Tuesday, July 30, 2013

Who Owns the Nursing Home in Your Neighborhood?



Chances are the owner is not a person or company that lives in your neighborhood. Despite attempts to appear to the contrary, many nursing homes are part of large national, or even multi-national corporate chains. Make no mistake; the nursing home industry is BIG business. Because of this, many of these corporate nursing homes are controlled by private equity firms, which have a goal of maximizing profits.

While being a for-profit nursing home chain doesn’t necessarily speak to the level of care provided at a given facility, there have been several studies that have found for-profit—especially those that are investor owned—nursing home facilities provide lower quality nursing care than nonprofit or public homes. For instance, in a 2002 article, Does Investor-Ownership of Nursing Homes Compromise the Quality of Care?, the authors found that investor-owned nursing homes “provide worse care and less nursing care” than nonprofit or public nursing home and that “nurse staffing ratios were markedly lower at investor-owned homes.”

Ten years later, in 2012, the University of California, San Francisco published a research article which found that the top 10 for-profit chains had lower registered nurse and total nurse staffing hours than governmental facilities. The article, Nursing Staffing and Deficiencies in the Largest for-Profit Nursing Home Chains and Chains Owned by Private Equity Companies also found that when compared to government facilities other for-profit facilities also had lower staffing and that in some instances nursing home chains purchased by private equity companies had an increase in the number of serious deficiencies when compared to early ownership.

Again, this is not to suggest that a for-profit nursing facility by definition provides inferior care. These studies do, however, provide a reminder that many nursing homes are run by corporations that, despite the warm slogans and sometimes even best intentions, ultimately answer to a bottom line. This is something to consider when selecting a nursing or looking into why a nursing home may be operating a particular way.

The following is a list of national for profit nursing home chains in Missouri and Kansas: Golden Living, Kindred Healthcare (Missouri only), Life Care Centers, HCR ManorCare, National Healthcare Corporation (NHC) (Missouri only), Sunrise Senior Living, Evangelical Lutheran Good Samaritan Society (Kansas only), Skilled Healthcare Group, Five Star Senior Living, LCS, Brookdale Senior Living, Benedictine Health Systems, Stonegate Senior Living (Missouri only), Vetter Health Services, Medicalodges, and Emeritus Corp. In 2012, each of these national for profit nursing home chains was listed among the Top 50 Largest Nursing Facility Companies, according to Provider Magazine.

-Tom and Ryan

Sunday, July 21, 2013

Another Resource for Researching Nursing Homes



Every morning I have a sequence of websites I like to peruse before getting started with my day. I don’t think I am unique in this practice and I like to think of it as the2013 version of reading a newspaper. I will almost always go to a news site (both local and national) and my favorite sports blog. Then on some days I might also check out an entertainment site, checking in on a few favorite blogs of interest and, on Fridays, look at any reviews for movies I’m interested in. Thus I have hit the “front page”, the “sports” page, the “entertainment page”, the “op-ed” and the “movie reviews.” I’m not suggesting ProPublica should be added to your stable of regularly rounded websites, but I do think it’s worth checking in on everyone once in a while, depending on your needs/interest.


In a previous post I discussed the enforcement mechanisms put in place by the Nursing Home Reform Act to improve the administration of care in nursing homes, including the performance of annual and complaint surveys of nursing homes in each state. Additionally I provided various links to look up nursing homes and see how they fared in recent surveys. Whether you’re an attorney dealing with a nursing home, an individual researching potential nursing homes to utilize, or are concerned about the care being provided to a loved one currently in a nursing home, ProPublica is another very useful resource to review the quality of nursing homes.


By way of background, ProPublica was formed in 2007 as an online news source of investigative journalism in the “public interest.” Over time it has won a number of journalism awards, some of which were awarded for the first time to an online news source. While ProPublica covers the gamut of news it deems in the public interest, of particular interest for purposes of this blog is the work it’s doing on nursing homes.


