Uncensored Inspection Notes

 ProPublica released unredacted write-ups of problems found during nursing home inspections around the country.   For several months now, ProPublica has made redacted versions of this same information available in an easily searchable format in our Nursing Home Inspect tool. These versions, which reside on the U.S. Centers for Medicare and Medicaid Services website, Nursing Home Compare, sometimes blank out patients’ ages, medical conditions, dates and prescribed medications.

 

The agency has said the redactions are intended to balance patient privacy concerns with the need to inform consumers about the quality of care. ProPublica requested the unredacted reports because they are public records and because the added information can make them more useful.

For example, prescription information in the unredacted write-ups can help identify cases in which patients received medications such as antipsychotics that are dangerous for those with dementia.

Nursing Home Inspect allows patients and their families to quickly find nursing homes in their states and identify those with serious deficiencies and penalties in the last three years. The entire national collection of reports — listing more than 267,000 deficiencies — is searchable by keyword.

At this point, Nursing Home Inspect continues to link to only the redacted inspection reports. To search through the unredacted versions, you’ll have to download them and use a program like Microsoft Excel or a text editor that enables you to hunt for keywords or phrases.

The unredacted reports are grouped by CMS region and can be downloaded here. A list of states in each of the 10 regions is here.

 

Quality Indicator Survey Needs Improvement

McKnight's had an article about thenew GAO Report showing that The Centers for Medicare & Medicaid Services need to make serious improvements in the tools it uses to evaluate the quality of nursing home care.  The Government Accountability Office conducted an investigation to determine whether CMS was doing an adequate job in monitoring implementation of the Quality Indicator Survey process. The GAO found that CMS has not established quality measures or performance goals to evaluate if QIS objectives are being met.

Both the GAO and the Department of Health and Human Services recommended that CMS “routinely monitor the extent to which progress is being made in meeting the objectives of the QIS and systematic methods for monitoring and facilitating states' efforts to implement the QIS.”


 

George Houser Trial

The Rome News Tribune reported on the ongoing trial of George Houser.   The linked article summarizes another administrator testifying about deficiencies cited by state regulators and bills for food and other items that were not being paid.   Greenway testified that lab work could often not be done, garbage sometimes piled up and she and other staff members paid for food because the bills had not been paid on the items.  The former administrator at the facility testified about “tags,” which are deficiencies noted by the state. Once nursing homes are tagged with deficiencies, they must submit a correction plan and a follow-up visit is scheduled to make sure the plan has been followed. Greenway also testified that the Mount Berry facility was tagged twice for a violation involving the Residents’ Trust Fund, which comes from the resident’ Social Security benefits and sometimes from family members. The funds are supposed to be available to residents to use for expenditures.

Houser, the former owner of Forum Healthcare Group, which owned two facilities in Rome and one in Brunswick, is on trial in U.S. District Court in Rome, accused of defrauding Medicaid and Medicare out of $30 million between 2004 and 2007 and willfully failing to pay taxes. 

According to the federal indictment, residents of the Housers’ nursing homes lived in substandard conditions, with broken air-conditioners and leaky roofs, while the couple raked in millions of dollars, purchasing homes, property and expensive cars.  According to the indictment, Houser submitted false or fraudulent claims to Medicare and Georgia Medicaid that were “worthless.”

 

Why wasn't the License revoked?

Austin Weekly News reported on the numerous violations of the standard of care at Columbus Manor Residential Care Home.  Columbus Manor was not in compliance with 11 federal requirements for nursing homes that participate in the Medicaid program, according to an Illinois Department of Healthcare and Family Services notice.  The violations - based on surveys the state health department conducted at the facility in April, July and August - involved resident rights, quality of life issues and the physical environment, among other problems.

"The August survey cited the nursing home staff for failing to supervise one resident - a registered sex offender with a history of sexual aggression. The resident left the facility without permission, was hit by a car and admitted to the hospital for a knee fracture in February. The facility failed to create a care plan for the resident before and after the incident to prevent unauthorized departures from the nursing home, according to the August survey."

The Illinois Department of Public Health was also in the process of revoking Columbus Manor's license - which allows it to operate as a long-term care facility - due to a previous incident.  On March 17, 2010, a nursing home administrator yelled in an "intimidating manner," used profanity toward the investigators, threw medical charts and documents, and threatened the Illinois Department of Health with "repercussions if the department wrote up violations," according to the notice of license revocation.

