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Tuesday, March 1, 2022
Rethinking Guardianship- Carol Kelly
Monday, February 7, 2022
More is not Always Better - CMS Adds Staffing Information to Care Compare
The Centers for Medicare and Medicaid Services (CMS) recently announced that it will add data on staff turnover rates and weekend staffing levels to its Care Compare website, giving consumers another tool when choosing a nursing home. The official Medicare website, previously called Nursing Home Compare, offers up to five-star ratings of nursing homes based on health inspections, staffing, and quality measures. Users can search for nursing homes by location and directly compare one institution to another.
CMS will post the following additional information for each nursing home on its website:
- Weekend Staffing: The level of total nurse and registered nurse staffing on weekends provided by each nursing home over a quarter.
- Staff Turnover: The percent of nursing staff and number of administrators that stopped working at the nursing home over a 12-month period.
CMS will begin adding the information to the Care Compare website in January, but the information will not be incorporated into the rating system until July 2022.
The staffing information could not come at a more meaningful time. Nursing homes are plagued by chronic understaffing and high turnover rates. The problem has existed for years, but is exacerbated by the COVID-19 pandemic. A study reported in Health Affairs found that the turnover among nursing staff was 94 percent in 2017 and 2018 and mean turnover rates were as high as 140.7 percent among registered nurses, 129.1percent among certified nursing aides and 114.1 percent among licensed practical nurses.
CMS previously noted a relationship between turnover and ratings. CMS noted in a memo that:
"facilities with lower nurse turnover may have more staff that are familiar with each resident’s condition and may therefore be more able to identify a resident’s change in condition sooner. In doing so, the facility may be able to implement an intervention to avoid an adverse event, such as a fall, acute infection, or hospitalization, which are indicators of quality. Similarly, facilities with lower nurse turnover may be more familiar with the facility’s policies and procedures and can potentially operate more efficiently and swiftly to deliver a higher quality of care to residents. Lastly, facilities with lower administrator turnover may have greater leadership stability, direction, and operations, which may help staff provide care more consistently or effectively to residents."
Regardless of the reasons for the association between turnover and quality, CMS acknowledging the relationship is encouraging.
CMS has also acknowledged that the additional information is important and is thus valuable to consumers. For example, regarding weekend staffing, CMS acknowledged that consumers may not realize that nursing home staffing levels can vary on weekends. CMS hopes to encourage facilities to hire more weekend staff by adding weekend staff numbers to the nursing home rating system.
The fundamental underlying question, though, is whether adding additional information will help transform a questionable and unreliable system into a more meaningful system for consumers. There is good reason to remain skeptical; there are numerous reports and examples suggesting that the federal ratings are inaccurate or misleading. Consider the following:
- NYT: "Maggots, Rape and Yet Five Stars: How U.S. Ratings of Nursing Homes Mislead the Public;
- Nursing Homes Create Phony Diagnoses to Sedate Patients with Dangerous Drugs, Doubling Risk of Death;
- Nursing Home Compare Does Not Accurately Reflect Patient Safety In Nursing Homes;
- Half of Most Dangerous Nursing Homes Remain Treacherous for Residents After Homes Are Cleared By Regulators.
Worse, even if information regarding nursing homes is more accurate, it does little to help the most vulnerable seniors, those being transferred from acute care in a hospital to a nursing home for rehabilitation; patients are simply given little guidance or information to help them direct accurately their own care decisions:
Providing additional information through Care Compare will only be comforting for consumers and planners when the reporting deficits underlying the system are fixed, and seniors are provided quality of care information prior to transfer.
Industry reaction to the change has been "mixed," according to Amy Novtney, writing for Mcknight's Longterm Care News. David Grabowski, professor of healthcare policy at Harvard Medical School, told industry stakeholders during a LeadingAge conference call, that the timing of the change “feels like a gut punch to nursing homes who are really struggling right now.”
Grabowski called on providers, however, to view the move as a positive development for the industry in the long run. Grabowski said the data could provide benefits such as shedding light on the fact that there aren’t staff available to work on the weekends, that turnover is high and that there’s a high use of contract nurses. That, in turn, could lead to policy changes.
