‘System in Crisis’: US Senate Hearing Calls for More Funding, Staffing for Nursing Home Inspections

By Zahida Siddiqi

The nursing home inspections system is underfunded and understaffed and needs federal assistance for alleviating inspection backlogs, or residents will remain in peril, experts and legislators said at a U.S. Senate hearing on Thursday.

Officials from the long-term care ombudsman program as well as leaders from state inspections and regulatory bodies were among those who testified before the U.S. Senate Special Committee on Aging, following the release of its investigative report.

“The report paints a picture of a system in crisis,” said Sen. Bob Casey (D-Penn), who blamed a shortage of inspectors and low funding as factors that are jeopardizing the annual nursing home inspections process. “The result is that nursing home residents are being put at risk because of this problem … My fear is that the trail is going cold for too many residents before nursing home inspectors can arrive on the scene.”

The report titled, “Uninspected and Neglected,” was commissioned by Sen. Casey to investigate the efficacy of state inspection agencies across the nation.

“My investigation reveals unacceptable rates of vacancies at state survey agencies, threatening the safety and health of nursing home residents as their complaints collect dust while inspectors struggle to meet the demand,” Casey said.

Inspection backlogs

As a result of fewer inspectors, most states have nursing home inspection backlogs.

The report found 31 states and the District of Columbia had inspection staff vacancy rates above 20% on average, and nine were short-staffed by 50% or more. Meanwhile, the highest vacancy rates were in Kentucky at 83%, Alabama at 80% and Idaho at 71%.

Severe staffing shortages and high turnover rates driven by inadequate salary compensation for state inspectors hampered the annual survey process and prompt reporting of complaints, the report found. Given this scenario, the report called into question the timeliness and accuracy of the Care Compare tool used by prospective residents to evaluate nursing homes.

Since inspectors are registered nurses, pharmacists, social workers and dieticians, competition with jobs in the private sector impacts their recruitment and retention rates.

Meanwhile, much of the funding for inspections is aided by federal dollars, and while the last three administrations have requested this funding, it has yet to be approved by Congress.

“Survey agencies have not received a meaningful increase in federal funding to complete these critical oversight responsibilities since 2015, yet the cost to recruit and retain survey staff, the volume of work and additional work expected of survey agencies has significantly increased,” said Shelly Williamson, president of the board of directors for the Association of Health Facility Survey Agencies (AHFSA). “These factors have resulted in many survey agencies being unable to complete recertification and complaint surveys timely, leaving nursing home residents at risk of substandard care.”

Williamson is also administrator of the Section for Long-Term Care Regulation at Missouri Department of Health and Senior Services.

Since 2015, Congress increased that spending by a meager 2.5%, while the budget for inspections will need to be increased 30% to keep up with inflation.

Williamson said that since states have recently increased their budgets to fund surveys and salary increases for inspectors, the federal government will need to step up funding for these endeavors.

The Senate report also suggests that the Biden administration’s proposed nursing home regulations might not succeed unless the problems in the inspections process are addressed.

Greater visibility of staffing roles, numbers

During the hearing, staffing shortages at nursing homes were also cited by experts as being important for better health outcomes, especially as they relate to mental health concerns of residents.

“I think one of the things that we continually need to address are the nursing home staffing shortages, so that we can get back to those [social] activities … The ombudsmen have seen firsthand that the activities are still lacking and are not quite what they should be,” said Leah McMahon, director at Colorado State Long-Term Care Ombudsman Program in Denver. Ombudsmen are authorized by federal and state law to settle disputes and resolve resident problems.

To improve the process of choosing a nursing home, McMahon said it was important to enforce more transparency on quality of staffing.

“We’re talking about potentially wanting to know staffing levels. How many nurses are in the building at any given time? Who is the medical director that is overseeing and coordinating the overall care, and maybe any instances of abuse and neglect that have happened?” McMahon said. “I think those are really important things to know.”

Improving the visibility of the activities of the medical director, and perhaps putting limits on how many residents can be overseen by each medical director should be an important goal, McMahon said.

“I do believe that requiring nursing homes to report their medical directors to CMS and state survey agencies could increase quality of care in nursing homes,” McMahon said.

Sometimes medical directors are spread too thinly as they oversee several nursing homes within a chain, she said.