In August 2012, ProPublica published a story about nursing homes and with it launched Nursing Home Inspect. According to ProPublica, the inspection tool improved on the search capabilities of the Federal Government’s nursing home website. Over time ProPublica has made improvements to its application, including frequent updates to the raw data upon which the application searches. Then in December 2012, ProPublica made significant enhancements to the application which, among other things, allowed “users to easily compare the nursing homes in each state in a variety of areas: the number of deficiencies cited by regulators in the past three inspection cycles (roughly three years); the number of serious deficiencies per home (that is, deficiencies in which patients were put at immediate jeopardy of harm); the amount of fines imposed; and how often the government has suspended payments to the home for new patients, another type of penalty.” Then just in the last month (June 20th), ProPublica has once again updated the raw data for the application (the raw data is available to be downloaded if desired).


I encourage you to go to the site and check out all of the types of information you can learn about a particular nursing home or the nursing homes in a particular area. And while you might not check it out on a daily basis, most of us at some point in the future are going to have someone we care about in a nursing home and this an excellent resource investigating prospective facilities.


-Ryan

Saturday, July 20, 2013

I Want My EMR (In Long Term Care Facilities)



This past May, Tom and I gave a presentation on discovery in the Electronic Medical Records (EMR or EHR—used synonymously, though technically they are not) in which we discussed some of the issues EMR presents in the discovery phase of litigation that were previously never an issue during those halcyon days of paper records that so neatly fit in a three-ring notebook. The presentation focussed largely on the impact of EMR on the discovery process, but in researching the presentation, Tom and I noted something we thought was odd: virtually none of the research we are doing involved long term care facilities. Our talk was designed to focus primarily on hospital records—and in the future we will no doubt write much more on the issues that arise with EMR and some of the ways that with a little patience, EMR can be a source of previously unknowable information—but we both have done a lot of nursing home work and realized that we had never really come across even a rudimentary EMR system in one of our nursing home cases. Why? And who cares?


The “why” is perhaps a more difficult question to answer than the “who cares.” We should all care. While just about everyone has a complaint about EMR—a disdain universally embraced by health care providers, defense attorneys, and plaintiffs’ attorneys alike—when understood, EMR can be actually be a beneficial to everyone. In addition to the benefits of the administration of health care—uniformity, legibility, accessibility, transportability, functionality, etc.—it can also shed light on circumstances when things have gone wrong. The metadata—the data which forms the data seen by the end user in EMR—is available and discoverable in lawsuits. But such information and benefits associated with EMR are not available to patients when a provider, such as long term care facilities, do not implement the systems. EMR provides benefits to patient care and allows for the accessibility of more information about such care.


So where is EMR in long term care facilities? One of the major reasons long term care facilities have been slow to implement EMR is that the financial incentives that exist for implementation in hospitals and physician offices are not equal to the incentives for long term care providers. Almost all long term care facilities are “for profit” and EMR systems are expensive. Irrespective of the potential benefits to residents, if it’s not cost effective, these companies are not likely to implement the systems. I will not bore you (or at least bore you further) with a lengthy explanation of HITECH (Health Information and Technology for Economic and Clinical Health Act), but among the many things the legislation does is provide incentives to health care providers to adopt EMR systems that have a “meaningful use.” In 2011 there was optimism that such incentives would lead to a higher level of adoption in the long term care setting. However, there was a concern by some that the incentives in HITECH for long term care facilities would be ineffective given how far behind these types of facilities already were in terms of implementing any type of technology into their record keeping. And the fact is, at this point, nursing home facilities are not eligible for such incentives and thus despite the adoption of EMR in more acute care settings, the rate of adoption in long term care facilities continues to drag behind. Despite the myriad benefits for patient care, in the absence of financial incentives, the adoption of EMR is “dismally” low.


