Nursing Homes, like deteriorating public schools, crumbling bridges and other pieces of our society’s essential infrastructure have been neglected for a long time. Now, HeatlhBeat reader Gregory Pawelski reports that this year, Congress is finally give nursing homes the attention they badly need.
“Last year,” he observes, “the House Energy and Commerce Subcommittee on Oversight and Investigations held a hearing on nursing homes—for the first time since 1977. One could say that this indicates a rather lackadaisical attitude on the part of Congress in regards to our senior and infirmed population. The last significant change in nursing home regulations was the Nursing Home Reform Act of 1987.”
Following that hearing, the House and Senate introduced the Nursing Home Transparency and Quality of Care Improvement Act of 2008. But the 110th Congress adjourned before legislators had a chance to consider the legislation.
Last week, Senators Chuck Grassley and Herb Kohl reintroduced the bill. But, Pawelski warns, the bill lacks the teeth of the original legislation. Last year, the bill’s backers stripped it down in hopes that, despite opposition from lobbyists, it might squeak through Congress. Now, Pawelski says, with more progressives in Congress, a stronger bill could–and should—become law.
He explains: “Last year’s subcommittee recognized the problem. Each individual state performs inspections of nursing homes on behalf of the Centers for Medicare and Medicaid (CMS). But CMS says it does not have enough inspectors to visit the country's over 16,000 nursing home facilities. Meanwhile, CMS has been putting out the word that surveyors shouldn't cite anything they don't absolutely have to, while accepting self-reported and unaudited data from the nursing homes.”
“According to government documents, in 2001, Bush wanted to ease regulatory requirements on nursing homes, reducing the frequency of inspections and while lowering –or even eliminating– some penalties. The Bush administration explained that it wanted to move away from adversarial enforcement toward a more collaborative approach: regulators would work with nursing homes to improve care. “
In short, the Bush administration wanted to deregulate nursing homes. No surprise, this more permissive climate whetted investor interest in nursing home chains. Private-equity firms that are unregulated and new to the nursing home market moved in.
Private Equity Firms Scoop Up Nursing Homes
Roughly two-thirds of U.S. nursing homes are now owned by for-profit firms, and “many worry that the top priority for these new private-equity owners would be profits, rather than providing the staffing and resources necessary to ensure top quality care for our loved ones,” Pawelski explains. “Frequently, they use complex corporate structures, separating the nursing home real estate from the operating companies and putting multiple layers of limited liability partnerships between themselves and the day-to-day operations of the nursing home.
Ownership structures with multiple stakeholders have been used by other private-equity firms to minimize liabilities and shield them from regulator inquiries –such as when cutting staff is made to improve profit margins. This is how they avoid taking responsibility—even while when taking control of the nursing homes.
“Private equity is buying up this industry and then hiding the assets,” he adds “and when residents die from lack of proper care, there is little the courts or regulators can do. Meanwhile the private investors skim off the profits to line their pockets — or to plow the money into separate ventures that have nothing to do with nursing home care. “
In 2007, when The New York Times took a look at nursing homes that had been purchased by private equity firms it discovered:
- Serious quality-of-care deficiencies – like moldy food and the restraining of residents for long periods or the administration of wrong medications – rose at every large nursing home chain after it was acquired by a private investment group from 2000 to 2006, even as citations declined at many other homes and chains.
- "Staffing Cuts, Sometimes Below Legal Levels "At 60 percent of homes bought by l large private equity groups from 2000 to 2006, managers have cut the number of clinical registered nurses, sometimes far below levels required by law. During that period, staffing at many of the nation’s other homes has fallen much less or grown.”
Last spring when Congress began to turn up the heat on nursing homes, Lewis Morris, chief counsel to the inspector general of the Department of Health and Human Services told of violations that can only be described as abuse of patients: “We have found nursing home residents who were grossly dehydrated or malnourished,” Mr. Morris said. “We’ve found patients with maggot infestations in wounds and dead flesh. We’ve found residents with broken bones that went unmended.”
