One of the major issues with America’s health care system is how we treat people with addictions.  Anyone who has been affected by the ongoing opioid crisis can attest to the lack of resources for those addicted to the deadly scourge.  Many are stuck in nursing homes.  This is not an ideal situation for numerous reasons.  Rehabilitation hospitals work with patients to achieve therapy goals. But for long-term care, if a patient isn’t able to live independently in the community, the patient typically goes to a nursing home.

Athena Health Care Systems, a privately owned long-term care company based in Connecticut, has become one of the health care providers to offer programs to care for patients who have a history of addiction on top of the physical care diagnosis for which they are referred.  However, nursing homes are licensed by the state Department of Public Health and are surveyed by DPH to certify that they comply with federal Medicare and Medicaid regulations. They are not regulated as detoxification or addiction recovery centers. Athena-owned facilities are the only ones that have developed partnerships with drug treatment centers and in-house programs to train staff and support patients who also have substance use disorders.

“It’s an excruciating problem,” Peter Zawrotniak, program manager in addiction counseling services at UMass Memorial Medical Center, said about placing patients with substance use disorders in appropriate aftercare, particularly if they need methadone treatment.

Zawrotniak said none of the long-term care facilities in the area is equipped to address the full range of services needed for treatment and recovery. Suboxone, as long as it is prescribed by a physician with a waiver to do so, can be dispensed by nursing home staff and is easier to manage, Zawrotniak said.

Methadone, another form of medication-assisted treatment for opioid addiction, can only be administered to patients at a licensed methadone clinic. Patients must be registered with the clinic, a bureaucratic process that can be time consuming to coordinate. One patient waited in a hospital bed for two weeks. The nursing home must then transport the patient to the methadone clinic every day for their dose.

The state DPH’s Bureau of Health Care Safety and Quality issued a letter in 2016 about admission of residents on medication-assisted treatment for opioid use disorder. According to the letter, patients who have completed detoxification and are receiving medication-assisted treatment, and are otherwise eligible for admission to the long-term care facility, are expected to be admitted and have their treatment continued as prescribed by the patient’s physician or opioid treatment program.

There is no federal guidance on what reasonable accommodations need to be made for patients with substance use disorders. And extra services such as addiction counselors and enhanced security measures are not reimbursed by Medicare or Medicaid.

 

Many of us do not realize that one day soon we will need to deal with long term care for ourselves or a loved one.  Some laws require adult children to pay for long-term care bills their parents run up. Either the government or non-government providers of care can use the laws. I believe these laws will increase in future years by states and long-term care facilities that need the cash.  If found liable under the laws, an adult child’s wages can be garnished and liens can be filed against property.

Right now, Medicaid (not Medicare) has a reimbursement provision that applies to the Estate. Federal law requires states to try to collect money Medicaid spent on long-term care, even when a person qualified for Medicaid when the care was delivered and fraud isn’t suspected. The money can be collected from the estate of the person whose care was paid for by Medicaid. Most states seek payment from the estate primarily when it had exempt assets when Medicaid was applied for. Exempt assets aren’t counted in determining the person’s eligibility for Medicaid.

Filial responsibility laws were at issue in the seminal 2012 Pennsylvania court case, Health Care & Retirement Corp. of America v. Pittas which allowed a nursing home to sue a son for his mother’s care at the facility despite no allegations of wrongdoing or fraud by the son or that he guaranteed her care.

Some nursing homes reportedly have improperly started sending letters demanding children or other relatives of residents to pay. The children are advised that to avoid personal responsibility they need to either see that the bills are paid or that the parent enrolls in Medicaid. However, this is often untrue, Filial duty laws apply only under certain special circumstances. For example, the parent must be indigent or otherwise unable to support himself or herself. A child who is financially unable to provide support doesn’t have to pay for a parent’s care. The child also doesn’t have to pay if there is evidence of neglect or abuse by the parent before the child became an adult.

 

 

Joel Freedman wrote a great editorial that I wanted to share this Thanksgiving.  I hope you all enjoy the Day of Gratitude.