The administrator ended the mandatory meeting and ordered the investigators to leave the facility - an automatic license revocation.  However, for some unknown reason, the license was not revoked.

 

OSCAR Reports show Deficiences in Majority of Nursing Homes

A new report has been completed by nursing home expert Charlene Harrington and her colleagues at the University of California, San Francisco, showing trends in U.S. nursing homes by state for 2005 through 2010. The data are from the federal On-Line Survey and Certification System (OSCAR) reports that are completed at the time of the annual nursing home surveys by state Licensing and Certification programs for the U.S. Centers for Medicare and Medicaid Services.

The average nursing home received almost 10 deficiencies for poor quality of care and almost one-fourth of nursing homes had deficiencies that caused actual harm or jeopardy to residents. Moreover, continued wide variations in staffing, residents, quality of care and deficiencies were found across states. 

. The highlights of the new report for all US nursing homes show that:

Facility Characteristics
• In calendar year 2010, 15,622 nursing homes with 1.66 million beds were surveyed by state agencies.

• Of the 1.4 million residents in nursing homes, 63.4 percent had their care paid by Medicaid, 22.2 percent had care paid directly out of pocket or by private payers, and 14.4 percent of residents were paid by Medicare in 2010.

• The number of for-profit nursing homes increased from 66 percent of all homes in 2005 to 67.6 percent in 2010, while the number of non-profit nursing homes and public homes declined slightly. Nursing home chains were 54.7 percent of the total homes in 2010, showing a 4 percent increase over 2005.

Quality of Care
• Across the country, about 146,000 deficiencies were issued to nursing homes for violations of federal regulations in 2010, indicating many quality problems in the nation’s nursing homes.

• In 2010, 23 percent of the nation’s nursing facilities received deficiencies for poor quality of care that caused actual harm or jeopardy to residents.  

• In 2010, 43 percent of nursing homes failed to provide adequate infection control and 43 percent failed to ensure a safe environment for residents to prevent accidents. Violations of food sanitation regulations were found in 39 percent of nursing homes and 34 percent received deficiencies for failure to meet quality standards.

• In 2010, 30 percent of nursing homes received deficiencies for failure to meet professional standards, 28 percent for failure to provide comprehensive care plans, 23 percent for giving unnecessary drugs, 21 percent for poor clinical records, 20 percent for failing to ensure resident dignity, 20 percent for poor housekeeping, and 19 for failure to prevent pressure sores.

Staffing
The average number of registered nurse (RNs) hours per resident day increased by 18 percent between 2007 and 2010 (from 0.6 to 0.7 hours). The number of licensed practical nurses (LPNs/LVNs) increased by 14 percent and total nurse staffing increased by 5 percent between 2005 and 2010. The increase in staffing may be attributable to the rating of nurse staffing on the government’s Medicare Nursing Home Compare system introduced in 2008.

Studies have shown facilities with more RN staffing have higher quality of care on average. The average staffing levels are below the level recommended by experts which is 0.75 RN hours per resident day and 4.1 total hours of nurse staffing per resident day.

Resident Characteristics
• Although the present of residents reported with pressure sores declined by 13 percent from 2005 to 2010, about 90,000 residents (6.5 percent) have pressure sores. Most pressure sores can be prevented with adequate nursing care.

 

CMS Announces Nursing Home Compare Changes

The Centers for Medicare and Medicaid Services has announced plans to post new information required by the Affordable Care Act on Nursing Home Compare. These are among the first nursing home transparency requirements in the health care reform law to be implemented. The agency also officially announced that it will "freeze" quality measure data that are currently reported in the five-star ratings for six months as it transitions to new data derived from MDS 3.0. See the CMS memo to state survey directors below.

CMS officials told the Consumer Voice that they do not yet have plans to post some other ACA-required data, including links to state survey reports on state websites and the number of criminal violations by nursing homes and their employees.

