Des Moines Register had a great article on how Iowa has been investigating and prosecuting Medicaid fraud.  Iowa Department of Inspections and Appeals’ Medicaid Fraud Control Unit, an 11-person task force, last year quietly pursued dozens of cases involving elder abuse and Medicaid fraud. 

Over the past two years, the unit has stepped up its enforcement efforts, ferreting out more forms of fraud and winning significantly more criminal convictions. It’s a unit of government that pays for itself – and then some. During the 12-month period that ended in March, the unit recovered $11.1 million in Medicaid overpayments. The unit’s expenses consumed only $1.1 million in state and federal resources.  It is also happens to be the right thing to do.

Dean Lerner, the head of the inspections department, says the unit’s work – fighting elder abuse and recovering taxpayer money lost to health care fraud – is critical. Iowa has one of the nation’s oldest populations, and every dollar lost to Medicaid fraud is a dollar that can’t be used to care for the poor and the sick.

Since late 2008, the unit has been headed by John Judisch.  He has aggressively pursued cases of fraud and abuse. Since Judisch took over, annual Medicaid overcharges recovered by the unit have grown from $1.7 million to $11.1 million.  Criminal convictions have increased from 24 per year to 62 per year.

While 49 of the 50 states have their own Medicaid fraud control unit, the Iowa office appears to be among the most aggressive and, therefore, most cost effective. Among the states, only 12 have fewer employees in their fraud units, yet Iowa ranks seventh in terms of criminal convictions.

Some fraud cases involve national settlements with major drug companies or other health care providers doing business in multiple states. In those cases, Iowa shares in the millions of dollars recovered by investigators working at the national level.

 

The unit once focused more of its efforts on elder abuse – cases that now get less attention from the unit. Last year, the unit investigated 139 complaints of abuse, a significant drop from the previous year’s 233 investigations.

Federal officials say state and federal agencies lose at least $60 billion each year to various forms of corporate health care fraud.

Some examples are:

Gerald Bruening pleaded guilty of stealing $34,769 from the Marian Home care facility in Fort Dodge, where he had worked as the administrator. Between September 2005 and August 2008, Bruening took money from the facility, used it for personal expenses and then factored those purchases into the facility’s federal cost reports to justify increased Medicaid funding from the state and federal government. Bruening was sentenced to two years of probation.

In Clinton, Fire Chief Mark Regenwether and the city’s emergency medical services director, Andrew McGovern, were fired after the city agreed to pay $4.5 million to settle a lawsuit alleging Medicaid overcharges related to ambulance calls. The lawsuit was brought by one of the city’s own firefighters, who claimed the city had falsely categorizing routine ambulance calls as trips that required advanced life support measures. The scheme enabled the city to collect a higher rate of payment from Medicaid and Medicare.

Kathryn Milton was a 96-year-old resident of Des Moines’ Calvin Community nursing home when two of her caretakers began stealing checks from her room. Over a period of four weeks, nurse aides Jolene McNew and Jodi Smith repeatedly forged checks from Milton and two other residents of the nursing home, stealing $9,415.

A onvicted burglar named Vincent Stroman was running We Care Wheelchairs, a Sioux City company paid by Medicaid to provide transportation for the disabled. Over a period of several months, Stroman submitted a series of bogus bills for fictitious trips, collecting an extra $153,338 from the taxpayer-funded program.
 

Savannah Morning News had an article about the embezzlement case involving a mother and son team.  Mary Burroughs and Aaron Brent Burroughs pleaded not guilty in federal court to conspiracy, embezzlement and related charges involving her former employer, Riverview Nursing & Rehabilitation Center. 

The Burroughs are charged in a new indictment in the scheme that government contends benefited Burroughs Heating and Air Conditioning where Aaron Burroughs is general manager.

The prosecutor told U.S. Magistrate Judge G.R. Smith the defendant has violated her release by adding debt without the court’s approval.  Mary Burroughs has been free on a $50,000 pre-trial release bond since June 30, but First Assistant U.S. Attorney James Durham has challenged her release.

Smith allowed Burroughs to remain free, with new admonishments against moving any assets, but scheduled a bond hearing to determine if any violations have occurred. Meanwhile, Aaron Burroughs was allowed to remain free on a $20,000 unsecured bond.

Smith also admonished Burroughs against incurred any new debt or moving assets as a condition of his release.