 “U.S. Sen. Chuck Grassley, R-Iowa, recently remarked that mistreatment of residents in America’s nursing homes remains a “systemic problem. Hardly a week goes by without seeing something about nursing home abuse or neglect in the national news.”

For every such story that is reported, countless other abuses, including abuses in for-profit, and non-profit nursing homes, including VA nursing homes, go unreported.

Various surveys of nursing home care providers, who are promised anonymity, have concluded that at least 10 percent of nursing home personnel have at least occasionally physically abused residents, and at least 40 percent have verbally abused them. About 50 percent of nursing home employees also acknowledge they have sometimes neglected residents.

Several years ago, the federal Office of Inspector General reported on a study of people admitted to nursing homes for Medicare rehabilitation services. One-third of these people subsequently suffered from preventable harm, which required a prolonged stay in the nursing home or hospitalization, caused permanent injury, necessitated life-sustaining intervention, or resulted in death.

If the experiences of people admitted to nursing homes for short-term services are often awful, consider the plight of even more vulnerable long-term care residents who suffer from preventable pressure sores, dehydration, malnutrition, nasogastric tube misuse, overdrugging, poor hygiene care, and physical or psychological abuse.

I believe camera monitoring should be implemented at all facilities housing our most vulnerable citizens to help prevent and detect abuse and neglect. Without camera monitoring, fear of reprisals, sometimes violent ones, are realities that often prevent the reporting of cruelty witnessed by conscientious, but fearful, care providers, or by residents and their families.

Most large stores are camera-monitored. This usually deters any dishonest customers or employees from committing thefts, and results in detecting thefts and other crimes. Honest shoppers and employees usually aren’t offended by camera surveillance and understand the need for it. If it is justified to have surveillance in stores to prevent shoplifting, then it certainly should be justifiable to require surveillance in nursing homes and other places to help protect care-dependent people.

To prevent maltreatment caused by understaffing, facilities providing skilled care for dependent people should also be required to employ enough qualified staff to assure good care for everyone.

Our country’s nursing home mess has been well known since the 1970s, when numerous governmental investigations and newspaper exposés began to reveal the plight of people in nursing homes. One of the reasons elected officials or governing agencies are influenced more by the wishes of well-financed nursing home businesses and their lobbyists than by the needs of nursing home residents is that there is not enough pressure on them from the rest of us to make meaningful and permanent nursing home reform a priority. That is why none of the candidates hoping to be elected to the White House, to Congress, or to state legislatures are even mentioning, let alone vigorously campaigning for, nursing home reform — even though about 40 percent of Americans will spend time as nursing home residents.

Back in the 1960s and early 1970s, U.S. Rep. David Pryor, of Arkansas, became a crusader for nursing home reform after he got a job as an aide, his true identity concealed, at a nursing home in Washington, D.C. I doubt we can find many legislators nowadays willing to do what Pryor did.

What also is needed is a modification of our attitudes toward older Americans, especially those who are infirm, and the means by which our society deals with people approaching the end of their lives. In a society that prizes youth over old age, nursing home residents can be painful reminders of reality. They remind us that our own bodies will change, our physical and mental prowess will diminish, families and friends will eventually be left behind, and the time will come for each of us to deal with end of life. Unless a nursing home becomes a necessity for us or for a family member or close friend, we don’t like to think about nursing homes or about the lives of their residents.

Far too many nursing home residents rarely or never get visits from family or friends. Agonizing loneliness can be devastating for them even in the best facilities.

Much more interest and involvement is needed by both public officials and ordinary citizens to help assure that nursing home residents are not forgotten, and that they are treated with compassion, dignity and respect. After all, a nursing home can be in anyone’s future.

CMS last month announced that it would add a new icon—which is a red circle with a white stop hand in the center—to the site to alert consumers when a nursing home has been cited for incidents of abuse, neglect, or exploitation. According to the data-analysis company StarPRO, CMS has affixed the icon to ratings for only 760, or roughly 5%, of the 15,262 facilities on the site.

CMS said the consumer alert icon would appear next to facilities that have been cited in inspection reports for abuse that caused a resident harm within the past year, as well as abuse that could have potentially caused residents harm in the past two years, and the move has been applauded by experts and consumer advocates in the nursing home industry.

