The feds ahave been pounding states to issue more citations, and presto, we get more citations.

The primary measurement of "quality" is the number of location of nurses' signatures in the voluminous medical records.

Secondarily, the surveyors look at actual health care.

The Centers for Medicare & Medicaid Services (CMS) is loath to do anything in regards to the inspections by surveyors at nursing homes. It contracts out the oversight of each nursing home to each state’s health department. Numerous reports have shown how corrupt the oversight system is.

The problem with nursing home inspections is they depend on the paperwork to verify the residents are getting good care. They pay nurses to make sure the paperwork is perfect, thereby ensuring a good inspection.

To really inspect a nursing home, they should have decoy residents to actually experience and observe what goes on in a nursing home on a day to day basis. Or else have an inspector be hired as a staff nurse and work there for a few weeks to see what is really happening.

CMS uses “stealth” moves like putting out the word that surveyors shouldn’t cite anything they don’t absolutely have to, cutting or under-funding oversight budgets, looking at self-reported not non-audited data, etc. With the Carlye Group take-over of Manor Care, this just got worse for their residents.

Congress is turning up the heat on nursing homes, or so it seems. The House Energy and Commerce subcommittee on oversight and investigations held a hearing that focused on problems with regulation and full disclosure of ownership.

Surprisingly, this subcommittee had not held an oversight hearing about nursing home care since 1977. This indicates a rather lackadaisical attitude on the part of Congress in regards to our senior population. The last significant change in nursing home regulations was the Nursing Home Reform Act of 1987.

Now it seems Congress maybe serious enough in examining whether standards continue to provide an appropriate level of care and protection for residents of nursing homes.

The subcommittee released a report commissioned by the Centers for Medicare and Medicaid (CMS) that suggested that the regulatory enforcement system for nursing homes has a lot of problems.

All 46 Manor Care nursing homes in Pennsylvania staff below a standard recommended in a Centers for Medicare and Medicaid Services (CMS) study as putting residents at risk.

CMS contracts out the oversight of each nursing home to each state's health department. Not only is the each state's health department the problem, CMS may be part of the problem too!

CMS uses stealth moves like putting out the word that surveyors shouldn't cite anything they don't absolutely have to, cutting or under-funding oversight budgets, and looking at self-reported and unaudited data (data reported by the facilities themselves and no oversight agency verifies audits to ensure that it is even true).

Nursing home inspections depend on the paperwork to verify the residents are getting good care. Manor Care pays nurses to make sure the paperwork is perfect, thereby ensuring a good inspection.

In the past few years, a wave of new owners and investors has begun purchasing nursing home chains. These private-equity firms are unregulated and new to the nursing home market.

Many worry that the top priority for these new owners will be profits, rather than providing the staffing and resources necessary to ensure top quality care for our loved ones.

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.

The Carlyle Group already planned to restructure its take-over of Manor Care, which will comprise about 300 corporate entities that could obscure ownership and make it more difficult to regulate care. It split the company's real estate holdings from the rest of the business so the properties could be used as collateral to raise funds in credit markets.

Ownership structures with multiple stakeholders have been used by other private-equity firms to minimize liabilities and shield them from regulator inquiries like when cutting staff is made to improve profit margins. They use these kinds of structures to avoid taking responsibility when taking control of nursing homes.

Private equity is buying up this industry and then hiding the assets, and when residents are dying from lack of proper care, there is little the courts or regulators can do, while they skim off the profits to line the pockets of investors or plow the money into separate ventures that have nothing to do with nursing home care.

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. There is a crisis in our nation's nursing homes. The residents their need help!

Facing a new wave of congressional scrutiny, the nursing home industry is mobilizing some of Washington’s most well-connected lobbyists to fend off tough reform-minded legislation.

http://www.politico.com/news/stories/0508/10627.html

How Much Do We Spend on Nursing Homes?

The nursing home sector accounts for roughly 6 percent, or $124.9 billion of the more than $2 trillion that we invest annually in healthcare. As always, the question is “Are we getting good value for our money?”

