Long-Term Living had an article about Sunrise Senior Living, Inc.’s $204 million sale transaction for 21 wholly owned assisted living communities, located in 11 states, with BLC Acquisitions, Inc., an affiliate of Brookdale Senior Living Inc.

At closing, Sunrise received approximately $60 million in net proceeds after payment or assumption of approximately $134 million of mortgage loans, the posting of required escrows, various prorations and adjustments, and payments of expenses by Sunrise. Sunrise will use $25 million of the proceeds to pay down its bank credit facility and will place $20 million into a collateral account for the benefit of other creditors.  None of it will go into improving care at their other nursing home facilities. Sunrise expects to record a gain of approximately $50 million in connection with the closing of this transaction.

Long Term Living posted a response to a question submitted to their site on turnover rates and resident longevity/mortality.  It is a great question and the answer was interesting by Susan D. Gilster and Jennifer L. Dalessandro

A reader asks, “Is there a correlation between nursing staff length of service and resident longevity? 

 While we cannot point to a specific piece of research that specifically correlates resident longevity to staff retention, what we do know is that consistent staff and low turnover does result in better care and enhanced resident, family, and employee satisfaction.

 

Turnover and the impact on residents in assisted living and long-term care have been studied. Nicholas Castle (2007) measured the effect of administrator turnover on the quality of care and determined that leadership turnover leads to many negative outcomes for residents.1  He found that when there is a loss of an administrator there are increasing pressure ulcers, resident catheters and use of psychoactive drugs, deficiencies and citations, and over twice the normal turnover of staff. Sadly, the turnover for administrators in assisted living and long-term care ranges from 43%-70% annually. When an administrator leaves, so does staff—RN turnover rises to 76%, LPN’s to 78%, and certified nursing assistants to 107%!  In addition, turnover often results in increasing workloads for the remaining staff. And it is expensive. An average community housing 200 residents often spends as much as a million dollars per year on staff turnover.

 

It is clear that staff turnover influences the quality of care, is very expensive, and diverts monies that could have otherwise been spent on care.1 Turnover truly weakens the level of care provided and directly affects residents. Changes in staff distresses residents who develop relationships with caregivers, relying on them for recognition, support, and kindness—only to find that they are gone and a new person has taken their place. Can you imagine, when you are most dependent upon another human being for care, seeing that your needs are addressed and desires met and suddenly they are gone? Now you have to rely on a stranger who may or may not care to know you as a person, ensure that your needs are addressed, or be there when you call?

 

It is important for those of us working in assisted living and long-term care to remember that we are in the “people business,” and that our product or service, so to speak, is about meeting the needs of people, long term. Unlike acute care settings where time is often limited, long-term care offers the opportunity to meet and know the residents we serve and their families. Human relationships are special and it does not really matter where people come from, what they have experienced, where they live or play. People are all the same at the core. We all need respect, a sense of belonging, to be included, appreciated, valued and loved in order to survive. Consistent, knowledgeable, caring staff that has come to know the resident as a valued person and not a task will provide the kind of care that encourages a desire to live and nurture relationships with others. Regardless of the resident’s ability to participate, being with people each day is what makes life worth living.

 

Consistency creates a positive environment for staff as well, who enter this field with a desire to serve and genuinely care for others. Encouraging relationships means that leadership must allow for consistent staffing as well as value and reward employees for the good work they do. Leaders must allow employees the time to visit with residents and families, to know them personally, their life, their experiences, accomplishments, needs, and desires. Whether expressed from the resident or shared by the family, staff needs to hear the stories and experience the resident’s reactions and emotions directly. Staff should come to know the resident from many perspectives, and when they do it is a beautiful experience where everyone benefits.

 

It does not, however, happen by chance. Staff and resident longevity exist when leadership and staff value relationships and respect. This is found only in an organization that is committed to a vision and philosophy of service, where the vision lives in the daily life of all in the facility.

 

References:

 

1. Castle, NG; Engberg, J; Anderson, RA: Job satisfaction of nursing home administrators and turnover. Medical Care Research and Review 2007; 64(2):191-211.