CMS’ Nursing Home Compare website assigns a certain number of stars to nursing home facilities, similar to systems used to rate hotels. The best possible rating Medicare can give to a nursing home is five stars based on staffing, quality measures, and other factors. The ratings are designed for both consumers and providers. CMS added the icons to the site, and they appear directly next to the names of facilities that have received citations.

CMS said it will use the agency’s latest inspection data to update the icons each month, and it will remove the consumer alert icon when nursing homes have fixed the issues that caused the citations. According to the Wall Street Journal, CMS will remove the icon once a flagged facility goes without an abuse citation for one year.

Consumer advocates praised the icon’s introduction, but said the tool is imperfect and is based on an inspection system that often misses cases of abuse.

Richard Mollot, executive director at the Long Term Care Community Coalition, said, “We just hit the tip of the iceberg here. We are not finding the harm that’s out there. If we see a few occasions that are getting out, I think it’s an important alert for the public.”

 

Medication errors are a serious problem in the nursing home industry. Federal law requires skilled nursing facilities to keep errors within a 5% margin. This margin is broadly defined, but includes errors such as not mixing medication as directed, giving medications at the wrong time, or not dosing the last small portion of a medication. Consumer advocates and experts estimate that at least 7 million Americans experience a medication error each year. These mistakes are preventable and costly – estimated at over $21 billion.  Errors within this 5% window don’t impact licensing and they’re the types of medications many people make at home when administering their own medications.

Nursing homes which are often understaffed, medication errors are rampant. Errors are likely underreported and that the medical coding system makes it easy to cover up error-related deaths. Under a different system, the CDC argues that medication errors might be the third most common cause of death among nursing home patients.

If you’re responsible for the health and safety of an older adult,you need to understand medication administration, particularly within nursing home settings.  By building good habits around medication preparation and administration, nursing facilities can improve patient outcomes and help minimize error rates at their facilities.

Given the potential problems stemming from improper medication administration, nursing homes need to invest in better prevention practices. That starts with increasing staffing level, a strategy that could also help prevent nursing home abuse. These facilities are chronically understaffed because of low pay and poor management and have a high rate of turnover. That means staff also aren’t familiar with patients’ care regimens and are more likely to make mistakes.

In addition to increasing staffing levels, nursing homes can decrease error rates by adopting a strong medication reconciliation program.  Reconciliation processes are especially important in nursing homes, as many patients are unable to verify their medications.

Finally, as part of reducing error rates, nursing homes should minimize high-risk behaviors, such as not properly disposing of discontinued medications or medications from discharged patients, improperly transporting medications, or administering medications without fully reviewing the label directions.

Nursing home residents are the most vulnerable members of our community and they deserve safe, careful, and appropriate treatment.

Nursing homes provide care to about 1.4 million nursing home residents—a vulnerable population of elderly and disabled individuals. CMS, an agency within the Department of Health and Human Services (HHS), defines standards nursing homes must meet to participate in the Medicare and Medicaid programs.  The Centers for Medicare & Medicaid Services (CMS) is responsible for ensuring nursing homes meet federal quality standards, including that residents are free from abuse. To protect vulnerable nursing home residents from abuse, the Centers for Medicare & Medicaid Services (CMS) contracts with state agencies—known as survey agencies—that can cite nursing homes for incidents of abuse.  Most are overworked and without adequate budgets and support for enforcement.

Abuse citations doubled from 2013-2017. GAO recently reviewed a 2016-2017 sample of narratives substantiating abuse citations and determined that physical and mental/verbal abuse were more common than sexual abuse, and that perpetrators were often staff.

CMS can’t readily access this information, which it could use to improve its oversight by focusing on the most prevalent problems. GAO recommendations address this and other issues GAO found.

Nursing Home Abuse by Type and Perpetrator among the Sample of Narratives in Our Review

Bar chart showing physical and mental/verbal abuse and staff perpetrators most common

GAO also found gaps in CMS oversight, including:

Gaps in CMS processes that can result in delayed and missed referrals. Federal law requires nursing home staff to immediately report to law enforcement and the state survey agency reasonable suspicions of a crime that results in serious bodily injury to a resident. However, there is no equivalent requirement that the state survey agency make a timely referral for complaints it receives directly or through surveys it conducts. CMS also does not conduct oversight to ensure that state survey agencies are correctly referring abuse cases to law enforcement.

