Finding a solution to improve nursing home care

• Daniel Simmons-Ritchie/PennLive
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  Investigative/enterprise reporter for the Patriot News/PennLive.

Do you want to improve nursing home care in Pennsylvania? Advocates and researchers say these are the eight key solutions Pennsylvania could undertake to protect the elderly from dangerous care.

RAISE THE MINIMUM STAFFING LEVEL

Experts recommend that nursing home residents receive a minimum of 4.1 hours of care per resident per day from direct care staff. This doesn’t mean every resident necessarily needs that much care – some patients will need barely any help and some may need a lot of help – but 4.1 is the recommended average across a home.

In Pennsylvania however, the recommended minimum is only 2.7 hours of care per resident per day. Experts say that’s far too low. Given the intense medical needs of most nursing home residents, facilities that are providing anything less than 3.5 are often providing dangerously low levels of care, experts say.

The single biggest thing that Pennsylvania can do to improve nursing home care, experts say, is to require nursing homes to provide at least 4.1 hours of care per resident per day.

That 4.1 hours should consist of an average of at least 45 minutes of registered nurse care, 33 minutes of licensed practical nurse care and 168 minutes of certified nurse care.

TOUGHER VIOLATION GRADES

A key problem, advocates and researchers say, is that state regulators in too many states, including Pennsylvania, understate the severity of nursing home violations.

They say that when inspectors visit nursing homes and find problems, such as a medication mistake that causes resident’s death, too often inspectors don’t grade that violation as a severe error.

That’s a problem because under federal regulations the severity of a violation dictates the severity of the resulting punishment. A 2016 PennLive investigation found that Pennsylvania routinely understated the severity of problems that caused resident deaths, meaning the Health Department rarely penalized homes or only fined them a few thousand dollars – a pittance for a major nursing home chain.

Since that reporting, Pennsylvania has issued tougher violation grades but advocates say there’s reason to believe the department is still falling short. A PennLive analysis found that Pennsylvania issued the severest grade of violation, called “immediate jeopardy”, only 35 times in 2017 – still one of the lowest rates in the nation. Because there’s little reason to believe Pennsylvania’s nursing homes are better than those in other states, that discrepancy is likely a result of weak oversight.

North Carolina, for instance, issued 151 immediate jeopardy violations in 2017 despite having nearly a third fewer nursing homes.

In order to ensure that nursing homes are appropriately penalized for serious errors, researchers and advocates say, Pennsylvania’s Department of Health needs to appropriately grade serious violations.

TOUGHER PENALTIES

Although the severity of a violation is one of the biggest determinants of the penalty, even when Pennsylvania appropriately grades citations the resulting penalty is often far too small or non-existent.

For instance, PennLive found that of the 104 inspections that led to citations for Golden Living’s former nursing homes in 2017, the state issued penalties in response to 10.

Beyond the small number of sanctions, some sanctions appear unusually lenient. In one case, PennLive found the department fined a Tunkhannock home $15,000 following a medication error that caused a terminally-ill resident to have a narcotic overdose and become unconscious.

Without tougher penalties, advocates say, there is no discentive for unscrupulous nursing home operators to provide low quality care.

Some advocates also suggest more innovative penalties: if a nursing home is part of a chain or larger company, perhaps the agency should directly fine the chain organization or its parent company.

TOUGHER VETTING

Pennsylvania’s Health Department says it only approves nursing home licenses to operators that can prove they can provide safe care.

However, PennLive discovered that the Health Department has no internal policies to determine what “safe care” is.

Although the department does ask applicants whether any of their other nursing homes have been charged with fraud or have faced state or federal penalties, it doesn’t appear to assess staffing levels, citation numbers or other quality metrics that would help it truly determine whether a new operator has a track record of good care.

In order to ensure that new nursing home operators can live up to their promises, researchers and advocates say the Health Department should create clear policies to assess an operator’s quality. If nursing home operators don’t have a history of good care, they shouldn’t be granted a nursing home license.

FINANCIAL VETTING AND BONDING

In addition to failing to assess the quality track record of new nursing home license applicants, PennLive found that it doesn’t appear that Pennsylvania assesses the financial stability of license applicants either.

That’s particularly salient following the mysterious financial problems of Skyline Healthcare. In April, the New Jersey company suddenly abandoned about 100 facilities across the country, including nine in Pennsylvania. State agencies in affected states, including the Pennsylvania Health Department, took temporary control of those homes in order to protect residents. According to the department, the cost of that takeover was $408,000.

A PennLive review of licensing documents for seven Skyline nursing homes in Pennsylvania found no evidence the department assessed the financial health of the company.

In order to prevent a repeat of Skyline’s problems, advocates says that agencies should require new nursing home applicants to provide proof they have adequate financial resources and aren’t overly leveraged.

If a company can’t prove that it has adequate financial resources, some advocates say that Pennsylvania should require those companies to pay a bond to the agency. If a nursing home operator suddenly abandons its homes, that bond will be used to recoup the cost of temporary management by the state.

BETTER INVESTIGATIONS

An ongoing concern elderly care advocates is that Pennsylvania’s nursing home inspectors don’t thoroughly investigate resident complaints.

In particular, some say, inspectors rarely speak with residents or their families about the complaints they’ve filed. In most cases, they believe that the inspectors simply speak with the nursing home and trust their version of events.

In order to ensure that complaints are thoroughly investigated, advocates believe that inspectors should contact complainants in most situations in order to gain further information about a problem or to check statements made by the nursing home operator.

INCREASE MEDICAID FUNDING

Although researchers recommend that nursing homes provide at least 4.1 hours of care per resident per day, it remains an open question whether all nursing homes can afford to do that.

State and federal governments are the primary payers for the vast majority of nursing home residents. Residents receiving short-term rehabilitation are generally covered by Medicare, administered by the federal government. Long-term residents are generally covered by Medicaid, administered by state governments.

The problem is that state Medicaid programs, as in Pennsylvania, pay nursing homes far less than federal Medicare – sometimes as much as a third.

Although nursing home advocates and some researchers believe for-profit nursing homes routinely skimp on care in order to paid their profits, there are also genuine concerns about whether Pennsylvania’s Medicaid funding is adequate.

Researchers recommend how much of existing Medicaid and Medicare dollars are going to profit and administrative costs in homes. That would help determine whether Medicaid rates need to be raised and, if staffing standards are also raised, how much additional funding they need to provide those levels.

BETTER FINANCIAL ACCOUNTABILITY

Many nursing home advocates believe there’s a simple reason so many nursing homes are low quality: they’re pocketing taxpayer dollars and skimping on care.

In order to ensure that nursing homes aren’t sacrificing patient care, researchers say there’s a number of steps that states could take.

The biggest is for Pennsylvania to revise its Medicaid funding formula so that any increases in Medicaid funding are required to go directly to staffing levels. Other states have had success with so-called “pass through” policies.

The other larger change, some say, would be for the federal government to require nursing homes abide by a “minimum loss ratio”. Although the term sounds technical, the concept is relatively simple: all nursing homes would be required to spend only a certain percentage of their revenue on administration and profit.

A similar cap – known as a ‘medical loss ratio’ by policymakers – was placed on health insurers following passage of the Affordable Care Act in 2010. It meant that only 20 percent of an insurer’s revenue could go to profits and administration.