14News reported a nasty outbreak of scabies at Parkview Care Center nursing home.  Several patients and staff members have shown symptoms of scabies.  Scabies is not an infection, but an infestation. Tiny mites called Sarcoptes scabiei set up shop in the outer layers of human skin.

mites in macro

The skin does not take kindly to the invasion. As the mites burrow and lay eggs inside the skin, the infestation leads to relentless itching and an angry rash. Another hallmark of scabies is the appearance of track-like burrows in the skin. These raised lines are usually grayish-white or skin-colored. They are created when female mites tunnel just under the surface of the skin. After creating a burrow, each female lays 10 to 25 eggs inside.

Nursing home staff are trained to recognize the possibility of scabies in the institutional setting. A simple microscope can identify mites, eggs, or fecal matter from a skin scraping.  It is contagious and can spread quickly through close physical contact. The scabies mite can’t jump or fly, and it crawls very slowly.  Scabies typically spreads through prolonged, skin-to-skin contact that gives the mites time to crawl from one person to another.  Scabies is so contagious, doctors often recommend treatment for entire contact groups.  The CDC recommends all long-term care patients and staff be regularly screened for scabies.

Crusted scabies (also called Norwegian scabies) is a very severe infestation involving tens of thousands of mites on a single person. This causes the skin to develop thick crusts full of mites and eggs. Crusted scabies is most common in people with weakened immune systems, the elderly, and people who are disabled. This type of scabies is highly contagious and requires swift recognition and treatment to prevent outbreaks and fatalities.

The NonProfit Quarterly had a great article on for-profit nursing homes defrauding Medicare by providing therapy to sick and dying residents to pad their profit margins.  Such are the main findings of a study authored by four professors from the University of Rochester School of Medicine, published in the Journal of the American Medical Directors Association.

“Nursing home residents on the verge of death are increasingly receiving intense levels of rehabilitation therapy in their final weeks and days, raising questions about whether such services are helpful or simply a lucrative source of revenue,” reports Tara Siegel Bernard in the New York Times. The practice, she notes, was twice as prevalent at for-profit nursing homes as nonprofit ones.

The fact that the study found this practice to be twice as common at for-profit nursing homes than non-profit nursing homes is not surprising. As NPQ’s Karen Kahn wrote earlier this year, “Multiple studies over the last two decades indicate that for-profit ownership of nursing homes, particularly for-profit chain ownership, correlates with substandard care.” Unfortunately,  for-profits control nearly 70 percent of all nursing homes.

Toby Edelman, a senior policy attorney for the Center for Medicare Advocacy, notes there are two problems: “Nursing facilities are providing more therapy than needed in order to increase their reimbursement, and nursing facilities are not providing appropriate maintenance therapy to residents who need it.

 

Last month, the Alabama Supreme Court held that an enforceable arbitration agreement was never formed because the resident lacked capacity and the daughter who signed on his behalf lacked power of attorney.  In Stephan v. Millennium Nursing & Rehab Ctr., 2018 WL 4846501 (Ala. Oct. 5, 2018), the decedent’s estate sued the nursing home for wrongful death. The nursing home moved to compel arbitration. The trial court granted the motion to compel, and the Supreme Court of Alabama reversed.

The decedent’s daughter had signed the admission paperwork but did not have power of attorney or any other legal authority to contract in his name at the time the contract was signed. In reviewing the record, the court found decedent was incapable of entering into a contract on the date of the admission documents due to his dementia. In addition, the decedent could not have understood the effect of allowing his daughter to agree to arbitrate, so she lacked apparent authority. Furthermore, the daughter was not personally bound to the arbitration clause, and thereby precluded from suing as personal representative, because she signed in her capacity as her father’s relative, not in her own capacity. Therefore, the arbitration agreement never existed and could not be enforced.

 

Dylan Thomas Burger, an employee of a nursing home, is accused of stealing more than 128 prescription Hydrocodone-Acetaminophen pain pills from two residents.  According to court documents, Burger is charged with felony criminal possession of dangerous drugs and two counts of misdemeanor theft after extreme damage to the residents’ pill packs tipped off nursing home staff that someone with access to the pills had stolen them.

Officers spoke with Burger, who was on shift when they arrived to investigate on Sept. 28, and he claimed he first noticed the damaged packaging on Sept. 20 but did not report it to his supervisor.  In the initial interview, Burger also admitted he had used pills in the past, but he had overcome his pill addiction.

Only five employees were qualified to administer the medication, and only one of those is scheduled per shift. Employees reported that someone had forced the narcotics out of their bubble packaging, replaced them with Motrin PM and then poorly taped the packages back together.

Upon reviewing the nursing home’s surveillance video footage, officers observed Burger unlocking the narcotics drawer, handling the narcotics and taking single pills from the packaging and concealing them in his pockets. At one point, Burger allegedly took an entire blister pack of narcotics and hid them in an unlocked drawer.

The footage also showed Burger taping up the blister packs to conceal the theft.  In a follow-up interview with police, Burger allegedly admitted he had a drug problem and had stolen the nursing home residents’ pills for his own recreational use.

The New York Times had another nursing home article discussing the AMDA’s recent study on nursing home residents on the verge of death  increasingly receiving intense levels of rehabilitation therapy in their final weeks and days, raising questions about whether such services are helpful or simply a lucrative source of revenue.  That is the heart of a new study published in the Journal of the American Medical Directors Association, which found that the practice was twice as prevalent at for-profit nursing homes as at nonprofit ones.

More broadly, the study’s findings suggest that some dying residents may not be steered to hospice care, where the focus is on their comfort.

