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nursing home industry panned last year’s proposed model, known as the Resident Classification System, because it used outdated data to establish payments.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.

McKnight’s had an interesting article about the changing demographics in nursing homes throughout the United States.  Younger residents are using facilities more often — bringing with them fewer physical demands and more behavioral health diagnoses.  Across the country, the under-65 proportion of residents climbed steadily from 16.5% of residents in 2011 to 17.4% in 2015. The rate jumped most for those between 55 and 64, up from 9.8 % to 11.1% in 2015.

“We’ve typically had this image of a nursing home of being (for) older adults, and now they are middle older adults,” said Ian Matt Nelson, a research scholar at Miami University’s Scripps Gerontology Center.  Nelson recently co-authored a report on this new generation of nursing home residents for the state of Ohio, where 20% of Medicaid long-stay residents were under 65 in 2015. That puts it 11th in the nation.

Co-author John Bowblis told McKnight’s that unpublished data from the study shows Utah leads the nation in the prevalence of young long-term care Medicaid patients, followed by Illinois, Nevada, Missouri and Arizona.

Almost half of the young Ohio residents had a diagnosis of severe mental illness — including bipolar disorder or schizophrenia — and nearly a quarter had paralysis. Those numbers compared to one-quarter and one-tenth, respectively, among seniors.

Meanwhile, younger residents are less likely to need help with activities of daily living that nursing home workers are typically trained to handle. In 2015, 28% of Ohio’s under-65 population had one or fewer ADLs.

Katherine Judge, a professor of psychology at Cleveland State University, told Crain’s Cleveland that younger adults will present a challenge for nursing homes.

“I think the implications are what are we doing on the community side and on the nursing home side to address the needs?” Judge asked. “It’s not clear for example what community services would best meet the needs of these individuals, or at this point how nursing homes might be able to offer different services to address their needs.”

 

The Kansas City Star had an interesting article about Skyline Healthcare–whose headquarters are above a pizza parlor in New Jersey.  Last month, the Kansas Department for Aging and Disability Services petitioned the courts to take control of Skyline’s 15 nursing homes across Kansas, saying Skyline was on the brink of financial collapse and 845 nursing home residents were at risk.  Nebraska officials had taken similar action about a week earlier with 21 facilities owned by a subsidiary of Skyline.

Formed in 2008, Skyline grew exponentially as its owners took over operations of 110 nursing homes in six states between 2015 and 2017. In two years, Skyline — through dozens of subsidiary LLCs — took control of dozens of homes in Massachusetts, Florida, Arkansas, Nebraska, Kansas and South Dakota.

William Murray III, an attorney who has filed malpractice and neglect suits against Skyline nursing homes in several states, said the numerous LLCs associated with Skyline — like Dorothy Healthcare Management — are gimmicks.

“Oftentimes in the change of ownership process, new operators will create companies that have no track record and no history, even though the people behind them do, in order to escape any scrutiny about whether they’re qualified to take over the facilities,” Murray said.

“Where are all the people who supposedly work on the second floor of a New Jersey pizza parlor? The people who are supposedly working for Dorothy Healthcare Management, taking care of all these frail, elderly Kansans?”

When Skyline took over the ownership and operation of the nursing homes, vendors didn’t get paid and staff paychecks would be direct deposited, taken back and then re-issued days later on paper checks.

“I really think there needs to be a more intensive financial review for them coming in,” said Cindy Luxem, the executive director of the Kansas Health Care Association. “Because I honestly don’t believe the Skyline people had a year’s worth of working capital.”  “The people that own Skyline, they’re not health care providers,” Luxem said. “They’re merely people looking for an investment. Unfortunately, there’s a lot of that in our industry right now, but I wish the state of Kansas had a little bit better checks and balances on people coming into our state.”

The company was owned by a single family, the Schwartzes (Joseph, Rosie, Michael and Louis).  Stephen Monroe, a partner at a research firm called Irving Levin Associates that specializes in the senior housing and health care investment markets, said nursing home industry watchers used to joke about their office above the pizza joint in Wood-Ridge, N.J.