Nevertheless, the American Health Care Association, a trade group for nursing homes, opposed the 2008 legislation. Bruce A. Yarwood, president of the association, said: “We should not be increasing fines, adding auditors and encouraging a ‘gotcha’ mentality. We should be testing new, less punitive ways to measure and improve the quality of care.”
In September, when a Department of Health and Human Services report revealed that more than 90 percent of nursing homes had been cited for violations last year –and that out 17 percent of nursing homes had deficiencies that caused “actual harm or immediate jeopardy” Yarwood acknowledged: “We know we have to do a better job.”
.Part of the problem is that “CMS and the states lack the tools to keep up with the rapid changes in the industry to know who actually owns the country's nursing homes and who should be held accountable for the residents in their care,” Pawelski explains. “There is a crisis in our nation's nursing homes, more than at any time in the past. The residents living in them need our help.”
2009 Legislation
Sen. Chuck Grassley and Sen. Herb Kohl reintroduced the Nursing Home Transparency and Improvement Act last week. But Pawelski says some elements of last year’s bill need to be restored. For example, “The original bill increased civil monetary penalties. In addition the 2008 legislation focused on independent audits of facilities that are part of chain. Now the focus has shifted to internal quality assurance and compliance and ethics programs that include procedures to detect criminal, civil, and administrative violations.” Pawelski explains. “Congress should hike those penalties to as much as $100,000 if a resident is harmed or dies due to negligent care. If simply composing a typical generic Plan of Correction is the only remedy required for verified violations, where is the motivation for the facility to change their practices?”
Downsizing has created an even greater problem. “When there are not enough caretakers “residents don't receive even basic humane care,” says Pawleski. “They are not hydrated, changed, bathed, turned, given their meds on time and/or given correctly. Lack of staffing also creates a constant high turnover among even the most highly-trained, dedicated workers. Mandatory staffing levels were taken out of last year's bill, hoping it would have a better chance of passing. Mandatory staffing levels should be put back into this legislation.
House sponsors of the legislation, Rep. Pete Stark and Rep. Jan Schakowsky, are expected to reintroduce their version of the bill in April. “Now is the time,” says Pawlewski, “for caregivers who have loved ones in a nursing home, and hopefully everyone else, to call/write their federal legislative representatives to pass this legislation, with ‘mandatory staffing levels’ put back into the bill.”
Full Disclosure: Pawleski has seen nursing home conditions up close. Until recently his own mother was in a Manor Care home. Manor, which is the nation’s largest nursing home chain, is part of the Carlyle Group, the country’s largest private equity firm. (Recently, Carlyle’s name has come up news about the bank bailout. The Washington Post reports that the Carlyle Group has raised $1 billion and hopes to add $2 billion more for investments in financial institutions that come up for sale under President Obama's economic rescue plan. As the Post noted, “Carlyle has been looking for the right price.”
As 80 million boomers look at this future for themselves maybe that will help drive legislative initiatives?
Mandatory staffing is necessary as is improved wages and benefits for the minimum wage staff
My personal anectote is my 88 y/o father being extorted by my 86 y/o mothers caregiver in the nursing home.(“I’ll take better care of your wife if you give me 50 dollars a week)
Dr. Rick Lippin
Southampton,Pa
Following a thirty-five-year career in the food business my post-retirement employment has been in the senior living environment. Five years in a hospital owned “independent” apartments and assisted living facility, and now as a non-medical sitter with occasional assignment via an agency. During this time my mother lived two years in a church-sponsored, government-subsidized senior apartment facility with on-site prn caregivers available at an hourly rate. Before she died in January she was in a nursing home for a year, so I have had recent personal experience with this subject. Here are my observations.
Skilled nursing facilities include a wide quality range from the nightmare descriptions above to a few places like my mother was fortunate enough to reside. I never imagined she would be able to stay anywhere as nice as the place we found.
