Trump’s $2 trillion spending bill includes $200 million in bailing out nursing homes with a windfall to improve infection-control procedures in the nation’s nursing homes.  And to reward those facilities with poor infection control, the sweeping legislation would raise Medicare fee-for-service payments to nursing homes by 15% for all residents with a primary or secondary diagnosis of COVID-19 infection. The Centers for Medicare & Medicaid Services (CMS) has placed infection control at the center of its emergency nursing home inspection protocols, suspending all non-emergency surveys and releasing stricter guidance for operators earlier this week.

CMS’s updated guidance was a direct reaction to the COVID-19 outbreak at a nursing facility in Kirkland, Wash., which resulted in the death of more than 25% of residents in less than three weeks from the first sign of symptoms.

“We used our experiences in Kirkland to develop a new inspection approach, and we’re also learning from the newest data about the virus and relying on longstanding principles of infection control,” CMS administrator Seema Verma said Monday.

The stimulus package also bolsters unemployment benefits by offering full pay to laid-off workers for four months, several news outlets have reported, while also sending $130 billion to hospitals.

Why are so few of the Germans who are diagnosed with the coronavirus dying? Is it because their leader acted early or because they have universal health care in a socialist society?

In Italy, 9.5 percent of the people who have tested positive for the virus have succumbed to covid-19, according to data compiled at Johns Hopkins University. In France, the rate is 4.3 percent. But in Germany, it’s 0.4 percent.

The biggest reason for the difference is Germany’s early testing to track and contain infection clusters. That means Germany has a truer picture of the size of its outbreak than places that test only the obviously symptomatic, most seriously ill or highest-risk patients. Germany, with 31,150 cases at midday Tuesday, appeared to have a larger outbreak than France, with 20,149. But the higher death rate in France implies there were more undiagnosed cases there. France’s outbreak could be larger than Germany’s. Because testing is not universal, and many people with the coronavirus might never be diagnosed, a true death rate is impossible to ascertain.

Germany coronavirus death rate

Initially, at least, the country’s health authorities tracked infection clusters meticulously. When an individual tested positive, they used contact tracing to find other people with whom they had been in touch and then tested and quarantined them, which broke infection chains. Germany’s initial testing criteria were no wider than Italy’s. People were tested if they had symptoms and had been to a risk area, or if they had contact with a confirmed case. But many initial cases had clear links to overseas travel.

Dr. Antony Fauci has rapidly become America’s security blanket.  The well-respected head of the National Institute of Allergy and Infectious Diseases, Fauci’s fact-based approach to the pandemic has been a rational alternative to the President’s misrepresentations, falsehoods, and exaggeration during the infamous daily press conferences on the virus. The more TV you do, the more the press writes positive things about you, the more Trump begins to turn on you.  Fauci has been blunt in recent interviews about Trump’s false promises and how he deals with them. In a candid interview with Science Magazine over the weekend, Fauci repeatedly acknowledged that he disagrees with Trump and that the President veers into misinformation at times.

“[Fauci] has grown bolder in correcting the president’s falsehoods and overly rosy statements about the spread of the coronavirus in the past two weeks — and he has become a hero to the president’s critics because of it. And now, Mr. Trump’s patience has started to wear thin.”

There are signs that Trump is jealous of Dr. Fauci’s because he is well-respected and competent. We know that Trump doesn’t like any star to shine brighter than his. Trump is aware of Fauci’s star status:
“The people behind me are total pros. All over the world, they’re respected — Dr. Birx; Anthony, who has become a — where is Anthony? — become a major television star for — for all the right reasons. No, he’s just so professional. So good.”
 Fauci and other experts have been explicit that the current social distancing measures need to be kept in place and perhaps even tightened in order to curtail the spread of coronavirus and to flatten the curve of those needing to be hospitalized so that we can assure proper care for them.

The Washington Post wrote an insightful article on the difficulty of dying with dignity at home surrounded by loved ones.  Most people want to die at home and not in a hospital or nursing facility.