 

Anderson Independent Mail posted an article by Lee Bowman and Thomas Hargrove/Scripps Howard News Service about a statistical analysis of the federal government’s first-ever ratings of nearly 16,000 nursing homes.  The study revealed some comon sense conclusions including an uneven level of quality across the nation and shows how complicated it is to find a good nursing home.

The Scripps Howard analysis of the Centers for Medicare and Medicaid Services’ Nursing Home Compare system shows that:

In Institutions run by for-profit corporations, which account for about two-thirds of all nursing homes, generally get lower scores than those run by nonprofits groups.

Homes with more nursing staff per patient, which also tend to be run by nonprofit groups, generally do better in the ratings.

Homes with more than 100 beds tend to get lower scores in all categories, including health of residents and levels of nursing care.

Ratings are lowest in Southern states, particularly for nursing care and registered-nurse staffing, and highest for homes in the Northeast.

Slightly more than 20 percent of nursing homes nationwide have been regularly given the lowest ratings, and 12 percent to 13 percent have received the top rating.   

While more than 500,000 Americans die in nursing homes each year, more than 2 million return home after a nursing-home stay of less than three months.

CMS collects data on all nursing homes that care for Medicare or Medicaid patients and displays the information at www.medicare.gov/NHCompare. The system, implemented late last year, includes everything from fire safety and food preparation to rates of residents suffering from bedsores.  Even CMS officials agree that while the same criteria are used for the inspections, the focus and depth of the assessments may be different from state to state, so the ratings of different facilities should not be compared across state lines.

The rating system is on a scale from one star to five stars. Five stars indicate that a nursing home ranks “much above average,” four stars are “above average,” three are “about average,” two are “below average” and one is “much below average.” Rankings are updated every three months, and some data are revamped monthly.

There are about 15,700 nursing facilities listed on Nursing Home Compare.

Health-care advocates say data on nursing-staff levels — self-reported by home administrators and including time spent on administrative chores as well as actual patient care — don’t give a clear picture of the care being provided.

“Even though we’re skeptical about some of the information, it’s the best starting point available for research,’’ she said. “But people need to understand that the stars may not reflect what they’ll find inside a facility.   “Unfortunately, for many families, they’re lucky if they get 24 or 48 hours before a (hospital) discharge to make a decision. That’s not enough time to do much homework, but at least the ratings and the other information on the site might help you rule some facilities out.”
 

 Long-Term Living posted an interview online on Dec. 3, 2009 with a former administrator who has written a book about his career as an administrator in Maryland nursing homes.  Elliott D. Cahan, a retired administrator, gives in his book, A Place Like Home, candid reflections on running facilities for for-profit and not-for-profit operators in Maryland.  Below are just a few of the excerpts from the interview where he admits that corporate control of the budget, concern about proftis, and quality of staff cause problems in trying to run a nursing home.   Cahan elaborated on all of these points in an interview with Richard L. Peck, former Long-Term Living Editor-in-Chief.

Peck: Your comments in your book, though, present quite a mixed picture—principally, that the administrator’s job is a juggling act. Would you elaborate?

Cahan: All the disparate parties involved in resident care—residents, families, staff, regulators, owners—come at it from different angles, but ultimately, it’s the administrator who is holding the bag for providing the care. Put it another way, it’s like a stack of cards and you’re never quite sure which card is holding up the stack—take away the DON, the nursing assistant, the RN, and will the whole thing collapse? It’s a precarious business. And yet I always found it interesting that Maryland had no requirement for a state surveyor to have worked in a long-term care facility. It’s a job that is more difficult than many people think.

Peck: Would you say that an administrator’s principal focus would be on staff?

Cahan: I think a principal role for the administrator is to clear the way of all red tape and roadblocks so that staff will have an environment for success. If you do this, they will provide good care. You can’t pay the highest wages, although they should be competitive, but basically if you provide an environment where staff feel appreciated and want to show up every day, good care will result. Specifically, that means giving them the supplies, the equipment, including maintenance and repair, and in general eliminating frustration from their daily work.

Peck: By the same token, what do administrators need?

Cahan: They need to be empowered by the owner, the board, and the corporate office. They need more than “sometimes” authority—for example, having no control of the budget but being held accountable for spending nine bucks for doughnuts at a staff meeting.

