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.

The Department of Housing and Urban Development is selling a group of nursing homes it took over 18 months ago after the biggest default in the history of a government mortgage insurance program that provides support to the nursing home industry. The housing agency has managed the chain, Rosewood Care Centers, with the help of a court-appointed receiver since the previous owners defaulted on $146 million in government-guaranteed mortgages.  The agreement involves Greystone, a New York real estate finance firm, for the chain of Chicago-area elder care facilities. Greystone is a major lender to the nursing home industry, and was servicing Rosewood’s mortgages when the former owners defaulted.

Greystone was identified as the incoming owner of the Rosewood chain in a licensing application filed in December with the Illinois Department of Public Health. The application documents indicate that Greystone will own and operate the facilities through a series of shell and sham limited liability companies. The firm also intends to rename each of the facilities, according to the application.

The default raised questions about the department’s oversight of a decades-old mortgage insurance program that backs 15 percent of the nation’s nursing homes.  It is not clear how Greystone is paying for the facilities, or if the firm is getting any credit from HUD for the losses it may have incurred in the default.

HUD solicited bids for the Rosewood facilities — a dozen nursing homes and one assisted living center — until the end of May, but it has repeatedly and suspiciously declined to disclose the name of the prospective buyer or the purchase price. According to court filings, there were four bids for the properties, which the department had valued at $95 million. The department has spent nearly $30 million since August 2018 to make up for shortfalls in funding at the Rosewood facilities and to pay for repairs.

Court records also show that federal securities regulators are close to reaching a financial settlement with a former owner of the Rosewood facilities. The Securities and Exchange Commission in September charged a Chicago-area rabbi, Zvi Feiner, with defrauding a group of Orthodox Jewish investors who had put money into the Rosewood properties and other elder care facilities. HUD said in court documents that the owners had improperly diverted millions of dollars in federally insured funds to another nursing home that was not part of the program. Mr. Feiner paid a $1 million penalty to HUD this summer for failing to file several years of audited financial reports required by the mortgage insurance program.

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.”

 

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.

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.”

 

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

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

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

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

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

GAO also found gaps in CMS oversight, including:

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

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

Boston 25 News obtained a letter sent out to residents, their families and staff members at Lutheran Rehabilitation and Skilled Care Center in Worcester discussing what they are calling “an isolated incident.”  The alleged isolated incident is the tragic and wrongful death of a resident under suspicious circumstances.  As a nursing home attorney for over 20 years, we can smell a rat.

The incident in question involves a certified nursing assistant and one resident dead. A state investigation is underway.

The facility released a meaningless statement that omitted any key facts:

“The resident was injured and sadly passed away the following day at the hospital. As a result of this unfortunate event, Lutheran is the subject of various enforcement actions and additional review by the Massachusetts Department of Public Health.”

The center’s administrator, Ziad Baroody, declined to go in front of a camera, but sat down with Boston 25 News to answer some questions.

While Baroody could not comment on the specifics of the incident, he confirmed the nursing assistant involved is no longer employed by Lutheran and the rest of their staff has undergone additional training and new safety measures related to the incident have been implemented. The type of training was not mentioned.

In a statement, a DPH spokesperson said that after the serious incident on Sept. 15 they “immediately conducted an unannounced onsite inspection to ensure the health and safety of residents, imposed a freeze on admissions and continues to work with the nursing home on a corrective action plan to address identified deficiencies.”

 

The HHS Office of the Inspector General (OIG) notes an increase in nursing home complaints last year according to the most recent set of data from the Department of Health and Human Services.  High-priority incidents that were not investigated within the proper timeframe rose 23% in a year.  The number of high-priority grievances that failed to be investigated within the mandatory 10-day period peaked at 6,540 in 2018, as compared to 5,305 the year before.Obviously, the Trump Administration feels these incidents are not a high priority.

The OIG rolled out its 2016-2018 trends in nursing home complaints on individual state surveys — with the most recent 2018 complaint average reaching its highest level in two years at 52.3 out of 1,000 residents, versus the previous year’s 49.9 per 1,000.

On a state-by-state basis, Hawaii received a mere 8.7 complaints per 1,000 for 2018, with only four high-priority incidents. Texas, at the other end of the spectrum, saw 102.3 complaints per 1,000, with 3,043 high-priority complaints — 1,304 of which were not investigated in 10 days — and 10 immediate jeopardy complaints not probed in two days.

Source: HHS OIG

This past week, CMS rolled out a number of new assessment tools — including a rubric and grading scale — for the State Performance Standards System (SPSS), which took effect for the 2020 fiscal year beginning October 1.