For the first time since the early part of the 20th century, more Americans are dying at home than in the hospital or a nursing home. This finding, included in a recent study by me [Haider J. Warraich] and co-author Sarah Cross, is encouraging because the vast majority of Americans say they prefer to die at home. So this reflects that many more people are being able to achieve that goal.”

However, the authors understand that caregiver burden is a growing problem in America. Taking care of a loved one can be exhausting physically and emotionally, and sometimes caregivers lose themselves. Making shared living space work is just one issue. If dying at home is important to someone, that person and their caregivers should think about it and make clear that they want to die at home. Family, friends and medical teams need to know that. Physicians and nurses will frequently ask patients how they would like their end to be, particularly what types of intensive treatments they might or might not want. They rarely ask people where they would like to die, however.
A person at the end of life will probably have feelings about who they want to spend time with — or who they don’t want — so it is important to discuss in advance who will provide caregiving, along with who might provide occasional backup for regular caregivers. There are often community resources available as well, such as end-of-life doulas trained to care for the physical, emotional and spiritual needs of a dying person.

Online resources are available through such organizations as Compassion & Choices. The Conversation Project can provide guidance for patients and their loved ones about what to expect in the final days.

Perhaps the most critical resource available for those wanting to die at home is hospice care. Hospice is covered by Medicare (and most other insurance) for patients with an expected life expectancy of less than six months. It is designed to help caregivers take care of a dying loved one at home with 24-hour call-in numbers to answer urgent questions, visits from hospice nurses, social workers and other staff. But home hospice does not provide full hands-on service, and caregivers still carry the bulk of the responsibility.

Hospice is the primary reason more Americans are able to die at home today. Yet, only half of Americans who die receive hospice help. One reason may be that some people don’t ask for it because they think it is sending a depressing message to their ailing loved one or admitting what they may not want to acknowledge — that the person is in their last days.
With advances in public health, medicine and longevity, people now live longer with disabilities. Death is not just the terminal event in our mortal lives, but the final word of a story that can often take years to unfold.  But for many, fulfilling a loved one’s wish to die at home provides a fitting and natural end to the story of that person’s life.

McKnight’s had another great and informative article on Covid-19 and the CMS response as they relate to long term care facilities. The federal government has removed regulations related to Medicare telehealth coverage as a response to the coronavirus outbreak, which feeds on person-to-person contact and has proven deadliest for elderly individuals.

Centers for Medicare & Medicaid Services Administrator Seema Verma announced the temporary coverage expansion. In addition, insurers have been asked to expand telehealth coverage, and physicians will see relaxed HIPAA enforcement so that they can use their cell phones to a greater extent when treating patients, for example, Verma said. Also, the HHS Office of Inspector General is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs, CMS said.

As a vehicle for this expansion, CMS is widening Medicare’s telehealth benefits under the 1135 waiver authority and the Coronavirus Preparedness and Response Supplemental Appropriations Act. Until today, there had been coverage only for rural providers, existing patients and a few others.

Now, clinicians will be able to consult with patients in nursing homes or numerous other locations without stressing crowded waiting rooms or increasing risk with face-to-face visits.

Clinicians will be paid for a wider range of telehealth services for beneficiaries “residing across the country,” including in their homes, dating back to March 6, CMS said.

“A range of healthcare providers, such as doctors, nurse practitioners, clinical psychologists and licensed clinical social workers will be able to offer telehealth to Medicare beneficiaries,” Verma said. “Beneficiaries will be able to receive telehealth services in any healthcare facility including a physician’s office, hospital, nursing home or rural health clinic, as well as from their homes.”

This change broadens telehealth flexibility “without regard to the diagnosis of the beneficiary, because at this critical point it is important to ensure beneficiaries are following guidance from the CDC including practicing social distancing to reduce the risk of COVID-19 transmission,” she added.

 

The Iowa Dispatch reported the disturbing “care” provided to residents at Rowley Memorial Masonic Home. The nursing home cut staffing to compensate for financial losses and landed on the federal watch list after inspectors cited the facility for contributing to a resident death, hiring an unlicensed caregiver, failing to protect residents from sexual abuse and allowing a kitchen worker to supervise its dementia ward.

