The Syracuse Post Standard had an article recently discussing the (small) fine that a nursing home received for neglecting a resident who died as a result of choking.  How could they levy such a small fine for a preventable death? 

The government fined a Minoa nursing home $13,300 for failing to provide prompt emergency care to a choking resident who died.  The Centers for Medicare & Medicaid Services said The Crossings put residents in immediate jeopardy and provided substandard quality of care, the most serious deficiencies.

The Crossings was one of four nursing homes in the region fined for poor care between June 1 and Sept. 19, according to the Long Term Care Community Coalition.   The fine against The Crossings stems from an Oct. 15, 2007, incident involving a resident:  The report said:

The woman was served a dinner of blueberry pancakes and sausage that a nurse aide cut into bite-sized pieces. A short time later, the aide noticed the women’s mouth was open, she was not breathing and her lips were blue.  The aide failed to call a "code blue," an announcement that alerts all staff to an emergency situation and summons them to provide assistance. It also activates the 911 system. The aide also failed to start the Heimlich maneuver.  A licensed practical nurse who came to help did not take these steps, either.  The registered nurse supervisor who arrived on the scene did not immediately call a "code blue" or 911.

I wonder what "a short time later" means?  I am surprised the nursing home did not claim that the resident had a DNR so they did not need to intervene!!

The SCDHEC website has an interesting question and answer session where they discuss nursing homes.  SCDHEC is responsible for licensing and enforcing the standards at nursing homes.  They are woefully understaffed and underfunded.  Below is an excerpt from "conversations with the Commissioner.

How many licensing people in DHEC’s whole health licensing side? How many are assigned only to Community Residential Care Facilities?

DHEC’s Division of Health Licensing has 45 positions; three are vacant. The division has 29 inspectors. The community care oversight program has 13 positions. An additional inspector position is proposed, but has not been hired. One administrative person from the division’s operation support program is assigned responsibilities of processing CRCF applications for licensure.

How many investigators in DHEC’s whole health licensing side? How many are assigned only to CRCFs?

We have 30 investigator positions. Of these, 11 are specifically assigned to CRCF in the Community Care Oversight Program.

Does DHEC need more inspectors and investigators for the CRCF program? How many?

Currently, the DHEC’s Division of Health Licensing licenses 489 CRCF’s with a total of 16,637 beds. We are assessing the CRCF program to determine how best to achieve the goals and responsibilities of the program. We’ll be happy to share the results once the study is completed.

Does this program have annual reports? (DHEC’s solid waste division, for example, produces annually a nice comprehensive report.)

No.

How many natural deaths occur each year in CRCFs?

We do not collect that information as it is not required to be reported to DHEC by the facilities. We are to be notified by the facility of a death where there is an unusual circumstance that involves an investigation by the coroner or local law enforcement. We would investigate to determine whether there would be any violations of DHEC regulations that occurred. The investigation into the cause of the death and any criminal charges brought in the matter would be left to the coroner and local law enforcement agencies under their authority.

How many deaths due to staff negligence or inadequate staffing occur each year in CRCFs? (This question includes residents like the wheelchair death of a Peachtree Manor man, who was a resident but he was being pushed down the road.)

We are to be notified by the facilities when there is a death that is investigated by the coroner or local law enforcement. Criminal charges that may be brought would be done by those local authorities.

How many injuries occur each year in CRCFs? What is the nature of the injuries?

The facilities are required to notify DHEC of serious injuries that require hospitalization due to incidents involving fractures, burns, lacerations, hematomas, etc. While that information is reported to DHEC, we do not have the specific numbers compiled.

How many complaints do you get each year about CRCFs? How many are justified? What are the categories of complaints?

For the fiscal year July 1, 2007 to June 30, 2008, we received 569 CRCF complaints alleging 2,592 various issues which resulted in 579 citations.

For the current fiscal year from July 1, 2008, we have received 186 complaints alleging 886 issues for which 14 citations have been cited. Some findings for this period are inconclusive at this time as most of the complaints are still open.

Often the citations noted were not associated with the original complaint. Many times we are unable to determine if the complaint was justified.

