The website Skillednursing News.com had a conversation with a nursing home therapist about the new reimbursement model Patient-Driven Payment Model (PDPM). The early takeaway from PDPM is the effect of therapists who work at skilled nursing facilities.

Almost instantly after the PDPM shift on October 1, Skilled Nursing News received a flurry of e-mails from therapists who were laid off or saw their hours reduced as providers adapted to the new system — which bases reimbursements on resident acuity, and not the volume of services provided.

The federal government framed the shift as a way to reduce the unnecessary provision of therapy minutes for financial gain, which officials asserted was all too prevalent under the previous Resource Utilization Group (RUG) system. But experts, consumer advocates, and therapists claim that operators are cutting therapy services to the detriment of resident outcomes.

One of the therapists who sent in concerns to SNN’s inbox agreed to take part in our regular Confessions series, a Q&A feature that offers players in the post-acute and long-term care space an anonymous platform to express their opinions.

Tell me about your experience with the PDPM shift.

I’ve worked mainly the past 10 years in nursing homes — primarily the same nursing home, basically. But in 10 years, even though I’ve been in the same nursing home, one, two, three, four different employers have come and taken over the therapy. I think that seems to be common with with therapy departments —they lose contracts with national companies, or they go in-house, and it just switches around.

There’s always changes with Medicare; over the past 10 years, there’s been Medicare changes, but it’s been sort of a gradual decline. We haven’t had a pay raise since 2011.

The company has changed, like I said, four different times. So there’s been a deterioration — you’re not going to get a raise, but we still want you to do more. And then there’s obviously been some big changes — PDPM, and there’s probably more to come.

People have been laid off as the companies changed. People have lost their jobs — like a few here, and then a few in the next round of changes, and then I lost my job with PDPM.

How many other people lost their jobs, or had their status change?

I think it was just me this time. When we changed, some people left on their own, and with PDPM, we had one person elect to leave because PDPM also coincided with the change of company again. It was kind of: Two things happened at the same time. This all happened the beginning of October.

Walk me through how your bosses conducted the PDPM transition from your perspective — over the last 18 months, a lot of leaders told me about their plans for the change, but what did it functionally look like on the ground?

From my perspective, we started 2019 with the big national company, and they were preparing us with webinars, and then they’d do teleconferences. [It was] mandatory — everyone would sit around the phone and listen on about what changes they were going to make.

But then, in the springtime, that’s when we went in-house. And once we went in-house, they didn’t prepare us. They just didn’t have any in-services for us, or tell us anything about it. And then I guess it was around October when we were no longer in-house; another company took us over, a smaller company. At that point, they just told us to do group.

And then they also said to do concurrent. This has been the main push, that you have to do groups, and they want you to do concurrent. We used to do that 10 years ago — we were doing that, and then we were told not to do it, and now we’re being told to do it again.

What sort of justification is being given for these shifts? In theory, PDPM is supposed to allow therapists to tailor their services more closely to residents’ needs, but I have heard anecdotal stories about therapists being told to hit certain thresholds.

It seems to be that we just need to do it and we’re not told why. Ten years ago, we did groups because we just had a lot of patients. We didn’t have a lot of therapists, and I suppose it was an economic factor.

We do groups in rehab, because the focus is more that it’s socialization, and you’re going to have a topic, and it’s very well planned — whereas skilled nursing has always been difficult. You can’t always schedule your day; it’s hard to schedule a group sometimes, because people don’t want to do it all, you know, at 11 o’clock. They’re not ready.

It’s just now we don’t have as much time to schedule our patients as you do in acute rehab.

From your standpoint, do you think PDPM will achieve the goals that the government has laid out for it? For me, it’s hard to reconcile the two main opposing forces: the government saying the old system encouraged fraud, and the many therapists reaching out to me saying the new system is just making it worse in different ways.

I agree that the RUG system was just taking minutes. Fortunately, the facility I’ve been in the past 10 years, we didn’t keep people 100 days just to keep them. I mean, there was pressure, if it was the last day of their ARD and they couldn’t get their minutes, you might be asked to go back because they would lose out on money that they’d been working on for weeks up until that point. There was pressure like that.