Part of the challenge to nursing homes is that they are designed for round the clock skilled nursing but that mission is widened by a variable number of residents more appropriately cared for in an assisted living environment. Since there is no tax money for such places residents (like my mother) with no assets run out the 100-day Medicare benefit and become “custodial,” supported by Medicaid with no place else to go.
I have the impression that nursing homes regard these low-maintenance residents as cash cows which enable them to reduce staff expenses. The number of for-profit places in metro Atlanta is a large multiple of the not-for-profit places. My limited experience leaves me with the impression that the quality of care is better in not-for-profit places, mainly because they can employ more people.
This year the CMS website has a feature which lists nursing homes in a searchable data base for a designated radius. Three places can be compared using a star-rated system reflecting five or six metrics. This is an invaluable feature.
A trend to CCRC’s (Continuing Care Retirement Communities) includes both skilled nursing and Alzheimer’s facilities, but these tend to be high-end places out of reach for all but the mose well-to-do seniors. These may be either for-profit or church-sponsored, but it is a growing field. Unfortunately, some outfits are getting into both CCRC and so-called “senior living” businesses without experience or good consultation. Attention to details such as security, safe carpeting, dining areas allowing room for fleets of walkers and wheel chairs, etc. sometimes get overlooked in the planning and may or may not get retrofitted. I don’t know about other states but Georgia’s inspectors seem to have succeeded in making the places where I worked very alert to the details of their expectations.
Another trend in assisted living facilities is more rooms designated “memory care” for dementia/Alzheimer’s residents.
One final observation… Many of the care-givers (RN’s, CNAs, and RA’s) are from other countries. I’m not sure what this is about, but it may be related to cultural differences. My impression is that in most of the world elderly people are not warehoused as they are in America, with extended family care instead as the expected norm. In many caregivers from other countries I sensed a caring spirit that seems less prevalent among American-born employees, but that may reflect a personal bias on my part. I see an opportunity for better training, raising the bar (and pay) for certification.
I hope I am reading you wrong Dr. Lippin. A caregiver in the facility who was taking care of your mother wanted $50 from you personally, to see to it that she was well taken care of? It sounds like a personal bribe or perhaps a form of blackmail. I doubt the facility would condone it, even the worst of them. It is illegal for any worker to accept gifts or money from any resident, although it is usually overlooked say at Christmas time, if the resident or their family choose to do so.
Hootsbuddy, I agree that the vast majority of non-profit facilities provide excellent services because “profit” is not their bottom line, like private-equity for-profit ones. Residents are thought of as “cash cows” in the private-equity for-profit nursing homes.
State Surveys are independent evaluations of nursing facility performance. Annual surveys are conducted by state survey agencies, usually the state’s department of health, using protocols, procedures, and forms developed by the Centers for Medicare & Medicaid Services (CMS).
A consumer concern about surveys is the repeated finding by the Government Accountability Office (GAO), in a series of reports issued since 1998, that surveys understate deficiencies and cite deficiencies as less serious than they actually are.
The survey component of CMS’s proposed ranking system provides a more positive statement about quality than justified. States are increasingly using their state enforcement systems, instead of the federal system, to sanction facilities for noncompliance with standards of care. State enforcement actions do not appear on Nursing Home Compare.
The National Senior Citizens Law Center recommends that consumers use the new rating system with caution, and only as an aid while also pursuing other information and strategies. Consumers need to understand that the five-star system is a beginning, not an end.
A nursing home’s quality can shift from month to month, so you have to be savvy in asking the right questions. Existing residents and their family members should be asked for their opinions.
Inspection data is mostly based on a once-a-year survey and may not accurately reflect the nursing home’s performance today. Staffing information and quality measures are “self-reported” data by the nursing homes themselves. Self-reported data makes nursing home quality “appear” to be better than it actually is. It cannot easily be reduced to a star rating.
A recent GAO study found that nursing homes over-report staffing levels compared with staffing reported on audited Medicaid cost reports. Over-reporting of nursing coverage is associated with for-profit ownership of nursing homes.
Researchers recommend more careful scrutiny of staffing levels in for-profit facilties during the survey process and that improvements be made to the process of public reporting of staffing levels.