The complaints are typically taken under the following headings:

Abuse
Accessibility
Activities
Administrative
Animals
Background Checks
Care Plans
Charting/Records
Dietary/Food
Dirty Needles
Dumping
Finances
Fire Code
Housekeeping
Incident Reports
Level of Care
Maintenance
Misappropriations
Oxygen
Patient Rights
Pharmacology
Quality Program
Recreation Staff Unlicensed
Safety
Staff
Staff Training
TB Requirements
How many CRCFs has DHEC closed in recent years?

Within the most recent years DHEC has actively been involved in the forced closure of one facility; Peachtree Manor.

All other closures have been as a result of the voluntary surrender of the facility’s license or closure of the facility as a decision made by the licensee/owner. Our enforcement actions have contributed to many of the voluntary closures.

About how many CRCFs are like Still Hopes (a CRFC in West Columbia) where mostly upper income folks go.

We do not compile information whether a facility is strictly private or whether it accepts residents that receive the Optional State Supplement (OSS) or both. You can contact the S.C. Department of Health & Human Services to request information on those facilities residents who receive the OSS supplement.

The CRCF at Still Hopes is only one part of that overall facility. Still Hopes has apartments for independent living as well as a skilled-care nursing home.

Describe briefly DHEC’s main concerns with its CRCF program.

Compliance with the requirements of Regulation 61-84, Standards for Licensing Community Residential Care Facilities. Pam Dukes and Commissioner Hunter can elaborate on this question at your meeting this afternoon.

Describe briefly how DHEC wants to address those concerns.

The Division of Health Licensing is reviewing Regulation 61-84 for possible revision. We are studying possible changes in the programs. We expect to have that process completed within the next 30 days.

Can I attend the 1 p.m. Oct. 22 CRCF meeting at the Heritage Building in Columbia mentioned in Ken Moore’s Sept. 26 memo?

This meeting is for our staff and invited directly affected stakeholders to review the CRCF program and potential regulatory changes. As such, the session is not considered a “public” meeting based on input from the agency’s legal staff as the group does not constitute a public body. Allowing media participation may significantly limit our ability to engage stakeholders in a completely open and frank dialogue. We do encourage you to attend future public CRCF meetings that will be held as we continue this process.

(Question 1 response) You write, “The Community Care Oversight Program has 13 positions.” Q. My questions: How many of these positions are filled with full-time on-duty people?

All 13 are full-time on-duty staff.

How many of these positions with full-time on-duty people are devoted EXCLUSIVELY to CRCFs? (The 489 facilities you regulate).

None of the 13 are devoted exclusively to CRCF.

Of the positions EXCLUSIVELY devoted by CRCFs and filled now by full-time on-duty FTEs, how many are investigators? Inspectors? (This entire question may be most easily addressed on the phone with someone. I just want to be sure we are describing your staffpower accurately. For example, we have a lot more positions in our newsroom than actual workers. We have lost many through buyouts, attrition, etc. Saying you have a position doesn’t reveal much about actual staffing.)

The CRCF program staff that inspect facilities are inspectors. The program does not use the position title of investigator.

(Questions 2 response) Does the “Community Care Oversight Program” only concern the 489 CRCFs, or does it include other types of facilities?

The Community Care Oversight program includes 87 Intermediate Care Facilities for the Mentally Retarded (MR15 and MR16). There are a total of 1,864 ICFMR beds.

(Question 8 response) You say for FY 07-08 you received 569 CRCF complaints alleging 2,592 issues… etc. (my question: Does this include the complaints forwarded to you by the Ombudsman’s office and Gloria Prevost’s group, Protection and Advocacy, which does about 85 contract inspections of CRCF’s a year for Department of Mental Health and forwards complaints to DHEC?)

Yes, but not all information forwarded to the CRCF program from these groups requires a DHEC investigation. Often, either the findings provided from their complaint investigation or the complaint itself is not within our scope of authority.

(Question 9 response)… Any idea how many closures in the past 3-4 years have been attributable in part to DHEC enforcement actions besides Peachtree?

Approximately 16 since 2004

On a different but related note: How many patients in state nursing homes? How many nursing homes?