But PDPM should be a good thing because they’re running out of money, and we don’t want to be giving services [that people don’t need]. And I know there are nursing homes that just keep people 100 days and give them lots of minutes of therapy when it’s not appropriate.

So I think it’s a good thing, but my concern is that because the money is running out, it’s our problem. It becomes our professional problem, because I think nurses are getting raises — and they’re working within the Medicare system. And the CNA is getting a raise. But because therapy is not making money, we get directly affected in our salary. There’s less emphasis on in-servicing about patient care, and more in-servicing about which code to use — and telling us that we need to do more of the administrative [work].

We don’t have a rehab tech, so we have to scan our documents and do all this extra [work] because they don’t have money, I guess, to pay for a tech to help us to transport or to do these things. We used to have a tech — 10 years ago, we had two of them.

So yeah, I think PDPM is good, but it’s bad how the companies are reacting — and they just take everything out on us. I don’t think they’ve had a pay cut, whoever is the director of the companies, or the director of the nursing home; they’re getting a cost-of-living increase, or they’re probably getting a raise, but we’re not.

It’s all the small little things that make you feel like you just are being erased, and you’re not valuable to them because you’re not making money anymore.

In the wake of the change, there’s been a sort of feeling that layoffs were inevitable, or that companies should have cut even more jobs just based on the math — but even more so than in other industries, you are dealing with people’s lives.

I’ve worked in health care enough to know that you have to change. They’re always changing their focus in rehab to where the money might be.

Twenty years ago, I was in acute rehab, and they all of a sudden started a vent unit because I think it was going to be something they could get money from. The focus wasn’t: “Oh, we have a lot of people on ventilators that need to be weaned.”

Maybe I’m cynical, but it has to be driven by: “Can we make money off this type of care?”

Is there anything else that you want leaders in the space to understand about your experience and the state of therapy today?

Residents and family are seemingly unaware of the changes. They don’t seem to know that they’re in a group because there’s been changes to Medicare and their length of stay is going to be shorter.

If the executives have any plans of educating Medicare recipients and family so they don’t expect their mom to get, you know, an hour of therapy — they might get 30 minutes — not to make big promises anymore about therapy, because we’re stretched too thin.

I saw an interesting story that raises moral, ethical, and legal issues related to dying with dignity and chocie.  What do you think?

On April 5, 2018, Andy Jurtschenko went into surgery at Newark Beth Israel Medical Center in New Jersey.  He needed a new heart but instead Andy suffered extensive brain damage due to a lack of oxygen during the heart procedure.

As one of the top 20 programs statistically across the nation, Jurtschenko felt safe in Newark Beth Israel’s hands especially Dr. Mark Zucker, and the main surgeon, Dr. Margarita Camacho. The program is nationally known for maintaining a high success rate while taking on the sicker and riskier patients, operating on older, overweight, and those who have had regular visits to the intensive care unit because of their hearts.

For a single heart transplant, a hospital usually bills insurers around $1.4 million, and the better survival rates look to the public, the more patients that will choose to receive treatment at the facility. This business mindset forces transplant teams to look at patients not as humans, but as “percentages” and “numbers”.

A do-not-resuscitate order, or DNR order, is a medical order written by a doctor. It instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient’s breathing stops or if the patient’s heart stops beating.  A DNR order is created, or set up, before an emergency occurs. A DNR order allows you to choose whether or not you want CPR in an emergency. It is specific about CPR. It does not have instructions for other treatments, such as pain medicine, other medicines, or nutrition. The doctor writes the order only after talking about it with the patient (if possible), the proxy, or the patient’s family. Families order DNRs for multiple reasons. Sometimes a DNR is the obvious choice. It would preserve a patient’s dignity and reduce the amount of suffering the patient and the family will have to endure throughout the process.

Before a heart transplant surgery, a patient is not able to have a DNR in their file because the new heart may require stimulation to begin to pump, but after surgery, a patient or surrogate can ask for a DNR at any time and it must be sign by the physician and placed in their medical record.  It is a numbers game rather than a moral dilemma.  So when the Jurtschenko family requested a DNR for Andy, the doctors refused to sign.  On the morning of Oct. 31, 2018, Andy Jurtschenko passed away from a weakened heart after a long six month unnecessary battle between his value as a statistic and his doctors in the Newark Beth Israel’s hospital over his request for a DNR.