“It’s a group of good ol’ boys from the East Coast buying up a whole bunch of nursing homes in the Midwest because we’re the cheaper ones,” said Carol Tsiames, a former administrator at the Kaw River Care & Rehabilitation Center in Edwardsville, who left about eight months after Skyline took over.  “They abuse the system. Encourage you to use local vendors, and then they don’t pay. … It puts an administrator in a bad position.”

1011Now reported the arrest of nursing home employee after officials said she stole pills that were for residents.  The Lancaster County Sheriff’s Office said Joan Jilek was taken into custody and charged with acquiring a controlled substance by fraud.

According to LSO, one of Jilek’s duties at the Waverly Care Center was to distribute medicine to residents.  LSO said Jilek is suspected to have been stealing pills for about three weeks and stole 22 Oxycontin and oxycodone pills.  Eventually, other employees noticed that pill counts were off and reported prescriptions missing.

 

 

See article about the tragic and preventable death of a long time nursing home resident.  Mark Billiter died as a result of the nursing home’s failure to realize and communicate to police that he was missing from the nursing home.  Billiter suffered from a heart attack-induced dementia which made him confused and wander away from the nursing home.  Police reports  indicate he used the elevator security code and walked out while following another patient’s visitor.  A nursing home staff member ushered them both out, the reports show.The nursing home is required to supervise him to keep him safe.

Billiter had slipped out the care facility where he had lived for years. Billiter had not been reported missing by the time a Canton police officer encountered him hours later.  The police found him but no one informed them he was missing from a nursing home.  They drove him to the city limits. National Weather Service records show the temperature dropped to 32 degrees and was below freezing Monday into Tuesday with a wind chill consistently in the 20s.  He was found dead there two days later.

“This is a person who has obviously lived in a sheltered care facility for three years and is now outside …,” said Tracey Laslo, the family’s attorney. “He lacks cognition to live outside of a nursing facility. This was supposed to be a safe harbor and a place of protection for him.  He was a known risk. That’s the reason he was in a secured unit,” she said.

“If the nursing facility had reported this to the family and to police, this tragic ending would not have happened. The police would’ve been able to secure him and return him, and Mark would’ve been OK at this point. The travesty in this case is the nursing home did not follow (its) own policy. There should’ve been an immediate perimeter check of the facility by the staff, the family should have then been contacted so that they could assist and the police should’ve been contacted.”

The St. Louis Post-Dispatch had an article on the neglect that led to a resident almost freezing to death outside the home on three different occasions.  Two other residents were also allowed to wander away from the facility.  Staff at Autumn View Gardens assisted living facility put residents in imminent danger in January when three residents with dementia were found outside the building in freezing temperatures, according to a state investigation.

The facility, owned by Colorado-based Bethesda Senior Living Communities, satisfied investigators’ citations by installing a new door alarm system, retraining staff on supervision policies and adding a full-time receptionist at the front desk.

One resident with Alzheimer’s disease went outside without a coat for 10 minutes on Jan. 3 when the temperature was 27 degrees. The next day, the resident again went outside without a coat or shoes when the temperature was 18 degrees. On Jan. 6, with a temperature of 4 degrees, the resident went outside a third time without coat or shoes. Family members had previously expressed concern about the resident’s tendency to wander, inspectors from the Missouri Department of Health and Senior Services wrote in a February report after a visit to the facility.

During the inspectors’ visit, there was no documentation of the resident as an “elopement risk” and no picture posted at the front desk as recommended. The resident’s doctor told the inspectors that the resident had worsening dementia and should not be allowed to go outside unsupervised.

A second resident with dementia was found sitting on the ground two blocks from the facility on Jan. 24 with no coat and wet pants in 42-degree weather. A passer-by had alerted staff at the facility of “an older person walking down the street.”

A pastor at St. Richard’s Catholic Church across Schuetz Road from the facility brought back a third resident with known confusion and memory problems who had walked into the church without a coat on Dec. 30, when the high temperature was 25 degrees.

Staff members told the investigators that the front doors were locked at night but that residents could still get outside. They need to ring a bell to get back in, but “if a resident got confused and did not understand how to ring the bell or if staff were busy assisting another resident, he/she could be outside for a long time,” the report states.

