Category Archives: Regulatory Enforcement

South Carolina continued to rank No. 49 nationally on Sunday in terms of the percentage of its population getting tested – even though state lawmakers appropriated an additional $45 million to SCDHEC over a month ago for more testing.  The agency entered the current fiscal year with a $105.8 million surplus so not sure why it needed the extra $45 million.

According to The COVID Tracking Project, only 1,726 completed tests had been conducted in South Carolina per every 100,000 citizens – putting the Palmetto State ahead of only Virginia (1,710 completed tests per 100,000 citizens) on this key metric.

Testing for the virus and its antibodies is necessary to determine how safe we are to reopen.

Providers’ staffing totals published on the CMS Nursing Home Compare website will be used to supply personal protective equipment needs during the coronavirus pandemic, according to a new memo from the Centers for Medicare & Medicaid Services. CMS will publish a list of the average number of staff members onsite at facilities each day. The information will be used to provide an adequate number of PPE and testing to nursing homes.  The agency also is now waiving requirements for submitting resident assessment data (Minimum Data Set) and staff data (Payroll-Based Journal).

The CMS  memo also announced a freeze to nursing homes’ current star ratings on the Nursing Home Compare website following the suspension of survey inspections during the coronavirus pandemic. In late March, the agency announced that it would suspend standards surveys for nursing homes and prioritize inspections regarding Immediate Jeopardy, infection control and self-assessments.

“This would disrupt the inspection domain of the Nursing Home Five Star Quality Rating System because many nursing homes that would normally be inspected, will not, thereby over-weighting and impacting the ratings of those facilities that are inspected. This could then potentially mislead consumers. Therefore, we will temporarily maintain and hold constant the health inspection domain of the rating system,” the memo stated.

CMS added that results of health inspections conducted on or after March 4, 2020, will still be posted publicly but not be used to calculate a nursing home’s health inspection star ratings. The memo also answered several frequently asked questions related to the agency’s actions regarding visitation, surveys, waivers and other guidance.  The fox is guarding the henhouse.

The American Health Care Association put out a recommendation April 11, calling for nationwide reporting of COVID rates and incidence at facilities.  The nursing home industry lobbyists have been pushing for immunity and a bailout.  The CDC reporting tool will ask for information on admissions, confirmed COVID-19 cases, suspected cases and deaths — regarding both residents and workers. Providers will be required to report COVID-19 numbers on a weekly basis.  The CDC will gather data from providers and pass along the information to CMS, which will then post results to the public-facing Nursing Home Compare website, or a similarly effective vehicle.  That seems vague and unlikely to happen.

So finally CMS decides to require nursing homes to report COVID-19 infections.  However, failure, intentional or not, to disclose within 12 hours and report only gets you a  fine of $1,000 per week.  That is chump change for these national for-profit chains.  And it won’t be implemented until May 1, 2020 with a “graace period” of several weeks.  Way too late for thousands of nursing home residents and their families. The “reporting tool” the agency will supply to providers is not ready yet.

LeadingAge President and CEO Katie Smith Sloan said elements of the Sunday surprise did not sit well with her group. It had supported disclosure of infections to local health authorities, residents and families, “with the expectation of prioritization for personal protective equipment and tests as our members battle this pandemic.”

“We are concerned with the specifics of the new reporting requirements, announced on Apr. 19 by the Centers for Medicare & Medicaid Services, that were not previously disclosed to us,” she said in a statement early Monday.   “Without sufficient PPE and testing supplies, our members are not fairly armed to fight the novel coronavirus, and are not able to protect staff and residents,” Smith Sloan said.

“The other thing we announced last night is that [the Federal Emergency Management Agency] is particularly focused on nursing homes, and you’ll hear more about their efforts to directly supply nursing homes to ensure that they have PPE,” Verma told reporters. “From the early results of our surveys, as well as investigations, hand washing continues to be an issue. Use of PPE continues to be an issue, and probably the more significant one is isolating or cohorting patients according to their COVID status,” she said. “That continues to be a challenge for nursing homes. That’s why it’s so important for state and local officials to really support nursing homes.”