Peck: Among the more controversial statements you make in your book is that, from a quality standpoint, not-for-profit facilities are preferable to for-profit facilities. Would you discuss that?

Cahan: That probably is the most controversial statement in my book. But I can only go by personal experience. I’ve heard for-profit management of one chain admit that it was all about the quarterly share price, not the residents. At least they were honest. In general, the for-profit chains thought that they would create efficiencies through centralization but it never happened. Also, they went through a period when they bought provider companies at crazy prices, with huge mortgages that operations could never support. It made me wonder whether investors really understood the field, but this had a bearing on quality. I’m not saying this is a hard-and-fast rule—there were for-profit facilities in inner city neighborhoods that offered much better environments than was available at home, and I’ve seen not-for-profits that provided low quality of care. I was just addressing the overall situation with that comment.

 

There seems to be an increase of nursing home employees abusing, neglecting, stealing, or otherwise taking advantage of the vulnerable residents in their care.  Below are just some of the stories from the past few weeks:

RocNow by Democrat and Chronicle had a story about a CNA who is accused of stealing a credit card from a nursing home patient and then submitting a forged application for public benefits to Monroe County.   Latoya Harding, 28, employed at the Blossom South Nursing and Rehabilitation Center, was arraigned on several charges including fourth-degree grand larceny, offering a false instrument for filing, both class E felonies, and second-degree criminal possession of a forged instrument, a class D felony.

After Harding was fired from Blossom South because of the theft allegation, she allegedly applied for unemployment benefits. Harding allegedly submitted an application with a forged signature of a Blossom South employee and falsely claimed that she was laid off from Blossom South.   Harding is also accused of stealing a credit card from a 90-year-old patient suffering from dementia to pay her own cable, cell phone and utility bills. She also allegedly purchased items from Wal-Mart and made several cash withdrawals.

—————————————————————————————————————————–Woodtv.com had an article discussing the jail sentence of Michael James White.  He will only spend six months in jail for sexually molesting an 84-year-old resident of a nursing home. The woman is mentally and physically incapicitated.  White admitted to one count of criminal sexual conduct in the 4th degree.  The incident took place this past summer at Metron of Lamont.

——————————————————————————————————————————– The Star-Ledger had an article about a nursing home employee arrested on charges he stole about $48,000 by forging employee paychecks, including those of mentally-challenged individuals who worked at the home.  Roel Lopez was responsible for distributing paychecks to mentally-challenged employees. An investigation found that Lopez kept employee paychecks and deposited them into his own account. Lopez also had phantom employees on the payroll, said the release. The thefts occurred over an approximately four-year period.  Lopez was charged with theft by deception and forgery. 

———————————————————————————————————————————The Advertiser had an article about another nursing home employee accused of cashing an elderly woman’s check at a Lafayette store.  She was arrested and booked into the Lafayette Parish Correctional Center.   Brandy Nicole Wilkins was charged with exploitation of the infirm and 11 counts of money laundering/transactions involving proceeds of criminal activity.

Wilkins, a former employee of Golden Age of Welsh Nursing Home in Welsh, is the second person arrested in connection with the incident. Vercey Lawdins, 26, was arrested on Oct. 13 on the same charges as Wilkins.  Lawdins is accused of stealing a $6,050 check from an elderly resident of the nursing home.  She and Wilkins then allegedly cashed the check at a Lafayette Wal-Mart store and used the money to buy 11 $550 gift cards, Gerdes said.

 

The Charelston Gazette had an interesting article about a former employee of Broadmore Estates who has sued the Putnam County assisted-living facility for allegedly overlooking alcohol and substance abuse by its employees, and ignoring state regulations for drug distribution.  Lynn Gomez of Elkview filed the lawsuit in Putnam County Circuit Court on against Broadmore and the facility’s director, Delores Miles.  Gomez alleges in her lawsuit that she was ostracized and lost her job because of several complaints she brought to Miles about drug abuse and employee conduct.

Gomez was hired in February as a registered nurse and as director of wellness at Broadmore’s assisted-living facility in Hurricane.    When she began working, Broadmore’s patient charts and medical records were in disarray, the facility was understaffed and staff members did not follow state regulations for drug distribution.