In the case of Andy Jurtschenko, a DNR could have reduced the suffering he and his family experience, but because his death would lower the program’s one-year survival rate, it could be assumed that doctors convinced the family that he would make a full recovery in the future.  It was not until Andy Jurtschenko was admitted into a nursing home where they caught the mistake that he was not supposed to be resuscitated, meaning the hospital never placed the DNR request in his record.

 

 

 

 

 

EHR systems can track a patient’s vital signs, prescriptions, and health records, forcing the medical profession into a new era of electronic healthcare. With the advancement of technology, major medical corporations are starting to switch over to an electronic healthcare record (EHR) system that may increase efficiency in the health care market but several issues have been raised in cases where the new system has failed resulting in death. This often happens in nursing home cases that we prosecute.

In reviewing state and federal court filings about EHR wrongdoing, Kaiser Health News (KHN) and Fortune found around 24 cases of safety and installation concerns. In the case of Midwest Regional Medical Center in Oklahoma, doctors were finding the device unable to accurately track specific drug prescriptions and dosages correctly, creating the possibility for a major health and safety concern with their patients. This suit claimed that the hospital chain based out of Tennessee gained millions of dollars in the promised government subsidies by fraudulently covering up and ignoring flaws in the EHR systems from the Oklahoma hospital. Other suits claimed that corporations knowingly falsified government-mandated reviews, put in place to ensure the patient’s safety, just to receive federal subsidies. KHN found that nearly 28% of doctors and 5% of hospitals who claimed to have met government standards failed later audits to the system.

These systems were created and encouraged by the health care industry to eliminate medical errors that are caused by stupid mistakes or false documentation. Congress, in 2009, granted subsidies from $44,000 to $64,000 if they switched to this new electronic system and completed an “open book test” on the program. In order to receive the funding promised, doctors and vendors have turned towards “doctoring” their programs in order to receive certification. And this is only the start of the fraudulent system.

Corporations such as Community Health Systems (CHS), Medhost, and eClinicalWorks deny any allegations brought to court, reaching million dollar settlements without admitting any wrongdoing.

It’s a new era of health care fraud. Hospitals and doctors going unchecked and are putting their patient’s lives at risk for a big payout. In the end, the ones suffering from this fraud are patients, and it is up to whistleblowers and federal offices to enlighten the world on the abuse of power from doctors, hospitals, and corporations alike.

 

The shortage of nursing home workers is caused by low pay, the working conditions at many nursing homes, and the lack of benefits especially health insurance. Nursing home work is harder than most; it involves lifting, bathing, cleaning up after our elders who can’t manage on their own so well anymore. Another reason is that workers have plenty of other options to work for minimum wage. Nationally, just 3.5% of the workforce is unemployed, the lowest in roughly 50 years.

Nursing homes are desperate for staff at all levels, from registered nurse to certified nursing assistant, a job that doesn’t necessarily even require a high school diploma.  For nurses, it’s scary to have so few of them on each shift, and many flee to work at places that aren’t so understaffed.

The economy will decline and shift in favor of nursing home employers, but demographics will exacerbate this particular staff shortage for at least a decade or two. Soon, the huge generation of Americans born in the baby boom after World War II will start entering nursing homes. The later generations that make up the work force are smaller, and therefore the ratio of people of nursing home worker age (18 to 64) to senior citizens (65 and older) has shrunk rapidly.

Meanwhile, lobbyists are pushing a bill that would require “safe staffing” levels at all nursing homes.  Most experts and consumer advocates contend that a minimum of 4.1 is needed for safe staffing.

 

 

Hidden cameras should be allowed in nursing homes to protect residents; prevent fraud; and to monitor the effectiveness of treatments. Recently, I read a tragic story about the abuse and neglect suffered by Skip MacNally, a resident of Peak Resources nursing home.

Her daughter, Renee Herwin, had suspicions about the care her 86-year-old mother, Skip MacNally, was getting at the nursing home in Cherryville, N.C. So, she decided to install a hidden camera to find out. She immediately discovered disturbing video of staff at the nursing home abusing her mother.

