On October 26, 2016, CMS published the final revised federal nursing home regulations for nursing homes participating in Medicaid or Medicare programs (Requirements of Participation).  These requirements have been implemented in three phases: Phase 1 went into effect on November 28, 2016;  Phase 2 on November 28, 2017; and Phase 3 was implemented on November 28, 2019.

The Phase 3 regulations include:

§483.12 Freedom from abuse, neglect, and exploitation
(b)(4) Coordination with QAPI Plan

§483.21 Comprehensive person-centered care planning
(b)(3)(iii) Trauma-informed care

§483.25 Quality of care
(m) Trauma-informed care

§483.40 Behavioral health services
(a)(1) As related to residents with a history of trauma and/or post-traumatic stress disorder

§483.70 Administration
( d)(3) Governing body responsibility of QAPI program

§483.75 Quality Assurance And Performance Improvement
Entire section except for the following provisions implemented in Phases 1 and 2:
(a)(2) Initial QAPI Plan must be provided to State Agency Surveyor at annual survey.
(g)(1) QAA committee — All requirements of this section with the exception of subparagraph (iv), the addition of the IPCO
(h) Disclosure of information
(i) Sanctions

§483.80 Infection Control
(b) Infection preventionist (IP)
(c) IP participation on QAA committee

§483.85 Compliance and ethics program
Entire section

§483.90 Physical environment
(f)(1) Call system from each resident’s bedside

§483.95 Training requirements
Entire section except for the following provisions implemented in Phase 1:
(c) Abuse, neglect, and exploitation training
(g)(1) Regarding in-service training, (g)(2) dementia management & abuse prevention training, (g)(4) care of the cognitively impaired
(h) Training of feeding assistants

However, according to a memo issued by CMS, the Interpretive Guidelines for the regulations will not be released until the second quarter of 2020. CMS notes that until the guidance is released, “our ability to survey for compliance with these requirements will be limited.”  At the same time, the agency emphasizes that facilities are still required to comply with these regulations even without guidance.

A recent report published in the Journal of the American Medical Association that looked at the past six decades of mortality data noted a decline in overall life expectancy in the United States for three consecutive years. The JAMA report looked at life expectancy and mortality across the country from 1959 through 2017. Final life expectancy numbers for 2018 will be released soon by the U.S. Centers for Disease Control and Prevention. The general trend: Life expectancy improved a great deal for several decades, particularly in the 1970s, then slowed down, leveled off and finally reversed course after 2014, decreasing three years in a row.

Despite spending more on health care than any other country, the United States has seen increasing mortality and falling life expectancy for people age 25 to 64, who should be in the prime of their lives.  Death rates from suicide, drug overdoses, liver disease and dozens of other causes have been rising over the past decade for young and middle-aged adults. By age group, the highest relative jump in death rates from 2010 to 2017 — 29 percent — has been among people age 25 to 34. The all-cause death rate — meaning deaths per 100,000 people — rose 6 percent from 2010 to 2017 among working-age people in the United States.

In contrast, other wealthy nations have generally experienced continued progress in extending longevity. About a third of the estimated 33,000 “excess deaths” that the study says occurred since 2010 were in just four states: Ohio, Pennsylvania, Kentucky and Indiana. The state with the biggest percentage rise in death rates among working-age people in this decade — 23.3 percent — is New Hampshire, the first primary state.  All five of these states are part of the opioid crisis.

The risk of death from drug overdoses increased 486 percent for midlife women between 1999 and 2017; the risk increased 351 percent for men in that same period. Women also experienced a bigger relative increase in risk of suicide and alcohol-related liver disease.
Obesity is a significant part of the story. The average woman in the United States today weighs as much as the average man half a century ago, and men now weigh about 30 pounds more. Most people in the United States are overweight — an estimated 71.6 percent of the population age 20 and older, according to the CDC. That figure includes the 39.8 percent who are obese, defined as having a body mass index of 30 or higher in adults (18.5 to 25 is the normal range). Obesity is also rising in children; nearly 19 percent of the population age 2 to 19 is obese.

Healthcare IT News reported that Virtual Care Provider Inc., which provides hosting and IT services to post-acute care facilities nationwide, was hit by the Ryuk variant, locking access to patient data at 110 nursing homes.  VCPI estimates that  20% of its servers were affected by the attack. The company’s clients are primarily senior living and long-term care facilities, including 110 nursing home organizations with some 80,000 computers across 45 states. The hack against Virtual Care Provider Inc. (VCPI) means some locations cannot access patient records, use the internet, pay employees or order medications.

A ransomware attack carried out by Russian hackers has potentially put the safety of nursing home patients at risk, after Milwaukee-based cloud hosting firm Virtual Care Provider Inc. was hit with Ryuk encryption, preventing access to electronic health record and medication administration data. The Russian hackers, who demanded $14 million in bitcoin for a decryption key that VCPI cannot afford, apparently spread by the ransomware via the TrickBot virus, according to company officials, who said they are “feverishly working” to restore access to critical data.