Other proposed issues existing for long term care facilities not faced by their acute care brethren in implementing EMR include “differences in clinical processes and information needs lack of staff, leadership and organizational skills and capacity to acquire, implement and use technology; and lack of awareness of and need for interoperable HIE [Health Information Exchange] solutions.” While such difference may exist, the viability of such differences to justify the glacial adoption of EMR by long term care facilities strikes me as dubious in light of the benefits EMR affords in patient care. The fact is, the slower long term care facilities are to adopt EMR—and one of the reasons suggested for why long term care facilities have been so slow to this point is because of a pre-existing dearth of technology employed by such institutions—the further behind they will fall in providing patient care and the harder (and more expensive!) it would seem implementing EMR will be. EMR is here to stay and while implementation is not cheap, clearly it’s not money for nothin’.-Ryan

Friday, July 19, 2013

Allegations of Horrendous Abuse and Neglect at a Georgia Nursing Home

After posts describing mechanisms to improve care provided at long term care facilities—i.e.,surveys and hotlines to report inadequate care—it seemed timely, if not disappointing, to come across an article on Yahoo! not long ago by David Beasley concerning abhorrent allegations of abuse in nursing homes. A Georgia nursing home is facing more than 70 criminal charges stemming from allegations of abuse towards its residents. In addition to physical abuse, there are allegations that the residents were subjected to inhumane conditions, tied up with bed sheets, and double diapered to diminish the frequency a resident’s soiled diaper would require changing. If you or someone you know has been the subject of nursing home abuse or neglect, please do not hesitate to report such conduct to the facility’s administration, call the appropriate government entity, and/or contact an attorney, such as Tom or me, who is experienced in handling matters involving nursing home negligence. -Ryan

Thursday, July 18, 2013

Surveying the Survey



I gave significant thought to a catchy title playing on Watchmen, but ultimately I’m not that clever. Plus, suggesting that reading a nursing home survey is anything close to reading or watching Watchmen borders on fraudulent (even for those disgusted that it was made into a movie). BUT, don’t let my failures in creative writing (or even my failure to come up with a proper metaphor since Watchmen doesn't quite work) dissuade you from reading on. Nursing home surveys are very important and being able to read a survey can be an invaluable source of information into how a nursing home operates. Whether you have a loved one in a nursing home or are going through the process of prospectively considering nursing homes, a survey gives you some insight into issues state surveyors may have found during inspections.


By way of background, nursing homes that accept Medicare and/or Medicaid residents are regulated by an ominous sounding set of regulations known as OBRA—Ominibus Budget Reconciliation Act. In 1987 the Federal Nursing Home Reform Act was attached to the 1987 Omnibus Budget Reconciliation Act (known as OBRA ’87, which would make for a cool band name) and required facilities accepting federal payments for resident care to comply with various statutory requirements. One of the enforcement mechanisms put into place were periodic surveys of the facilities. The federal government contracts with each state to conduct surveys of the facilities located in each state—in Missouri it is the Missouri Department of Health and Senior Services (MDHSS)and in Kansas it is the Kansas Department of Aging and Disability Services (KDADS). In Missouri the state law requires a survey be conducted twice a year, whereas federal law requires a survey every 9 to 15 months. Kansas simply follows the federal law and requires a survey once every 9 to 15 months. In addition to these “annual” surveys, “complaint” surveys are conducted following complaints to the state about care at a specific facility.


Surveys are often lengthy because they frequently include extended narratives from interviews the investigator conducts with selected staff members or residents, as well descriptions of documents such as policy and procedures or medical records. References to staff members and residents are anonymous, often referred to in the survey by letter or number to the individuals. The narrative may be of interest if you are looking for a specific issue or if the survey addresses a complaint you made. But if you are looking for a more general takeaway from the survey, there are a couple of places you can quickly look to get a feel for the nature and severity of any deficiencies.


The first things to consider are the “F-Tags.” These are numbers that reference the type of deficiency found. For example, a survey may reference “F323.” This is in reference to the rule requiring a facility maintain a hazard free environment. The specifics of how the facility violated this requirement can then be found in the narrative. Click here for an excellent resource in explaining each type of F-tag.


The next thing to consider is the severity and scope of the tag. This can often be found under the tag and will be represented by letters A through L. The higher the level, the greater the severity and scope. For a great explanation of meaning of each letter, go here.


Another important thing to consider is whether any penalties were assessed against the facility for the deficiencies. Often, if deficiencies are found, a facility will be required to craft a “plan of corrections” in which it must outline how it will rectify the deficiencies. Sometimes, with more serious deficiencies, a facility can be fined or even lose its reimbursement from Medicare or Medicaid. Nursing homes are required to keep recent surveys on-site for public accessibility. Additionally, if surveys for any facility can be found here.