“At a very high level, I think it’s fair to say nursing homes have been at ground zero,” Verma said in response to a question asking if nursing homes were the true “front line” of the coronavirus pandemic.  She said there is now recognition among government agencies that “nursing homes can be an early predictor for communities.” Full, complete, and accurate disclosure is necessary to keep us all safe and to contain the spread of the virus.

 

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!

In a bizarre attempt to protect campaign contributors, the Trump administration is further relaxing federal oversight on nursing homes amid a deadly viral pandemic that is particularly dangerous for short-staff and poorly managed nursing homes.  According to the New York Times, this plan has been in the works since last summer but the Trump Administration is using the tragedy for their political benefit. The Trump administration would eliminate the requirement that nursing homes keep at least one infection-prevention specialist on hand. This will not keep people safe.

According to Times, CMS reports that about 380,000 residents die from infections annually, and infection prevention is the number-one failure that earns nursing homes federal citations.  COVID-19 is especially vulnerable to the elderly than other age groups, accounting for most of the deaths so far, and residents of long-term care facilities have the kinds of pre-existing conditions that increase the risk of contracting COVID-19.

CMS did announce mandatory restrictions on nursing home visitors and non-essential personnel, as well as limitations on group activities among residents. But relaxing oversight over an industry responsible for caring for the country’s most at-risk population in the middle of a national emergency? Now really doesn’t feel like the time.

Genesis HealthCare, a large publicly traded firm that owns and operates nursing homes, agreed to pay Vermont $740,143 to resolve allegations of neglect resulting in three serious injuries and a death. The agreement settles claims relating to the state’s vulnerable adult statutes and the False Claims Act. The settlement stems from preventable incidents at three facilities in 2018 and 2019.

The three facilities — St. Johnsbury Health & Rehab, Berlin Health & Rehab Center and Burlington Health & Rehab Center —have a history of problems. The St. Johnsbury and Berlin homes both have one out of five stars, based on metrics that include three years’ worth of health inspections, staffing levels and clinical outcomes for residents. The Burlington facility has two stars. The statewide average for nursing homes is 3.2 stars, while Genesis-owned homes average 2.6. Genesis is a Pennsylvania-based corporation that owned or managed 425 facilities in 29 states as of December 2018, according to its reports filed with the Securities and Exchange Commission.

In addition to paying damages and penalties, Genesis said it would create a position for a patient care coordinator, who would be in charge of training staff at the three facilities and report progress to the state. The company also agreed to hire an independent monitor to perform an annual review of the three facilities. However, Genesis denied the clear violations of standards but agreed to the settlement “to avoid the delay, expense, inconvenience and uncertainty of litigation,” according to settlement documents.   In 2017, Genesis agreed to pay $53.7 million to the U.S. Department of Justice to settle claims of false billing practices. Over the past three years, the company has also paid $131,687 in regulatory fines for deficiencies at its nine Vermont facilities. The company reported $4.98 billion in revenue in 2018.

Staffing problems factored into multiple incidents the state flagged as part of the Genesis settlement. In two instances, short-term staffers at the Burlington and St. Johnsbury facilities gave residents who were on specialized diets the wrong food, and the residents choked. The St. Johnsbury resident required hospitalization; the Burlington resident later died.

The state also cited an incident at the Berlin Health & Rehab Center in which staffers identified two ulcers on a resident’s leg but failed to perform required wound assessments. The resident required hospitalization to treat the ulcers.

In an April incident, the Burlington Health & Rehab Center improperly discharged a resident with lower-body paralysis after failing for months to treat his emotional issues and alcohol addiction. A staffer dropped the resident off at a nearby hotel, booked a one-night stay for him and left, despite knowing that he could not get into bed, use the toilet or access food, drink or medications without help. The facility did not notify his family or the Visiting Nurse Association about the discharge until the next day.

After the man spent a single night in the hotel, staff asked police to check on his welfare. He wound up at a hospital, where staff noted he was covered in feces, had a burst catheter bag, and was suffering from fever and an acute kidney infection.

The settlement noted that the facility billed Medicaid for the man’s care the day after he was dropped off.