“Some of these services are being provided in the last week and sometimes on the day of their death,” said Dr. Thomas Caprio, one of the study’s authors. Dr. Caprio, who specializes in geriatric medicine, hospice and palliative care, is an associate professor at the University of Rochester Medical Center.  Rehabilitation services — physical, occupational and speech therapy — are “a potential revenue source for these facilities,” he added. “And when the plan of care shifts to hospice care and palliative care, that revenue stream disappears.”

Jonathan Chait wrote an interesting article for New York Magazine about Trump’s repeated but failed attempts to destroy the Affordable Care Act.  The department of Health and Human Services revealed that premiums on the exchanges for 2019 policies are actually dropping. The Department’s figures also reveal other signs of health in the exchanges: insurers who had left the markets are returning to offer plans, and the number of regions with only one insurer has fallen.

“Obamacare is finished, it’s dead, it’s gone,” gloated President Trump last year, “There is no such thing as Obamacare anymore … It’s a concept that couldn’t have worked.” Trump was highlighting the anticipated effect of his many moves to undermine the hated law that he had failed to repeal. He had withheld payments to insurers that they were owed under the law, allowed healthy customers to be skimmed out of the customer pool with cheap plans that would raise rates for others, virtually eliminated the outreach budget to enroll customers in the exchanges, and would later repeal the individual mandate. All these steps were intended to destroy the economic basis for making its individual market exchanges work.

They failed.

The law’s viability has been a point of intense dispute for years. Conservatives had two reasons to oppose Obamacare. Philosophically, they objected to the idea of expanding government in order to create a new social benefit. Politically, they wanted to deny credit to a Democratic president. But, since neither of these arguments had much persuasive power with the electorate — which agreed with the goal of covering the uninsured, and tends not to support politicians who openly root for the failure of the opposing party’s program — they instead settled on a different argument. They insisted Obamacare could not work.

To be sure, there was a plausible mechanism by which the law could fail. The way to kill its exchanges would be to trigger a “death spiral,” in which healthy customers decided not to buy plans, so only sick people remained in the risk pool, driving up costs, and driving out more healthy people, and so on. But Obamacare was actually well-designed with safeguards to prevent such a thing from happening, And by 2016, it was fairly clear the predictions of doom were all totally wrong. The customer base and the rates were stable and profitable.

 The law, meanwhile, has become popular as Republicans tried to kill it:

And yet the Trump administration’s extensive efforts to sabotage Obamacare administratively and legally were potent enough that many health policy analysts thought the administration could actually reach the intended effect. Republicans could trigger the death spiral they had predicted, and then would argue it was Obamacare’s fault and was going to happen anyway. Indeed, Trump was arguing this.

All the uncertainty around Obamacare fomented by the administration, and the repeated steps to undermine it, had their effect: premiums shot up during Trump’s first year. States that took steps to counteract the sabotage have seen their premiums drop sharply — in New Jersey, for instance, a state controlled by Democrats, premiums will fall by 14 percent. If Democrats regain control of government, they could implement similar steps very quickly and bring down rates.

But even in the majority of states, where Republicans have blocked such action, premiums are largely stable. There is no death spiral. Obamacare has lived. And conservatives will have learned no lessons from their failed predictions.

Joseph Zupnik, the president, and financial officer Daniel Herman of Focus Otsego were fined only $1,000 each and sentenced to 250 hours of community service each.  Attorney Kathleen Boland from the state Attorney General’s Office said the two men will also split a $1 million fine imposed by her office.  The former owner and manager of the Focus Otsego nursing home – which is now Centers Home Health Care under new ownership – will have to pay fines and do community service for their part in endangering an elderly resident.

The lawyers for the executives argued that the four Focus employees who falsified records regarding treatment of M.P., the woman left in a chair for 41 hours over Memorial Day Weekend 2016, made it impossible for the executives to know the truth of what was happening at the facility.  The two men pleaded guilty to second-degree endangering the welfare of an incompetent or physically disabled person after failing to provide sufficient staff that could provide the necessary care to a 94-year-old resident who was left in a recliner for approximately 41 hours in 2016.

For her part, prosecutor Boland noted that Focus Otsego, under county ownership as Otsego Manor, had a “caring, nurturing” reputation.  The new owners “changed it from a neighborhood to a warehouse.”

 

The Telegraph in UK reported on the ongoing trial of nursing home staff accused of verbal abuse and neglect towards a dementia patient.   The woman with dementia was taunted by care worker Mary Craddock, who she said had eaten her imaginary pet show bird. Other residents were allegedly neglected and denied access to the toilet, slapped and verbally abused at Winterbrook Nursing Home in Oxfordshire between 2015 and 2017. The prosecution alleges the women committed offences against six victims between April 2015 and July 2017.

Prosecutor Kim Preston said that the elderly residents were “humiliated”, “distressed” and the former employees were “a law unto themselves”. Miss Preston  added that the former employees also bullied new staff, who were told off if they did not follow the established rules.  She also remarked how there was a rule that they were not allowed to use the toilet for up to 90 minutes during mealtimes, sometimes causing residents to soil themselves.

Mary Craddock, 59, Joan Lovell, 63, and Elizabeth Collins, 62, are charged with alleged ill treatment but deny all 18 counts.

Marjorie Willsman, 80, who suffers from Parkinson’s and arthritis, claimed that on one occasion Mrs Craddock told her she was “bloody inconsiderate” for asking to go to the toilet and refused to take her. Mrs Willsman said this happened “reasonably often” and sometimes caused her to have “accidents”, which left her feeling humiliated.

Home Manager Mrs Collins and supervisor Miss Lovell, who are sisters, are accused of having “turned a blind eye” to such behavior, as well as mistreating vulnerable residents themselves.  Prosecutor Preston said: “When you are working with people, and vulnerable people in particular, you have an obligation to be respectful and treat them with dignity and kindness. Those residents were not treated as they should have been, and there is no excuse for that.”