The Washington Post had an interesting article on the unintended consequences of Trump’s decisions on nursing home residents.

In December 2017, Trump proudly “deregulated” the nursing home industry.  However, certain regulations were essential to protect vulnerable and disabled nursing home residents, and to prevent waste, fraud, and crime in Medicare payments.

Nursing homes regulations were always poorly enforced and few administrations made them a priority. President Obama attempted to craft policies to put pressure on poorly managed facilities. In 2014, he issued policy guidelines that urged regulators to issue daily fines against nursing homes for infractions until those violations were remedied. By 2016, that approach applied to two-thirds of cases. He also issued a rule that would have barred facilities from requiring that disputes with residents be settled in private arbitrations that limit the companies’  exposure.

Trump rolled back these policies. The number of per-day fines plummeted. The ban on mandatory arbitration was blocked. Trump delayed the enforcement of new health and safety requirements by 18 months, much to the delight of the nursing home industry. Less accountability for nursing homes that treat their residents poorly. 

“They were fighting it, and they got a lot of what they wanted,” said Toby Edelman, a senior policy attorney and expert on nursing home regulation at the nonprofit Center for Medicare Advocacy.

 The Kaiser Family Foundation published an analysis that found that under the Trump administration, the average fine levied against nursing homes that have endangered or injured residents dropped from a high of $41,260 in 2016 to $28,405 in the first quarter of 2018.   This is important because elder care is a multibillion-dollar field, and nursing homes have revenue in the millions of dollars. Small, one-off fines barely register in this context.

CMS’s record looks even uglier when it comes to how it’s regulating the worst of the worst in the industry — nursing homes known as “special focus facilities.” These are the nursing homes cited for a pattern of serious infractions: residents falling; medication not getting to patients; staff slapping residents for not cooperating with treatment; bed sores neglected for so long that they become gaping, bloody wounds.

Edelman has been closely tracking these nursing homes, especially those that the federal government classified as having “not improved” since they were first listed as special focus facilities. She has found that the Trump administration has largely pulled back its enforcement of them.

McKnight’s recently reported that the Government Accountability Office strongly urged the Centers for Medicare & Medicaid Services to respond to recommendations made in the GAO January 2018 report on assisted living.  It has already been more than a year!

The GAO said it will continue to monitor actions taken by the Department of Health and Human Services in response to its recommendation, one of 404 “priority recommendations” — 54 of them at HHS — that were open as of April 7. The agency said it sent letters to the heads of the HHS, Veterans Affairs, and Defense departments “urging them to continue focusing on these issues.”

The 2018 report, “Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare is Needed” contained a to-do list for CMS including reporting of deficiencies in care and services provided to Medicaid beneficiaries in assisted living communities.

Investigators recommended that CMS Administrator Seema Verma:

  1. Provide guidance and clarify requirements for states regarding their monitoring and reporting of deficiencies in assisted living communities.
  2. Establish standard Medicaid reporting requirements that all states could use to annually report information on critical incidents.
  3. Ensure that all states submit annual reports for home- and community-based services waivers on time, as required.

These all seem reasonable and CMS has somewhat addressed #1 and 2.

 

 

Massachusetts Attorney General Maura Healey announced settlements with seven nursing homes over systemic failures that led to five residents’ deaths and several injuries.  The failures identified by Healey’s office include allegations of staff ignoring serious injuries that led to two residents bleeding to death. They also include a fatal medication error, failure to treat residents with histories of substance abuse, and allowing a resident with a history of wandering to escape from a locked, supposedly secure unit.

Healey’s office said it weighed the evidence and determined civil enforcement was the best way to improve safety and quality in these nursing homes.  The settlements impose fines on the nursing homes ranging from $30,000 to $200,000. Five of them will be required to upgrade staff training and policies, conduct annual audits of their progress, and report that progress to the attorney general’s office for three years.

One company, Synergy Health Centers, has been banned from operating any taxpayer-funded nursing homes in Massachusetts for seven years.  Synergy is a troubled New Jersey company that started buying Massachusetts nursing homes in 2012 and quickly ran into problems with serious patient injuries as it bought 10 more facilities.

Candi Hitchcock, whose mother, Betsy Crane, died in one of the cases, said she is still grieving her mother’s horrific death. Crane, a resident at Beaumont Rehabilitation and Skilled Nursing Center, fell at least 19 times because staff failed to adequately intervene. She died after the 20th fall. “She was my best friend, and our family had to watch her bleed out from head trauma over 10 days and die an unnecessarily painful death,” Hitchcock said.

Hitchcock said she discovered her mother bleeding from her head hours after that fall in late July 2015. Hitchcock said she pleaded with nurses for help, and eventually one applied a Band-Aid. But the 89-year-old woman complained of not feeling well and staff eventually sent her to the hospital. By then it was too late. The internal bleeding was too great.