I wonder if Trump and the Republicans will blame Ukraine?

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.”


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.

Alzheimer’s disease is a growing problem especially with the Silver Tsunami or the graying of America.  The neurodegenerative disease that leads to brain cell degeneration and a decline in cognitive functions is estimated to kill a third of seniors and Alzheimer’s-related fatalities have increased nearly 150%.

Several of the world’s largest and most successful pharmaceutical companies have sought to tackle the disease. Researchers have focused on creating a drug that will effectively treat or cure Alzheimer’s when the disease has already manifested itself and progressed too far. However, new research suggests that preventative care may be best.  Changing how we interact with patients and detect traditional signs of the disease well before it takes hold may lead to early detection and create opportunities to develop new treatments or determine which drugs may help if given to patients earlier.

The prevailing theory behind the cause of Alzheimer’s has been the amyloid hypothesis, which asserts that the disease evolves from a build-up of a protein fragment called beta-amyloid in the brain. Researchers who subscribe to this theory believe that the disease ultimately stems from biological problems related to production, accumulation, or disposal of this protein.  But now the amyloid hypothesis has come under scrutiny and even abandoned by some researchers.

A team of researchers at the German Center for Neurodegenerative Diseases (DZNE) led by neurologist Mathias Jucker found a link between the blood biomarker neurofilament light chain (Nf-L), a protein that collects in the body, and early signs of Alzheimer’s.  In the center’s study, Jucker and his colleagues detected increases in Nf-L 16 years before symptoms of Alzheimer’s were present in a cohort of patients with familial Alzheimer’s disease. Nf-L has already demonstrated success in facilitating the early detection and/or prognosis of a variety of neurodegenerative diseases, including multiple sclerosis, Parkinson’s disease, and Lewy body dementia.

While preliminary, the results mark a significant advance toward a blood test that could detect the disease well before symptoms. Early detection would completely change the equation for companies developing new therapies by enabling trials using drugs on early-stage disease when the drug has a better chance of being effective. This also gives patients more resources, including time, to make choices when it comes to treatment or preventative care.

Forbes had a great article written by Mayra Rodriguez Valladares about The Carlyle Group’s private equity investments in nursing homes and long-term care. It appears they stole all the money and let the operating entities go bankrupt. Last year, the Washington Post and Esquire journalists exposed the suffering of nursing home patients at The Carlyle Group-owned ManorCare. While the Carlyle Group owned the ManorCare until it went bankrupt, 25,000 elderly nursing home residents were exposed to significant health risks. There were 2,000 health-code violations, a rise of 26% from 2013 to 2017, at the 230 residences of the ManorCare chain. According to Kaiser Family Foundation data, not-for-profit as well as for profit nursing homes receive significant Medicare and Medicaid funds. Private equity firms are manipulating the tax system to enrich themselves as the expense of vulnerable residents.

As a taxpayer like Ms. Valladares, I care where our taxpayer money goes and am also grateful that Senators and Representatives are asking important questions and sponsoring ‘Stop Wall Street Looting Act’ to “ close the legal, tax, and regulatory loopholes that have long allowed private equity firms to capture rewards of their investments while passing the risk on to target companies, investors, workers, and consumers.”

The Carlyle Group was asked to provide information including a list of all its investments in nursing home and any other long-term care facilities for the past twenty years; what services the nursing home and long-term care facilities offer; what its ownership stake in these facilities is; the total revenue each facility makes; and what percent of the revenue is from Medicare as well as from Medicaid. Answers to these questions can help taxpayers hold The Carlyle Group and other private equity firms accountable.

“Numerous research pieces and articles, especially those by Professor Charlene Harrington, show significant deterioration in the care of patients at nursing homes when private equity firms take over because they cut staffing, training, and supplies. According to the Journal of Health Care Finance a significant problem is that “Private equity nursing homes have lower RN [registered nurse] staffing intensity and lower RN skill mix compared to the control group.”

The Carlyle Group like most large for profit chains have a complex ownership and operation structure of private equity investments. This means that the private equity firm and the nursing home are often immunized from legal judgments, and nursing home residents and their families are left without justice.

“Another good question posed by the legislators is whether any of The Carlyle Group’s nursing homes or long-term care facilities benefit from Section 232 Department of Housing and Urban Development mortgage insurance on loans that cover residential care facilities. These loans help finance nursing homes, assisted living facilities, and board and care facilities. This mortgage insurance protects lenders against losses when borrowers defaulting on their mortgage loans. It is important to see whether the Carlyle Group is loading facilities up with debt, as many private equity companies do. Will taxpayers be left holding the bag if nursing homes default on their debt?”