-year phase-in period that includes defined milestones, with full implementation expected by January 1, 2010.

“The 2009 National Patient Safety Goals represent ongoing opportunities for improvement that can immediately benefit patients,” says Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint Commission. “By taking action to consistently meet the Goals, health care organizations can substantially improve patient safety in America.”

A revision of the requirements for the existing medication reconciliation Goal is based on feedback obtained from a Medication Reconciliation Summit convened in late 2007 and is included in the 2009 update.

The 2009 Long Term Care National Patient Safety Goals:

Improve the accuracy of resident identification.
· Use at least two resident identifiers when providing care, treatment, and services.

· Prior to the start of any surgical or invasive procedure, individuals involved in the procedure conduct a final verification process, such as a time-out, to confirm the correct resident, procedure and site, using active, not passive, communication techniques.

Improve the effectiveness of communication among caregivers.
· For verbal or telephone orders or for telephone reporting of critical test results, the individual giving the order verifies the complete order or test result by having the person receiving information record and “read-back” the complete order or test result.

· There is a standardized list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.

· The organization measures, assesses, and, if needed, takes action to improve the timeliness of reporting, and the timeliness of receipt of critical tests and critical results and values by the responsible licensed caregiver.

· The organization implements a standardized approach to hand-off communications, including an opportunity to ask and respond to questions.

Improve the safety of using medications.
· The organization identifies and, at a minimum, annually reviews a list of look-alike/sound-alike medications used in the organization, and takes action to prevent errors involving the interchange of these medications.

· Reduce the likelihood of resident harm associated with the use of anticoagulation therapy. (Note: This requirement applies only to organizations that provide anticoagulation therapy and/or long-term anticoagulation prophylaxis (for example, atrial fibrillation) where the clinical expectation is that the resident’s laboratory values for coagulation will remain outside normal values. This requirement does not apply to routine situations where short-term prophylactic anticoagulation is used for venous thrombo-embolism prevention (for example, related to procedures or hospitalization) and the clinical expectation is that the resident’s laboratory values for coagulation will remain within, or close to, normal values.

Reduce the risk of health care-associated infections.
· Comply with current World Health Organization (WHO) hand hygiene guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

· Manage as sentinel events all identified cases of unanticipated death or major permanent loss of
function related to a health care associated infection.

· Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections. Note: This requirement covers short and long term central venous catheters and PICC lines.

Accurately and completely reconcile medications across the continuum of care.

A process exists for comparing the resident’s current medications with those ordered for the resident while under the care of the organization.
When a resident is referred or transferred from one organization to another, the complete and reconciled list of medications is communicated to the next provider of service and the communication is documented. Alternatively, when a resident leaves the organization’s care directly to his or her home, the complete and reconciled list of medications is provided to the resident’s known primary care provider, or the original referring provider, or a known next provider of service. (Note: When the next provider of service is unknown or when no known formal relationship is planned with a next provider, giving the resident, and family as needed, the list of reconciled medications is sufficient.)
When a resident leaves the organization’s care, a complete and reconciled list of the resident’s medications is provided directly to the resident, and the resident’s family as needed, and the list is explained to the resident and/or family.
In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed. Note: This requirement does not apply to organizations that do not administer medications. However, it is important for health care organizations to know what types of medications their residents are taking because these medications could affect the care, treatment, and services provided.
Reduce the risk of resident harm resulting from falls.

· The organization implements a fall reduction program that includes an evaluation of the effectiveness of the program.

Reduce the risk of influenza and pneumococcal disease in institutionalized older adults.
· The organization develops and implements protocols for administration of the flu vaccine.

· The organization develops and implements protocols for administration of the pneumococcus vaccine.

· The organization develops and implements protocols to identify new cases of influenza and to manage outbreaks.

Encourage residents’ active involvement in their own care as a resident safety strategy.
· Identify the ways in which the resident and his or her family can report concerns about safety and encourage them to do so.