CMS should provide more and better information on Nursing Home Compare, including links to the actual survey forms and information about staff turnover. Also, CMS should use payroll data to report staffing information.
Anything to do with “quality indicators” is bogus. When de-regulation failed under the previous administration, they wanted, among other things, the “quality indicator” process to eventually replace traditional annual surverys because it relies upon self-reported, unaudited data supplied by the facilities themselves and is without consequences for failures. But it still relies upon self-reported, unaudited data supplied by the facilities themselves.
It leaves you with that warm-n-fuzzy “we’ll-help-them-fix-their-problems,” even though 99% of their failures are failures of practices they should already be experienced in before they are granted a license. It is part of the “kid-gloves,” don’t be-so-hard-on-the-bad-nursing-home.”
Nursing home care is a very difficult issue from a healthcare cost standpoint on several levels. First, while I have no love for Manor Care or the Caryle Group, the quality of care that a given home is able to provide is driven importantly by its patient payer mix – private pay, Medicare and Medicaid. Operating a nursing home is a very labor intensive business. Even though most employees are paid modestly, aggregate salaries and benefits add up quickly. Medicaid pays a much lower per day rate than either Medicare (which only pays for a short time under limited circumstances) or patients who self-pay. Nursing homes interested in making themselves reasonably attractive to private pay and Medicare patients have plenty of incentive to provide decent care even if they are for profit entities. Many patients who start out paying privately soon exhaust their resources and become dependent on Medicaid to pay. Medicaid is now the dominant payer of long term care costs. As I’ve noted before, when my father was in a nursing home between 2000 and 2001 before he died, we self-paid at a rate of $163 per day. That was a 37% premium to the NJ Medicaid rate of $119 that was in effect at the time. The bottom line is that patient mix has a huge effect on the quality of care a given home can provide regardless of whether it is a non-profit or a for profit business. Separately, home healthcare is also subject to widespread abuse, especially in the area of upcoding and, sometimes billing for services that were never provided or for services that were clearly not needed. For patients who need around the clock care and would like to have it in their own homes, the cost is prohibitively expensive for all but our wealthiest seniors and their families.
The second issue relates to ancillary services like physical therapy. Gregory and I are both aware of instances where these services are provided to drive revenue for the nursing home even when they are unlikely to benefit the patient. Much of this could be prevented if primary care doctors adequately supervised nursing home patient care. Unfortunately, they are not paid anywhere near enough to enable them to do this, especially with respect to Medicaid patients.
The third issue is around aggressive medical treatment of the frail elderly as compared to what might occur in other countries. While I have no data, I would be interested if anyone can provide comparisons of the number of nursing home patients as a percentage of the total in the U.S. vs. other countries who are on feeding tubes and/or ventilators or who are receiving kidney dialysis. How often do elderly nursing home residents with dementia or Alzheimer’s undergo major surgery here vs. in Canada or Western Europe? To the extent that we treat more aggressively here, at very high cost, it’s just another manifestation of what I consider unrealistic, unreasonable and overly demanding patient expectations combined with aggressive physician practice patterns in the U.S. which is, I think, a significant factor contributing to our excessive healthcare costs.
Gregory- I think this is extortion (not bribery).It may be illegal but according to my father it happenned.And he was of sound mind.
We decided not to report the underpaid worker -nor did we give her the requested $
Dr.Rick Lippin
Southampton,Pa
Barry
My colleagues and me were discussing this article. You will find it of interest based on your comment. Unfortunately, while there is a need, reimbursement is so lousy that attracting good talent is a virtual non-starter.
Brad
http://www.annals.org/cgi/content/abstract/150/6/411
A highlight conclusion of the article Brad F mentions states “We contend that rather than accepting a diminished presence of physicians in nursing homes and finding alternative care models, it is time to fully consider, appropriately fund, and test the nursing home specialist model.
http://www.annals.org:80/cgi/content/full/150/6/411
Dr. Rick, Hootsbuddy,Barry, Brad, Gregory
Dr. Rick– sounds like extortion to me–but it would be hard to prove unless another family confirmed it.