According to Novtney, Grabowski continued:
“I do think longer term this data will add value and can serve as a signal to all of us that we need to invest more in direct care staff. We get the turnover we pay for and since we aren’t paying enough, we’re seeing high turnover. That’s not something nursing homes can fix on their own. I really believe we need more reimbursement from Medicaid and Medicare to make that happen.”
Other industry associations agree that the decision’s timing is unfortunate given the ongoing challenges related to the pandemic.
Others criticized the addition information as impotent to improves staffing issues. “While we support transparency and agree that staffing hours and turnover metrics are important, more reporting will not solve this issue,” the American Health Care Association/National Center for Assisted Living said in a statement to McKnight’s this week. “The addition of this reporting requirement when we are in the middle of the worst labor shortage the nursing home sector has ever faced is tone deaf. We need public health officials to do more than acknowledge these challenges, but stand up to address them. By offering funding and policy solutions that will help us attract and retain the caregivers we so desperately need, policymakers can ensure nursing home residents are well supported.”
To read CMS’s announcement about this new policy, click here.
Friday, November 12, 2021
Annual Gift Tax Exclusion for 2022 Increases to $16,000.00
The rate of inflation hit a 31-year high in October. Shortly thereafter, the IRS announced adjustments to certain inflation-indexed tax provisions for returns filed in 2023.
The inflation adjustments for tax years 2021 and 2022 inform taxpayers what they might expect going forward. In the event that inflation isn’t temporary, the adjustment determinations now will be all the more important come tax time in 2023. The other changes follow:
New standard deduction, tax brackets, gift tax and EITC
• The standard deduction rises to $25,100 for married couples filing jointly in their 2022 returns. That’s a $300 increase. It rises to $25,900 for 2023 returns, an $800 rise.
• For single filers and married individuals filing separately, the standard deduction in 2021 returns climbs to $12,550, a $150 increase. The following year, the deduction increases to $12,950, a $400 increase.
• The income levels applying to each tax bracket are increasing up and down the income scale. For example, in 2021 returns, the top 37% rate applies to individuals making $523,600, or $628,300 for married couples filing jointly. In 2022 returns, the richest households face the top rate for incomes above $539,900 or $647,850 for married couples filing jointly.
• The annual exclusion on the gift tax rises for the first time in several years. From 2018 to 2021, $15,000 was the threshold before taxes applied on gifts, according to the IRS. It rises to $16,000 in 2022, with returns filed in 2023.
• The Earned Income Tax Credit, a credit for low- and moderate-income households, also increases. For example, the maximum credit for 2021 returns of qualifying households with three or more eligible children is $6,728. The following year, households with three or more kids will receive $6,935, the IRS said. The American Rescue Plan passed in March expanded the EITC’s rules, qualifications and potential payouts, particularly for workers without children.
Wednesday, November 3, 2021
Promissory Note Executed by Nursing Home Resident’s Daughter Is Not Illegal Third-Party Guarantee
The efforts of nursing homes to create and enforce filial responsibility, i.e., hold children financially responsible for a parent's long term care, even where state legislators have not enacted such legislation, is a frequent topic of articles on this blog:
Another recent example comes courtesy of a Kentucky appeals court which held that a promissory note executed by a nursing home resident’s daughter, agreeing to pay the nursing home for the resident’s outstanding expenses, is not illegal because there was no evidence her mother’s stay in the nursing home was conditioned on her signing the note. Roberts v. Mt. Washington Health Care, LLC (Ky. Ct. App., No. 2020-CA-1190-MR, Oct. 29, 2021). Federal law provides that “a nursing facility must . . . not require a third party guarantee of payment to the facility as a condition of admission (or expedited admission) to, or continued stay in, the facility...” 42 U.S.C. § 1396r(c)(5)(A)(ii).
Erma Basham entered a nursing home in 2018. She applied for Medicaid in 2019 and was approved, but she owed $34,742.26 in expenses for her care before her Medicaid application was approved. Ms. Basham’s daughter, Christy Roberts, executed a promissory note, agreeing to pay the nursing home monthly to pay down Ms. Basham’s bill. Ms. Roberts made one payment and defaulted on the note.
