Several Kentucky lawmakers are sponsoring bills to improve conditions in the state’s nursing homes, which have ranked among the nation’s worst. But the powerful nursing home industry will fight any such legislation.  The industry is a big campaign donor with too much political clout.  The nursing home industry is represented in Frankfort by the Kentucky Association of Health Care Facilities, which has given several hundred thousand dollars in political donations in recent years.  Overall, nearly half of Kentucky’s 282 nursing homes are rated as “much below average” or “below average” by the federal government based on poor scores for patient care, staffing and health inspections.

“Inadequate staffing is the basis for so many of problems that we see. Most nursing homes are owned by for-profit companies, and unfortunately, one way that you make a profit is to keep your costs down by not hiring as many people as you should,” said Wanda Delaplane, a nursing home reform advocate in Lexington who has testified to state lawmakers.

Among the proposals is House Bill 215, which would establish minimum safety staffing standards for nursing homes, such as at least one nurse’s aide for every nine residents during day shifts; for every 10 residents during evening shifts; and for every 19 residents during night shifts. The bill also would set rules for how many nurses would have to be on duty at different times to oversee resident care.

Federal law only requires that nursing homes have “sufficient” staff to meet residents’ needs, although states are invited to set their own more rigorous standards. Kentucky has chosen not to, and the state’s nursing homes regularly are cited and sued for neglect as unattended residents fall and get hurt, soil themselves in bed and suffer bedsores from lack of movement.

Two other proposals — House Bill 228 and Senate Bill 36 — would require nursing home staff to be training in properly caring for residents suffering from Alzheimer’s and dementia.

Sen. Reginald Thomas, sponsor of the Senate bill, said he was motivated by his study on a special legislative task force on Alzheimer’s and dementia. Many direct-care workers in nursing homes — who often are low paid and without much training — don’t know how to handle the unpredictable and sometimes aggressive behavior of these special residents, Thomas said.

“In the year 2020, the fact that they get no training in Alzheimer’s or dementia care really does surprise me,” said Thomas, D-Lexington. “This is not a new phenomena. This is a growing trend that we’re been facing with our aging population over the last 20 years.”

Meanwhile, a former executive of Signature HealthCare, Adam Mather, was politically appointed to be the “watchdog” for Kentucky’s troubled nursing home industry. Signature HealthCare is based in Louisville and owns more than two dozen low-rated nursing homes around the state.  Mather will be paid $112,381 a year to oversee a state office that — among other duties — inspects several hundred nursing homes in Kentucky on behalf of the federal government, which pays for the bulk of residents’ care through Medicare and Medicaid.

A Herald-Leader analysis of 42 Signature facilities in Kentucky shows that 25 are rated as “much below average” or “below average” by the U.S. Centers for Medicare and Medicaid Services five-star rating system, which considers quality of patient care, staffing and health inspections.

Signature HealthCare at Jefferson Place in Louisville, for example, was hit with $140,421 in fines in 2018 after inspectors cited repeated cases of resident neglect that led to physical injuries and personal humiliation. It’s rated as one-star, or “much below average.” Signature executives alone have made at least $20,500 in political donations since 2015, according to state campaign-finance data.

“It’s troubling that someone from the industry now gets to oversee the industry,” said Toby Edelman, senior policy attorney for the Center for Medicare Advocacy in Washington. Edelman tracks problems with nursing homes nationwide.

“I don’t know him personally, so who knows, maybe he’ll turn into a whistle-blower,” Edelman added. “But generally, I think our regulators should be independent of the industries they regulate and not come from within their ranks. There should not be this revolving door between them, with people moving back and forth. Why not appoint an advocate, someone who cares about the residents and who has a track record of being a little more skeptical of the companies?”

 

Federal watchdogs at the U.S. Attorney’s Office for the Southern District of Florida completed one of the largest Medicare fraud schemes in history with the announcement of prison sentences for modern day Bonnie and Clyde–Rodolfo Pichardo and Marta Pichardo.  The Pichardo are husband and wife each sentenced to several years in prison for their roles building “a vast empire of fraud” from May 2010 through September 2016.  The Pichardos purchased multiple properties, high-end vehicles, expensive jewelry, plane tickets, vacations, cosmetic procedures and more, both for themselves and family members, court documents state. The couple’s empire included at least six fraudulent home health agencies, three fraudulent therapy staffing companies and two fraudulent pharmacies.

Quality Care Home Health Agency, Rapid Home Health Services and Tender Home Health Services were just some of the business names reportedly in the Pichardos’ fraud scheme. Other company names included Alegre’s Home Health Care, B&M Home Health Care, Apple Health Care Services, RP Staffing Inc. and more.

Over the years, the Pichardos and their co-conspirators used their phony network to submit more than $38 million in false and fraudulent claims, according to Department of Justice officials. Medicare ultimately paid out more than $33 million of that.