The home is now on the Centers for Medicare and Medicaid Services’ Special Focus Facilities list. The national list was created to identify those homes that have an established pattern of numerous, serious violations related to resident care. The home is still allowed to operate on a conditional license from the state.

The home is owned by the Herman L. Rowley Memorial Trust and is part of the Rowley Masonic Community complex, which includes assisted living units and independent living apartments. The facility is run by Health Dimensions Group, a Minnesota company that manages nursing homes in Iowa, Colorado, Wisconsin, Illinois and other states.

In May 2019, the home was cited for failing to have on hand any portable liquid oxygen tanks for the residents who had been prescribed continuous oxygen. Inspectors determined the facility’s oxygen-tank supplier had stopped making deliveries of oxygen due to non-payment of past-due bills.

The inspectors then discovered there were 31 vendors – including suppliers of medical equipment – that were owed almost $600,000 by the Rowley Memorial Masonic Home. Seven vendors that provided essential resident-care services told inspectors they would no longer do business with the home. In addition to that, the facility was $600,000 behind on its mortgage, inspectors said.

At the time, the facility was also cited for a 16% medication-error rate. One resident had to be taken by ambulance to a hospital after being found unresponsive in bed after a staff-induced drug overdose.

Inspectors also cited the home for failing to have a functional call-light system that would allow residents to summon the staff for assistance. Residents reported soiling themselves as they waited 40 minutes for someone to come to their aid. An audit of the call-light system revealed 472 instances, over a seven-week period, in which residents waited 15 minutes or more for a response.

In the wake of that inspection, federal officials fined the home more than $106,000.

Two months later, in July 2019, inspectors returned to the home and cited it for failing to protect a male resident of the home’s dementia unit from sexual abuse at the hands of another male resident. In one instance, a worker saw the alleged perpetrator pin the victim against the wall and put his hand in the other man’s pants. The facility was also cited for medication errors, insufficient staff, and inadequate training for the staff. Residents were waiting up to 62 minutes for a response to their call lights, inspectors alleged.

In October 2019, inspectors returned to the home and issued a 111-page report detailing 21 additional violations, including failure to complete background checks on workers; failure to report physical altercations among the residents; medication errors; improper use of psychotropic drugs; and employing as a nurse aide an individual who had failed the skills test three times and wasn’t state certified as required by law.

The home was also cited for having insufficient bedside medical equipment for a tracheostomy patient who was found in bed, not breathing, three days after admission. With no equipment readily available to suction the resident’s airway, a nurse aide tried to breathe air into the man’s lungs using only her mouth on the surgical hole in his neck. The man was rushed to a nearby hospital where he died two hours later.

The home’s nurse manager and director of operations each told inspectors the man should never have been admitted to the home given the level of skilled care he required.

On at least nine occasions in the month leading up to the October inspection, the only person working a shift in the home’s dementia unit was a kitchen worker who told inspectors he had been “sitting shifts” in the nursing department for about two months, although he had no medical certification of any kind. He told inspectors that while he couldn’t legally provide resident care, he supervised the unit and could shut off residents’ call lights and inform them someone else would eventually come to assist them.

Other workers told inspectors the facility was often short-staffed and residents were falling and being injured as a result. They acknowledged their practice was to answer call lights by shutting them off with a promise to return later and provide whatever assistance the residents needed.

Even with state inspectors on site, there were times when the dementia unit was either entirely unstaffed or had only one nurse aide present. An inspector observed one resident near a doorway repeatedly yelling, “Help me,” with no workers responding.

Additional state inspections were conducted at the home in November, December and January, but the Iowa Department of Inspections and Appeals has yet to publish the findings from those inspections on its web site.

In November, the agency suspended all Medicaid and Medicare payments for new admissions to the home. About damn time!