The nursing home sued Ms. Roberts. The trial court found Ms. Roberts had executed a valid promissory note and entered judgment in favor of the nursing home. Ms. Roberts appealed, arguing that the promissory note was illegal because under federal law, the nursing home cannot require a third-party guarantee of payment as a condition of admission or continued stay in the facility.
The Kentucky Court of Appeals affirmed in part, holding that the promissory note is not illegal. According to the court, there was “no testimony or other evidence of record apart from [Ms.] Roberts’ unsupported assertions indicating that her mother’s admission or continued stay at the appellee’s facility was conditioned upon [Ms.] Roberts executing the February 12, 2019 promissory note.”
The court did find that the interest charged Ms. Roberts was too high and remanded the case to the trial court to enter a lower interest rate.
Tuesday, October 19, 2021
SSI and other Social Security Benefits Set to Increase 5.9% in 2022
People with disabilities receiving Supplemental Security Income (SSI) and other Social Security benefits will receive the biggest rise in their monthly payments since 1982. The Social Security Administration says that benefits will grow 5.9% in 2022.
The change is the result of an automatic cost-of-living adjustment, or COLA, tied to inflation, and is another indication of a post-pandemic surge in inflation. The annual adjustment is based on the Consumer Price Index (CPI) from the U.S. Department of Labor’s Bureau of Labor Statistics which rose 5.4% in September from a year earlier, the largest annual gain since 2008.
With COLA, the maximum federal SSI benefit for individuals will be $841 per month in 2022, up from $794 this year. For couples, the maximum will be $1,261 next year, up from $1,191.
Beneficiaries may see payments that are greater than the federal maximum since some states chip in extra.
The new amounts will take effect in January for the nation’s 64 million Social Security beneficiaries and will start Dec. 30 for 8 million SSI beneficiaries.
The Social Security Administration said beneficiaries are usually notified by mail beginning in early December about their updated payment amount for the coming year and most people will also be able to view the information online through their Social Security account at that time.
In the last 10 years, COLA has increased by an average of 1.65% annually.
Wednesday, October 13, 2021
Senior Care Staffing Shortage Crisis- Nightmare Scenario Warns One-Half of Facilities Could Close
- Three rural nursing homes in Maine close because they cannot hire enough staff to maintain care for patients and residents.
- One of the oldest nursing facilities in Summit County, Ohio closed, citing an array of post pandemic financial difficulties, including cost of maintaining adequate staff.
- A senior living facility in Camden County, Georgia was forced to close due to staffing shortage.
- A nursing home in Oklahoma shuts its doors due to staff shortages.
- A nursing home in Kansas closes due to staff shortages.
- A new industry survey reports that only 1 percent of nursing homes and 4 percent of assisted living facilities (ALFs) say they are fully staffed, while 89 percent of nursing homes and 82 percent of ALFs report moderate or severe shortages.
- Fifty-eight percent of nursing homes and 28 percent of ALFs say they are limiting admissions because they do not have enough staff to care for residents.
- As many as one-half of all nursing homes and assisted living facilities in the nation could close within the next year, if the current staffing crisis is not alleviated, according to Washington Health Care Association CEO Robin Dale.
Gleckman notes that staffing shortages don't impact just nursing homes and assisted living facilities, but impact the entire spectrum of senior care. For example, the operator of a Maryland home health agency claims it is turning away families looking for assistance because it does not have sufficient aides; “We cannot provide the care our clients deserve with the staff we have,” she told Gleckman.
Fundamentally, though, as resources are spread thin across the entire health care industry, opportunities for cover and redundancy are disappearing. Whether those opportunities are within or outside of a formal system, seniors are forced to rely upon less in the hopes that care quality will remain high. The reality is that a system can provide generally high quality care only when it's component parts work to support each other; hospitals support care institutions, care institutions rely upon a full complement of staff within a facility, and upon other outside institutions, to supplement and support care and accept patients best placed in the care of others.