Memo: March 18, 2011

TO: State Survey Agency Directors

FROM: Director Survey and Certification Group

SUBJECT: April and July 2011 Changes to Nursing Home Compare - Nursing Homes Memorandum Summary 

The purpose of this memorandum is to describe changes that the Centers for Medicare & Medicaid Services (CMS) will make to the Nursing Home Compare website http://www.medicare.gov/ on April 23, 2011 and on July 21, 2011. CMS is soliciting comments about these website changes. CMS will be evaluating the website in a systematic way, including seeking comments from stakeholders and visitors to the site. Based on these evaluations, CMS will continually making revisions to the website in the future.

 Section 6103 of the Affordable Care Act requires that a wide variety of new information be posted on Nursing Home Compare at different time intervals. On April 23rd, CMS will make three changes to Nursing Home Compare. The first change will be to add information to allow consumers to more directly file complaints about nursing homes with State Survey Agencies. These changes include adding links from Nursing Home Compare to State complaint websites and making State phone numbers and fax numbers more prominent on Nursing Home Compare. CMS is also adding a standardized complaint form that consumers can use in cases where they prefer to submit a complaint by fax.

 The second change that will take place on April 23 is to add a more visible consumer rights section that clearly spells out resident and consumer rights and provides more information about courses of action that consumers can take if they feel that their rights are being violated. This section will also have information on how to choose a nursing home and the Long-Term Care Ombudsman program.

 In July 2011, CMS will make an additional change to Nursing Home Compare to display information for each nursing about the number of substantiated complaints received and about the number of enforcement actions (specifically Civil Money Penalties and Denials of Payment for New Admissions) that have been levied.

 Finally, in addition to changes mandated by the Affordable Care Act, on April 23 CMS will "freeze" quality measure data and the five star quality measure ratings currently on the website for a period of six months. The quality measures displayed on Nursing Home Compare since January 2011 reflect MDS 2.0 data submitted during quarters one, two and three of 2010. Historically, CMS has updated quality measure data each quarter. However, new MDS 3.0-derived quality measure data are not yet available for display, so CMS will retain the current QM scores and star ratings until October 2011. We anticipate that new MDS 3.0 QM data will be available in early 2012.


 

 

 



 

Advocates Fight Wisconsin's Unconstitutional Caps

The Journal Sentinel of Milwaukee Wisconsin had a story about numerous advocates criticizing Wisconsin's attempt to take away the right to a jury trial and cap noneconomic damages to an arbitrary limit and prevent punitive damages.

Family members of those residents abused and neglected oppose the caps.  One family member said "The idea that our lawmakers now want to shield nursing homes from full responsibility for their neglect is the worst kind of public policy at the worst of times."

 AARP, the Coalition of Wisconsin Aging Groups, Disability Rights Wisconsin, Alzheimer's Association of SE Wisconsin, Mental Health of America of Wisconsin, the Wisconsin Alliance for Retired Americans, an affiliate of the AFL-CIO, and other advocacy groups also oppose the bill.

They opposed not only the caps on damages but also provisions that would shield the information in an incident report required by federal and state law whenever a resident is injured, preventing certain state reports from being used in court.

When a resident has been injured, he or she can sue for economic, noneconomic and punitive damages.  Economic damages, which are tied to lost earnings and medical expenses, can be relatively limited for residents in nursing home and assisted living centers.  f the injury results in death, adult children can sue for wrongful death. Those awards by state law are capped at $350,000 for adults.  The cap on punitive damages, designed to deter or punish a defendant, could be the most significant change.  The caps on noneconomic and punitive damages would limit plaintiff attorneys' leverage in negotiating settlements because nursing homes and assisted living centers wouldn't have to fear multimillion-dollar awards if the lawsuit went to trial.

Families can be compensated for funeral and out-of-pocket medical expenses. But awards for medical expenses stemming from the injury, such as hospital costs, typically reimburse Medicare, Medicaid and insurance companies.

Medicaid is fully reimbursed when a resident or his or her estate is awarded damages for negligent care. And the Coalition for Wisconsin Aging Groups estimates that Medicaid pays for 62% of all nursing home residents in Wisconsin.

 

New Hampshire Ratings

The Union Leader had an article about the quality of nursing home care in New Hampshire. More than half the nursing homes in New Hampshire are rated above average by a federal oversight agency, one-quarter of them rank below average.  When it comes to finding the right home for a loved one, advocates say using the wealth of data that's out there, in tandem with personal visits, is the best approach.