When opened, the facility’s front door and side exit doors send alarms to staff members’ pagers, “but staff did not always have time to check the doors if they were busy assisting other residents,” according to the investigators’ interviews.  This occurs when the facility is short-staffed.

On Feb. 2, investigators found no one sitting at the front desk at 9 a.m. and watched a resident walk outside without signing out. Staff did not respond to the resident or to several other instances when investigators opened various doors in the facility, according to the report.

An aide told investigators that he or she had brought concerns to management about the lack of supervision of residents. There were 72 people living in the facility at the time of the investigation.

“They are supposed to be assisted living, but cannot check on everyone, assist with activities of daily living, pass medications and supervise residents when there are only two or three of them on duty,” the aide said in an interview with investigators.

Lauren Weiler for CheatSheets wrote about the dark secrets nursing homes do not want the public to know.

1. Some contracts don’t allow you to sue if something goes wrong:

Knapp & Roberts notes you should review all of the print in your paperwork, and keep a watchful eye out for anything noting “binding arbitration agreements.” Essentially, this agreement means you must settle your differences outside of court, removing your right to sue. If anything serious happens, you certainly don’t want to be bound by this clause.

2. Residents don’t always have as much freedom as they want:

One study found out of 65 nursing home residents interviewed, about half felt depressed due to a lack of independence and freedom, as well as loneliness. The interviewees also seemed to prefer homes that had programs designed to reduce their sense of isolation from others.

3. Residents don’t always get enough to eat:

 A 2015 overview from Nursing Older People found nursing home residents are among those who have higher rates of “anorexia of aging,” and over 50% of residents studied also complained of constipation. Your home of choice should have a plan in place to combat these issues.

4. Some of the ‘nurses’ aren’t nurses at all:

Every nursing home has some number of permanent nurses — but not everyone working is a staff member you’ll see again. Bottom Line Inc. explains “agency nurses” are often employed when a home is low on permanent staff. These temporary nurses work for staffing agencies and rarely form bonds with residents because of their position. For your comfort, it’s wise to choose a home with a staff that’s at least 80% permanent nurses.

5. Residents often have to leave the doctors they’re used to behind:

Knapp & Roberts explains most nursing homes have assigned physicians, which makes it difficult for residents to keep the doctors they’re used to seeing. If you’re really attached to your current doctor, it’s best to ask a potential home about their rules regarding this. You should also ask the home how often the physicians see their residents and what the health care plans may look like before committing.

6. Low staffing levels are a huge issue:

Up to 95% of American nursing homes may be understaffed.

Some homes have a difficult time finding enough staff, but other homes purposely understaff to cut costs. Having a bad patient to staff ratio is stressful for the staff and bad for your care. It may also leave you vulnerable to neglect and abuse. Be sure to ask what the patient to staff ratio is in your chosen home so you can ensure you’re getting the care you’re promised.  There should be at least 4.1 hours per person per day of direct nursing care.

7. Nursing homes may send a bill to relatives for the resident’s care:

According to Mass Mutual, the average amount paid for assisted living in 2017 was $3,750 per month. While you may have multiple ways of taking care of these costs, you should ensure none of the expenses accidentally get sent out to relatives. This happened in 2012 to a man who was forced to pay nearly $100,000 of his mother’s care without realizing it. Know what your state laws are regarding billing, and as always, have both you and your family members read the fine print.

8. The staff isn’t always clean:

Nursing home staff are careful with washing their hands, right? While this may seem like an obvious practice of personal hygiene and to prevent the spread of infections and communicable diseases, not all staff members participate. The New York Times reports many nursing homes are being cited for “hand hygiene” deficiencies.  Unsurprisingly, the nursing homes that were understaffed found the most hand-washing issues. Finding a well-staffed home may be key to your overall health.

9. Nursing assistants don’t need as much training as you think:

They may seem official, but many nursing assistants have no formal training at all to take care of you. NursingAssistantGuides.com explains some clinics will hire untrained workers and train them to be nursing assistants at the facility. Even for those who have a degree as a CNA, that can be acquired online with no hands-on experience. And many CNAs start at nursing homes and then move on to jobs with better pay, making the turnover rate incredibly high.  CNAs are not licensed health care providers.