 

What a surprise!  The Trump Administration and the Republicans are paying back one of their most significant donors; the nursing home industry lobbyists.  Kaiser Health News released a study showing that nursing facilities have seen their fines drop by more than 30% during the Trump administration.

The industry has been vocal demanding Trump to move away from penalizing providers for each day out of compliance with a regulation. Instead, facilities are issued a single fine for two-thirds of infractions. The average fine dropped from $41,260 to $28,405.

The report notes examples of preferential treatment for nursing homes including an 18-month moratorium on imposing monetary fines for most violations. Trump also revoked a rule that barred nursing homes from requiring residents to sign pre-dispute mandatory arbitration agreements.

Fines need to be large enough to change facility behavior,” said Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care, a nonprofit based in Washington. “When that’s not the case and the fine is inconsequential, care generally doesn’t improve.”

 

 

The Office of the Inspector General discovered that state agencies aren’t doing enough to make sure that nursing homes are correcting deficiencies.  The majority of state agencies do not verify that nursing homes’ fixed or corrected problems, as required and needed for the health, safety, and well-being of the residents.

“If state agencies certify that nursing homes are in substantial compliance without properly verifying the correction of deficiencies and maintaining sufficient documentation to support the verification of deficiency correction, the health and safety of nursing home residents may be placed at risk,” the office wrote.

“The unevenness of surveyors’ findings and enforcement actions taken by state surveyors is well documented,” LeadingAge spokeswoman Lisa Sanders told McKnight’s. “State survey agencies are frequently short-staffed, and turnover at these agencies is often rampant, which means that those responsible for surveying nursing homes may have neither the training nor the experience to know what they are seeing and whether conditions comply with federal standards and requirements.”

 

A Walterboro, S.C. veterans nursing home has been fined again by the federal government following an inspection by state regulators indicating it improperly administered medications to a resident.  A letter to Veterans’ Victory House from the Centers for Medicare & Medicaid Services informed administrators at the facility of the violations and that “substantial compliance” was required by June 14.

The letter also stated that a physician’s notes regarding how and when to administer the medication were not followed, which constituted a separate violation. The violations occurred in August 2018 and were officially reported in October, according to a summary of the inspection report by the S.C. Department of Health and Environmental Control.  Veterans’ Victory House will be required to pay a daily fine of $515 until it is in “substantial compliance” with provisions of the Social Security Act it violated, according to the letter sent to the facility. Victory House could stand to lose its Medicare and Medicaid provider agreements if the facility fails to comply with the government.

The $28 million, 160,000-square-foot facility is overseen by the state Department of Mental Health but contracts with a private company, HMR Governmental Services, according to the nursing home’s website.  Veterans’ Victory House had to shell out roughly $15,000 a day between Dec. 12 and Dec. 30, according to the letter provided by DHEC. That money was placed in an escrow account while a new in-person review of the nursing center was carried out. After that review, according to the most recent letter from the government to the facility, the fines were reduced to $515 a day effective Dec. 31 and will remain in place until the nursing home achieves “substantial compliance.”

This incident, however, was not the first time that Veterans’ Victory House has attracted scrutiny from officials.

Dwayne Walls, 76, who lived there in September 2008, died after another resident beat him with a cane. The incident spawned an investigation by state authorities. After Walls’ death, a DHEC investigator found that the facility had not properly reported the incident involving Walls and the 88-year-old man who beat him, as the law required.

The Reading Eagle had an incredible story about Joseph Schwartz who grew his New Jersey-based nursing home chain, Skyline Healthcare LLC, from about two dozen homes to 120 scattered across 10 states until the chain collapsed amid allegations of fraud, abuse, and waste.  Skyline’s financial collapse forced the state Department of Health to remove managers at seven of its homes in Pennsylvania only a year after it approved the company to operate them.Schwartz had a history of unethical and illegal behavior prior to Skyline.  In Florida, he was accused of diverting insurance premiums that should have been spent on employee health care claims.  In addition to the Florida lawsuit, that record includes a 2009 Pennsylvania lawsuit from a pharmacy claiming breach of contract, several business liens and a $2,500 New York State Insurance Department fine from a decade ago, levied when Schwartz, without a license, helped a company act as an insurance broker.

“I want to know how the state didn’t know,” said Robinson, who works at Rose City Nursing and Rehabilitation in Lancaster. “These people are doing business in your state.”

Documents obtained under Pennsylvania’s Right-to-Know Act prove that Pennsylvania relied on unverified and incredible self-reported information.  Consequently, hundreds of nursing home residents in Pennsylvania were put at risk and employees were put in an untenable position, attempting to care for patients that Skyline could no longer afford to feed or medicate.

