Medicare reimburses skilled nursing facilities, or SNFs, for “rehabilitation therapy” according to the amount and level of care they provide. The amount of care is measured in minutes per resident per week. The largest payments are awarded to SNFs for residents who receive “very high” or “ultra-high” therapy, respectively equal to at least 500 and 720 minutes per week.

Consumer advocates and experts have objected that this payment method incentivizes SNFs to subject some residents to excessive rehabilitation therapy to hit a higher-paying threshold.  A Wall Street Journal report last August quoted current and former industry employees who said they faced financial pressure to maximize reimbursement rates for rehabilitation services. “The system really rewards high-intensity care,” David Grabowski, a Harvard University expert on nursing-home spending, told the Journal. “There are patients being treated who aren’t appropriate.”

 The data released by CMS recently supports their concerns. In a March 9 press release announcing the data, CMS noted that nearly two thirds of residents who received ultra-high therapy received between 720 and 730 minutes per week — just enough, but little more, to qualify the SNF for a rich payout from Medicare. A majority of residents in the very high therapy category received between 500 and 510 minutes of rehabilitation per week.  CMS also observed that at more than 200 SNFs, 100 percent of all patients receiving ultra-high therapy got 720 to 730 minutes of weekly therapy. 

At least 19 of those facilities, located in 11 states, ​administered 500 to 510 minutes of therapy to every resident billed ​to CMS as having received very high therapy and administered 720 to 730 minutes of therapy to every resident billed as having received ultra-high therapy. Collectively, according to the newly released CMS data, these 19 nursing homes billed Medicare for more than 2,000 residents whose therapy minutes fell into one or the other of those 10-minute bands. ​​​​​​​​Not a single eligible resident treated at any of these facilities in 2013 received 511 to 719 minutes of therapy per week.

To help ensure that patient need rather than payment incentives are driving provision of therapy services,” CMS stated in its release, “CMS is providing approval to the Medicare Fee-for-Service Recovery Auditor Contractors (RACs) to investigate this issue.” 

The Augusta Chronicle reported on another lawsuit filed against the national for profit chain PruittHealth.  Gloria Jessie, the grieving widow of a neglected resident who died after a six-month stay at a PruittHealth nursing home in Augusta, has filed a wrongful-death lawsuit.  The lawsuit filed on behalf of Lyons’ heirs is the fourth against PruittHealth in Augusta since 2014.

Grady Lyons Sr. was admitted to PruittHealth Augusta in September 2013. He died March 20, 2014.  The lawsuit contends PruittHealth was responsible for providing the level of care Lyons needed and the facility represented that it would deliver. But Lyons suffered catastrophic injuries, disfigurement, extreme pain, suffering and mental anguish, accelerating the deterioration of his health. Lyons specifically experienced weight loss, poor hygiene, pneumonia, falls, fractures and then death.

The neglect would not have occurred had corporate officers properly responded to the alleged critical shortage of nursing staff, the suit alleges. PruittHealth executives were aware of care-based indicators such as falls, pressure sores, weight loss, dehydration and use of psychotropic medications at the nursing home.

According to the Medicare Nursing Home Comparison Web site, the facility was found overall to be much below average. Health inspections were judged to be below average, and staffing was much below average.

Long Term Living reported the good news that nursing home antipsychotic drugging rates are going down but are still too high. According to the latest federal data, 21 percent of the approximately 1.3 million nationwide nursing home resident population received an antipsychotic drug during the fourth quarter of 2015.  Less than 2 percent of the United States population has a diagnosis that antipsychotic drugs might be appropriate. The Centers for Medicare & Medicaid Services (CMS) launched a national action plan in 2012 to protect nursing home residents from unnecessary antipsychotic drug use.

“While we are glad to see some reduction in the use of antipsychotics, the persistence of this shameful problem four years after the federal Centers for Medicare & Medicaid Services (CMS) promised action and almost five years after Inspector General Levison said that the government, residents, families and taxpayers ‘should be outraged’ is, itself, outrageous,” says Richard Mollot, executive director of the Long Term Care Community Coalition (LTCCC) in a press release. “Why aren’t basic federal protections prohibiting inappropriate drugging and the use of chemical restraints being enforced? Why are taxpayers footing the bill for so much substandard care and resident abuse?”

LTCCC has compiled and released fourth quarter of 2015 data from Medicare. Using that data, the advocacy organization has also prepared two Excel files: one with the non-risk-adjusted antipsychotic drugging rates for all 50 states and a state-by-state breakdown of every licensed facility’s antipsychotic drugging rate.

