Valley News reported on Vermont’s new law that will change the way officials scrutinize nursing home ownership changes after the state’s oversight came under scrutiny last year when the 67-bed Brookside Health and Rehabilitation Center closed because of unaddressed health and safety violations.  The Brookside incident aside, state officials also have been engaged in a more general discussion of changes in the nursing home industry. Those changes include a trend toward large, out-of-state companies buying nursing homes, then breaking up home operations and real estate into separate corporations.  This is done to avoid accountability for abuse and neglect, and to siphon funds to related entities.  Green Mountain Care Board member Jessica Holmes told the House Health Care Committee earlier this year that such companies are “buying up small mom-and-pop nursing homes, operating them at arm’s length and extracting short-term gains.”

The law created an eight-member group to study the ways to improve the state’s oversight of nursing homes. Nursing Home Oversight Working Group is supposed to “examine the oversight of nursing homes in Vermont, including financial stability and licensing criteria, in order to ensure the provision of high-quality services and a safe and stable environment for nursing home residents.”  The working group will look at a wide variety of issues, including the information currently reported by nursing homes and “what types of additional financial data may be necessary to evaluate nursing homes’ ongoing financial stability.”

Also, as of July 1, oversight of nursing home transfers will switch from the Green Mountain Care Board to the Agency of Human Services.  Officials with both entities support the change, saying the care board is ill-suited to regulate the increasingly complex world of nursing home ownership. Human Services Secretary Al Gobeille is pledging to develop “a very thorough, very credible review process” for when his agency takes over.   “I completely agree with the Green Mountain Care Board’s assessment that this is not the work for them,” Gobeille said.



Fox4KC reported on the new Missouri law that requires nursing and other group homes to report sexual assaults to law enforcement. Current law only required reporting to the state agencies involved.  The mandatory reporting requirement for long-term care facilities will prevent cover-ups and increase the quality of supervision by the regulatory agencies.

This law was a result of a sad and tragic story.  Margaret (not her real name) was raped in her Missouri nursing home and died one day later. The facility notified the state but mistakenly thought the Russell family had called police. In fact, the family believed the home had called police, too.  By the time they were notified, detectives said the evidence was no good and no one was ever arrested in the death of the 93 -year-old woman.

“We applaud the Missouri legislature for passing this critical piece of legislation that will provide important protections to long-term care residents,” said Lynn Faunda Donovan, executive director of VOYCE, a long-term care ombudsman program for 21 Missouri counties.

In a statement, the group noted that between 1995 and 2016, there were 128 known cases of elder sexual abuse and assault with only 20 ending in convictions.

VOYCE and Russell believe mandatory reporting will help law enforcement investigate cases before they go cold.


Law360 had an interesting article about the Trump Administration decision to ignore requests for public information about nursing homes.  At least four lawsuits have been filed in federal courts since early April accusing CMS of wrongly impeding access to various records. The allegations include improper redactions and charging of excessive fees in violation of the Freedom of Information Act.

Abuse and neglect in the nation’s 16,000 nursing homes is a widely recognized problem. Two years ago, the U.S. Department of Justice launched 10 task forces targeting “grossly substandard care” in nursing homes. Last year, a federal watchdog urged CMS to take “immediate action” to address the underreporting of physical and sexual abuse in the nation’s nursing homes.

“The Trump administration is hindering plaintiffs attorneys who investigate abuse and neglect of seniors by heavily redacting nursing home records and charging tens of thousands of dollars to produce such records, according to interviews, government correspondence and newly filed lawsuits.”

This is clearly a decision to help the nursing home industry cover up neglect and avoid accountability.   Some of the recent litigation brought by plaintiffs attorneys is aimed at gathering evidence of the administration’s motivations. In a lawsuit filed last month, two plaintiffs attorneys — Ernest Tosh of Tosh Law Firm PLLC and David Marks of Marks Balette Giessel & Young PLLC — sought any communications between CMS and third parties concerning the disclosure of nursing home records.  The attorneys want those communications in order to determine “whether CMS’ reversal of its prior policy regarding disclosure … resulted from, or was influenced by, pressure from nursing home industry representatives or others acting at their behest,” according to the suit.