For clarification, are you asking how many nursing homes are owned by the State of South Carolina, and how many patients are served in those homes? Or, is your question more general?

The general answer is that in South Carolina, we license 195 nursing homes with 19,647 beds. Most nursing homes in the state operate at over 95 percent occupancy.

If you want to know how many are State of South Carolina owned and how many beds are in those homes, we will need a couple of days to get you that information.

 

Numerous media outlets have discussed the recent report from the Inspector General that shows that 92% of all nursing homes violate the standards established by the federal and state governments.  ABC News had a good article here.

A government report released found extensive problems in America’s nursing homes. Nearly one in five of the nearly 15,000 nursing homes examined were cited for violations that put patients in immediate harm in 2007.   92 percent were cited for some type of deficiencies during each of the last three years.

The quality of care in nursing homes was the focus of those deficiencies. Experts also found that  far too many residents waited too long to get the help they needed.

"Very few of these deficiencies ever result in a financial penalty," said Wes Bledsoe, founder of A Perfect Cause, a non-profit group that advocates for the reform in long-term care. "And if they do, they are not collected. The system has no teeth."

"It’s a priority for me in this office because sometimes it’s a double crime," New York State Attorney General Andrew Cuomo said. "First of all, it’s a fraud against the taxpayer. In many cases, taxpayers are actually funding these organizations and these institutions and they’re being defrauded. And secondly you are literally affecting the most vulnerable in our society. And that’s our first priority — to protect those people who literally can’t protect themselves."

This week’s report revealed that for profit homes are actually more likely to have problems than facilities run by local governments or non-profits despite having more resources and making substantial profits.
 

The NY Times had a recent article about the prevalence of violations in the vast majority of nursing homes. National for profit chains seem to get more violations than others.  The article cited that more than 90 percent of nursing homes were cited for violations of federal health and safety standards last year.   About 17 percent of nursing homes had deficiencies that caused “actual harm or immediate jeopardy” to patients, said the report, by Daniel R. Levinson, the inspector general of the Department of Health and Human Services.

Problems included infected bedsores, medication mix-ups, poor nutrition, and abuse and neglect of patients.  Inspectors received 37,150 complaints about conditions in nursing homes last year, and they substantiated 39 percent of them, the report said. About one-fifth of the complaints verified by federal and state authorities involved the abuse or neglect of patients.

About two-thirds of nursing homes are owned by for-profit companies, while 27 percent are owned by nonprofit organizations and 6 percent by government entities, the report said.  The inspector general said 94 percent of for-profit nursing homes were cited for deficiencies last year, compared with 88 percent of nonprofit homes and 91 percent of government homes.

“For-profit nursing homes had a higher average number of deficiencies than the other types of nursing homes,” Mr. Levinson said. “In 2007, for-profit nursing homes averaged 7.6 deficiencies per home, while not-for-profit and government homes averaged 5.7 and 6.3, respectively.”

On Monday, Mr. Levinson issued a compliance guide for nursing homes that says some homes “have systematically failed to provide staff in sufficient numbers and with appropriate clinical expertise to serve their residents.” Researchers have found that people receive better care at homes with a higher ratio of nursing staff members to patients.

The inspector general said he had found some cases in which nursing homes billed Medicare and Medicaid for services that “were not provided, or were so wholly deficient that they amounted to no care at all.”

More than 1.5 million people live in the nation’s 15,000 nursing homes. The homes are only inspected once a year and must meet federal standards as a condition of participating in Medicaid and Medicare, which cover more than two-thirds of their residents, at a cost of more than $75 billion a year.

Medicare pays a fixed daily amount for each nursing home resident, with higher payments for patients who are more severely ill. Mr. Levinson said some nursing homes had improperly classified patients or overstated the severity of their illnesses so the homes could claim larger Medicare payments.

 

An independent, broad-based national expert panel should be convened to re-examine the oversight process for nursing homes, a task force from the American Association of Homes and Services for the Aging (AAHSA) concluded in its final report, "Broken and Beyond Repair: Recommendations to Reform the Survey and Certification System."