She also alleges that, within her first few weeks at Broadmore, she was approached by a staff member and a pharmaceutical representative about a nurse who consistently came to work drunk or with alcohol on her breath.  Gomez alleges that the nurse approached her and stated "Lortabs do nothing for her and that she had already had four Percocet that day."

Gomez states that she approached Miles about the woman’s statement and was told the nurse "had been on drugs for a long period of time, and could practice while on the medications." She also was told the nurse had been off work for a medical condition, the lawsuit states.

Gomez alleges that the nurse falsified patient charts, saying she had administered drugs that she actually had not, and that Miles falsified documents to reflect that the drugs had been properly administered and were accounted for.

The nurse eventually was fired after an outside pharmaceutical representative discovered that the nurse had falsified drug distribution records, the lawsuit states.

Gomez wants back pay, compensation for emotional and mental stress and attorney’s fees.
 

The Gazette Extra had an article about the death of Jesse Brown because of the neglect and breaches in the standard of care suffered at Alden Meadow Park Health Care Center.

On Feb. 21, Brown complained of severe abdominal pain and was taken to the hospital where he died from a severely impacted bowel.   Brown’s son, Printess Pritchard, of Chicago is suing the nursing home for negligence by failing to care for Brown and failing to hire qualified staff.

The also suit claims Alden Meadow Park violated the regulations of the federal Nursing Home Reform Act of 1987. The Wisconsin Department of Health Services is listed as an involuntary plaintiff because the state oversees the payment of Medicare and Medicaid. The two could be entitled to reimbursement, according to court documents.

The suit seeks damages, payment of legal fees and hearings on the compensation due to Medicare or Medicaid.
 

The Brown University Center for Gerontology and Healthcare Research has launched a website designed for nursing home researchers that will also be enthusiastically received by many consumer advocates looking for detailed data and more sophisticated comparison tools than provided on Nursing Home Compare. 

The interactive database, www.LTCfocUS.org, incorporates information from a number of government sources-Medicare reimbursement claims, OSCAR (CMS’s Online Survey, Certification and Reporting system), the MDS (Minimum Data Set), and Brown’s own survey of state Medicaid policies. Vincent Mor, chairman of the Department of Community Health at Brown, was co-recipient of NCCNHR’s 2009 Public Service Award for his research on racial disparities in nursing homes; and he announced the impending launch of the website in his acceptance speech at the NCCNHR Annual Meeting Oct. 25. Mor demonstrated use of the database to identify racially disparate quality and access to care in two urban areas. 

Users can interact with the website by creating interactive maps and tables with comparative information about states, counties, or individual nursing homes. All data provided on the website are also available to download.

 Example of Use 

Users can choose up to five variables, for example, to create a chart comparing all nursing homes in a state. The broad range of variables from which to choose includes number of beds; for-profit and chain status; percent of Medicare and Medicaid beds; Alzheimer’s units; occupancy rates; age ranges, gender and race of residents; direct care staffing (RN, LPN, CNA); acuity of care; certain MDS quality measures; source of admissions (hospital or home); and 30-day rehospitalization rates (a potential indicator of quality not found on Nursing Home Compare). 

The website is sponsored by the National Institute on Aging-funded Shaping Long-Term Care in America project housed at the Brown center. While its stated purposes are to "allow researchers to trace clear relationships between state policies and local market forces and the quality of long-term care" and to allow policymakers "to craft state and local guidelines that promote high-quality, cost-effective, equitable care to older Americans," Mor also encouraged consumer advocates to use the site.

 

 

NCCNHR (formerly the National Citizens’ Coalition for Nursing Home Reform) is a 501(c)(3) nonprofit membership organization founded in 1975 by Elma L. Holder to protect the rights, safety and dignity of America’s long-term care consumers.   NCCNHR issued the following Bulletin:

The health care reform bill passed by the House of Representativesbefore includes not only sweeping health insurance reforms but also nursing home transparency, criminal background checks on long-term care workers, and a voluntary payroll deduction system that would provide benefits for long-term care services. The bill, H.R. 3962, the Affordable Health Care for America Act, can be downloaded at http://thomas.loc.gov.

 

As expected, the bill includes-without amendment-nursing home transparency provisions requiring:

1)  Public disclosure of individuals and entities that own, govern, operate, finance, provide services to, and/or control the nation’s nursing homes.