 

The Union Leader had an article about the quality of nursing home care in New Hampshire. More than half the nursing homes in New Hampshire are rated above average by a federal oversight agency, one-quarter of them rank below average.  When it comes to finding the right home for a loved one, advocates say using the wealth of data that’s out there, in tandem with personal visits, is the best approach.

One good place to start is medicare.gov, where you’ll find 80 licensed nursing homes in the state rated from one to five stars (five is the best). The ratings are based on health-inspection reports, staffing levels and quality measures the nursing homes are required to report to oversight agencies.  The state’s Health Facilities Administration is required by federal law to inspect every licensed nursing home sometime between nine and 15 months after the previous inspection.

New Hampshire has 16 five-star nursing homes, rated "much above average."  Most are nonprofit or church-related.  The state currently has three nursing homes rated one-star, considered "much below average," and 17 "below average" two-star facilities. (One facility that got one star is no longer a licensed nursing home.). Sixteen homes get three stars, rated "average," and 27 are "above average" with four stars.

Kathleen Otte, administrator of the state Bureau of Elderly and Adult Services, said families should use the five-star ratings as a foundation for their decision-making. But then they need to "do their homework in another area, the human element," she said. "I would suggest people go unannounced, meet the staff, meet families if possible, review the survey results that they can find at the administrator’s office, and see for themselves." "Because every family member will have certain expectations, and you want to make sure that that facility that you’re touring can meet those expectations," Otte said.

Each home is required to publicly post the results of surveys conducted by state inspectors.  hat’s where you’ll find any deficiencies such as fire-code violations, and data about how many patients had bedsores, physical restraints, pain, anxiety or depression. Families also can obtain inspection reports from the state, and on medicare.gov.

Fmilies can find help making these decisions from the trained counselors at ServiceLink resource centers. She noted New Hampshire was first in the nation to create this statewide network of Aging and Disability Resource Centers.

For health and safety reports on nursing homes, go to medicare.gov and click first on "facilities and doctors," then "compare nursing homes." There’s also a "Nursing Home Checklist" to help narrow your choices.

Free counseling about long-term care options is available at the state’s ServiceLink resource centers. Call 1-866-634-9412.

 

Marcos Campos, a nursing home supervisor at Chateau Village Living Center, a Willowbrook nursing home, was sentenced  to four years in prison. Campos pleaded guilty in August to one count of criminal sexual assault for forcing himself sexually onto one of the workers in 1998. He was originally charged in 1998 for sexually assaulting two of the housekeepers and fondling a third as they worked in 1997 and 1998. He also was charged with battery for allegedly grabbing the arm of a fourth housekeeper and pulling her into a closet, court records indicated.

The August plea agreement called for charges involving the other three women to be dropped.

Campos still maintains his innocence, but that he pleaded guilty to avoid a longer prison sentence and the problems it would cause his wife and three children.  They should not let him plead guilty and maintain his innocence.

Assistant State’s Attorney Anne Therieau told the Court that in the assault to which Campos pleaded guilty, the victim was forced into a basement storage room, had her clothes ripped off her during a struggle and then was sexually assaulted.

Campos was accused of targeting financially vulnerable women. He threatened to fire the women from their jobs if they didn’t accede to his sexual advances. Three of the women had agreed to testify in the trial. A fourth had died.

Campos had faced up to 15 years in prison, but prosecutors agreed to ask for no more than eight when he pleaded guilty, and the Court sentenced him to the four-year minimum.
 

Chicago Sun Times had an article about Rainbow Beach Nursing Center’s failure to protect a resident with debilitating schizophrenia.  Ingrid Williamson was impregnanted while a resident.  Based on her mental illness, she could not give legal consent to sexual relations..

Ingrid’s family visited often and noticed the obvous changes to her body. “We would visit her every Saturday and think ‘wow her stomach is getting really big,’” her sister recalled of those summer 2003 visits. “We asked [nursing home staff] and they told us ‘oh it’s just the medications that are making her puffy.’ My husband said ‘she’s pregnant.’”

He was right. A home pregnancy test in August and a follow-up visit to the doctor determined she was 5 1/2 months pregnant.  No one knows who the father is but some believe that it is another patient suffering from mental illness or an employee.  No test has confirmed either.

Williamson, now 54, gave birth to a baby boy the following January. Williamson Ofori-Amanfo, who became her sister’s and now-6-year-old nephew’s legal guardian, is suing the nursing home for negligence.  The nursing home has a duty to supervise, protect, and keep resident’s safe.