Rodolfo Pichardo, 71, was sentenced to more than 15 years in prison for health care fraud and wire fraud scheme. Marta Pichardo, 66, was sentenced to eight years in prison for her role in the scheme.

“This case involves the largest fraud scheme in terms of loss amount ever charged in the history of the Medicare fraud strike force,” U.S. attorney Wilfredo A. Ferrer said at a press conference at the time. “The case allegedly involved an elaborate cycle and network of bribery, deceit and kickbacks that compromised Medicare care services for thousands of [Medicare and Medicaid beneficiaries] at south Florida hospitals, skilled nursing and assisted living facilities.”

As part of the Pichardos’ scheme, the couple offered and paid kickbacks to numerous patient recruiters in exchange for referrals to home health agencies that he owned. The conspirators also offered and paid cash kickbacks to owners and operators of multiple Miami-Dade medical clinics in return for acquiring medically unnecessary home health prescriptions for the recruited Medicare beneficiaries.

Prescriptions were then used by the Pichardos’ various home health agencies and pharmacies to bill Medicare for purported services and pharmaceutical drugs that were provided to allegedly qualified Medicare beneficiaries.

During the long-running scheme, the Pichardos took several “calculated steps” to conceal the fraud and avoid detection, according to DOJ officials. That included using nominee owners, changing names and locations of their fraudulent entities, and creating shell companies to hide assets.

 

As we all know, abuse and neglect are rampant in the industry.  Skilled nursing facilities are also required to notify federal and state agencies of potential abuse and neglect. Allowing facilities to self-report and then refusing to punish them when they cover up incidents increases the likelihood that abuse and neglect will continue.  Reports of nursing home staff slapping patients, calling them names, and leaving them in their own filth all day are made to law enforcement but are not reported to state and federal agencies obligated to investigate.

NBC26 I-TEAM compared police reports at PruittHealth nursing home with federal reports over the same 12-month period. What they uncovered is reports going to law enforcement are often for “information only” whatever that means. For example, one resident called the police after laying in his own waste and filth for over 9 hours but the report is listed as “info only” and the officer immediately closed the case. It was never investigated as neglect. There was no investigation.

The news is shocking because neglect is a punishable offense like abuse. Staff is required to report those allegations to law enforcement. In fact, a staff member called police after Glenn made a similar complaint about lying in his own waste for too long the previous year. Staff member stated she “wanted the incident documented.” But like the other one, this was listed as information only — not neglect.

We looked 12 months of police reports. In one report, a nurse allegedly hit and slapped a patient with pressure sores. It’s listed as a medical complaint. In another, an employee allegedly berated a patient, calling her “ugly ugly” while taking picture to show her just how ugly she is. It’s information only, too.

More than half of these 28 reports are information only.

Federal complaint investigations were compared with local police reports. None matched each other. This isn’t just a local problem. Last year, the inspector general determined nursing homes across the country aren’t reporting potential neglect and abuse. Nursing homes are graded partially based on these investigations.  Every agency is looking at the other agency to investigate.

Crimes Against the Vulnerable and Elderly (CAVE) made its first nursing home arrest last year. CAVE operates on the Georgia side. South Carolina has no such task force.

I saw an interesting story that raises moral, ethical, and legal issues related to dying with dignity and chocie.  What do you think?

On April 5, 2018, Andy Jurtschenko went into surgery at Newark Beth Israel Medical Center in New Jersey.  He needed a new heart but instead Andy suffered extensive brain damage due to a lack of oxygen during the heart procedure.

As one of the top 20 programs statistically across the nation, Jurtschenko felt safe in Newark Beth Israel’s hands especially Dr. Mark Zucker, and the main surgeon, Dr. Margarita Camacho. The program is nationally known for maintaining a high success rate while taking on the sicker and riskier patients, operating on older, overweight, and those who have had regular visits to the intensive care unit because of their hearts.

For a single heart transplant, a hospital usually bills insurers around $1.4 million, and the better survival rates look to the public, the more patients that will choose to receive treatment at the facility. This business mindset forces transplant teams to look at patients not as humans, but as “percentages” and “numbers”.

A do-not-resuscitate order, or DNR order, is a medical order written by a doctor. It instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient’s breathing stops or if the patient’s heart stops beating.  A DNR order is created, or set up, before an emergency occurs. A DNR order allows you to choose whether or not you want CPR in an emergency. It is specific about CPR. It does not have instructions for other treatments, such as pain medicine, other medicines, or nutrition. The doctor writes the order only after talking about it with the patient (if possible), the proxy, or the patient’s family. Families order DNRs for multiple reasons. Sometimes a DNR is the obvious choice. It would preserve a patient’s dignity and reduce the amount of suffering the patient and the family will have to endure throughout the process.