“Often medical directors are absent from the nursing home for long periods of time. It is rare that you will see a medical director physically in a nursing home,” she said. “By increasing accountability for medical directors, it could ensure they’re fulfilling their critical obligations under the regulations. And when that doesn’t happen, ombudsmen have another tool to take to the survey agency as a concern.”

Other experts who testified at the Senate hearing sought to improve the pool of inspectors by increasing training and recruitment efforts at colleges.

Advocates’ push against staffing mandate

Advocacy groups for nursing homes said the Senate committee’s work underlines a widespread staffing crisis within the sector. They renewed calls to resist the forthcoming proposed minimum staffing mandate and improve funding.

“We appreciate the Senate Committee on Aging’s focus on this important issue and share concerns surrounding the backlog of nursing home surveys. Conducting timely surveys of nursing homes is important for consistency in the regulatory process,” said Holly Harmon, senior vice president of Quality, Regulatory, and Clinical Services at AHCA/NCAL, in a statement. However, Harmon also said, “The shortage of state surveyors is indicative of a larger workforce crisis facing the entire long term care profession. As the committee’s report signals, addressing this labor crisis requires significant investments, not mandates. We need a concerted, supportive effort to help recruit more individuals to serve our nation’s seniors.”

Moreover, Harmon said the oversight process needs to be more resident-driven.

“We need to focus on the science of quality improvement by recognizing good faith efforts, leveraging continuous learning, and effectively remedying identified issues,” Harmon said. “Enforcement alone will not transform America’s nursing homes.”

Need for consensus

In closing, Sen. Casey compared the current findings to work of the Senate committee on nursing home oversight almost four decades ago, and said, “We heard similar warnings today and these warnings must not be ignored.”

Aside from more funding, Casey recommended adding more transparency to the survey process and scrutiny of independent contractors as well as boosting the health care workforce.

“The [Senate] Aging committee’s oversight in the 1980s paved the way for landmark nursing home reforms that President Reagan signed into law. Today’s hearing and the committee’s investigation provide another opportunity to find common ground to make sure nursing home residents are kept safe and receive the care that they and their families deserve and have a right to expect,” Casey said.

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‘System in Crisis’: US Senate Hearing Calls for More Funding, Staffing for Nursing Home Inspections

Feds Order More Weekend Inspections Of Nursing Homes To Catch Understaffing

The federal government announced plans Friday to crack down on nursing homes with abnormally low weekend staffing by requiring more surprise inspections be done on Saturdays and Sundays.

The federal Centers for Medicare & Medicaid Services said it will identify nursing homes for which payroll records indicate low weekend staffing or that they operate without a registered nurse. Medicare will instruct state inspectors to focus on those potential violations during visits.

“Since nurse staffing is directly related to the quality of care that residents experience, CMS is very concerned about the risk to resident health and safety that these situations may present,” the agency said in a notification to state inspection offices.

The directive comes after a Kaiser Health News analysis found there are 11 percent fewer nurses providing direct care on weekends on average, and 8 percent fewer aides.

Residents and their families frequently complain the residents have trouble getting basic help — such as assistance going to the bathroom — on weekends. One nursing home resident in upstate New York compared his facility to a weekend “ghost town” because of the paucity of workers.

Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group in Manhattan, welcomed the new edict but said it was only necessary because state inspectors have not been properly enforcing the rules already on the books.

“The basic problem is the states don’t take this seriously,” Mollot said. “How many studies do we have to have, year after year, decade after decade, saying it all comes down to staffing, and there are very few citations for inadequate staffing and virtually all of them are identified as not causing any resident harm?”

CMS said it will identify potential violators by analyzing payroll records that nursing homes are now required to submit. Those records, which became public this year, showed lower staffing than what facilities had previously told inspectors during their visits, according to the KHN analysis.

“CMS takes very seriously our responsibility to protect the safety and quality of care for our beneficiaries,” CMS Administrator Seema Verma said in a statement.

The nursing home industry criticized the heightened scrutiny.

“Unfortunately, today’s action by CMS will enforce policies that makes it even more difficult to meet regulatory requirements and hire staff,” said Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, an industry trade group, in a written statement. “Rather than taking proactive steps to address the national workforce shortage long-term care facilities are facing, CMS seems to be focusing on a punitive approach that will penalize providers and make it harder to hire staff to meet the shared goal of increasing staffing.”