Williamson asked a nursing home supervisor: “Why are you letting these people have sex?” Staff told her the patients have a "right" to engage in sexual relations. “We [family members] said, “OK, then why don’t you give them birth control?” “They’re allowing them to [have sex] with complete disregard for the consequences.

In addition, the nursing home failed to recognize the pregnancy for 5 months, and didn’t provide pre-natal care and medication.  In fact, the home continued to give her psychotropic drugs to treat the schizophrenia for the next 3 months — even though family asked that staff stop administering for fear it could hurt the fetus.  Today, the boy suffers from autism and is developmentally delayed.

“She shouldn’t have gotten pregnant in the first place,” Gravlin said, placing the blame squarely on the nursing home. “Now she’s got a son who’s got to be provided for.”  Taxpayers are going to end up paying for the child unless the nursing home is held accountable.
 

University of Central Florida researchers have authored a new book– Improving the Quality of Care in Nursing Homes–a guide for long-term care facilities on how to improve quality and efficiency.  The book is a collection of research and articles the authors compiled over the years.  The researchers received a grant from the National Institutes of Health in 2003, which enabled them to conduct their analysis of long-term care facilities throughout the county.

The researchers gathered information from more than 17,000 nursing homes in the country. They analyzed what worked and what did not work to determine how to improve the facilities–an "evidence-based approach." 

 

 

 Public Justice announced a new video about Public Justice – mission, successes, members and supporters – is now available on the home page at www.publicjustice.net under "Breaking News."

 

The video provides a brief, but educational and entertaining overview of the many kinds of cases they take on in the public interest, as well as the critical role that our members and supporters play in ensuring that we can continue protecting people and the environment; holding the powerful accountable; challenging government, corporate and individual wrongdoing; increasing access to justice; combating threats to our justice system; and inspiring attorneys and other advocates to serve the public interest.

 

Deborah Mathis
Communications Director
Public Justice Foundation

email: dmathis@publicjustice.net
voice: 202-797-8600
web: http://www.publicjustice.net

 

Winona Daily News in Wisconsin had an article about the nursing home CNA assaulting a 93 year old resident.  The employee, Shawna Hardesty, punched a 93-year-old patient at St. Michael’s Lutheran Home three times in the head, leaving a large bruise, court documents show. Hardesty is charged with felony intentional abuse of a nursing home patient.

Hardesty was an employee for a year at the time, she was suspended without pay after the Administration received the complaint, and was fired following an internal investigation.

The patient reported Hardesty abused her and had a "baseball-sized bruise" on the patient’s forehead. The patient told police she was punched three times in the head with a fist. While the social worker was speaking to the woman, Hardesty entered the room. The patient identified Hardesty to the social worker as the person who hit her after Hardesty left the room, according to the criminal complaint.

 

 

There have been several articles from numerous news media regarding the death of a resident after his roommate attacked him repeatedly with a rod used to hang clothes in the closet.  The articles try to absolve the facility from any responsibility without any investigation or asking the right questions.  Did the attacker have a history of violence?  Were there past incidents? Had the two been arguing previously?  Why didn’t they keep them apart? Was it racially motivated?  did he have a mental illness?  Why wasn’t he in a room by himself?

Deputies arrested William McDougall, 81, on suspicion of homicide. The Sheriff’s Department identified the victim as Manh Van Nguyen. Both men were patients at the Palm Terrace Healthcare and Rehabilitation Center in California.  Prosecutors say an argument over singing in Vietnamese may have led to the attack.
 

 

The San Jose Mercury News and L.A. Times had articles on the tragic and preventable death of a 60 year old nursing home resident at California’s Eskaton Care Center Manzanita.  The facility was fined $100,000, the highest penalty under state law, after a mechanical lift that was not properly maintained broke and dropped a patient who injured her head and later died.  The sling that broke was supposed to be checked monthly, but had not been checked in five years, according to the facility maintenance director.

The resident was confined to a wheelchair and needed help getting up and into bed, according to a California Department of Public Health investigator’s report. A state investigator found Eskaton Care Center Manzanita staff failed to maintain the lift used to transfer the woman to bed. On July 20, 2008, as nurse assistants were transferring the woman from her wheelchair into bed, the lift sling holding the woman broke and she fell and hit her head on a nearby door, according to a nurse’s notes. The woman was transferred to an emergency room, where medical records show she later suffered bleeding in her brain, brain damage and a stroke. She died four days later.

This never should have happened.  Why wasn’t the staff trained to check the lift before using it?  How many others had fallen in the last 5 years?  The investigation should have checked the records for other falls involving that lift.