Prevent health care associated pressure ulcers (decubitus ulcers).
· Assess and periodically reassess each resident’s risk for developing a pressure ulcer (decubitus ulcer) and take action to address any identified risks.

The development, annual review and modification of the National Patient Safety Goals, first introduced in 2003, is overseen by the Sentinel Event Advisory Group, a panel that includes widely recognized patient safety experts, nurses, physicians, pharmacists, risk managers and other professionals who have hands-on experience in addressing patient safety issues in hospitals and other health care settings. Each year, this panel works with The Joint Commission to undertake a systematic review of the literature and available databases to identify potential new Goals and requirements. The Joint Commission also conducts an extensive field review of candidate new Goals and seeks input from practitioners, provider organizations, purchasers, and consumer groups among others. The Joint Commission’s Board of Commissioners approves the Goals and requirements each year. Compliance with the requirements is a condition of continuing accreditation or certification for Joint Commission-accredited and -certified organizations.

The full text of the 2009 National Patient Safety Goals and requirements for all accreditation programs, along with the elements of performance, can be found on The Joint Commission’s website. Compliance with the requirements is a condition of continuing accreditation or certification for Joint Commission-accredited and -certified organizations.

Mother Jones had an interesting article about Ken Connor, the conservative Christian Republican who testified in support of a bill that would ban the use of mandatory binding arbitration clauses in nursing home contracts. Most nursing homes today, as a condition of admission, force vulnerable elderly people to waive their right to a jury trial. Instead, they must take any complaints about neglect or abuse to a private arbitrator, chosen and paid by the nursing home, in secret proceedings where awards are much lower. The arbitration agreements are often buried in a stack of complicated paperwork, where in some cases, they have been signed by blind people and those suffering from Alzheimer’s.

The nursing home arbitration bill should pass overwhelmingly. That’s why Republicans really, really don’t want to vote for the nursing home bill, and one reason Connor’s advocacy is making them squirm.   Connor sues nursing homes for a living. Just last month, Connor won a $2 million verdict against Sunrise Senior Living in California for failing to prevent and care for an elderly woman’s fatal bedsores. . As such, Republicans would love to dismiss Connor as just another greedy trial lawyer. But Connor’s religious-right bona fides simply make that impossible.

For three years, Connor served as the president of the Family Research Council, a leading social conservative outfit, and became a rock star among the GOP’s evangelical wing when he went to work in 2004 for then-Governor Jeb Bush to defend a Florida law that would have prevented doctors from removing Terri Schiavo’s feeding tube. For Republican legislators, Connor has moral authority. He also gives money to many of them, so Republicans have to tolerate him, even as he forces them into a corner where they have to chose between devotion to industry and devotion to God and life.

While the GOP views trial lawyers as its mortal enemies, Connor doesn’t see any contradiction between his profession and role as family values crusader. Instead, he sees his lawsuits against nursing homes as an extension of the work he did in the Schiavo case. "Removing the feeding tube, letting Teri Schiavo starve to death," he said in an interview, "I see this all the time with the elderly." Connor believes that the frail elderly are second only to the unborn in their suffering due to what he sees as a prevailing "quality of life" mindset, as opposed to one focused on the sanctity of life. He says he’s witnessed bioethicists in Florida argue that if an elderly person suffers from dementia, there would be nothing wrong with hastening his or her demise. "If you call yourself a Christian, you have an obligation to fight for social justice," he says, noting that, "It’s much easier to make the case for the elderly than for the unborn." 

He testified about some of his experiences with nursing homes: "All too often, the story is the same: avoidable pressure ulcers (bed sores) penetrating to the bone; wounds with dirty bandages that are infected and foul smelling; patients languishing in urine and feces for hours on end; hollow-eyed residents suffering from avoidable malnutrition, unable to ask for help because their tongues are parched and swollen from preventable dehydration; dirty catheters clogged with crystalline sediment and yellow-green urine in the bag."

Read More →

Politico’s Samuel Loewenberg wrote an article about how high priced lobbyists are attempting to get rid of necessary reforms for nursing home care to improve.