The conditions became so dire that Skyline employees tried to shield their residents from the fallout. Employees interviewed for this story described purchasing, at their own expense, snacks for sick patients and gasoline for company vans to transport them. Staff also reported hiding cash in a freezer to pay wary vendors who refused to accept Skyline’s checks.

At least two-thirds of the facilities Schwartz’s Skyline began to manage were former Golden Living homes. In Pennsylvania, those homes had a long history of quality issues, dating to Beverly Healthcare’s management before Golden Living took ownership in 2006. Those issues included insufficient staffing. A proper staffing level is universally recognized as the key to making good care possible.

In Kansas, Department of Aging and Disability Secretary Timothy E. Keck filed a lawsuit alleging that Schwartz and his wife and sons “deliberately withheld premium payments from employees’ paychecks for health insurance and other benefits but did not purchase health insurance for the employees.”

The Schwartzes either lacked the capital to meet their payroll obligations, the suit alleged, “or converted the funds to their own use,” according to the complaint.

 

 

Universal Healthcare North Raleigh has a history of problems and was the subject of state and federal investigations last year over alleged patient abuse.  Universal Healthcare North Raleigh became the focus of a WRAL News investigation last May, after Rebecca Knaption shared footage captured on a hidden camera she installed in her father’s room. The video shows staff took more than an hour to respond after Richard Johnson fell out of his bed, and they then mocked and belittled him.

The incident led to state inspectors substantiating allegations of abuse at the north Raleigh facility and WRAL Investigates uncovering a history of violations at Universal Healthcare facilities across North Carolina.

Universal Healthcare officials promised changes, saying the staffers who mistreated Johnson were fired and the rest of the staff received additional training. But WRAL Investigates has found new problems at the north Raleigh facility in recent months. Sources also told WRAL Investigates that state inspectors are looking into the recent deaths of two residents of Universal Healthcare North Raleigh, who were both reported to have fallen, as well as unexplained bruises on residents.

A woman in need of constant care was sent home in December after she couldn’t pay her outstanding bill and was left to fend for herself.

The woman, a diabetic amputee in a wheelchair, said that Universal Healthcare staff pressured her to pay, and when she couldn’t, she was given a 30-day notice. Instead of finding another facility that would take her, she said she was transported to her Cary mobile home and left her with no food, family or care plan.

She said she had to call 911 after four hours and was taken to a hospital.

The Centers for Medicare and Medicaid Services threatened to terminate Universal Healthcare North Raleigh from the Medicare program, meaning it could no longer be reimbursed for services for Medicare-eligible patients, if violations found last year weren’t addressed by Oct. 15. As of last July, CMS also was levying daily fines on the facility for ongoing problems.

It’s unclear whether fines are still being levied, if the government ever collected any of the money owed or if Universal Healthcare was able to correct deficiencies to remain in the Medicare program.

 

A Centers for Medicare & Medicaid Services (CMS) official in a letter to the journal Health Affairs suggested that the public would benefit from more information about resident safety at nursing homes — including the explicit identification of bad actors.  Writing in response to a November study about the correlation between Nursing Home Compare star ratings and safety, CMS chief medical officer Kate Goodrich laid out a case for strengthening existing data sources for consumers

“While we view patient safety and quality improvement as a continuum, we agree that specifically ‘calling out’ facility performance on patient safety can resonate with and be beneficial to consumers,” Goodrich wrote. “In fact, CMS highlights performance on safety measures as a discrete domain in programs for other types of facilities, including those for hospitals and dialysis facilities.”

“We do believe that NHC contains additional measures that either directly capture harm or are highly correlated with harm that were not evaluated by the authors  — such as the measure for inappropriate use of antipsychotics, which is strongly linked to falls and other adverse events,” she wrote. “Nonetheless, we agree that NHC captures only a subset of harm, and a broader set of harm measures may be beneficial.”

WCSC reported that South Carolina’s Department of Health and Environmental Control is taking enforcement action against Phaire’s Care after a “history of noncompliance,” according to a DHEC representative.  Phaire’s Care is an assisted living home located in Orangeburg County.  A complaint from September said “bad things are happening at the facility.” That complaint listed problems including staff yelling at people who live there, deplorable conditions, underfed residents and possible rats in the building.

Enforcement from DHEC comes after 57-year-old Curtis Johnson Wilson went missing from the facility but was later found by police.

“We’re looking for him to be safe at all times,” Curtis’ sister Barbara Wilson said. “We’re looking for him to receive the sufficient amount of food, adequate care.”

DHEC representative Chris Delcamp said the department completed its most recent investigation. Since then, someone filed another complaint with the department, which Delcamps said requires investigating.

Investigation reports from DHEC show us during a site visit in January, crews found a laundry list of problems.

Medication was not administered to patients correctly, three of 11 employees did not have background checks on file, bed bug-like insects and mouse-like droppings were in one of the rooms–the list goes on.