The report’s 31 recommendations include improved communication to surveyors and providers about new requirements and changes to the survey process, standardized job descriptions for surveyors, more efficient use of survey resources, and flexibility to adapt to culture change. The task force’s overarching recommendation is that an independent commission, such as the Institute of Medicine, reexamine the survey and certification process to "create a common vision for how our nation should care for its frailest citizens and to recommend a new oversight model for ensuring that this vision becomes reality in every nursing home today."

Bonnie Gauthier acknowledged that "our short-term suggestions alone won’t bring the system back to the intent of OBRA 87 — achieving optimal, quality-based, resident-centered care — but they will tide the system over until broad systemic change can occur." Immediate changes needed, according to the report, include better public reporting of survey results, joint education of providers and surveyors, and greater overall consistency in the process."

To inform its conclusions, the report includes a digest of interviews with survey agency representatives from seven states and a catalog of surveyor job descriptions from numerous states.
Larry Minnix, AAHSA’s president and CEO, said  "This system is angry, broken and can’t be fixed. A system based on consistency, fairness and accuracy will help us move toward the day when there are two types of nursing homes: the excellent and the non-existent."

Get copies of the report 

About AAHSA
The members of the American Association of Homes and Services for the Aging ( www.aahsa.org) help millions of individuals and their families every day through mission-driven, not-for-profit organizations dedicated to providing the services that people need, when they need them, in the place they call home. Our 5,800 member organizations, many of which have served their communities for generations, offer the continuum of aging services: adult day services, home health, community services, senior housing, assisted living residences, continuing care retirement communities and nursing homes. AAHSA’s commitment is to create the future of aging services through quality people can trust.
SOURCE American Association of Homes and Services for the Aging
 

The Milwuakee Journal had an excellent 2 part series on nursing homes recently.  They can be found here and here.

The Journal describes how dozens of nursing homes in Wisconsin have been cited for improper care after the deaths of 56 residents since 2005 – a period marked by a dramatic surge in serious violations around the state.  Neglect was noted after hundreds of elderly or disabled nursing home residents were found with bruises, broken bones or pressure ulcers – some so deep they tunneled to the bone.   In hundreds of cases, reports document how inadequate training, lack of supervision and understaffing contributed to a rising number of injuries.

The Journal Sentinel built a database from thousands of pages of nursing home regulatory records over the past 3 1/2 years. Among the findings:

• Health care violations that put patients in jeopardy or resulted in harm spiked 34% the past three years.

• Dozens of homes are cited repeatedly for serious violations.  Many of the homes cited multiple times are owned by out-of-state corporations.

• Deaths and injuries are occurring at a time of significant worker turnover. In one case, a problem home reported nursing staff turnover rates as high as 257% last year while it led the state in serious citations.

• Families are often kept in the dark about citations issued after the deaths of their loved ones. Four families learned from the Journal Sentinel that serious citations had been issued months and even years after their loved ones were buried. 

Uunprecedented growth and profits in the industry is expected to continue. Last year, the federal government spent about $75 billion on nursing home care through the Medicare and Medicaid program.

The ownership and operation of Wisconsin nursing homes has changed dramatically. Locally owned mom-and-pop operations have given way to out-of-state for profit corporations that own clusters of homes. 

Health care experts cite other factors that have affected nursing home care.   The increase in pressure iulcers are a major concern and a leading indicator of neglect.   Pressure ulcers occur when nursing home residents are left in one position too long. The ulcers get worse when people are forced to lie in their own waste which is common in uunderstaffed facilities.  Without immediate attention, the ulcers can be life threatening.

High turnover rate is an major problem.  The aides do not get paid well and are typically asked to do the work of 2 or 3 aides.  Most aides don’t stay at one facility for long. The Journal Sentinel found that turnover for full-time nursing assistants at Wisconsin nursing homes can be as high as 200%, with an average of 42% last year.   Many nursing assistant jobs start at less than $9 an hour.

"It’s a hard job, but it’s better than working at McDonald’s," said Jim Wilson, administrator at Oak Park Nursing and Rehabilitation in Madison.   The turnover of full-time professional nurses who monitor residents’ care is also high. Among the homes cited repeatedly for serious violations, the turnover rate for full-time registered nurses averaged 57% last year with some homes reporting turnover as high as 300%. The state’s average turnover for full-time registered nurses in all nursing homes was 32%.