Before a heart transplant surgery, a patient is not able to have a DNR in their file because the new heart may require stimulation to begin to pump, but after surgery, a patient or surrogate can ask for a DNR at any time and it must be sign by the physician and placed in their medical record.  It is a numbers game rather than a moral dilemma.  So when the Jurtschenko family requested a DNR for Andy, the doctors refused to sign.  On the morning of Oct. 31, 2018, Andy Jurtschenko passed away from a weakened heart after a long six month unnecessary battle between his value as a statistic and his doctors in the Newark Beth Israel’s hospital over his request for a DNR.

In the case of Andy Jurtschenko, a DNR could have reduced the suffering he and his family experience, but because his death would lower the program’s one-year survival rate, it could be assumed that doctors convinced the family that he would make a full recovery in the future.  It was not until Andy Jurtschenko was admitted into a nursing home where they caught the mistake that he was not supposed to be resuscitated, meaning the hospital never placed the DNR request in his record.

 

 

 

 

 

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How can you trust numbers when they are self-reported and directly affect the rating of the nursing home?  A new study proves that nursing homes do not report quality measures such as falls. University of Chicago researchers found 150,828 major-injury falls that occurred at nursing homes were reported in hospital claims. Just 57.5% of those were reported on the MDS item (J1900C) used by Nursing Home Compare.   Falls data used by the Nursing Home Compare website “may be highly inaccurate,” says researchers whose new study shows that nursing homes fail to report major-injury falls.

The study assessed the accuracy of nursing home self-reporting of major injury falls on the MDS. Researchers used data from Medicare claims between 2011 and 2015 for the investigation. The data was then compared to MDS 3.0 assessments submitted by providers during those same years.

About 62.9% of major-injury falls were reported for long-stay residents on the MDS item, while 47.2% were reported for short-stay residents. Findings also showed that major-injury falls in white residents were reported at a higher rate than non-white residents — 64.5% compared to 37.4%.

“Our study indicates an urgent need to assess the value and limits of patient safety measurement that is based on the MDS. Given the amount of research that has been based on the MDS, it may be important to revisit some of our understanding of nursing home quality of care,” the authors wrote.

Full findings were published in Health Services Research.

Recently, I read about a murder at a nursing home in Florida.  Apparently, a 95-year-old man in a nursing home was killed by a trespasser. Police were told a nurse walked past the victim’s room when she noticed an unknown male sitting on top of the victim’s chest with a pillow over his face, according to police.

The nurse yelled out for another nurse to call 9-1-1 and the unknown male took off running from the facility while police were called. No word yet on how he gained entrance to the facility, but there is a notice on the door explaining that visitors must be buzzed in if they are trying to enter the premises outside of normal business hours (8 AM- 8 PM).

According to police, dispatchers received a call from a nurse at Tiffany Hall Nursing and Rehabilitation Center shortly after midnight saying “someone tried to hurt a patient.” When police arrived on scene they found an adult male dead.

Where was the supervision?  How could no one hear what was going on?

When police arrived, they set up a perimeter and searched the area with a K-9 unit but police say they were unable to find the unknown male, who was only described as a white male.

 

 

As we have discussed previously, nursing homes often abandon residents and kick them out of the facility without legal justification.  The facility must have a reason and give the resident time to find a new home.  There is a problem in this country where the facility makes up a reason the kick “low paying” residents (i.e. those on Medicaid) so they can replace the resident with a high paying resident (i.e. private insurance, Medicare, Hospice,etc.).

Richard Bloxham, a paraplegic man from Oklahoma claims he was kicked out of his nursing home on New Year’s Eve.  Richard says he lived at Hillcrest for six months before being told he had to be out by January 27th.  Authorities told Hillcrest that a court order is needed for an eviction.

“I was supposedly a danger to other residents and myself. Which was a lie,” said Bloxham.  The 34-year-old wheelchair-bound paraplegic Bloxham is obviously not a danger to others at the facility.  But after a short stay in the hospital, Richard returned on New Year’s Eve only to be told he wasn’t allowed in the building.

“I go to the hospital and they act like they don’t even know what I’m talking about,” said Bloxham. ”They were just trying to get me out quicker.”

However, officials at the Hillcrest Nursing Home are holding firm on this ridiculous assertion and refuse to allow Bloxham back.

He called Moore Police, who spoke with Hillcrest COO Tammy Whorton.  The police report quotes the officer who investigated, “The staff on scene did not have any issues with Richard”.  Going on to say, “They did not agree with the decision.”  The report also says Tammy admitted to telling Richard “he had until the 27th to gather his belongings and vacate the facility.”