The profitable nursing home industry is mobilizing Washington’s most well-connected lobbyists to fight needed reforms,  Recently state and federal investigators and outside experts have agreed to certain reforms as a gaggle of industry lobbyists plotted strategy.

Among the lobbysts was The Carlyle Group, the politically connected and powerful private equity firm that recently bought Manor Care, one of the nation’s largest nursing home chain, for $6.3 billion.  

“In spite of existing oversight mechanisms, we continue to see examples of horrific treatment of nursing home residents,” testified Lewis Morris, general counsel for the Department of Health and Human Services’ Office of the Inspector General.

The lobbyists are carefully watching the Senate, where legislation could increase the oversight and enforcement of the industry.  It is well documented how deficient the oversight and enforcement of the industry is as evidenced by the recent GAO Report.  The senators are expected to try to attach the legislation to the upcoming Medicare payments package.

The industry lobbyists are fighting provisions to fully disclose ownership of nursing homes.  Why? No one knows. Clearly, families of residents should be able to understand who owns and operates the facility where they place loved ones. 

Additionally, penalties would be increased to as much as $100,000 if a patient is harmed or dies due to poor care. The penalties, which have not been changed in two decades, are now capped at $10,000.

To gird for the increased regulation, the industry is using a half-dozen of Washington’s most politically potent lobbying firms on both sides of the aisle.  “It is going to be pretty much battening down the hatches, because we’re not going to have a fair shake with a Democratic majority,” said a nursing home industry lobbyist who spoke on the condition of anonymity.

Since Carlyle took over Manor Care, some homes have reported significant patient care problems, said SEIU spokeswoman Julie Eisenhardt.   Meanwhile lobbyists for The Carlyle Group are stating that there is no evidence that private equity ownership negatively impacts care.   Both the Government Accountability Office and the Senate Finance Committee are still investigating the negative effect of private equity ownership on nursing home quality.

The issue is at the heart of one of the most controversial parts of the Grassley-Kohl legislation: a requirement that the sometimes-twisted ownership structures of nursing homes be made more transparent.   Congressional staff, experts, and advocates for the elderly say that private equity firms often establish layers in ownership structure as a way to dodge responsibility and legal liability.

And GAO reported how federal government regulators often miss signs of abuse and care deficiencies, ranging from failure to ensure “proper nutrition and hydration and [prevent] pressure sores” to serious deficiencies that could lead to “actual harm and immediate jeopardy.”

Here is a link to the recent GAO Report that shows a lack of investigation into nursing home neglect and abuse.  The NY Times ran a great article on this report.  Below are some excerpts from that article.

Nursing home inspectors routinely overlook or minimize problems that pose a serious, immediate threat to patients, Congressional investigators say in a new report.   In the report, the investigators from the Government Accountability Office, say they have found widespread “understatement of deficiencies,” including malnutrition, severe bedsores, overuse of prescription medications and abuse of nursing home residents.

The accountability office found that state employees had missed at least one serious deficiency in 15 percent of the inspections checked by federal officials. In nine states, inspectors missed serious problems in more than 25 percent of the surveys analyzed from 2002 to 2007.

The nine states most likely to miss serious deficiencies were Alabama, Arizona, Missouri, New Mexico, Oklahoma, South Carolina, South Dakota, Tennessee and Wyoming, the report said.

“Poor quality of care — worsening pressure sores or untreated weight loss — in a small but unacceptably high number of nursing homes continues to harm residents or place them in immediate jeopardy, that is, at risk of death or serious injury,” the report said.   Nursing homes must meet federal standards as a condition of participating in Medicaid and Medicare.

Lewis Morris, chief counsel to the inspector general of the Department of Health and Human Services, said he had often been frustrated in trying to identify the owners of nursing homes that provided substandard care.  “We have found nursing home residents who were grossly dehydrated or malnourished,” Mr. Morris said. “We’ve found patients with maggot infestations in wounds and dead flesh. We’ve found residents with broken bones that went unmended.”