Staff turnover can directly affect care, said Julie Eisenhardt, a spokeswoman for the union representing nursing assistants. Inspection records back that up.

Sava Senior Care, a Georgia-based corporation, operates 185 homes nationally. Two of its four homes in the state have been cited with serious violations at least three times since 2005.
Even when large fines or other enforcement actions are imposed against nursing homes after serious injuries or deaths, families might never know about them. Neither federal nor state law requires that families be notified.

A Journal Sentinel analysis found that nursing homes in Wisconsin were cited for poor care after the deaths of 56 residents since 2005. But Nursing Home Compare doesn’t offer any details about those deaths.   The Web site also doesn’t mention anything about corporate ownership, meaning that consumers would be unable to determine if the nursing home was owned by an out of state corporation or even one with a history of violations and fines.  "Figuring out who is accountable for poor care can be very difficult," said Alice Hedt, executive director of the National Citizens’ Coalition for Nursing Home Reform. "Consumers often don’t know who owns and operates a facility. Unless a facility tells them, there is no public way to find that out."   For consumers, knowing who owns a home is important if they want to determine whether the same problems are showing up in multiple homes owned by the parent corporation.

The number of nurses and aides on staff to help residents is a key factor in determining whether quality care is being provided, according to experts.   "The higher the staffing, the better the quality," said Charlene Harrington, a professor of sociology and nursing at the University of California in San Francisco.   Staffing numbers provided by Nursing Home Compare are merely a two-week snapshot from the most recent inspection – and in an industry that has widespread staff turnover, those numbers can’t always be trusted, Hedt said.

S.C. to post Medicaid payments to doctors, nursing homes online 

South Carolina is now posting how much the local nursing home or doctor gets in Mediciad reimbursements.

"We are pleased to be able to offer the public a way to track how their money is spent in the Medicaid program," Emma Forkner, director of the state Department of Health and Human Services, said in a statement. "This kind of spending transparency is key to ensuring accountability from government agencies and those who get paid by them."

The move by DHHS, which administers the $5.4 billion Medicaid program, will help DHHS locate "unusual billing patterns"  and hopefully detect fraud.  

The site also provides information about dentists, hospitals and any of the other nearly 30,000 health care providers in South Carolina who participate in the Medicaid program. It includes their reimbursements as well as the number of patients they saw. More than 800,000 South Carolinians receive Medicaid, the health insurance program for the poor and disabled.

To access the data, go to http://www.dhhs.state.sc.us/dhhsnew/Transparency.asp and click on Medicaid Transparency Database.

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Pantagraph.com had an article about a Bloomington nursing home paying a reduced $14,500 fine for failing to protect residents from a sex offender who was a patient at the facility.  This is outrageous and shows why lawsuits are necessary to insure that nursing homes are held accountable for their negligence and gross stupidity. 

Asta Care, 1509 N. Calhoun St., failed to screen a male resident who made inappropriate sexual advances to staff and two mentally disabled residents. The acts were noted in nursing records dating to October 2006 at the 117-skilled bed facility but were ignored by management.  The man, who was identified as a sexual offender,  was allowed to remain at Asta Care even after complaints were made by staff. 

Clearly this situation was avoidable if the nursing home simply checked the man’s background.  It is shocking that the nursing home only had to pay a small fine for such outrageous conduct.

Arizona Daily Star reported an investigation into the lack of investigation of neglect and abuse in Arizona nursing homes.  The investigation was bold and tragic and led to the reopeing of several complaints, and the conclusion that Arizona fails to protect elderly and vulnerable nursing home residents.  Below are excerpts from the story and investigation.

tAnita McEvoy put her 92-year-old mother in a Tucson nursing home so she wouldn’t get hurt as Alzheimer’s disease took its toll. Instead, her mother shivered in bed while nursing aides took no notice. She died of hypothermia complications.

Another elderly woman, who couldn’t see well and trusted nursing aides to bathe her, did not know they used a cell phone camera to photograph her in the shower, then went to the nursing station to show the photos and laugh about them with others.