Given how vulnerable nursing home patients are, questions about quality deserve special attention. Maggie Mahar does the basics, how much do we spend on nursing homes?

http://www.healthbeatblog.org/2008/06/health-care-spe.html

Nursing Home Transparency and Improvement Act of 2008

Summary of Major Provisions of the Act

Improve transparency and accountability in the ownership and operations of nursing homes

Corporations would be required to disclose their owners, operators, financers, and other related parties. Facilities that were part of chains would be required to submit annual audits. Purchasers would have to demonstrate that they were financially able to run facilities.

Require disclosure of how Medicare and Medicaid funds are spent

Providers would have to report wage and benefit expenditures for nursing staff on cost reports. Cost reports would be revised to categorize spending for direct care, such as nursing and therapies; indirect care, such as housekeeping and dietary services; capital costs, including buildings and land; and administrative costs, which often include the company’s profits.

Establish independent monitoring of chains

The federal government would develop a protocol for an independent monitor of chains to analyze their financial performance, management, expenditures, and nurse staffing levels. It would provide for corrective action and collection of civil monetary penalties.

Collect accurate information about nurse staffing

The government would collect data electronically from nursing homes on the number of RNs, LPNs, and nursing assistants, using payroll records and contracts with temporary agencies as the source. Data would include turnover and retention rates and hours of care per resident provided by each category of worker.

Provide better public information about nursing homes

Nursing Home Compare would be updated with more timely reporting of surveys; ownership information; accurate nurse staffing data, including turnover and retention rates; links to survey reports (Form 2567) when states put them online; enforcement actions; and all Special Focus Facilities identified for three years. The government would undertake a study on how to improve the website to make it more useful and understandable.

Implement new consumer complaint processes

The government would develop a standardized form consumers could use in filing complaints with the state regulatory agency or ombudsman. States would be required to establish a complaint resolution process for residents’ representatives who were retaliated against, including denied access to residents, if they complained about quality of care or other issues.

Provide for higher civil monetary penalties and other CMP reforms

Federal civil monetary penalties would be increased for the first time since the 1987 Nursing Home Reform Act – up to $100,000 in the case of a resident’s death. Fines would be held in escrow during appeals of deficiencies, no longer delayed until appeals were resolved. Federal CMP funds, which are now returned to the U.S. Treasury, are encouraged to be used for the benefit of residents.

Provide for reporting of closures and continuation of federal payments

Nursing homes would be required to give 60 days notice of closure, including a relocation plan and assurances that residents would be transferred to the most appropriate facility or other setting. No new residents could be admitted after the notice was given, and the federal government could continue Medicare and Medicaid funding for residents until relocation was completed.

Authorize studies of temporary management; special focus facilities; culture change; and nurse aide training

The bill provides for studies of temporary management; the characteristics of Special Focus Facilities, including ownership; best practices in culture change; and training of nurse aides and supervisors. Dementia management would be added to the initial 75-hour nurse aide.

Legislate Federal Mandatory Staffing Levels

Many states fought twenty world-wars to get mandatory staffing levels, even then, it was constantly being attacked. In one state, when there was a possibility of cutting Medicaid funding, the industry jumped at the chance to use that funding cut as an excuse to abandon the staffing level requirements.

Federal law only requires nursing homes to provide sufficient staff and services to attain or maintain the highest possible level of physical, mental, and psychosocial well-being of each resident, and we know this is insufficient.

There have been numerous federal bills requiring various mandatory staffing levels, only to be defeated or die on the vine. Now is the time for those mandatory staffing levels!

While the Nursing Home Transparency and Improvement Act of 2008, passed under the umbrella of the recent Medicare bill, proposed collecting accurate information about nurse staffing by comparing it with payroll records, mandatory staffing levels wasn't in the nursing home bill.

Write or call your federal congressional delegation to be on the ground floor at getting this much needed legislation passed.