Many long-term care workers are leaving the health care profession entirely. Widespread shortages of low-wage workers in the hospitality industry give aides the opportunity to work for as much money—or even more—at jobs that are far less physically and emotionally demanding.
Gleckman also warns that these labor shortages appear to be growing at the same time the long-term care industry is confronting another equally important trend: consolidation. Not only are facilities closing, but operators are selling out. Small facilities being acquired by mid-sized chains and large chains are selling out to bigger ones, often owned by private equity firms.
How will these owners, often obsessively focused on the short-term bottom line, confront these labor shortages? It is hard to know, but the answer will be critically important to workers as well as to residents and their families.
Wednesday, October 6, 2021
Three Assisted Living Workers Charged in Death of Resident
Three assisted living facility workers are being prosecuted in the death of 86-year-old, Hazel Place, a resident who suffered from Alzheimer’s disease. Authorities alleged the three left Ms. Place outside in sweltering weather for six hours.
Jamie Johnston, 30, Jenny Logan, 50, and Letticia Martinez, 27, employees of Cappella Assisted Living and Memory in Grand Junction, Colorado, were charged with negligent death of an at risk person and criminally negligent homicide, both felonies.
Johnston and Martinez were also charged with a misdemeanor for allegedly forging patient records, according to court documents describing the charges.
National Weather Service data shows that the high temperature in Grand Junction that day was 102 degrees Fahrenheit (38.9 Celsius).
The court documents detailing the evidence gathered against the workers have been sealed.
Place could walk and did so frequently in a routine that was familiar to caregivers, but was supposed to be checked on every hour because she was at risk of falling, her daughter, Donna Golden, told The Daily Sentinel in Grand Junction.
“What it boils down to, as the caregivers that day and probably on other days, none of them were doing their job. Not a one of them checked her,” she said.
Cappella Assisted Living and Memory said in a statement that it reported the circumstances surrounding Place’s death to regulators and conducted an internal investigation which led to the dismissal of two of the workers. The third worker was placed on “investigatory leave,” the statement said.
“We are very saddened by the passing of this beloved resident, and we continue to send our sincerest sympathy to this resident’s family and friends,” the statement said.
Wednesday, September 29, 2021
Scrivener’s Error and Limited Power of Appointment Do Not Make Property Available to State to Recoup Medicaid Benefits
Athena and Sotirios Koutoukis hired an attorney to transfer ownership of their real estate to their daughters, creating and retaining a life estate for their benefit. They also retained a power of appointment to convey the property to their children. Mr. Koutoukis received MassHealth (Medicaid) benefits before he died. After Mr. Koutoukis’s death, the attorney for the estate discovered that the deed included the words “tenants in common for life and further,” which was an error.
The estate filed an action in probate to correct the scrivener’s error, and the state filed a claim against the estate in order to recoup the Medicaid benefits paid on Mr. Koutoukis’s behalf. The state filed for summary judgment, arguing that because Mr. Koutoukis left property in his will to his wife, he did not intend to create a life estate and that the power of appointment in the deed made the property a countable asset. The estate also filed for summary judgment. The Massachusetts Land Court, Department of the Trial Court, granted summary judgment for the estate benefitting the Koutoukis family, holding that the deed can be reformed to correct the mistake, and the state cannot recoup benefits from the property. Estate of Koutoukis v. Secretary of the Executive Office of Health and Human Services (Mass. Land Ct., Dept. of the Trial Ct., No. 20 MISC 000004 (RBF), Sept. 17, 2021).
The court held that the power of appointment in the deed is a limited power that did not permit the Koutoukises to grant the property to themselves, so the property was not a countable asset for Medicaid purposes. More importantly, the court wrote that the evidence clearly established that the Koutoukises intended to create a life estate, and the state did not provide any evidence to the contrary:
On a motion for summary judgment, the nonmoving party cannot create a dispute of material fact simply by declaring that it disputes the material fact. The nonmoving party is supposed to provide some evidence that disputes the fact; that is, some evidence that, if credited, would support the opposite of the claimed undisputed fact. On these cross-motions for summary judgment, the defendant Secretary of the Executive Office of Health and Human Services (EOHHS) has attempted to forestall summary judgment on the plaintiffs’ claim for reformation of a deed due to a scrivener’s error by the simple expedient of saying the affidavits provided by the plaintiffs do not support the claim, without providing any evidence of its own to the contrary.