Each year, about 380,000 residents are killed by infections, according to the Medicare agency. Failure to prevent them is also the leading cause of citations that state inspectors bring against nursing homes. The Trump administration has been working to weaken safety standards governing America’s nursing homes, including rules meant to curb deadly infections among elderly residents.

Last July, the federal Centers for Medicare and Medicaid Services, or CMS, planned to weaken rules that required every nursing home to employ at least one specialist in preventing infections. The proposed rules eliminate the requirement to have even a part-time infection specialist on staff. Instead, the Trump administration would require that anti-infection specialists spend “sufficient time at the facility” which is not defined.

The push followed a spate of lobbying and campaign contributions by people in the nursing-home industry especially Brian Ballard, a Trump ally, according to public records and interviews.  As soon as Trump was elected, Ballard was hired by the nursing home industry lobbyists, the American Health Care Association. His firm, Ballard Partners, has earned $930,000 in lobbying fees from the group since Trump took office, records show.

Based on his financial and personal connections to Trump, Ballard is now one of the most powerful lobbyists in Washington, with the most clients of any registered lobbyist last year, according to an analysis by the Center for Responsive Politics. His firm has lobbied on behalf of nursing homes in his home state, Florida, for years, according to public records. (He was also a lobbyist for Trump’s Florida golf course, the Doral.)

The administration’s reckless and dangerous decisions were caused after intense lobbying by the nursing home industry, including by the firm run by Brian Ballard, Trump’s friend and a fundraiser.

The main federal regulator overseeing nursing homes proposed the rule changes last summer, before the coronavirus pandemic highlighted the vulnerability of nursing homes to fast-spreading diseases.

Infection-prevention specialists are supposed to ensure that employees at nursing homes properly wash their hands and follow other safety protocols. They are widely considered the front line for stopping infections, among the leading causes of deaths in nursing homes.

Attorneys general in 20 states have called the proposed rules a threat to “the mental and physical security of some of the most vulnerable residents of our states.”

“It adds up to less time, less infection control,” said Anthony Chicotel, a staff lawyer for California Advocates for Nursing Home Reform. He said the proposed change was “alarming.”

 

Howard Gleckman wrote a great article about nursing home closures.  4 percent of nursing facilities closed from 2015 to 2019.  There still are more than 15,000 nursing facilities in the US.  Gleckman argues that nursing homes are shutting their doors at a rapid pace because of growing pressures from payors, rising costs, the need to replace old buildings, increased competition from other forms of residential care, and shrinking demand from older adults who prefer to age at home.

“A new study by the senior services trade group Leading Age reports that more than 550 nursing homes closed over the past four years, and that the trend is accelerating. More than half occurred in nine states—Texas, Illinois, California, Ohio, Massachusetts, Wisconsin, Kansas, Nebraska, and Oklahoma. The Leading Age report was primarily based on government data. It measures closures but does not count new facilities that opened over the period.”

“A separate study by the National Investment Center for Seniors Housing & Care (NIC) ——based on an ongoing industry survey— helps explain the trend: Occupancy rates in skilled nursing facilities have been falling since 2015, though they stabilized over the past year. Medicaid, which pays the lowest average rates, represents a growing share of residents, while relatively fewer patients are covered by traditional Medicare—the most generous payor.”

NIC found occupancy rates have fallen from a peak of about 89 percent in 2015 to about 84 percent today. Leading Age reported the number of occupied beds fell by 16,000 over the same period, to about 1.325 million.

“At the same time, Medicaid residents grew from about 60 percent of volume in 2015 to 68 percent last year, traditional Medicare fell from about 18 percent to 11 percent, and managed Medicare grew slightly to about 6.5 percent. The share of lucrative private pay residents dropped from about 11 percent to 8 percent.”

“For years, the financial model of nursing facilities has been built on a system of government cross-subsidies. The facilities lost money on their Medicaid long-stay beds but made a healthy profit on their Medicare post-acute business. But as Medicaid payments fall further behind costs and Medicare managed care continues to squeeze margins, that business model is at risk.”

 

 

 

This image has been shared because it perfectly exemplifies the zeitgeist.