The Centers for Medicare & Medicaid Services (CMS) launched its Nursing Home Compare website in 1998 for the 17,000 nursing homes that participate in Medicare or Medicaid, and began its 5-star rating system for nursing homes in 2008 (see Medicare Nursing Home Compare).  The core indicators for nursing home performance include information from health inspections, staffing ratios, and five short-stay measures (residents in an episode whose cumulative days in the facility is 100 days or less in the quality reporting period) and 13 long-stay measures (residents in an episode whose cumulative days in the facility is 101 days or more in the quality reporting period) (see Nursing Home Quality Initiative Quality Measures).  Examples of those measures include:

Short Stay Quality Measures:

  • Percent of residents who self-report moderate to severe pain (short stay)
  • Percent of residents with pressure ulcers that are new or worsened (short stay)
  • Percent of short-stay residents who newly received an antipsychotic medication

Long Stay Quality Measures:

  • Percent of residents who were physically restrained (long stay)
  • Percent of residents who have depressive symptoms (long stay)
  • Percent of long-stay residents who received an antipsychotic medication

In April 2016 (see Further Improvements to the Nursing Home Compare Five-Star Quality Rating System), CMS will begin posting data for six new quality measures (QMs) on Nursing Home Compare:

  1. Percentage of short-stay residents who were successfully discharged to the community
  2. Percentage of short-stay residents who have had an outpatient emergency department visit
  3. Percentage of short-stay residents who were re-hospitalized after a nursing home admission
  4. Percentage of short-stay residents who made improvements in function
  5. Percentage of long-stay residents whose ability to move independently worsened
  6. Percentage of long-stay residents who received an anti-anxiety or hypnotic medication

The evolution of the CMS nursing home rating system is just one tangible example of how performance measurement is driving competition in the health care market.

In 2014, spending on freestanding nursing care facilities and continuing care retirement communities reached $155.6 billion, or an increase of 3.6% from 2013 (see National Health Expenditures 2014 Highlights).

In 2015, the median annual cost for a private room in a nursing home was $91,250 (with a median daily cost of $250), and the median annual cost of a semi-private room was $80,300 (with a median daily cost of $220) (see 2015 Median Nursing Home Private Room Cost Up 4% Since 2014, To $91,250 Per Year).

All health care costs for the population over the age 85, nursing home care ranked as the highest expense, with an average annual cost of $24,185 (Average Annual Out-Of-Pocket Cost For Medicare Population Is $1,185 Per Year For Recurring Health Services).

Over 500,000 persons with mental illness (excluding dementia) reside in U.S. nursing homes on a given day, significantly exceeding the number in all other health care institutions combined (see Mental Illness In Nursing Homes: Variations Across States).


Kristin Sweet was sentenced to 3 years in prison after admitting she impersonated a nurse when she wasn’t licensed, didn’t have a nursing degree and hadn’t been hired.  However, she may be released after 90 days to be treated at a correction center. Sweet pleaded guilty to identity fraud, deception to obtain a dangerous drug and practicing as a nurse without a license.

Sweet had applied for a nursing job at Brookdale Senior Living Facility and was allowed to administer the narcotic Tramadol to nursing home residents while supervised.  The nursing home had been waiting for a background check though and hadn’t hired her. Employees believed her story since she appeared on a list of potential hires, according to investigators.

Sweet told police she’s a nurse, but prosecutors said she listed someone else’s certification number as a licensed practical nurse on her application though.


The Star-Tribune reported on the tragic and preventable death of a nursing home resident who died less than 2 hours after nurses gave him 10 times his prescribed dose of morphine.  The Mahnomen Health Center has been cited for neglect and found responsible in the case for failing to transcribe the man’s medications accurately, according to a state investigation report.

 “The facility failed to have adequate policies in place to ensure medications were transcribed accurately and then administered correctly,” according to the report from the Minnesota Department of Health, which regulates nursing homes, assisted-living centers and other elder-care facilities.

A nurse at the facility told investigators that he had questioned another nurse about the size of the dosage, but was told it was correct. The error was detected about 15 minutes after the dose was given. Employees notified the patient’s family and they asked staff members to administer a drug, Narcan, to block the effects of the morphine. Meanwhile, the patient’s breathing had decreased to a mere two breaths per minute which is a known adverse consequence of too much morphine. The family requested another dose of Narcan, but the patient died before staff members could return from the hospital with the drug.

The resident’s primary physician said a large dose of morphine would have contributed to the death, according to the state report.

The medication error death comes amid a sharp increase in cases of abuse and neglect at state-licensed nursing homes. The number of maltreatment complaints from nursing home patients and their families has doubled over the past five years, from 588 complaints in 2011 to 1,177 in the 2015 fiscal year, according to the Health Department.

ProPublica had a shocking report on California’s lax oversight of dangerous and troubled caregivers.  It is a problem all over the country.  “The board charged with overseeing California’s 350,000 registered nurses often takes years to act on complaints of egregious misconduct, leaving nurses accused of wrongdoing free to practice without restrictions, our joint investigation investigation with The Times found.”