Hootsbuddy–
There are so many foreign workers in our nursing homes, in part because the pay is so low, but also because many Americans don’t want to work with “old people”
What you say at the end about foreign care-givers having a more “giving spirit” rings true. Unfortunately, our culture is so obsessed with youth
and tryng to be youthful that we don’t have the respect for the elderly that you see in other countries. IN the U.S., too often, the elderly are treated with contempt or disdain.
Barry-
The report that I talk about in the post shows that ” for-profit homes were more likely to have problems than other types of nursing homes, federal investigators say in a report issued on Monday.”
Later in the story, the numberes show that for-profit homes have 30% more violations.
This has little to do with the mix of patients.
Historically, profit nursing homes have attracted very sleazy operators–people who hope to exploit and make a profit on weak elderly patients who are less likely than other patients to complain (or to be heard if they do complain.)
We need to raise wages and benefits for nursing home workers, but we also need to find alernatives for long-term care.
In-home care is the best alternative–if the elderly person has a comfortable home.
In Germany, the elderly have a choice: they can go into a government-run nursing home,
Or, if they want to buy their own care, the govt will give them 50,000 Euros a year to do so.
It costs the govt 30% more than 50,000 Euros if they go into the nursing home.
We need to do something like that here. And we need to pay relatives who care for the elderly in their homes (or the elderly person’s home. European coutnries do pay relatives–and give them beneifts.
In France, if you are caring for a relative full-time, you get a two-week vacation; during that time a professonal care-giver comes in and takes your place.
Of course someone needs to be checking from time to time to make sure the person is getting good care.
Brad & Gregory–
I agree that physician pay in nursing homes is too low.
But Bob Wachter tells me that even if you raise the pay, very few people want to go into geriatric care. (And being a nursing home specialist would be a form of geriatric care.)
According to Wachter, no one wants to take care of old people full time. Christine Cassel, head of the American Board of Internal Medicine, was on the same phone call and she agreed.
A few people find a vocation caring for the elderly, but apparently most doctors find it too exasperating, depressing (the chornically ill don’t get better, they just keep on getting older)etc.
As the population ages this will be a real problem.
Maybe as boomers grow older they’ll have some sympathy for other aging boomers and 75-year-old doctors will care for other 75-year-olds . . .One can only hope.
I suspect that some boomers will create their own assisted living communities–recreating the communes of the 1960s.
(One of my friends talks about this–“You need only one or two people who can still drive at night; some people who can still hear,
etc . .”)
Let’s hope they can find a couple of doctors and nurses willing to join them . .
Gregory– I agree the star
system is a beginning–not an end.
And self-reporting is a joke.
We need minimum staffing levels and we need higher pay and benefits.
But I also think we need more alternatives to nursing homes–as I describe in my comment to
Barry above.
Carlyle Sees Handwriting On Wall
Treasury Secretary Timothy Geithner said that “new rules of the game” are necessary to restore confidence in the financial system after credit markets seized up and stocks fell the most since the Great Depression. He proposed requiring private-equity firms to register with the U.S. Securities and Exchange Commission and to disclose information about their holdings.
After opposing increased federal oversight for years, David Rubenstein, co-founder of private-equity firm Carlyle Group, admitted that they are not going to be able to stand in the way of including them in an overhaul of U.S. financial regulation.
The government would have the power to peer into the inner workings of companies like the Carlyle Group that currently escape most federal supervision. Private-equity funds operate almost entirely outside the regulation of either the Securities and Exchange Commission or the Federal Reserve.
Regulation of Carlyle’s Manor Care nursing homes is good and necessary, particularly since the company accepts taxpayer funds for the majority of the residents of their facilities. The private-equity for-profit operators of these nursing homes need to hire the best caregivers available and pay them a living wage. They need to provide clean, well-kept facilities that meet all state and federal standards, with good food and good access to healthcare services.
Gregory–
I entirely agree.