Currently, a tenth of inspections must occur during “off hours,” which can be either a weekend, or during a weekday before 8 a.m. or after 6 p.m. But for facilities that Medicare identifies as having lower weekend staffing, half of those off-hour inspections—or 5 percent of the total — must be performed on Saturdays or Sundays.

Medicare requires nursing homes to have a registered nurse on site for at least eight hours every day, but according to the payroll records, a quarter of nursing homes reported no registered nurses available at least one day during a three-month period. Since July, Medicare’s Nursing Home Compare website for consumers has highlighted homes that lack sufficient registered nurses and lowered their star ratings. Nursing Home Compare has downgraded ratings for 1,402 of 15,600 facilities for gaps in registered nurse staffing, records show.

The new directive instructs inspectors to more thoroughly evaluate staffing at facilities Medicare flags. The edict does not mean a flurry of sudden inspections. Instead, Medicare wants heightened focus on those nursing homes when inspectors come for their standard reviews, which take place roughly once a year for most facilities.

But what may appear to be staffing scarcities in payroll records may instead be clerical problems in which nurse hours are not properly recorded, say some nursing home officials.

Katie Smith Sloan, president of LeadingAge, an association of nonprofit providers of aging services, said in a statement that some homes are still struggling to adapt to the new data collection rules.
“We’ve been voicing our concerns to CMS and will continue to do so,” she said.

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Feds Order More Weekend Inspections Of Nursing Homes To Catch Understaffing

Nursing home fines skyrocket in 2017 after crackdown

PHILADELPHIA — The Pennsylvania Department of Health has fined nursing homes more in the first four months of this year than in the previous three years combined, as regulators started using a more rigorous penalty system after coming under fire for going too lightly on substandard care.

This year's four-month total for fines was $796,750, compared with $639,500 for the three years ending Dec. 31, state Health Department records show. The totals do not include federal fines that are recommended by the state and are typically much larger.

State surveyors sanctioned 86 facilities so far this year, including three in the Lehigh Valley region, compared with 72 in all of last year and 47 in 2014 and 2015 combined.

The state Health Department said it was responding to an auditor general report issued last summer.

"When the auditor general looked at our oversight of nursing homes, one of the key recommendations was to be more aggressive in our oversight and we are," the department said this week in a statement.

As to whether the tactic is improving care at the state's 700 nursing homes, state regulators said "it is too early to tell the impact this is having."

An industry spokesman said the impact was clear: The heavier sanctions are a financial strain on operators and are not likely to produce better outcomes for residents.

"Any time a dollar leaves the bedside that didn't have to leave the bedside, that's an opportunity lost to enhance the care provided," said Russ McDaid, president of the Pennsylvania Health Care Association and the Center for Assisted Living Management, both trade groups in Harrisburg.

But an advocate for the elderly, who helped spur tougher oversight of nursing homes with a 2015 report that criticized the Health Department for dismissing 92 percent of the complaints against Philadelphia nursing homes, welcomed the change.

"This jump in fines sends a clear message to nursing home operators that the days of lax oversight are over," said Sam Brooks, an attorney at Community Legal Services in Philadelphia.

"For years, nursing homes were allowed to provide inadequate care that resulted in widespread harm to nursing home residents across Pennsylvania. Easily preventable deaths and injuries became common, as nursing homes did not fear any penalty," Brooks said.

Secretary of Health Karen Murphy announced in October that the department would start using more discretion in deciding how much it would fine facilities, taking into account the level of harm, how long it takes for a problem to be fixed, the facility's track record of compliance and other factors.

Old Orchard Health Care Center in Bethlehem Township was fined $1,500 in January for violations discovered during an inspection in September. According to that inspection report, a resident with a history of falling fell off a bed while a nurse aide was helping her dress. She fractured a hip and required surgery.

Old Orchard Health Care Center did not comment Thursday. The state report says the home disciplined the employee and changed procedures so the resident and others in similar conditions would not be dressed while sitting on the edge of their beds.

Kirkland Village in Bethlehem was fined $2,000 in February for violations discovered during an inspection in December. The Morning Call previously reported about that incident. A resident fell and fractured a hip after being left alone in a restroom despite instructions that she was not to be left unattended.