Reporters examined the case of every nurse who faced disciplinary action from 2002 to 2008 – more than 2,000 cases in all – as well as hundreds of pages of court, personnel and regulatory reports. They interviewed scores of nurses, patients, families, hospital officials, regulators and experts.

Among the findings:

* The board took more than three years, on average, to investigate and discipline errant nurses, according to its own statistics. In at least six other large states, the process typically takes a year or less.

* The board failed to act against nurses whose misconduct already had been thoroughly documented and sanctioned by others. Reporters identified more than 120 nurses who were suspended or fired by employers, disciplined by another California licensing board or restricted from practice by other states – yet have blemish-free records with the nursing board.

* The board gave probation to hundreds of nurses – ordering monitoring and work restrictions – then failed to crack down as many landed in trouble again and again. One nurse given probation in 2005 missed 38 drug screens, tested positive for alcohol five times and was fired from a job before the board revoked his probation three years later.

* The board failed to use its authority to immediately stop potentially dangerous nurses from practicing. It obtained emergency suspensions of nurses’ licenses just 29 times from 2002 to 2007. In contrast, Florida’s nursing regulators, who oversee 40% fewer nurses, take such action more than 70 times each year.

California takes far longer to discipline registered nurses than many other large states, according to a review by the Los Angeles Times and ProPublica. Click graphic to see the full details.

“It’s a high-stakes gamble that no one will be hurt as nurses with histories of drug abuse, negligence, violence and incompetence continue to provide care across the state. While the inquiries drag on, many nurses maintain spotless records. New employers and patients have no way of knowing the risks.”

The Times and ProPublica found more than 60 nurses disciplined since 2002 who were accused of committing serious misconduct or mistakes in at least three health facilities before the board took action.

McKnight’s reported on the sentencing of Michael Reinstein, a Chicago psychiatrist, who prescribed the antipsychotic clozapine to thousands of nursing home residents in exchange for kickbacks.  He was only sentenced to 9 months in jail despite receiving close to $600,000 from pharmaceutical companies in exchange for prescribing Clozaril (the brand-name version of clozapine) to thousands of elderly hospital and nursing home patients in the Chicago area.  Clozapine is used to treat schizophrenia but is known to carry serious side effects for seniors, including a decrease of white blood cells, seizures and heart inflammation.

At one point in the early 2000s, Reinstein was the largest prescriber of clozapine to Medicaid recipients in the country — more than all of the doctors in Texas combined, according to ProPublica. In exchange for prescribing Clozaril, and later the drug’s generic version, Reinstein received consulting fees, meals, sports tickets and vacations.

Reinstein previously paid $3.79 million to settle a government-filed lawsuit that claimed he submitted at least 140,000 false Medicare and Medicaid claims for the drug.

There have been numerous stories of neglect and abuse in nursing homes that only come to light because of hidden video cameras.  Without these cameras, many of these incidents of abuse and neglect would go undiscovered.  Increasingly, hidden cameras, also known as “granny cams,” are being used to catch the abuse. How can South Carolina legislators continue to deny the benefit of hidden cameras to protect residents, prevent fraud, and deter abuse and neglect?

The Star-Tribune recently reported another brutal assault by caregivers at St. Therese of New Hope caught by hidden cameras.  State investigators found that an 85-year-old patient with a severe cognitive disability was repeatedly punched in the face and stomach, causing visible cuts and bruises, while another patient had a bath towel thrown in her face, among other abuse. State investigators also found that members of the facility’s staff witnessed the abuse late last June but did not immediately report the incidents, a violation of state law and common decency.

Five employees have been cited by state regulators for brutal treatment of two elderly patients over several months last year, based largely on hidden-camera footage.  Other employees at St. Therese of New Hope were caught on video talking on their personal cellphones rather than providing necessary care, according to a report from the Minnesota Department of Health.

 The report comes amid rising allegations of maltreatment at Minnesota senior homes and highlights the growing importance of hidden cameras in proving physical or emotional abuse in cases when frail patients have difficulty communicating. In this case, the video footage proved critical: The victims had cognitive disabilities and were unable to provide information, and staff members repeatedly denied the abuse.
In one incident, two employees were providing incontinence care for the elderly male patient, when one of them yanked him upward in the bed, jabbed at his chest with an open hand and punched him in the stomach with a closed fist. The other staff member did not immediately report the abuse after seeing it.

In a separate incident, an employee threw a towel at an 82-year-old female patient who suffered from Parkinson’s disease and was cognitively impaired. When the patient threw it back, the staff member balled up the towel and again threw it forcefully at the patient’s face. Footage also shows a staff member jerking a water glass out of the patient’s hand in an abrupt manner, with the patient crying.

The heartbreaking part of all this is that we have to wait for a vulnerable person to be abused, and to catch it on camera, before we feel like we can intervene,” said Amanda Vickstrom, executive director of the Minnesota Elder Justice Center in St. Paul.