2)  Compliance and ethics programs and internal quality assurance programs in nursing homes, and pilot projects to test ways to improve oversight of chains.

3)  Collection and reporting of staffing information based on payroll data, including hours of care per resident day, turnover and retention rates, and facility expenditures for wages and benefits.

4)  A review of Nursing Home Compare and addition of information about sanctions against facilities and the number of adjudicated crimes occurring in them.

5)  A categorical breakdown of expenditures on cost reports to show how much facilities spend on direct care versus other expenses.

6)  An improved state complaint process to help protect complainants against retaliation.

7)  An increase in federal civil monetary penalties and a process to hold CMPs in escrow during appeals (although only after an independent informal dispute resolution process was completed).
8)  Adequate notification when facilities decided to close, including the option for the government to continue reimbursement until relocation was achieved.

9)  Training of nursing assistants in dementia care and abuse prevention.

10)  The bill would authorize a program of national criminal background checks on all long-term care workers who have access to residents or patients–from those who provide in-home long-term care services to nursing home employees.

H.R. 3962 also incorporates the Community Living Assistance Services and Supports (CLASS) Act to create a national voluntary social insurance system through which enrollees who became disabled (after paying into the system for at least five years) could purchase community-based long-term care, services or supports. Nursing home residents who were Medicaid beneficiaries could retain 5 percent of their benefit, in addition to their personal needs allowance, for their personal use while the remainder was applied to the cost of their care. (See page 1562 of the bill.)

 

Last-minute efforts to add the Elder Justice Act to H.R. 3962 were not successful. The EJA is in the health care reform bill passed by the Senate Finance Committee.

 

 

 

As a follow up to recent posts regarding the kickback scheme involving OmniCare and Murray Forman and Leonard Grunstein, today I am going to post a well written article from the Chicago Breaking News about a doctor prescribing dangerous medications to nursing home residents.

Inside Chicago’s Maxwell Manor nursing home, Dr. Michael Reinstein’s patients suffered from side effects so severe that they trembled, hallucinated or lost control of their bladders. Staffers told state investigators that so many patients were clamoring to complain to Reinstein about their medications that a security guard was assigned to accompany him on his visits. In addition, staffers said Reinstein had induced patients to take powerful antipsychotic drugs with the promise of passes to leave the home.

Today he is one of the most prolific providers of psychiatric care in Chicago-area nursing homes and mental health facilities, even as he is trailed by lawsuits and complaints like the ones at Maxwell Manor.  An investigation by ProPublica and the Tribune found that Reinstein has compiled a worrisome record, providing assembly-line care with a highly risky drug.  Reinstein has been accused of overmedicating his mentally ill patients. His unusually heavy reliance on the drug clozapine — a potent psychotropic medication that carries five "black box" warnings — has been linked to at least three deaths.

In 2007 he prescribed various medications to 4,141 Medicaid patients, including more prescriptions for clozapine than were written by all the doctors in Texas put together. Records also show he is getting government reimbursement for seeing an improbably large number of patients. Documents filled out by Reinstein suggest that if each of his patient visits lasts 10 minutes, he would have to work 21 hours a day, seven days a week.  Reinstein sees 60 patients each day, he wrote in an audit report in 2007.

Working from a strip-mall office in Uptown, Reinstein says he is psychiatric medical director at 13 nursing facilities, seeing patients with chronic mental illness. Those include people with schizophrenia.

Autopsy and court records show that three patients under Reinstein’s care died of clozapine intoxication. Alvin Essary died at age 50 at the Somerset Place nursing home on the North Side in 1999.  Medical records show that when he died his blood contained five times the toxic level of clozapine.

The "black box" warnings — the FDA’s strongest — on clozapine’s label detail serious potential side effects, from enlargement of the heart to rapid drops in blood pressure to increased seizure risk.   Doctors also are required to take regular blood samples to ensure patients’ immune systems aren’t shutting down.

The FDA approved the drug two decades ago for only a sliver of the population: the actively suicidal or the quarter of schizophrenic patients who do not improve on medications with lesser side effects. Yet Reinstein last year said under oath that his practice once had more than 300 patients among 415 in one Chicago nursing home on clozapine.

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