And in a third local nursing home, a nursing aide assigned to feed a confused, 84-pound woman withheld a drink and demanded that the woman say "please" and "thank you," laughing while the woman kept asking: "What do you want? Who the hell are you?"

These cases and others over the past three years have this in common: State regulators did nothing about them.   Until Friday — when investigators reopened one of the cases as a direct result of the Star’s questions.   The inspectors showed a consistent pattern of weak enforcement.
Only 15 percent of the time did they substantiate allegations of abuse, neglect or other problems in how the homes cared for some of our most vulnerable people.

The Star reviewed nearly 1,000 citations for safety problems and more than 1,100 complaints of poor care to the Arizona Department of Health Services in Pima County’s 22 nursing homes in the three years ending in 2007.  The review mirrors what federal auditors have found nationally: State inspectors miss violations, underrate the severity of the offenses, and allow homes to yo-yo in and out of compliance.

The Star’s investigation also reveals:
● The state blew its own investigation deadlines in three out of every four cases, often compromising the findings because patients and staff members are no longer around. The median case is 72 days late.
● The state doesn’t give you enough information to determine whether a home is giving consistently good care. The public can’t see the patient’s side of any given complaint. You can’t see reports the nursing homes make when a patient is harmed. And the only snapshot of how a home is performing is up to 18 months old in some cases.
● The state fined poorly performing homes only 24 times in three years, even though it wrote 958 citations. Until recently, the fines were typically so small that even your next-door neighbor could pay them — usually not much more than $1,000.
● Unlike other states that have set precise staffing standards, Arizona adheres to a vague requirement of "sufficient" staffing. That standard, set by the federal government 20 years ago, is notoriously difficult to assess.
● Unlike doctors, nursing homes don’t have to disclose if they’ve paid out judgments or settlements. Dozens of cases have been settled secretly. It could become even harder to learn about improper care, because homes are getting patients to promise not to sue if something goes wrong.
● Because the state rarely substantiates complaints, sometimes staffers who are fired at one nursing home after being accused of abuse or neglect can be hired right away at another.

 

Read More →

The North Country Gazette has an article about Eden Park nursing home in Glen Falls, NY.  It appears that the ursing home never registered with the State and therefore is doing business illegally.

On Sept. 19, 2007, according to the state Department of Health, Certificates of Need were issued to Glens Falls Crossings LLC  for the operation of the nursing homes doing business under the Eden Park name.   However, the DOS Division of Corporations told The North Country Gazette, there is no record of a limited liability company under the name of Glens Falls Crossings LLC “nor do we have a record of an assumed name filed under the name of Eden Park Health Care Center."

The Warren County Clerk’s office says there’s no record of Glens Falls Crossings LLC doing business in the county.

Prior to NCG’s article, if one performed a “Google” search for Glens Falls Crossings, they were led to a website at www.glensfallscrossings.com which said it was “under construction” and to “check back soon”. The website was supposedly “created” by Creative Genius of Saratoga Springs and the domain was registered by National Health Care of Lynbrook, LI in June 2007.

The domain registration says the title of the website is “Glens Falls Crossings Center for Nursing and Rehabilitation”, a non-existent entity with the Department of State. The domain registration says it is affiliated with Cold Spring Hills Center for Nursing and Rehabilitation which specializes in “skilled nursing services for patients and families seeking long term care with dignity and respect for their individualized needs”. But Cold Springs officials say they’ve never heard of it.

How can one do business in the state without being legally registered, especially a health care facility?

In the state of New York, all LLC’s formed or qualified to do business in the state, are required to publish a notice of formation. This requirement does not affect the good standing status of the LLC; however, an LLC is required to complete this requirement in order to have access to the New York State court system. The publication is made at the county level in two newspapers as assigned by the local county recorder, for six consecutive weeks.

According to the Department of State, the four “Crossings LLC” entities, supposedly operating Eden Park nursing homes in the state, are not registered with the state as required.   Eden Park has obtained its certificate of need from the state DOH to operate the facility under a bogus legal entity that is not registered with either the state or county.