“I put the camera in on August 28. On August 29 I had a video of abuse,” she said. She had a second video within 24 hours of installing the camera.

The first video shows a nursing assistant yelling at MacNally—who is blind and suffers from Alzheimer’s disease—while changing her. In the video, you see the nursing assistant go from yelling at MacNally to violently moving her across the bed while changing her. MacNally cries out in pain several times over the course of the video.

“Have I done something?” MacNally asks the nursing assistant towards the end of the video.

“Devil’s wife,” the nursing assistant responds.

Herwin expected the hidden camera to capture evidence of her mother not being properly fed or going long periods of time without being checked on. She didn’t expect to find her mom being violently abused by staff.

A DSS report shows a social worker confirmed MacNally was abused but indicates the social worker didn’t even open an investigation. Fortunately, the police investigated and a detective wanted to press charges. But then the unthinkable happened.

“Well, he called me about four days later, told me the (assistant district attorney) was not going to file charges. I didn’t understand,” Herwin said.

To date, no charges have been filed against the employees in the video.

Herwin called WBTV in hopes the story of what happened to her mother would draw attention to a system that has lax regulation and little oversight.

“They need to have consequences for their actions! If you don’t have any consequences, it’s just going to continue to get worse,” she said.

 

How can you trust numbers when they are self-reported and directly affect the rating of the nursing home?  A new study proves that nursing homes do not report quality measures such as falls. University of Chicago researchers found 150,828 major-injury falls that occurred at nursing homes were reported in hospital claims. Just 57.5% of those were reported on the MDS item (J1900C) used by Nursing Home Compare.   Falls data used by the Nursing Home Compare website “may be highly inaccurate,” says researchers whose new study shows that nursing homes fail to report major-injury falls.

The study assessed the accuracy of nursing home self-reporting of major injury falls on the MDS. Researchers used data from Medicare claims between 2011 and 2015 for the investigation. The data was then compared to MDS 3.0 assessments submitted by providers during those same years.

About 62.9% of major-injury falls were reported for long-stay residents on the MDS item, while 47.2% were reported for short-stay residents. Findings also showed that major-injury falls in white residents were reported at a higher rate than non-white residents — 64.5% compared to 37.4%.

“Our study indicates an urgent need to assess the value and limits of patient safety measurement that is based on the MDS. Given the amount of research that has been based on the MDS, it may be important to revisit some of our understanding of nursing home quality of care,” the authors wrote.

Full findings were published in Health Services Research.

The Department of Housing and Urban Development is selling a group of nursing homes it took over 18 months ago after the biggest default in the history of a government mortgage insurance program that provides support to the nursing home industry. The housing agency has managed the chain, Rosewood Care Centers, with the help of a court-appointed receiver since the previous owners defaulted on $146 million in government-guaranteed mortgages.  The agreement involves Greystone, a New York real estate finance firm, for the chain of Chicago-area elder care facilities. Greystone is a major lender to the nursing home industry, and was servicing Rosewood’s mortgages when the former owners defaulted.

Greystone was identified as the incoming owner of the Rosewood chain in a licensing application filed in December with the Illinois Department of Public Health. The application documents indicate that Greystone will own and operate the facilities through a series of shell and sham limited liability companies. The firm also intends to rename each of the facilities, according to the application.

The default raised questions about the department’s oversight of a decades-old mortgage insurance program that backs 15 percent of the nation’s nursing homes.  It is not clear how Greystone is paying for the facilities, or if the firm is getting any credit from HUD for the losses it may have incurred in the default.

HUD solicited bids for the Rosewood facilities — a dozen nursing homes and one assisted living center — until the end of May, but it has repeatedly and suspiciously declined to disclose the name of the prospective buyer or the purchase price. According to court filings, there were four bids for the properties, which the department had valued at $95 million. The department has spent nearly $30 million since August 2018 to make up for shortfalls in funding at the Rosewood facilities and to pay for repairs.