Insufficient information collected on facility-reported incidents. CMS has not issued guidance on what nursing homes should include when they self-report abuse incidents to the state survey agencies. Officials from all of the state survey agencies in GAO’s review said the facility-reported incidents can lack information needed to prioritize investigations and may result in state survey agencies not responding as quickly as needed.

McKnight’s had an article on lawmakers attempts at figuring out the role of private equity firms in nursing home and long-term care, and how and why their involvement affects the quality of care provided.  Hint:  It is short-staffing to increase profits.

Letters asking for information were sent to Carlyle Group, Formation Capital, Fillmore Capital Partners and Warburg Pincus.  The letters questioned the firms’ impact on the “declining quality of care in nursing homes”  and their management of the facilities.  The legislators cited significant and credible research that “has shown that for-profit chain-affiliated companies often provide a lower quality of care and experience more serious health and safety deficiencies that non-profit facilities.”

“We have concerns about the rapid spread and effect of private equity investment in many sectors of the economy, especially industries that affect vulnerable populations and rely primarily on taxpayer-funded programs such as Medicare and Medicaid, like the nursing home industry,” the lawmakers wrote.

“We are particularly concerned about your firm’s investment in large for-profit nursing home chains, which research has shown often provide worse care than not-for-profit facilities,” they added.

Richard Mollot, executive director of the Long-Term Care Community Coalition, criticized real estate investment trusts’ role in the nursing home industry during a federal hearing last week.

The investment by (REITs) and other entities that have nothing to do with healthcare into the nursing home world has essentially savaged the industry and I think care across the country. We’re seeing that more and more with entities buy up nursing homes, they have no experience in the business, they sell out the underlying property,” Mollot added.

We’re seeing it over and over again that monies are being siphoned away from nursing homes and from care. They’re just being devalued and then sometimes even closing.”

The Military Times reported on the trial against Stephen Gore, owner of the Biological Resource Center of Arizona, ended with jurors finding in favor of 10 of 21 plaintiffs, awarding $8 million in compensatory damages and $50 million in punitive damages. A civil jury has awarded $58 million this week to 10 people who alleged a body donation facility mishandled the donated remains of their relatives and deceived them about how the body parts would be used.

Gore’s business was accused of fraud by claiming the donated bodies would be used for medical research, when it knew some of the remains would be sold for military testing, such as crashes and explosions. A woman whose son’s remains were sold for military testing was awarded $6.5 million.  The Army was mislead by the company to believe that the donors had consented to the bodies’ use in blast tests.

Each plaintiff acknowledged ahead of the verdict that Gore wasn’t likely to be able to pay a large award. They said they brought the case to trial to hold Gore and his business accountable.

Gore’s business was raided in January 2014 by FBI employees wearing hazardous-material suits and breathing through respirators. A retired FBI agent testified that body parts were piled on top of each other and had no identification.

He said he saw one torso that had its head removed and a smaller head sewn on, comparing the discovery to a character from Frankenstein. The retired agent also said the horrific discoveries during the raid led some FBI employees to undergo counseling.

Gore pleaded guilty in October 2015 to a felony charge for his role in mishandling the donated parts.

Though Gore denied the allegations in the lawsuit, he acknowledged when pleading guilty to illegally conducting an enterprise that his firm provided vendors with human tissue that was contaminated and used the donations counter to the wishes of the donors.

Michael Burg, an attorney representing donor families, said the industry will learn from the verdict that there are consequences for deceptive practices. “It sends a message to others that don’t want to be honest or trick people into doing this,” Burg said.

The death of an elderly man who fought with his Brooklyn nursing home roommate over a pair of pants has been declared a homicide.  First responders were called to the Crown Heights Center for Nursing and Rehabilitation about 3:15 p.m. on Aug. 10 after the staff failed to supervise and prevent Eitel Vargas from brawling with his roommate.