Nursing home surveys are not the final word on how well a nursing home is caring for a resident. Negligence can occur in the absence a poor survey and a poor survey does not necessarily establish negligence. But surveys are one tool that allow us to see how well a nursing home is providing care to its resident—at least in the eyes of the government. Thus, to take it back to a metaphor that may not quite work, we are all watching the watchmen.


-Ryan

Wednesday, July 17, 2013

"Hotlining"



My wife hates the recent trend of turning everything into a verb—“hotlining”. She’s an English major (actually, she would hate reading that, too, because she would say “I’ve already graduated so I have an English degree and I majored in English”) so she tends to get annoyed about such things. But I feel like the term “hotlining” has been around for a long time—and it certainly has been in the world of nursing homes.

In a previous post I discussed nursing home surveys and briefly mentioned that one type of survey is a “complaint” survey. Hotlining is often the impetus for a “complaint” survey. Missouri and Kansas each have departments set up to handle complaints made by residents, or families of residents, concerning care at a facility—in Kansas it’s the KS Department of Health and Environmentand the Kansas Department of Aging and Disability Services [800-842-0078] and in Missouri it’s the Missouri Department of Health and Senior Services [800-392-0210]. For a more detailed review of Missouri’s reporting process and the results of reports, I would encourage you to check out their 2011 publication concerning reporting and abuse.


Once a complaint is made the appropriate department will need to determine if the issue is within its jurisdiction. If it is, an investigation will ensue. If the complaint has not been made anonymously then the reporter will receive, in writing, the conclusions of the investigation in addition to the publicly available survey, should a deficiency be found. Additionally, if the investigator finds concerns about the care provided to the resident victim, the state will take actions to attempt to correct or prevent such deficient treatment.


If you are concerned about the care either you or a loved is receiving at a long term care facility you have options. Whether it is talking to the administrator or director of nursing at the facility or contacting the state, there are ways to help ensure that quality care is being provided. And if you or a loved one has been injured by what you believe to be inadequate care at a nursing home facility you should contact an attorney experienced handling such matters, such as Tom or me, to learn about your legal options. -Ryan

Monday, July 15, 2013

Taking a Critical Look at Nursing Home Staffing Levels



“As long as drive the speed limit, I can’t be negligent.” Wrong! Driving 70 mph during a blizzard isn't reasonable regardless of the speed limit. Nursing home owners and operators often argue that as long as they have met the state/federal staffing-to-patient ratios, they have complied with the standard of care relating to nursing home staffing. The problem with this “logic” is that the standard of care requires nursing home facilities to have enough staff to meet the needs of the residents. See 42 CFR § 483.30 ("The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessment and individuals' plans of care.") As Janet Feldkamp, JD, RN explained in her article, Light Staffing Can Mean Heavy Liability, “ a nursing facility must have personnel in excess of applicable state requirements if the facility's residents require more care or supervision than can be met by the state standard.”

This means that the number of staff needed is not based on some arbitrary number (like a speed limit) but is based on a variety of factors, including the physical layout of the nursing home, but, most importantly, the actual condition of the residents (sometimes referred to as resident acuity). Resident acuity changes often and therefore requires frequent assessments. Rarely, however, do nursing homes assess residents before making staffing decisions. More often than not, nursing homes use a mathematical formula to determine staffing without ever considering the condition or needs of its residents on a given day. In other words, nursing homes will take the default position of driving 70 mph every day without considering the weather, or, in this case, the condition of its residents. This practice is not only contrary to state and federal law, it’s dangerous and the cause for many avoidable nursing home resident injuries and deaths.

Nursing homes are paid good money to provide sufficient staff to meet the needs of the residents each and every day. That is their job. If a nursing home is unable to adequately assess its residents’ acuity prior to making staffing determinations, the nursing home needs to determine why it is unable to make such assessments and make the necessary changes. Notably, the need for continual assessment to adjust staffing levels in order to ensure sufficient staff to meet residents’ needs is becoming more and more important as nursing homes are taking on sicker and sicker residents whose conditions are likely to change more often and require more one on one supervision.

-Tom