As the affidavits do support the claim for reformation, there is no dispute of material fact. Based on the undisputed material facts and the applicable law, summary judgment shall enter reforming the subject deed to clarify that the parties’ intent was to create a life estate, and declaring that the life estate and the limited power of appointment in the deed do not make the subject property a
The court noted that state "has denied many of the asserted facts relating to the claim of scrivener’s error in the subject deed without providing any affidavits or other evidence whatsoever."Estate of Koutoukis, at p. 4.
The court concluded that the state cannot recoup Medicaid benefits from a Medicaid recipient’s property, left in a life estate notwithstanding a scrivener’s error, and a limited power of appointment. Estate of Koutoukis v. Secretary of the Executive Office of Health and Human Services (Mass. Land Ct., Dept. of the Trial Ct., No. 20 MISC 000004 (RBF), Sept. 17, 2021).
Monday, September 20, 2021
Liberal Magazine Fires Shot Across the Bow of Cruise Ship Roth IRA
Roth IRAs are similar to traditional IRAs, the biggest distinction between the two being how they are taxed. Roth IRAs are funded with after-tax dollars; the contributions are not tax-deductible. Once you start withdrawing funds, the money is tax-free. Conversely, traditional IRA deposits are generally made with pretax dollars; you usually get a tax deduction on your contribution and pay income tax when you withdraw the money from the account during retirement.
Many people use Roths because account holders don't have to start taking distributions at age 70½ as they do with traditional IRAs. The money can sit untouched and grow tax-free throughout the owner's lifetime—a big plus for those who don't need the assets to live on. And while those who inherit any type of IRA must start taking distributions immediately, they are permitted to stretch out those payments, allowing the bulk of a Roth account to continue growing tax-free.
This and other key differences make Roth IRAs a better choice than traditional IRAs for some retirement savers. They are, at the same time, increasingly unpopular among those who champion government intervention to alleviate wealth disparity. I have warned investors to consider seriously possible future changes to the laws governing Roth IRA's before investing, and particularly before implementing IRA conversions, i.e., liquidating a traditional IRA, and paying the taxes on the investment, in order to convert the investment to a Roth IRA that permits future tax-free withdrawals of both principal and income. See, "Roth IRAs Dim as Inheritance Vehicles- Beware the Rush to Covert."
Mother Jones Magazine (MJ) recently published an article critical of the government continuing to "support" wealthy individuals in an effort to avoid taxation using Roth IRA's. The article may be the first in a coming onslaught of attacks against the investment option, and may be a bell weather indicating reform.
Although the article often reads more like a partisan platform or political screed (the article is openly published under the MJ "Politics" section), language choice, narrative, and hyperbole aside, the article explores the uses and misuses of the Roth IRA, particularly as a tool of the ultra-wealthy:
"For many working Americans, a Roth IRA is a useful, if not particularly interesting, way to save money for retirement. For tech billionaire Peter Thiel, it was a way to accumulate more than $5 billion. The nonprofit journalism shop ProPublica ran an exposé in June revealing how a small number of extremely wealthy folks had ended up with Roths—federally subsidized retirement accounts meant for middle-class savers—worth tens to hundreds of millions of dollars and up. Thiel did so, the article noted, by “stuffing” his Roth IRA with wildly undervalued “founders shares” of pre-IPO startups—potentially an illegal tactic—and then watching as their values rose exponentially, and completely tax-free.
The story prompted congressional leaders to request data from the nonpartisan Joint Committee on Taxation, which reported that, as of 2019, more than 28,000 Americans held combined (Roth and traditional) IRA balances of $5 million or more, and 497 taxpayers had balances of at least $25 million. The latter group had socked away a combined $77 billion in their IRAs—on average, more than $150 million each. 'IRAs were designed to provide retirement security to middle-class families, not allow the super wealthy to avoid paying taxes,' Sen. Ron Wyden (D-Ore.) lamented in a press release.