10. Neglect is a common issue in the homes:

Next Avenue explains out of all the cases of nursing home abuse, neglect is the most common. While there are times when neglect is intentional, it isn’t always this malicious. Inadequate staffing and high turnover rates can also lead to this issue.  When choosing a nursing home, take a look at the other residents. Do they seem clean and well taken care of? The living quarters should also be clean and safe, with little wear and tear.

11. Some nursing homes may tell you to get extra aid outside of their care:

Staff in your chosen home are required to provide you with the care you need. If you’re ever told you need an outside aid to assist you for additional costs, Knapp & Roberts says to take note. This is negligence on the part of the nursing home.

12. The physical therapy units aren’t always up to snuff:

While you may be more concerned with what the rooms and eating areas look like, don’t forget to tour the physical therapy unit. Bottom Line Inc. explains if you require rehab of any kind, this is particularly important. Take a look at the machinery and ask if physical therapists are on the staff itself or just doing contractual work. If your nursing home is staffed with physical therapists, it’s likely to give you better service.

13. The ‘activities schedule’ might be a total bust:

U.S. News & World Report reminds us many nursing homes are still lacking in the activities department. While birthday parties and Bingo are commonplace, you’ll need more than that when choosing a place for your future. And the best homes will ask each resident about their interests to try and accommodate as many people as possible. Certain homes offer gardening clubs, cooking classes, and art therapy, so make sure you ask what’s available.

14. Most residents will have a lack of privacy:

While many folks in nursing homes like having company, there’s also another issue you may not have thought of: a lack of privacy. Bottom Line Inc. explains most homes offer a wide range of shared rooms, with private rooms costing serious cash. Not all shared rooms are bad, however. You’ll just want to make sure what’s dividing your bed from someone else’s is sturdier than a thin curtain.

15. More serious forms of abuse take place, too:

The National Council on Aging report about one out of every 10 Americans over 60 experience abuse — and it can even occur in nursing homes, Spangenberg Shibley & Liber LLP says. Neglect aside, the publication notes sexual assault and abuse has also been cited in certain homes. And many other instances of abuse go unreported. Do your research to see if any abuse allegations have been filed against your home of choice.

Cleveland’s The Plain Dealer reported that certified nursing assistant jobs have one of the highest reported rates of injury in Ohio and across the nation, according to researchers and government reports. Nursing assistants are injured three times more often than the average worker, data show.  The rate of injury among nursing assistants is similar to the rate among construction workers, police and firefighters, according to 2016 data from the U.S. Bureau of Labor Statistics.

For the more than 75,000 residents of Ohio’s 960 nursing homes, nursing assistants provide nearly all of the hands-on care. It is a job that requires dedication, passion and empathy.  State and federal officials have issued reports on injuries at nursing homes, dating back to 1999. The studies found that the lifting and moving of residents and the nonstop pace necessary to meet residents’ needs have caused thousands of Ohio nurses and nursing assistants to suffer injuries from overexertion and falls.

The pay in Ohio has trended downward for more than a decade, according to the Paraprofessional Healthcare Institute, a New York watchdog group that advocates for nursing assistants and home health-care workers. In 2006, their average wage was $12.80 an hour. In 2016, it was $11.96.  (It is about $10.50 in South Carolina).

“It’s appalling,” said Toby Edelman, the senior policy attorney for the Center for Medicare Advocacy in Washington, D.C. “That’s not a living wage for anyone.”

The low pay and the physical demands of the job result in an unusually high turnover rate. In Ohio, that rate was 54 percent for nursing assistants at nursing homes in 2015, the most recent data available, said John Bowblis of the Scripps Gerontology Center at Miami University in Oxford.

To offer quality care, staffs at nursing homes should provide an average of 4.1 hours of care for a resident each day, researchers said.

“A large proportion of people in nursing homes need two [assistants] to help them move, and many nursing homes just don’t have enough staff to offer that,” said Charlene Harrington, a professor emeritus of nursing at the University of California at San Francisco and an expert on nursing home staffing. “The better the staffing in nursing homes, the better the care and the less likely workers will get injured.”