William C. Lhotka of the St. louis Post-dispatch wrote an article about a Judge preventing a nursing home from evicting a resident from a nursing home.  Below is an excerpt of his article:

A judge has barred an Ellisville nursing home from discharging a resident in a billing dispute because of the possible traumatic effects of transferring her to another care facility.  The judge found for the family of Barbara H. Lindsay and against Bethesda Long Term Care Inc. which operates Bethesda Meadow.  The ruling means the nursing home cannot move Lindsay to another nursing home when Bethesda alleged Lindsay’s family owed the company past due bills.

Lindsay’s son Douglas contended that the bill was erroneous and that his mother was too fragile to move.   Jacqueline Levey, attorney for the Lindsays, argued before Vincent that "any nursing facility wishing to expel an elderly or disabled resident can simply manufacture a series of grossly inaccurate billing statements."

Bethesda lawyer James W. Erwin had contended that some billing errors by Bethesda didn’t negate the failure of the Lindsay family to make payments.  On the day before the hearing in October, the Lindsay family paid its bill in full. Nonetheless, the nursing home proceeded with the discharge, said Levey, the family’s lawyer.

Vincent cited medical testimony in his order that Barbara Lindsay "is very fragile and has very little strength." The judge said the nursing home provided no evidence that "a safe and orderly discharge could be accomplished."

Below is an excerpt of an article I recently saw from The Choate News about how California nursing homes used an increase in reimbursements from the State for profit instead of providing adequate care.

Nursing Home Pocket Money Meant For Care
By Jordan Rau

SACRAMENTO, Calif. — California’s nursing homes pocketed much of the $590 million that state lawmakers provided them to better tend to low-income people, while patient care declined by several key measures, according to a study to be released Tuesday.

A law boosting reimbursements from MediCal, the state’s health-care program for poor people, passed in 2004. By 2006, the first full year the higher rates were in place, average nursing-home revenues from MediCal had increased from $124 a day to $152 per day, according to the study by a team of researchers at the University of California, San Francisco — but few of the promised improvements for patients or staff had come to pass.

Nursing attention for patients grew, on average, by 3 percent. But the study also found that 144 homes, or 16 percent, did not meet the state’s minimum staffing standard.

Average wages for nursing assistants increased from $10.61 an hour to $11.32, not quite enough to keep pace with inflation, the study said.   Turnover among nurses grew slightly worse, with nearly 7 in 10 leaving their jobs that year.

The amount nursing homes spent on direct patient care actually decreased by 3.6 percent, according to the study. Substantiated complaints of patient mistreatment increased by 38 percent. State and federal regulators cited homes for 6 percent more violations.

“They got so much money, they should have been able to do something,” said the study’s lead author, Charlene Harrington, a UCSF professor and nationally recognized authority on nursing homes.   “The fact that they let the nursing-assistant wages actually decline with inflation, I think there’s no excuse for that,” Harrington said. “They’re the bulk of the workers and they’re the lowest paid.”

The higher reimbursement rates were pushed through the Legislature in the final two weeks of its 2004 session by a powerful alliance between the nursing-home industry and Service Employees International Union, which represents many health-care workers.

At the time, several nursing-home advocates objected that the measure lacked sufficient safeguards to ensure that the money went to patient care.

Along with more money, the new law changed the way facilities were reimbursed from a flat fee for each patient to one based on how much the homes spent on workers, patients and the physical plant. Supporters pledged that the change would reward homes that hired more nurses and paid them better.

The average nursing home netted $248,047 in 2006, a 233 percent increase from 2004, the study said.   The study found some areas where nursing-home spending did increase substantially.

For example, administrators’ wages rose by 13 percent, and the pay for licensed nurses — who have more training than assistants — grew by 9 percent.

Nonprofit nursing homes raised their wages more than for-profit homes. Still, said Michael Connors of California Advocates for Nursing Home Reform, a patient watchdog group, “to a great degree, no one knows where the money went and how it was used. What’s clear is it hasn’t been used for beneficial effects on residents, which is appalling.”