One good place to start is medicare.gov, where you'll find 80 licensed nursing homes in the state rated from one to five stars (five is the best). The ratings are based on health-inspection reports, staffing levels and quality measures the nursing homes are required to report to oversight agencies.  The state's Health Facilities Administration is required by federal law to inspect every licensed nursing home sometime between nine and 15 months after the previous inspection.

New Hampshire has 16 five-star nursing homes, rated "much above average."  Most are nonprofit or church-related.  The state currently has three nursing homes rated one-star, considered "much below average," and 17 "below average" two-star facilities. (One facility that got one star is no longer a licensed nursing home.). Sixteen homes get three stars, rated "average," and 27 are "above average" with four stars.

Kathleen Otte, administrator of the state Bureau of Elderly and Adult Services, said families should use the five-star ratings as a foundation for their decision-making. But then they need to "do their homework in another area, the human element," she said. "I would suggest people go unannounced, meet the staff, meet families if possible, review the survey results that they can find at the administrator's office, and see for themselves." "Because every family member will have certain expectations, and you want to make sure that that facility that you're touring can meet those expectations," Otte said.

Each home is required to publicly post the results of surveys conducted by state inspectors.  hat's where you'll find any deficiencies such as fire-code violations, and data about how many patients had bedsores, physical restraints, pain, anxiety or depression. Families also can obtain inspection reports from the state, and on medicare.gov.

Fmilies can find help making these decisions from the trained counselors at ServiceLink resource centers. She noted New Hampshire was first in the nation to create this statewide network of Aging and Disability Resource Centers.

For health and safety reports on nursing homes, go to medicare.gov and click first on "facilities and doctors," then "compare nursing homes." There's also a "Nursing Home Checklist" to help narrow your choices.

Free counseling about long-term care options is available at the state's ServiceLink resource centers. Call 1-866-634-9412.

 

Collusion between nursing home operator with investigator

Lexington Herald Leader reported the guilty pleas of Moses Young, assistant director with the Office of Inspector General, and Sharon Harris, a state-employed nurse who covered up the inappropriate relationship and unethical behavior they had with at least one nursing home operator.  Kentucky investigators learned they each lived in Lexington homes owned by Ralph Stacey Jr.  At the time, Stacey owned Garrard Convalescent Home in Covington.

An April 1 indictment against Young alleged that Young lived rent-free from July 2005 to March 2008 in a condominium owned by a third party in violation of state ethics rules, identified in documents only as "R.S."  A plea agreement said Young admitted that he and others made bogus rent receipts and presented them to a federal grand jury. sIn exchange, the indictment alleged, Young provided R.S. with inside agency information and instructions that would assist R.S. in passing inspections and obtaining favorable treatment with regard to administrative actions of the Cabinet for Health and Family Services. In exchange for the guilty plea, prosecutors said they would drop the charge related to Young allegedly providing inside information.

In her plea agreement, Harris admitted that she had "watched as others fabricated the receipts to thwart a criminal investigation." Her plea agreement said she told an FBI agent in April 2009 that she knew the rent receipts Young provided were genuine because she had personally delivered the receipts over time to the landlord.

Why didn't they arrest Ralph Stacey for bribery or something?

 Maybe this article from the Kentucky Lexington Herald Leader explains why. The Herald-Leader examined the industry's campaign donations following stories earlier this summer that revealed systemic gaps in the state's handling of abuse and neglect cases at nursing homes.  The nursing home industry gave at least $1.8 million to Kentucky politicians over the last decade while lobbying against bills that would require them to hire more direct-care employees, face higher fines for violations and abide by stronger precautions against elder abuse, among others.

Nursing home reform bills usually are assigned to the House Health and Welfare Committee, where they perish.  Committee chairman Tom Burch is invested in a real estate trust that includes nursing homes. Burch's former House aide, Eric Clark, now is chief lobbyist for the Kentucky Association of Health Care Facilities, the group representing for-profit nursing homes, and runs its political action committee, which has given at least $90,750 in campaign donations since 2005.  U.S. Senate Republican Leader Mitch McConnell gets more of the industry's money than any other Kentucky politician, at least $266,350 over the last decade. McConnell does not support nursing home reform.