Court records also show that federal securities regulators are close to reaching a financial settlement with a former owner of the Rosewood facilities. The Securities and Exchange Commission in September charged a Chicago-area rabbi, Zvi Feiner, with defrauding a group of Orthodox Jewish investors who had put money into the Rosewood properties and other elder care facilities. HUD said in court documents that the owners had improperly diverted millions of dollars in federally insured funds to another nursing home that was not part of the program. Mr. Feiner paid a $1 million penalty to HUD this summer for failing to file several years of audited financial reports required by the mortgage insurance program.

Recently, I read about a murder at a nursing home in Florida.  Apparently, a 95-year-old man in a nursing home was killed by a trespasser. Police were told a nurse walked past the victim’s room when she noticed an unknown male sitting on top of the victim’s chest with a pillow over his face, according to police.

The nurse yelled out for another nurse to call 9-1-1 and the unknown male took off running from the facility while police were called. No word yet on how he gained entrance to the facility, but there is a notice on the door explaining that visitors must be buzzed in if they are trying to enter the premises outside of normal business hours (8 AM- 8 PM).

According to police, dispatchers received a call from a nurse at Tiffany Hall Nursing and Rehabilitation Center shortly after midnight saying “someone tried to hurt a patient.” When police arrived on scene they found an adult male dead.

Where was the supervision?  How could no one hear what was going on?

When police arrived, they set up a perimeter and searched the area with a K-9 unit but police say they were unable to find the unknown male, who was only described as a white male.

 

 

A recent survey of nurses shows that more and more nurses are facing increasingly difficult working conditions and are burning out. There are nearly 3 million registered nurses in America and the profession is still one of the fastest-growing in the country.  According to a recent survey from AMN Healthcare, 22% of nurses hold more than one job as a nurse. And 37% of these nurses say that doing so “negatively affects their quality of life.” The survey also found that 27% of nurses have witnessed workplace violence, 41% have been victims of bullying, incivility, or any other forms of workplace violence, and 63% of nurses say their organization didn’t address the situation well at all. In the AMN survey, 66% of nurses said that they worry their job is affecting their health. In the AMN survey, 44% of nurses said they don’t usually have the time they need to spend with their patients.

The burnout leads to post traumatic stress disorder and an increase in substance abuse, addiction, and suicide rates. A study featured in the Archives of Psychiatric Nursing found that there are higher rates of suicide among those working in nursing compared to non-nurses. It also showed that nurses are “statistically significantly more likely to have reported mental health problems,” although it’s unclear whether or not their work environment plays a direct role in those figures.

“This is moral injury,” Mahon said. “They spent all these years in school, and they’re getting into an environment where basically they’re providing factory-level care. It feels like it’s so dehumanized.”  Amid these industry changes, nurses feel like they can’t provide the same level of quality care as they used to.

Cole Edmonson, a doctorally-prepared nurse and chief clinical officer at AMN Healthcare, pointed to the distribution of nurses across the industry.

If you look at the number of licensed nurses, there is not a shortage,” he said. “But you have to look at where those nurses are practicing, why they choose to practice in those area or leave those areas of practice.”

Vox: 9 Supreme Court cases that shaped the 2010s. By Ian Millhiser, 12/26/19.

Concepcion held that forced arbitration agreements may also ban class actions — a mechanism that allows many people who were injured by the same company to join together in a single lawsuit against that company. Concepcion reached this holding, moreover, despite the fact that the Federal Arbitration Act says nothing whatsoever about class actions.

Refinery29: What Happened To Gretchen Carlson After The Fox Settlement Seen In Bombshell? By Lia Beck, 12/20/19.

As she explained in her New York Times story, Carlson also worked with Congress members to introduce the Ending Forced Arbitration of Sexual Harassment Act, which sought to end the practice of cases of sexual harassment at companies being dealt with behind closed doors, rather than employees being allowed to sue and taken to their cases to court, as explained by Vox. As the publication also reports, in September, the House passed the Forced Arbitration Injustice Repeal Act, or FAIR Act, which encompasses the issue Carlson supported, but is more far-reaching.

Law.com: Battle Over Mandatory Arbitration in New Jersey Intensified in 2019. By Charles Toutant, 12/27/19.

New Jersey was at the forefront of a legal and public policy battle over mandatory arbitration of employment and consumer contracts in 2019. And 2020 promises more conflict as pro-arbitration interests and those opposing mandatory arbitration battle in state and federal courts.