Another lawsuit that Tosh and Marks filed last month accuses CMS of excessively redacting nursing home records. According to the suit, the federal agency in July 2017 demanded $9,000 to produce records, and so Tosh requested a sample of the records to ensure that they would be worth the money.

“The redactions included in the sample provided to Tosh indicate that any records [CMS] does eventually produce will be unlawfully redacted and functionally useless,” the lawsuit says.

Steele’s lawsuit is aimed at forcing CMS to certify its own estimates of appropriate staffing levels in nursing homes. CMS employees usually cannot be subpoenaed to testify about the accuracy of those estimates, and so certifications are essential to using the estimates as evidence that nursing homes were understaffed when patients suffered harm.

“It’s literally the only way we can use this in court cases,” Steele said.  “I think there absolutely was some sort of directive that came down … to cut off the spigot of data,” Steele said. “Because this data’s getting used effectively to hold these nursing homes responsible for the way that they’re treating their residents.”

The cases are Johnson v. Centers for Medicare & Medicaid Services, case number 2:18-cv-00590, in the U.S. District Court for the Western District of Washington, The Steele Law Firm LLC v. U.S. Department of Health and Human Services et al., case number 4:18-cv-00275, in the U.S. District Court for the Western District of Missouri, and Tosh et al. v. U.S. Centers for Medicare & Medicaid Services et al., case numbers 1:18-cv-00915and 1:18-cv-00949, in the U.S. District Court for the District of Columbia.


6ABC reported on the recent audit by the Federal Government which found an alarming number of nursing homes failing to report suspected abuse, including sexual abuse.  Action News Investigative Reporter Chad Pradelli has been investigating the nursing home industry in Pennsylvania for the past year.  Pradelli looked at every state inspection report in the 5 county region for 2016 and 2017.

He found dozens of cases where nursing homes failed to properly investigate and report neglect, abuse or possible abuse both physical and sexual.  The investigation found state inspectors cited nearly half of all nursing homes in the 5 county region for either failing to investigate and/or properly report possible abuse and neglect in 2016 and 2017. 85 facilities in all were cited.

Attorney Sam Brooks of Community Legal Services of Philadelphia said, “It’s not in the nursing homes interest to properly report issues and enforce regulations because it affects their bottom line.

Sam Brooks is a nursing home advocate who’s been investigating nursing home abuse. He says not only are facilities failing to report abuse or possible abuse, they do not adequately investigate.

He blames both nursing home staff and the State Dept. of Health that is responsible for overseeing them. He looked at every inspection report of nursing homes in Philadelphia from 2012-2014.

“We found 9/10 if you filed a complaint against the facility the Department of Health was not substantiating that complaint. So hundreds and hundreds of complaints were dismissed,” said Brooks. “What we were shocked by is over 3 years of complaints in Philadelphia we didn’t find one violation for sexual abuse or purposeful harm,” said Brooks.

The L.A. Times reported on a state audit that shows that California health regulators allow poor care at nursing homes around the state, and the number of incidents that could cause serious injury or death has increased significantly in recent years.  The state auditor singled out the California Department of Public Health for specific criticism, saying it had not performed necessary inspections or issued timely citations for substandard care. The audit also found that the department’s nursing home licensing decisions were inconsistent and lacking in transparency.  We have the same problems in South Carolina.

In California, confirmed cases of substandard care at nursing homes statewide increased by 31% from 2006 to 2015, according to the audit. And incidents of nursing home noncompliance that caused or could have caused serious injuries or fatalities rose by 35% in the same period.  Safety and accountability problems at nursing homes across the United States are rampant. Federal inspection reports, for example, show that infection control is routinely ignored. At the same time, the Trump administration has scaled back the use of penalties to punish nursing homes that put residents at risk of injury.

The audit showed that in the vast majority of cases where investigators found problems that could severely harm patients, the public health department failed to cite or fine the facility involved.  The quality of care at nursing homes will be critical as baby boomers age and demand for these services grows.