The Kentucky Association of Health Care Facilities gives annual awards to nursing homes that raise the most money for its political action committee, with special emphasis on companies that use payroll deduction to collect the money from employees.

In 2008, for instance, Barren County Health Center in Glasgow won an award from KAHCF for "most contributions raised overall per bed" for its region. That same year, the same nursing home received a Type A citation — the most serious — from the state after a resident choked to death on a fried chicken dinner.

Overall, KAHCF honored four nursing homes and consultants Wells Health Systems that year for their political fund-raising, according to the group's 2009-10 Membership Directory and Buyer's Guide.

The majority of the industry's campaign money goes to Kentucky's congressional delegation. The industry's national group, the American Health Care Association, reports spending more than $1.1 million so far this year lobbying Congress on Medicaid payments and rules that would require public disclosure of the size of nursing homes' direct-care staffs and how much they are paid, among other items.

Also, the Herald-Leader in July reported that Type A citations issued against nursing homes by the state sometimes sit in Conway's office or with local prosecutors for more than 18 months while officials decide whether to pursue criminal charges.

 

Ranking nursing homes

U.S. News & World Report issues the best and worst nursing homes every year based on federal and state inspections, surveys, and required data on staffing.  Here is the most recent article.  The rankings are only as good as the investigators which in most cases is poor.  On a given day, 1.5 million people are living in the nation's 16,000-plus nursing homes, and in a typical year more than 3.2 million Americans will spend at least some time in one. 

 

The U.S. News rankings rely on Nursing Home Compare, a program run by the federal Centers for Medicare and Medicaid Services. CMS analyzes information on all homes enrolled in Medicare or Medicaid.  The homes also receive ratings of one to five stars in each of three areas: health inspections, nurse staffing, and measures of care.

At Nursing Home Compare, you can search for a specific home or for all homes in a particular state or within a certain distance of your city or ZIP code. But you can't assume that all five-star homes, or those with three or four stars, are of the same quality. There are so many homes in each rating—1,855 in the five-star and 3,661 in the four-star categories alone—that the range of performance is bound to be very wide. Nor can search terms be combined if, say, you want only five-star homes within 50 miles of a specific city.

America's Best Nursing Homes addresses these and other issues. Homes are presented in tiers within each star category, based on their total stars in all three of the major areas. The topmost tier, for example, consists only of five-star homes that got 15 stars. The next tier down is five-star homes with 14 total stars, and so on.

Here are more details about the measures that go into the CMS ratings.

Health inspections. Because almost all nursing homes accept Medicare or Medicaid residents, they are regulated by the federal government as well as by the states in which they operate. State survey teams conduct health inspections on behalf of CMS about every 12 to 15 months. They also investigate health-related complaints from residents, their families, and other members of the public. "Health" is broadly defined, as is evident in the 180-some items on the checklist. Besides such matters as safety of food preparation and adequacy of infection control, the list covers such issues as medication management, residents' rights and quality of life, and proper skin care. A home's rating is based on the number of deficiencies, their seriousness, and their scope, meaning the relative number of residents who were or could have been affected. Deficiencies are counted that were identified during the three most recent health inspections and in investigations of public complaints in that time frame. State inspectors also check for compliance with fire safety rules, although their findings do not factor into the CMS ratings.

Nurse staffing. Even the best nursing care is not enough if there are too few nurses to spend much time with residents, so CMS determines average nursing time per patient per day. Homes report the average number of registered nurses, licensed practical nurses, licensed vocational nurses, and certified nurse aides who were on the payroll during the two weeks prior to the most recent health inspection and their number of hours worked. The information is compared with the average number of residents during the same period and crunched to determine the average number of minutes of nursing time residents got per day. 

Quality measures. Nursing homes have to furnish the latest three quarters of clinical data showing the status of each individual Medicare and Medicaid resident in 19 indicators, such as the percentage of residents who had urinary tract infections or who were physically restrained to keep from falling from a bed or a chair. The Best Nursing Homes rankings and Nursing Home Compare display data for each home on all 19. The ratings, however, are based on 10 that are considered the most valid and reliable, such as the two above and measures related to pain, bedsores, and mobility.