But it turns out IRAs are only the tip of the iceberg. The bigger problem, according to Steve Rosenthal, a tax attorney and senior fellow at Urban-Brookings Tax Policy Center, is that, thanks to a series of bipartisan bills Congress has passed over the past quarter-century, the government spends a fortune subsidizing a whole range of retirement plans whose benefits flow overwhelmingly to America’s most affluent. 'It’s unbelievable the amounts of dollars at stake, and how tilted they are to the high end,' Rosenthal told me. 'It’s just staggering.'"
The author acknowledges that reform of the Roth IRA is not likely or particularly popular, right now:
“'The wealth defense industry—the lawyers, accountants, and wealth managers to the super-rich—are paid millions to sequester trillions, stretching the limits of the law and sometimes writing the law themselves,' says Chuck Collins, director of the Program on Inequality and the Common Good at the Institute for Policy Studies and author, most recently, of a book titled The Wealth Hoarders. 'They have fracked every corner of the tax code, especially tax-advantaged retirement programs, to extract benefits for their wealthy clients.'"
The article concludes with a contributing source explaining possible reforms and illustrating the lack of receptiveness there is for reform in Congress:
"'To prevent stuffing and other kinds of self-dealing, [Steve Rosenthal, a tax attorney and senior fellow at Urban-Brookings Tax Policy Center] continues, Congress should just forbid people from holding non–publicly traded assets—like shares of a pre-IPO startup—in an IRA. Lawmakers also could enact a combined asset limit that covers all types of tax-advantaged retirement plans—as first proposed by the Obama administration. They also could strengthen nondiscrimination rules or consider shoring up Social Security—which appears to be in trouble—instead of further enriching the families who need the least help in their old age. “Congress will struggle to solve the problem they created,' Rosenthal told me in an email. 'But the longer they wait, the harder it will be.'
He’s not holding his breath. In July, when the Senate Finance Committee held a hearing titled 'Building on Bipartisan Retirement Legislation: How Can Congress Help?,' Rosenthal and University of Chicago professor Daniel Hemel submitted a statement for the record, but most of the professionals present at the hearing were part of what he calls the retirement-industrial complex: 'The benefits community, the practitioners, the retirement service industry—they testified. Nobody was invited to testify who says the emperor has no clothes.'"
MJ, despite is controversies, and mis-fires, has often been at or near the forefront of a once controversial position moving mainstream. MJ was, for example, among the first to overtly connect Former President Trump to the alt-Right, although it's effort was roundly criticized, from the Left because its article portrayed a neo-nazi in a "positive" light.
More importantly, the past few years have demonstrated just how quickly change is possible. Roth IRA's, like all investment options, should be considered carefully.
Tuesday, September 14, 2021
Nursing Homes Create Phony Diagnoses to Sedate Patients with Dangerous Drugs, Doubling Risk of Death
The New York Times (NYT), in a recent front-page Sunday article, "Phony Diagnoses Hide High Rates of Drugging at Nursing Homes," explores and exposes the use of chemical restraints, including antipsychotic medications, to control behavior of long-term care residents. This blog has previously discussed the use of pointless and dangerous drugs dispensed to terminally ill dementia patients in nursing homes. See, "Most Terminal Dementia Patients in Nursing Homes Given Pointless and Potentially Dangerous Drugs."
Antipsychotic drugs have faced criticism for decades as “chemical straitjackets. They are medically unnecessary and dangerous for older people with dementia, nearly doubling their chance of death from heart problems, infections, falls and other ailments. Understaffed nursing homes have, nonetheless, often used the sedatives so they don’t have to hire more staff to handle residents.
The battle against this pernicious practice is not new. In 1987, President Ronald Reagan signed a law banning the use of drugs that serve the interest of the nursing home or its staff, not the patient.