Here is an article from Long Term Living online editor John Oberlin that indicates that the economic slowdown will not affect the profits by the nursing home industry.  Cambridge Chairman Jeffrey A. Davis points out that all components of the senior housing sector appear to be in good shape, with nursing homes, assisted living, and independent living facilities all at their highest occupancy levels in years

Although the economy apparently is at a tipping point, the outlook for the senior housing/healthcare industry remains remarkably upbeat, one industry expert maintains.

"While no industry is completely recession-proof, owners and operators of senior housing/healthcare properties are better positioned to deal with an economic downturn than they’ve been at other periods in the past," believes Jeffrey A. Davis, chairman of Cambridge Realty Capital Companies, a senior/healthcare debt and equity financing firm.

"Historically, the pattern has been for the industry to go through debilitating boom/bust cycles. However, at this time, there’s no over-building and occupancy levels for all product types are high," he observes.

Davis points out that all components of the senior housing sector appear to be in good shape, with nursing homes, assisted living, and independent living facilities all at their highest occupancy levels in years.

"This time around, there has been significant restraint regarding new construction. Generally speaking, management appears to be more enlightened in this regard and consumers more aware of the expanding range of products available to them. Even if the economy tanks, the industry will not be as vulnerable as some other segments of the commercial real estate market because there hasn’t been an artificial demand component working against sound economic judgment," he said.

"Going forward, capital will continue to be available but more constrained in 2008. The crisis in confidence has impacted various lenders in different ways, and underwriting criteria has become more stringent across-the-board.

"But credit will be available from sources attracted to the industry by its long-term outlook. Investors and commercial lenders notice that demographics for the industry continue to move in a positive direction, and that the product that has emerged in the marketplace today has a much broader appeal to users than it did 25 years ago," he said.

HUD has emerged as the preeminent lender of choice for qualified borrowers in the skilled nursing home and assisted living segments and continues to solidify its role as a capital provider to under-served markets. But capital will also be coming from a variety of other sources, including Fannie Mae, Freddie Mac, commercial banks, insurance companies, private equity firms, and credit companies, he noted.

Oklahoma Center for Consumer & Patient Safety
PO Box 4481, Tulsa, OK 74159-0481


Contact: Hugh M. Robert, Ex Dir 918-850-0293

April 7, 2008



Tulsa, OK – The Public Health Committee in the Oklahoma House of Representatives considered the amended version of the bi-partisan approved Senate Bill 1549 this morning. Just minutes before the committee meeting was scheduled to begin, Representative Cox, the owner of several nursing homes, submitted a committee substitute which stripped out the insurance requirement. The committee members voted 10-9 to consider the committee substitute, falling one vote short of being able to hear the bill in the form already approved by the Senate.

“It is sad that Dr. Cox put his personal financial interest in front of requiring nursing homes be financially responsible,” said Hugh M. Robert, Executive Director of the Oklahoma Center for Consumer and Patient Safety. Robert went on to say “the Oklahoma Senate had overwhelmingly supported the amended bill and Dr. Cox, who purportedly operates his nursing homes without insurance, today showed his personal financial interest is more important to him than protecting his constituents or the citizens of the State of Oklahoma.”

The amended bill would have required nursing home operators to prove they have sufficient assets to cover claims of resident abuse or neglect. If the nursing home operator fails to keep sufficient assets and does not carry liability insurance the officers, directors and shareholders of the nursing home operator would be personally liable to a nursing home resident or their family when someone is abused or neglected.

One reason Dr. Cox as well as the nursing home lobby has cited for not carrying insurance is that the Medicaid reimbursement levels not being high enough to provide the owners with large profits and pay for insurance. However, this does not take into account the private pay residents and if the issue is with reimbursement rates, then Dr. Cox, in his capacity as a representative should work on reimbursement rates, not blocking a resident or family of a resident from holding responsible a nursing home who abuses or neglects a loved one.