The state audit also investigated three large private nursing home operators whose net incomes have skyrocketed over the past decade — from less than $10 million each in 2006 to between about $35 million and $54 million in 2015. The report confirmed that the owners of the three companies are increasing their profits by doing business with companies they own or in which they have a financial interest, and siphoning money away from patient care to these “related entities”.  The three companies, Brius Healthcare Services, Plum Healthcare Group and Longwood Management Corp., paid between $37 million and $66 million to related companies from 2007 to 2015, according to the audit.

Kaiser Health News found last year that about three-quarters of nursing facilities in the country outsource services to companies that they control or in which they have an interest.  The obvious and inherent risks of such arrangements are that owners will inflate their prices to increase cross-company profits, and that it is easier for commonly owned companies to engage in fraud and conceal it.

Michael Connors, with California Advocates for Nursing Home Reform, expressed alarm that nursing home operators are making such big profits by doing business with their own companies. Nursing home chains are using these deals to “siphon off money intended for care in order to pad and hide profits” — and that hurts residents, he said.

Modern Healthcare reported that CMS, the federal agency that regulates nursing homes, will  propose a new pay model called  Patient-Driven Payment Model which would replace the resource utilization groups model they are paid under now. This is the second time in two years the CMS has suggested a payment model to replace resource utilization groups. The proposed Patient-Driven Payment Model (PDPM), a switch from last spring’s originally pitched RCS-1, will replace the Resource Utilization Group system, or RUG-IV, used to categorize Part A residents into various payment groups based on their level of need.  The nursing home industry panned last year’s proposed model, known as the Resident Classification System, because it used outdated data to establish payments.

The nursing home lobbyists are worried that the new model could pay them less for services provided to Medicare patients.  The CMS said the new system should save nursing homes 2 million administrative hours annually, or $200 million per year in labor costs.  CMS also announced an $850 million pay raise for skilled nursing facilities for fiscal 2019.

The CMS pays skilled-nursing facilities on a prospective fee schedule, which means they are a paid a predetermined amount for services they provide. The current skilled-nursing pay system separates patients into two broad care categories based on the level of care they require: patients who need general nursing services and patients who need physical, occupational and speech therapy.

The new system will have five patient categories: nursing, non-therapy ancillary, physical therapy, occupational therapy and speech training in an attempt to add more precision to the payment system so providers receive more accurate reimbursement reflecting the costs for care of all SNF residents, according to the CMS.  The proposals would allow rehabilitation physicians to conduct some meetings without being physically in the room and also remove overly prescriptive admission documentation requirements.

The CMS proposed restricting group and concurrent therapy use in order to ensure that patients can receive individual sessions when clinically appropriate. In the past, SNFs would overutilize group therapy hours because they weren’t subject to the same limitations as individual sessions. The agency also worried the providers over-relied on group sessions to curb employee hours and costs.

Under the proposal, concurrent and group therapy can only account for 25% of the overall therapy a SNF provides.  The new system will make it easier for patients and providers to figure out which nursing facilities excel at care for patients with certain conditions like heart failure. Providers and patients may choose send patients to specific facilities based on their performance under the new model, Macmillan said.

The Medicare Payment Advisory Commission, HHS’ Office of Inspector General and others have criticized current nursing home payment strategy for years because it gives nursing homes incentives to bill higher intensity rehab codes to maximize reimbursement.  Between 2002 and 2016, the share of days classified into rehabilitation classifications in SNF facilities increased from 78% to 94%, according to MedPAC. The share of days assigned to the highest rehabilitation classifications codes increased from 7% to 58%.

The proposed rule for Fiscal 2019 also updates the SNF Quality Reporting Program to add costs of current measures so that CMS can better evaluate when the price outweighs the benchmarking benefit.  But the agency does expect to begin publicly displaying the four assessment-based quality measures, as well as displaying two years worth of data connected to community discharges and Medicare spending per beneficiary.

 Tennessee‘s health commissioner has suspended admissions to two nursing homes for significant violations found during separate investigations.  Health Commissioner John Dreyzehner said that Diversicare of Claiborne in New Tazewell and Brookhaven Manor in Kingsport are barred from admitting new residents until the violations have been corrected.  The health commissioner can suspend admissions to a nursing home when conditions are detrimental to the health, safety or welfare of the residents.