Nursing home staffers called 911 but the injuries were too severe. Vargas died three days later at Kings County Hospital, police said. The city Medical Examiner declared his death a homicide. The assault exacerbated the heart condition, which led to his death, officials said.

Vargas’ death remains under police investigation, said an NYPD spokesman who added that the department was never told of the fight.

The state Department of Health is also investigating.

“The New York State Department of Health takes these disturbing allegations with the utmost seriousness,” DOH spokesman Jeffrey Hammond said. “Upon learning of this incident, we immediately opened an investigation. As this is an ongoing investigation we cannot comment further.”

Nursing homes are required to report any incidents of assault and sexual abuse at their facilities to the state, and are required to identify residents whose personal histories put them at risk for abusing other residents, according to federal rules.

Vargas’ roommate still lives at the nursing home and has not been criminally charged, staffers said.
Relatives of nursing home residents were stunned by the news and said they were never told of the fatal fight.

“I wish I’d have known,” said one woman who was visiting her husband. “I’m not saying I would move (my husband), but I might have been more vigilant (about) his roommates and who’s up and down the hallway.”

Boston 25 News has provided details surrounding the death of a nursing home resident at the Lutheran Rehabilitation and Skilled Care in September.  According to the Department of Public Health’s report obtained by Boston 25 News, a resident was dropped from a mechanical lift while being taken out of bed in September.  DPH says the resident died at the hospital the next day.  This is why it is required and standard to have two people assist when using a mechanical lift.

The resident suffered a subdural hematoma, which is a collection of blood build up outside the brain, cervical spinal fractures, a pneumothorax, a condition where air leaks into the space in between the lungs and chest, two left rib fractures and a spinal fracture.

According to the report, the certified nursing assistant responsible tried to cover up the incident.

She only told fellow staff members and emergency workers they had just bumped the resident’s head on a metal bar.

The hospital didn’t find out about what had really happened until several hours after the resident had been dropped.

Alison Weingartner and Arlene Germaine, who work for the Massachusetts Advocates for Nursing Home Reform said they were mortified after reading about the Department of Public Health’s findings regarding the patient’s death.

“It is horrifying it’s totally unnecessary that this happened,” said Germaine. “It’s horrifying all the way around.”

The department issued a list of things to look out for when choosing a nursing home for your loved ones:

Choosing a nursing home for yourself or a loved one is an important decision, and there are several factors to consider when evaluating a facility. Both DPH and the Executive Office of Elder Affairs (EOEA) have made resources available online to help with decisions about nursing home care.

  • The Guide to Nursing Home Care brochure provides information, tips, and resources to help answer questions about long-term skilled nursing care.
  • The Long-Term Care Ombudsman is an advocate working to resolve problems related to the health, welfare, and rights of individuals living in nursing or rest homes. Ombudsman representatives are regularly onsite at nursing homes and can provide valuable insight when choosing a nursing home for a loved one. To connect with your local ombudsman, call (800) 243-4636 (800-AGE-INFO) or find their contact information online.
  • The Options Counseling Program, funded through EOEA, provides free, unbiased information and support to older adults, family caregivers and people living with disabilities. An Options Counselor can connect MA residents to resources and helps them make decisions related to long-term services and supports based on their specific needs.
  • There are a number of options for long-term services and supports, including assisted living, in-home care, adult day health programs and nursing facilities. To request an Options Counseling session near you, call (800) 243-4636 (800-AGE-INFO).
  • DPH’s Nursing Home Survey Performance Tool and the CMS Nursing Home Compare website are tools that allow consumers to compare certified facilities in their area and determine the facility that will best meet your or your loved one’s needs.
  • There is no substitute for visiting a nursing home. DPH encourages individuals to contact the facility to schedule an appointment for an informational meeting and tour. Prepare questions that can help in the selection process, and ask for a copy of the facility’s brochure, admissions policies, and resident bill of rights.
  • If a resident, their representative, or their family members have concerns about the care they receive while in a long-term care facility, they may contact the facility’s Long Term Care Ombudsman to provide assistance or they may file a complaint with DPH by calling (800) 462-5540.