The Centers for Medicare and Medicaid Services has flagged more than 50 nursing homes in the Carolinas.  The credible allegations range from sexual abuse to a maggot infestation inside a resident’s wound, according to federal inspection records.  Maggot infestation should never occur if proper care is being provided.

Nursing Home Compare has a new icon next to nursing homes with a history of abuse or neglect. The warning, a red circle with a hand inside, is part of an effort by the federal government to better alert the public before a loved one is placed in a nursing home.

The rolling alerts, which went into last year, are for facilities cited on inspection reports for one or both of the following:

  1. abuse that led to harm of a resident within the past year
  2. abuse that could have potentially led to harm of a resident in each of the last two years

Federal records show that many nursing homes have staffing numbers dropped as facility records show the patient population only decreased slightly. Some nursing homes dispute the figures even though they are based on information created and provided by the facility. They argue the nursing homes fail to report everything accurately.

Inspection records from the Centers for Medicare and Medicaid Services also showed the following violations across the greater Charlotte area.

  • Inspection records from January 2019 identify White Oak Manor in Charlotte for failing to protect two residents from sexual abuse by another resident.
  • Inspection records from February 2019 identify Pruitthealth-Rockingham, where a nursing assistant hit a cognitively impaired resident on her face with a closed fist.
  • Inspection records from 2018 identify Olde Knox Commons at the Villages of Mecklenburg in Huntersville, where a nursing assistant slapped a cognitively impaired resident and failed to prevent the abuse of two residents.
  • Inspection records from 2018 identify Bethany Woods Nursing and Rehabilitation Center in Albemarle for failing to supervise a resident who wandered out of the facility.
  • Inspection records from 2018 identify Meadowwood Nursing Center, now called The Ivy at Gastonia, for failing to provide incontinence care for eight hours, forcing a resident to lie in urine and feces.
  • Inspection records from 2018 identify Alexandria Place in Gastonia for allowing a maggot infestation inside a resident’s wound.
  • Centers for Medicare and Medicaid Services most recently added an alert to Lancaster Convalescent Center, after citing the facility in February 2019 for failing to ensure a resident was free from sexual abuse by another resident.
  • The federal government also recently added an alert to Salisbury Center after a 2019 inspection where “the facility failed to initiate medical treatment and pain relief for a resident that was complaining of hip, ankle, and back pain after falling in her room.” Records show the resident had a fractured ankle and had a break of the tibia and fibula.

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?”

 

The website Nursing Home Compare, published by the Centers for Medicare & Medicaid Services, is a resource for researching nursing home options for loved ones. The number of falls that lead to injury are a critical category of concern for nursing home residents, however, a University of Chicago researcher has found that the data used by Nursing Home Compare to report patient safety related to falls is highly inaccurate.

“This is a substantial amount of underreporting and is deeply concerning because without good measurement, we cannot identify nursing homes that may be less safe and in need of improvement,” Sanghavi said.

Falls are a leading cause of death among the over-65 population, and they can lead to other serious injuries. Patients become fearful of walking again for fear of reinjury, yet falls are considered widely preventable. They are a discrete event that is easy to identify and record, compared to other clinical conditions on Nursing Home Compare such as pressure ulcers or infections, so there should be a wealth of reliable data.

“That’s why falls are a patient safety measure on Nursing Home Compare,” Sanghavi said. “They reflect how well a nursing home does at preventing these injuries.”

Nursing Home Compare has faced prior scrutiny for using self-reported data. Sanghavi’s own research was sparked by a 2014 New York Times investigation into serious deficiencies found in nursing homes rated five stars by Nursing Home Compare.

“I found it odd that Nursing Home Compare would use self-reported data,” she said. “Having worked with Medicare claims data, I thought I could use it to study MDS reporting. The Medicare claims we used are hospital bills. They want to get paid and should not have an interest in nursing home public reporting. That’s why they are a more objective source than the self-reported data from nursing homes.”

Based on her results, Sanghavi suggests that the Centers for Medicare & Medicaid Services change their evaluation criteria for falls on Nursing Home Compare.

“They should use an objective source, like claims data,” she said. “It should be relatively easy for them to do, since they already have the data. There are other claims-based measures already used on Nursing Home Compare.”

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.