Kirkland Village did not return a call Thursday. It previously told The Morning Call it has policies and training to prevent such incidents, but the employee did not follow the policy and no longer works there.

An East Stroudsburg nursing home was fined $15,750 in January for violations discovered during an inspection in September.

The inspection found several violations including a resident who fell in a restroom and broke his thigh and a "pink slime-like film" in an ice machine, according to the report. Routine fire drills weren't done, two residents didn't receive adequate care plans for bladder problems and two residents weren't timely seen by a physician.

The home immediately cleaned the ice machine and submitted plans to correct other issues, according to the report.

The home, now known as The Meadows at Stroud for Nursing and Rehabilitation, was fined under its previous owner and operator, Golden Living Center-Stroud, according to Jeff Deutsch, vice president for business development at Priority Healthcare Group, which took over management in February.

Deutsch said he could not comment on the inspection and fine because they occurred under the facility's previous owner.

Golden Living, which is based in Texas, had the most fines from the Pennsylvania Health Department since 2014, a total of $165,150. It sold the operating licenses to its 36 facilities in Pennsylvania in October and February, the Health Department said.

Ron Barth, CEO of LeadingAge PA, a trade group for nonprofit long-term care providers, acknowledged there are horror stories in nursing homes and bad facilities, which the department rarely shuts down. Instead, he said the department seems to have decided that it will "fine all facilities into compliance."

One reason for higher fines is a new approach to citing nursing homes for "immediate jeopardy," which is defined by federal regulators as "a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident."

Brooks, the Community Legal Services attorney, said an example of immediate jeopardy is when residents who are not supposed to eat solid food are left alone during a meal. That is a dangerous situation that can and has led to choking deaths.

Last year, the state had 39 immediate jeopardy citations, up from 12 in 2015 and 11 in 2014. The state said a major reason for the increase was the decision to allow anonymous complaints in 2015. "Each time there is a complaint, our surveyors investigate, and by being on site more frequently they identified more immediate jeopardy cases. When there is an immediate jeopardy case, the issue must be corrected before the surveyor leaves to ensure the safety of the patients," the department said.

In a case that has baffled those in the industry, a surveyor cited a facility near Harrisburg for immediate jeopardy in March because the hot water available from a water purifier outside the CEO's office and near the activity room was too hot and residents could have been hurt if they pressed and held two red buttons to dispense hot water. In the past, the surveyor probably would have pointed out the potential problem and suggested that management fix it, Barth said. Now, the nursing home will be fined and its rating on Nursing Home Compare will plummet, he said.

"In the meantime, there are bad facilities out there that the department still allows to operate," Barth said.

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Nursing home fines skyrocket in 2017 after crackdown

Ohio among worst states for nursing home inspections, report says

CLEVELAND -- Ohio is among the U.S. states with the worst records for keeping up with nursing home inspections, according to a report out Sunday.

The Plain Dealer cites records it obtained showing that a key deadline for inspecting nursing homes hasn't been met since fiscal year 2011. It says Ohio is the fourth-worst state nationally in inspection intervals.

Advocates say inspectors offer important checks on the industry, detecting patient care issues.

The agency that provides inspectors is understaffed. Ohio has one inspector for every six nursing homes, the Plain Dealer reported. Meanwhile, nearby states Michigan, Kentucky and Illinois have one for every four facilities.

The Ohio Department of Health says officials are working hard to improve time intervals and there has been progress in the last two years.

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Ohio among worst states for nursing home inspections, report says

2 N.J. nursing homes put on notice to improve care

Two New Jersey nursing homes now require more frequent inspections because they've amassed too many health violations, according to an update issued in late January by the Center for Medicare and Medicaid Services, part of the U.S. Department of Health & Human Services.

Mount Laurel Center for Rehab and Healthcare, a 220-bed long term care facility in Mount Laurel, has been under increased scrutiny for 14 months, yet remains on a list of places "that have not improved," according to the report.

Meadow View Nursing & Respiratory Care in Williamstown, which has 180 beds, was added to the "Special Focus Facility" list two months ago.

"It's not a list you want to be on," said Mark Levine, a former nursing home administrator who now is a consultant in the industry. "It's the worst of the worst."