This is a gargantuan problem in nursing homes,” said Brian Lee, who leads a Texas-based national advocacy group for nursing home residents called Families for Better Care. “[Nurses and nursing assistants] are overworked, short-staffed and underappreciated. The burnout, the frustration, the injuries. They can all be prevented if employers just hire more people.”

 

McKnight’s had an article about the new in-depth analysis published by the Henry J. Kaiser Family Foundation.  According to the data, occupancy rates at nursing homes fell between 2009 and 2016, however, the needs of nursing home residents have grown considerably — placing more demands on unprepared and under-staffed nursing employees.  Average total nursing hours increased to 4.1 per resident day for 2016, up from 3.9 in 2009.

In 2016, nearly half of nursing home residents had a dementia diagnosis, and just under one-third had other psychiatric conditions such as schizophrenia, mood disorders or other diagnoses. In addition, the report found nearly two-thirds of residents received psychoactive medications, including anti-depressants, anti-anxiety drugs, sedatives, hypnotics and antipsychotics.

Over the past 25 years, numerous research studies have documented a significant relationship between higher nurse staffing levels, particularly RN staffing, and the better outcomes of care,” wrote lead researcher and staffing expert Charlene Harrington, RN, Ph.D., FAAN, professor emeritus at the University of California-San Francisco School of Nursing. “Nursing assistants who provide most of the care to these individuals often have limited training in working with this [behavioral health] population. … Regulations could implement ACA requirements to improve the quality of care for residents with cognitive impairments and further restrict the use of psychotropic agents.”

The report is based on the federal Online Survey, Certification, and Reporting system (OSCAR) and Certification and Survey Provider Enhanced Reports (CASPER) system and also examines staffing levels, payment, and compliance.  The most common deficiencies in 2016 were given for failures in infection control, accident environment, food sanitation, quality of care, and pharmacy consultation.

“In 2016, more than one in five facilities received a deficiency for actual harm or jeopardy,” Harrington wrote. “As with other outcomes, there was wide variation across states in these outcomes; however, some states had high rates across all top ten deficiencies.”

Other key findings of the report include:

  • Between 2009 and 2013, the average number of deficiencies per facility declined from 9.33 to 7.28, though there was a slight increase between 2013 and 2016.
  • The proportion of for-profit facilities increased from 67% in 2009 to 69% in 2016.
  • Medicaid is the primary payer source for most certified nursing facility residents, with 62% of residents — about 832,000 people — having Medicaid as their primary payer in 2016. States in the East have higher Medicaid population shares.

WFAA reported on the investigation into over-medication at Duncanville Healthcare and Rehabilitation Center.  Parkland Hospital investigators are conducting a review for possible over-drugging of patients in an alleged practice known as taking patients “to China.”  The reviews follow the WFAA series, “Drugged and Dying,” that investigated the unnecessary use of alleged powerful antipsychotic drugs to sedate or control patients.

In an effort to cut costs on staffing, many nursing homes drug the elderly rather than hire needed staff, patient advocates warn. They have dubbed the practice “chemical restraints.”  WFAA found in its “Drugged and Dying” series that about 70 percent of a typical nursing home expense goes to staffing.

Several witnesses have come forward stating that residents at Duncanville Healthcare and Rehabilitation were being sedated unnecessarily and inappropriately.   “They said: ‘Take this lady to China,’” the former employee told WFAA.  “It just can be any medication that will put a person to sleep,” the worker said.  “They took that lady to China, and she went to the hospital,” the worker said. “The lady never did come back from the hospital.”

The former employee claims the patient was given the antipsychotic drugs Risperdal and Seroquel. However, the patient, who had been awake and talkative – after receiving the drugs – was placed in bed and became nonresponsive, and within six hours was picked up in an ambulance – and later died, the worker said.  Advocates say the medications – particularly antipsychotics – may become another form of abuse when inappropriately and unnecessarily given. In fact, antipsychotic drugs may be potentially fatal for elderly patients.

Other patients at the Duncanville facility also may have been unnecessarily medicated, according to several workers.