This is one of the good things to come out of
economic melt-down: the hedge funds and private equity firms like Carlyle
will be regulated.
CMS uninterested in the quality of nursing home care
Events of the past year have confirmed my suspicions that the (at least Pennsylvania) Department of Health is part of the problem rather than part of the solution to the problems of private-equity for-profit nursing homes.
The 51 pages of a CMS complaint survey, conducted at a ManorCare Health Services facility from September 22-25, 2008, verified most of my concerns about the problems there (13 confirmed violations), as well as some complaints apparently filed by others.
It was not surprising that many major deficiencies and violations were observed because nothing was addressed by the Pennsylvania Department of Health during the last five years, and these were issues which the Administrator of the home was informed about.
One of the most egregious violations was from a review of the facility’s Monthly Infection Control Summary Tool that indicated the infection rate within the facility ranged from a low of 14.42% to a high of 44.55%, which is almost double to five times the CMS national average of 9%.
Even in an interview with the head CMS surveyor, the Administrator and the Director of Nursing acknowledged the Monthly Infection Control Summary Tools reflected an extremely high infection rate within the facility. That alone automatically justifies monetary penalties assessed to the home, according to a Congressional office.
This federal complaint survey’s confirmed violations at ManorCare Health Services, Sinking Springs, Pennsylvania, validated most of my complaints, those the Pennsylvania Department of Health has not dutifully and diligently investigated over the last five years. The federal surveyors found these violations only four months after the Department of Health’s inspection in May of 2008.
The Plan of Correction submitted by the facility has already been violated twice, in regards to my mother alone. That seems to be another Administration violation on its merit, as it is the responsibility of management to see that Plans of Correction are adhered to. Still, no reported monetary penalties, according to my Congressional representative’s office.
Surprise nursing home inspections by the Department of Health are in reality seldom random, and their level of predictability allows the home to conceal the evidence of abuse and neglect. They can anticipate when an inspector is coming, and employees are instructed to clean up the facility in time for the inspection. The number one problem at Manor Care is understaffing, and regulators cannot get the private-equity for-profit nursing homes to comply with mandatory staffing requirements. Instead, they go to great lengths to conceal data from inspectors when it comes to staffing.
There were numerous Clinical Record violations, Accidents & Supervisory violations, Infection Control violations and others at various scope and severity levels, but no Administration violations were cited. This lack of oversight translates into more taxpayer dollars down the drain because of the health problems and costly hospitalizations that wouldn’t have been necessary as a result of it. But loopholes in state laws and the lack of federal oversight have allowed these kinds of events to skirt regulation.
The facility has violated federal regulations about caregivers voicing concerns and grievances about care or treatment without discrimination or reprisal. Under 42 U.S.C. 1395i-3(c)(1)(A)(vi); 1396r(c)(1)(A)(vi); 42 C.F.R. 483.10(f), the resident [and/or the resident’s legal representative] shall have the right to voice concerns and grievances about care or treatment which has been furnished or not furnished, without discrimination or reprisal. The resident shall have the right to prompt response by the facility to resolve grievances, including those about the behavior of other residents.
I have had to ask for the assistance of the local police department myself on numerous occasions, due to Manor Care’s illegal ban on my mother’s right to decide who she wants to visit her. The first event involved a psychotic resident who repeatedly tried to get into my mother’s room and whom later accosted her in the hallway. The second event involved yet another rodent infestation (nesting in/chewing on/defecating on her clothing), leaving droppings all over her room.
The third event involved the police gladly assisting me again in securing her safe removal from the home on March 22, 2009, especially after I received an unsolicited phone call from CMS in Baltimore, strongly encouraging me to remove her from Manor Care for her health and safety.
I certainly expected CMS to be interested in the quality of care that was not provided to my mother and other nursing home residents. CMS has ultimately failed in its duty to monitor nursing home regulatory compliance to assure residents are receiving the highest quality of care possible.
very important article, we have to care the nursing homes, I’m so happy with your labor.
Tannia H.
Great post.