Nursing homes in the federal monitoring program have unannounced inspections every three months, instead of every 12-18 months, Levine said. They stay on that schedule until they can prove their progress is permanent.

If they don't get off the list, eventually they will be kicked out of Medicaid and Medicare - a death knell for this kind of business.

Most nursing homes will have some kind of "deficiency" noted in an inspection - just as health inspectors typically find small problems at restaurants, according to information provided by the monitoring program. The Center for Medicare and Medicaid Services says the average is 6-7 deficiencies.

But some places chronically have twice that number, bounce in and out of compliance, or have problems that carry a higher risk of harm to their residents. There are currently 86 nursing homes nationwide that require extra scrutiny.

The two New Jersey facilities have very different reasons for being on the list.

Meadow View, the center just added to the program, gets very low marks in the category of health inspections, yet maintains high marks for its staffing levels. Most importantly, it has attained the coveted five star Medicare rating for how patients fare there.

Those "quality measures" look at how many patients improve, how many get bed sores or infections, and how many report being in pain, among other things.

Those are important measures of patient health that can't be faked or fudged, Levine said, who has served as a court- appointed patient care ombudsman. By contrast, he said, the opinions of an inspector are can be more subjective.

To get five stars in any category, as Meadow View has, a facility must be in the top 10 percent nationally, Levine said.

However, Meadow View got only one star for its health inspection, which found many violations in building and kitchen maintenance: cobwebs, peeling sheetrock, dusty ceiling vents, a filthy microwave, and an emergency CPR cart stored behind "a large Christmas tree, some boxes, an organ, 2 large televisions, a podium, and a row of chairs."

Its report card meant it now has two stars on Medicare's "Nursing Home Compare" website.

The nursing home changed owners in late 2015, when it was acquired by Genesis Health Care in Pennsylvania, a company that owns nearly 500 health care facilities in 34 states.

Many of the problems occurred under previous ownership, said a Genesis spokeswoman. Since it takes two years for older inspections to drop out of the federal calculation, the current report "is not an accurate reflection of the care provided at Meadow View today," the spokeswoman said.

The facility has hired a new executive director and nurse executive since the acquisition, the spokeswoman said.

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2 N.J. nursing homes put on notice to improve care

Advocates seek night inspections in Oklahoma nursing homes

At least one-fourth of all state nursing home inspections should be conducted on evening, late-night shifts, weekends and holidays, the state Silver Haired Legislature recommends.

John Kusel, president of the OK
 Silver Haired Legislature

Also, nursing homes should have more staff working on overnight shifts of 11 p.m. to 7 a.m.

“Many residents living in nursing homes have Alzheimer's disease or another form of dementia,” the Silver Haired Legislature notes in a bill now heading to the 2016 Oklahoma Legislature.

“It is not uncommon that these individuals are active and awake at night. Also, falls may occur at night, when fewer staff are available to assist residents or respond to call lights,” said Silver Haired lawmakers who held their state convention Tuesday and Wednesday in Oklahoma City.

A Silver Haired Legislature bill calls for minimum staff-to-resident ratios of 1-to-6, 1-to-8 and 1-to-10 on three usual evening and night shifts.

The organization sends bills to the Legislature every other year or on odd-numbered years.

Currently, unannounced “off hour” inspections and investigations are conducted by the state Health Department. But the Silver Haired Legislators want to see such inspections increased to at least 25 percent to 33 percent of all inspections.

This week, a new Silver Haired vice president for legislation was chosen — long-time and now retired state Ombudsman Esther Houser.

“The Silver Haired legislators showed, once again, that their priority concerns revolve around the needs of the frail elderly and the risks those vulnerable elders face in both their homes and in care-providing facilities,” she said Thursday.  (Continue Reading)

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Advocates seek night inspections in Oklahoma nursing homes

Study: Texas Nursing Homes Among The Worst In The Nation

When it comes to nursing homes, Texas has the highest percentage of low ranked facilities than any other state. according to a report from Kaiser Health News.

Julie Appleby is a reporter for Kaiser Health News, a nonprofit news service committed to in-depth coverage of health care policy and politics. Her article “A top-rated nursing home is hard to find in Texas and 10 other states,” is at KaiserHealthNews.ORG.