 

Arkansas has done something that more states need to do–question the transfer of ownership of nursing homes to shady characters.  Christopher Brogdon is well-known in the long term care industry.  Brogdon’s past had also previously been the subject of scrutiny in the Democrat-Gazette, which in April reported that the state approved his assumption of other licenses in Arkansas despite an $83.1 million Securities and Exchange Commission judgment against him in a separate bond fraud case.  He has owned and operated hundreds of nursing homes.  Unfortunately for the residents of those nursing homes, he has not done a very good job.  Now Arkansas has done something about it.

Brogdon’s request to take over a pair of facilities was denied but he has struck back with a lawsuit, claiming that the authorities didn’t provide “sufficient justification” for their decision.  Brogdon claims that Arkansas health officials made an “arbitrary and capricious” decision when they blocked his attempted takeover of properties.

The facilities in question were previously run by the New Jersey-based Skyline Healthcare, whose stunning financial collapse across several states led to calls for increased scrutiny on nursing home owners and operators — particularly those without a historic presence in a given state.

After another operator took over from Skyline in 2018, a firm run by Brogdon assumed control of the properties on an interim basis, the Democrat-Gazette reported, investing about $700,000 in their operations — with the assumption that his affiliates would eventually receive approval to take over on a full-time basis.

But the state’s Human Services Department denied the applications, according to the publication, after officials determined that Brogdon failed to provide sufficient information about 11 other properties he owned in Georgia, Arkansas, and Oklahoma.

Though that rule — which requires applicants to prove that their other properties met state and federal regulations for the previous one-year period — had been in effect for nearly three decades, a spokesperson told the Democrat-Gazette that the Brogdon case was the first time it had been used to deny a transfer.

Ownership and operational transfers could be a key area of nursing home enforcement on both the state and federal levels over the next decade, as officials look to prevent providers with checkered pasts from setting up shop elsewhere. Kansas, which saw 15 Skyline properties fall into receivership, rolled out more stringent application rules for prospective nursing home operators last April, while also making it easier for officials to blacklist providers and owners deemed unfit.

Ohio followed suit in October, with lawmakers enshrining tighter transfer rules as part of its 2020-2021 operating budget; Pennsylvania was also in the process of developing new regulations around skilled nursing ownership changes, Skilled Nursing News reported at the time.

The Medicaid Asset Protection Trust (MAPT) is a tool that may protect your house from going to reimburse Medicaid for nursing home costs but only after the house is in the trust for at least five years. A trust is a legal entity that owns assets.  The MAPT is a good option to consider to keep the family home and other assets for your family and not the nursing home.

After the house is transferred to the MAPT, you still receive your STAR, veterans and other real estate exemptions. You maintain your house and pay your taxes like normal. You may even forget your house is in the trust. Your lifestyle stays the same.

If you put the house on the market, the trustee (manager) — usually one or two adult children — signs the binder and contract. At the closing the purchaser pays the trust. The trustee deposits the proceeds check into a bank account in the name of the trust. The grantors of the MAPT (the parents who transferred their house to the trust) still have their capital gains tax exclusions —$250,000 each, for living in the primary residence two out of the last five years.

The MAPT is an “income only” trust, which means the grantors (parents) only have a right to take income from trust assets but may not spend the principal. However, the trustee may purchase a new house with the proceeds and the new house is owned by the trust. Buying the new house does not start a new five-year period because the assets, whether real estate or cash, all stayed in the trust.

If the parents do not buy a new house with the sale proceeds, they may make gifts of trust principal to the children who are beneficiaries of the trust. The children and parents do not pay tax for the gifts.  If there is a house and cash in the MAPT, the parents may direct the trustee to use trust assets to pay for real estate taxes, home maintenance and repairs, and home insurance for the house in the trust. The parents may also invest the money in the trust and take income distributions from the investments.

As opposed to common thought, adding children’s names to the deed of the house is not a good idea. If your child is sued, their judgment creditor can put a lien on your house. If the child dies before you, you may own the house with their spouse. If the parents sell the house, the child may have to pay capital gains tax because they were not living in the house. The MAPT avoids these complications.

The MAPT allows preservation of assets, including the family home, from the devastating cost of care in a nursing home and at the same time provides flexibility upon the sale of the home.

The growth of spending on nursing home services and continuing care retirement communities (CCRCs) increased by 1.4% to $168.5 billion according to the latest figures released by the Office of the Actuary at the Centers for Medicare & Medicaid Services.  That is ridiculous.  The quality of care should be much higher.

Overall, spending on nursing and CCRC services made up 5% of the total U.S. healthcare spending in 2018.

Healthcare spending increased 4.6% to reach $3.6 trillion in 2018.

Spending on hospital care reached $1.2 trillion and made up 33% of total healthcare spending in 2018.

Additionally, spending on home health care services reached $102.2 billion, an increase of 5.2%, Medicare and Medicaid made up 75% of home health spending in 2018, the report stated.