The health department says problems with administration, performance improvement, records and reports, and resident rights were found at Diversicare.

At Brookhaven Manor, an investigation found violations related to administration, admissions, discharges and transfers, performance improvement and social work services.


AARP published an article on their website about the GAO Report detailing the lack of regulatory oversight for the emerging and very profitable assisted living industry.

“State Medicaid agencies are required to protect the health and welfare of residents in their assisted living facilities, including monitoring cases of abuse, neglect or exploitation. Yet 26 state agencies could not tell federal investigators how many critical incidents of this kind had occurred in the homes and other places under their supervision, the U.S. Government Accountability Office reported this week.”

State agencies also varied in what types of incidents they monitored, the GAO found. “A number of states did not identify other incidents that may indicate potential harm or neglect, such as medication errors [seven states] and unexplained death [three states],” says the report titled “Medicaid Assisted Living Services.”  See GAO Report on ALFs.

“Thirty-four states made information about critical incidents available to the public by phone, website or in person,” the report says, “while another 14 states did not have such information available at all.”

The reporting gaps prompted the GAO to recommend that federal officials keep a closer watch on state agencies to see that they properly monitor conditions in nursing homes and other facilities to protect residents.

The investigators recommended clarification of state requirements and annual reporting of critical incidents. Officials at the Department of Health and Human Services concurred with the need to clarify and said they would consider requiring yearly state reports.

Agencies in 48 states reported spending more than $10 billion on assisted living services in 2014, covering more than 330,000 beneficiaries.

The New York Times had an incredible (and scary) article on assisted living facilities. Billions of dollars in government spending is flowing to assisted living industry even as it operates under vague standards and limited supervision. “Federal investigators say they have found huge gaps in the regulation of assisted living facilities, a shortfall that they say has potentially jeopardized the care of hundreds of thousands of people served by the booming industry.”

The federal government lacks even basic information about the quality of assisted living services provided to low-income people on Medicaid according to the Government Accountability Office, a nonpartisan investigative arm of Congress.  The report provides the most detailed look to date at the role of assisted living in Medicaid, one of the nation’s largest health care programs. Titled “Improved Federal Oversight of Beneficiary Health and Welfare Is Needed,” it grew out of a two-year study requested by a bipartisan group of four senators.  See GAO Report on ALFs here.

States reported spending more than $10 billion a year in federal and state funds for assisted living services for more than 330,000 Medicaid beneficiaries, an average of more than $30,000 a person, the Government Accountability Office found in a survey of states.

States are supposed to keep track of cases involving the abuse, neglect, exploitation or unexplained death of Medicaid beneficiaries in assisted living facilities. But more than half of the states were unable to provide information on the number or nature of such cases.

Just 22 states were able to provide data on “critical incidents — cases of potential or actual harm.” In one year, those states reported a total of more than 22,900 incidents, including the physical, emotional or sexual abuse of residents.

Congress has not established standards for assisted living facilities comparable to those for nursing homes. In 1987, Congress adopted a law that strengthened the protection of nursing home residents’ rights, imposed dozens of new requirements on homes and specified the services they must provide.

Healthcare Finance News reported on how many for-profit chains are cheating the Five-Star Quality Rating System on Nursing Home Compare. The five-star rating system that Medicare uses to compare nursing homes is made up of three components: employing a base score from an on-site inspection, along with two scores from information on staffing and quality reported by the facility.  These overall ratings have climbed higher as self-reported scores have inexplicably trended upward.

A new study of nursing homes in California, the nation’s largest system, by faculty at Florida Atlantic University and the University of Connecticut found that nursing homes inflate their self-assessment reporting to improve their score in the Five-Star Quality Rating System employed by Medicare to help consumers.   Among the findings were that nursing homes that have more to gain financially from higher ratings are more likely to improve their overall rating through self-reporting.

The report states “We find a significant association between the changes in a nursing home’s star rating and its profits, which points to a financial incentive for nursing homes to improve the ratings.”