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Study: Texas Nursing Homes Among The Worst In The Nation

NY nursing home inspectors lax about bedsores, other care problems, report says

Syracuse, N.Y. -- Even though nearly one in 10 New York nursing home residents suffer from bedsores, the state rarely holds nursing homes accountable for failing to treat and prevent these largely avoidable skin wounds, according to a report.

The report by the Long Term Care Community Coalition says the state Health Department cites nursing homes less than 100 times per year for inadequate bedsore care. More than 9,000 N.Y. nursing home residents have unhealed bedsores, according to the report.

The Health Department had no immediate comment on the report.

Bedsores, also known as pressure ulcers, are wounds caused by unrelieved pressure on the skin. They often develop on the elbow, heel, hip, shoulder, back and back of the head. The federal Centers for Disease Control and Prevention says bedsores are serious medical conditions and a key measure of the quality of nursing home care.

The Manhattan-based consumer advocacy group's report found that when the state does cite nursing homes for poor bedsore care, its inspectors rarely find there was any harm to residents. Nursing homes are not likely to be fined or face other repercussions when inspectors determine a problem did not harm residents, the report says.

"Since pressure ulcers (bed sores) are, by definition, a wound and are well recognized as a serious problem, one might consider that any case of a pressure ulcer developing is harmful to the individual," the report says.

The report says nursing home inspectors in New York and other states also downplay other problems such as understaffing and inappropriate drugging of residents with antipsychotic medications.

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NY nursing home inspectors lax about bedsores, other care problems, report says

Bill would ban nursing home inspections in court cases

MEMPHIS, Tenn. — One patient choked to death, another claimed he was raped. WREG has uncovered new and very disturbing details about problems at a local nursing home.

The On Your Side Investigators also discovered these same details could be kept secret.

An inspection report from federal and state health surveyors shows Signature Healthcare at St. Peter Villa in MidTown Memphis was hit with more than 20 deficiencies in August of 2014.

Read full report here.

The survey shows one resident choked to death after the facility failed to provide the proper diet, neglected to monitor the patient during meals, and never even attempted a maneuver to stop the choking.

It also reveals Signature Healthcare at St. Peter Villa “failed to thoroughly investigate” an alleged rape.

The resident wasn’t sent to the ER for a rape kit, and the nursing home never even notified police.

The On Your Side Investigators recently uncovered problems at another Memphis nursing home owned by the same company.

Dozens of viewers contacted WREG after our report on Signature Healthcare at Saint Francis.

One wrote in an email, “My grandfather died in the care of the staff at Signature Nursing home.”

Another said in a Facebook message, “My mother was Resident #5 in the story you did last night about Signature Healthcare. So glad you have put this out there.”

However, details like the horrific ones in the surveys we revealed could soon be kept secret, if a bill sponsored by Tennessee State Senator Brian Kelsey and Representative Leigh Wilburn becomes law.

Senate Bill 889 would prohibit survey and investigation results from being used as evidence in malpractice cases.

Read bill here.

Cameron Jehl is a Memphis Attorney who has sued nursing homes before. He opposes the proposed legislation.

“If the nursing homes violates federal law and federal regulations, they’re required to comply with in order to keep and take care of the elderly, then they should be held accountable for their actions,” Jehl said.

However, Senator Kelsey says attorneys will sometimes misuse negative survey results to paint nursing homes with a broad brush, rather than focusing on a single incident that led to a injury or fatality.

“I think we have to look at the instances when this information should be available and what are the instances in which it’s being used in a way that’s not exactly the full and 100 percent truth,” Kelsey said.

The bill also addresses ads that law firms often run in newspapers about problems at nursing homes.

It stipulates that if the ad mentions a deficiency, it also must be noted if and when the deficiency was corrected.

Proponents say the advertisements, often run by out of state law firms, don’t always include timely information.

When asked about using inspections in court cases, and how such evidence could be used on behalf of a plaintiff to reveal a pattern of problems that the nursing home has been made aware of, Senator Kelsey told WREG, “This is really just the beginning of the conversation. This bill will be amended when it goes through the committee process. It will get a full hearing.”

Jehl added, “These nursing homes, when they neglect and abuse the elderly, they have to be held accountable.” (Continue Reading)

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Bill would ban nursing home inspections in court cases