If a nursing home resident is neglected or abused they should have a remedy. Robert comments “we require people who drive cars to carry mandatory insurance, why should nursing homes be any different.” “Forcing nursing home operators to show they are financially sound in order to have a license to take care of our elderly citizens just makes common sense, especially with the growing elderly population” Robert says. Most nursing home operators are for profit and carrying liability insurance is a legitimate cost of doing business. A nursing home does not have to choose between providing good care and being financially responsible, they should be required to do both.

About the Oklahoma Center for Consumer and Patient Safety- Please call 800-994-6025 or visit

Below is an excerpt from a great article from Dallas News about family councils in Texas.  The relatives of Texas nursing home residents have discovered there’s strength in numbers. Emboldened by a new state law, they’ve begun to organize more "family councils" at their nursing homes to advocate for better care.

"My mother was the one who taught me how to stand up and speak out, so it’s only fitting that I now step in for her," said Daisy Kincheloe, who knew she had to do something after her elderly mother fell at Doctors Healthcare Center in North Dallas.  Her mother’s accident was the last straw. Before that, she had discovered other problems that convinced her that some staff members weren’t paying enough attention.

Ms. Kincheloe and other families at Doctors have just formed the group to give each other moral support, act as added sets of eyes and ears around the nursing home, and bring grievances to the administration’s attention. By presenting a united front, family councils have persuaded nursing homes to respond more quickly to residents’ call buttons, improve the meals and even hire more staff.  Family councils are enjoying renewed attention nationwide because many of their newer leaders are baby boomers, whose generation is known for its activism.

Though administrators occasionally resist the councils at first, a growing number say they welcome the groups because they encourage family participation and accountability from staff.

Many families hesitate to bring up problems because they’re afraid the nursing home staff will retaliate against their relatives. Others complain but find their grievances fall on deaf ears.   A family council can add weight to a complaint, advocates say.


1. Determine the need. As few as two or three families can organize a council.

2. Advise the administrator. By law, nursing homes must provide private meeting space for councils.

3. Notify other families. Meeting announcements can be posted on bulletin boards. Administrators may also offer to mail notices.

4. Ask advocacy groups and the local ombudsman for help. Advocates and the state ombudsman program’s local representative can explain nursing home residents’ rights.

5. Hold your first meeting. Discuss the council’s purpose, ask the ombudsman to talk about the grievance process and invite the administrator to speak.

There is a great article about the use of the game Wii to help residents with socialization and physical therapyin nursing homes.  Wii-hab is the name of the game sweeping nursing homes across the region.
Morrell Nursing & Rehab Center in Hartsville and Bethea Baptist in Darlington are among the long-term care facilities taking part in the craze, much to the delight of their residents.  The new Wii-hab program uses the Nintendo Wii to promote exercise at the facility.   

The favorite game is Wii bowling, because it allows the residents to exercise upper body despite physical  limitations.  Residents and staff alike gather in the center’s sunny activities room to both play and watch others play such Wii games as bowling, tennis, baseball and boxing.

Mary Etheredge, activities director at Morrell, is the person responsible for bringing the program to all three of Wilson Senior Care’s facilities in the Pee Dee. She said so far, the program has been a great success.  Etheredge said the biggest challenge so far has been getting the male residents to participate.  The exercise from the Wii-hab is deceptively easy for many of the residents, Etheredge said, almost tricking them into doing rehab to make their daily lives easier.

“When they’re doing this, they really don’t realize how much they are moving,” she said. “It has them concentrating. They have to watch their eye and hand movement. It really works.”
While the tournament was going on, residents and employees gathered around Hopkins and Woodham to cheer them on with yells and clapping.

Etheredge said that sort of involvement has become almost commonplace since the Wii-hab program began at the facility. She said the Wii-hab program has made a difference in the quality of life for residents and it’s a change she plans on keeping around for a long time.

Hopefully this will become standard practice at other nursing homes.