Jimmy Gonzales visits wife through nursing home window.

Jimmy Gonzales visits wife through nursing home window. (KSAT)

The couple, who are both in their 90s, were heartbroken that they couldn’t spend time together and Jimmy Gonzales had to resort to visiting his wife, Isabel, through a window.

Drug abuse among health care professionals is a serious issue.  With their authority and access to a myriad of chemical substances the temptation is often too much to overcome.  Recently, residents of Palm Garden of Pinellas in Largo and Clearwater Central nursing homes said registered nurse Brett Edwards didn’t give them their pain medication. Coworkers there and at a Largo nursing home said Edwards appeared “impaired” during shifts.  Edwards was a nurse at Seneca Health and Rehabilitation owned and operated by SavaSeniorCare, the infamous for-profit chain. His South Carolina license to practice registered nursing was revoked in June 2019.

According to the emergency restriction order (ERO) that the Florida Department of Health placed on Edwards’ license on Feb. 7, Edwards can’t practice nursing until he’s cleared by the Intervention Project for Nurses (IPN), which monitors nurses with substance abuse problems.  The problems began revealing themselves, the ERO says, in 2019 at Palm Garden of Pinellas in Largo and Clearwater Central nursing homes. He resigned from each facility rather than take a drug test for reasonable cause.

During an Aug. 15, 2019, shift at Palm Garden, the ERO said, a “coworker observed that Mr. Edwards had a difficult time logging into the electronic medical records system and spelled his name wrong.”

Another coworker counted medication with Edwards at the end of the shift and found the count two Percocet tablets short. Edwards dodged a supervisor’s questions about the missing pain medication, then left Palm Garden without answering the questions. The supervisor told Edwards to come back to work to talk about the Percocet.

Edwards returned to a request for a reasonable cause drug screen. Edwards resigned instead.

Palm Garden wasn’t dropping things that easily. The hospital called Largo police, who got Edwards on the phone.

“Mr Edwards told the officer he did not submit a sample because he was taking performance drugs and did not want those to show up on the drug screen,” the ERO said. “Mr. Edwards denied diverting Percocet.”

 Seven days later, Clearwater Center hired Edwards.

Eight days into his employment, the ERO says, Edwards’ peers at Clearwater Center began seeing similar behavior that preceded his departure from Palm Garden.

He had been “acting oddly and having difficulty logging into the narcotic box,” repeating the troubles he had 15 days earlier at Palm Garden.

Another coworker “observed Mr. Edwards working very slowly and not treating his patients.” When the coworker asked Edwards if he was all right, Edwards said, “I am a big boy.”

 A third coworker noticed Edwards leaning over the medication cart and noticed Edwards didn’t see any of the patients to whom he was assigned.

“When a patient complained that he needed his medication, Mr. Edwards said that he ‘can wait,’ ” the ERO said.

“This colleague found Mr. Edwards asleep on the medication cart. She woke him up and he responded, ‘I am so tired.’ ”

Also, “multiple patients at CWC reported that Mr. Edwards did not give them their narcotic medications when they asked for them.”

Edwards told still another colleague, as she took over the narcotic box, that he lost some medication administration sheets.

Just as Palm Garden had, CWC administration asked for a reasonable cause drug screen. For the second time in just over two weeks, Edwards resigned.

When the Florida Department of Health ordered Edwards to see Dr. Lawrence Wilson, an addiction medicine specialist, in December, Edwards began admitting the depth of his problem. He told Wilson he bought pills on the street twice a year, most recently pain medication oxycodone two days before seeing Wilson. His last drink? One beer, six days earlier.

Blood, urine and hair samples came back positive for alcohol, methamphetamine, amphetamine, pain medications Ultram, morphine, oxycodone, noroxycodone, oxymorphone and hydrocodone in amounts that Wilson thought indicated “repetitive and frequent use of opiates, opioids, stimulants and alcohol.”

Wilson recommended an inpatient hospitalization program and a monitoring contract with IPN.

Edwards hasn’t done that yet.  I doubt he ever will.