But the practice persisted. In the early 2000s, studies found that antipsychotic drugs like Seroquel, Zyprexa and Abilify made older people drowsy and more likely to fall. The drugs were also linked to heart problems in people with dementia. More than a dozen clinical trials concluded that the drugs nearly doubled the risk of death for older dementia patients.
In 2005, the Food and Drug Administration (FDA) required manufacturers to put a label on the drugs warning that they increased the risk of death for patients with dementia. While FDA advisories generated public awareness, it is well known that prescribers’ compliance with black-box warnings is low. Seven years later, in 2012, with antipsychotics still widely used, nursing homes were required to report to Medicare how many residents were getting the drugs. That data is posted online and becomes part of a facility’s “quality of resident care” score, one of three major categories that contribute to a home’s star rating.
The only catch: antipsychotic prescriptions for residents with any of three uncommon conditions, schizophrenia, Tourette’s syndrome and Huntington’s disease, are not included in a facility’s public tally. The theory was that since the drugs were approved to treat patients with those conditions, nursing homes shouldn’t be penalized.
The loophole was opened. The NYT has discovered that residents are simply given "new" diagnoses of, for example, schizophrenia, attempting to justify the sedation associated with major antipsychotic medications, such as Haldol, despite the fact that such medications are contraindicated for dementia patients. According to the NYT, since 2012, the share of residents classified as having schizophrenia has risen to 11 percent from less than 7 percent. The diagnoses rose even as nursing homes reported a decline in behaviors associated with the disorder. The number of residents experiencing delusions, for example, fell to 4 percent from 6 percent.
Today, one in nine residents has received a schizophrenia diagnosis. In the general population, the disorder, which has strong genetic roots, afflicts roughly one in 150 people. Moreover, Schizophrenia, which often causes delusions, hallucinations and dampened emotions, is almost always diagnosed before the age of 40.
“People don’t just wake up with schizophrenia when they are elderly,” Dr. Michael Wasserman, a geriatrician and former nursing home executive who has become a critic of the industry told the NYT. “It’s used to skirt the rules.”
Some portion of the rise in schizophrenia diagnoses probably stems from the fact that nursing homes, like prisons, have become a refuge of last resort for people with the disorder, after large psychiatric hospitals closed decades ago.
But unfounded diagnoses are also undoubtedly driving the increase. In May, a report by a federal oversight agency said nearly one-third of long-term nursing home residents with schizophrenia diagnoses in 2018 had no Medicare record of being treated for the condition. Even for those for which there was some record of treatment, the treatment records, do not provide important details about the drug use (e.g., which antipsychotic drugs were prescribed; at what quantities and strengths; and for what durations). The lack of treatment records suggest the drugs are not being prescribed to treat a legitimate condition, but are being used for other purpose.
The revelation should come as no surprise: many facilities have found ways to hide serious problems, like inadequate staffing and haphazard care, from government audits and inspectors. The problem with misreporting staffing was so outrageous that, in 2019, CMS actually demanded payroll reports to verify nursing home reporting of staff numbers, immediately after which implementing such verification, more than one-third of nursing homes saw their ratings decline. See, this blog's article: "Medicare Ratings Fall for Short-Staffed Nursing Homes- One-Third of Nursing Homes See Ratings Drop." There were a minority of nursing homes that didn't even have a staff nurse, resulting in home closures.
The NYT, demonstrating the power of investigative journalism, reports:
According to Medicare’s web page that tracks the effort to reduce the use of antipsychotics, fewer than 15 percent of nursing home residents are on such medications. But that figure excludes patients with schizophrenia diagnoses.To determine the full number of residents being drugged nationally and at specific homes, The Times obtained unfiltered data that was posted on another, little-known Medicare web page, as well as facility-by-facility data that a patient advocacy group got from Medicare via an open records request and shared with The Times.The figures showed that at least 21 percent of nursing home residents...are on antipsychotics [link included in original].
That means a full one in five nursing home residents are receiving potentially unnecessary and dangerous medications! The reasons why this practice continues are obvious: caring for dementia patients is time- and labor-intensive. Workers need to be trained to handle challenging behaviors like wandering and aggression. But many nursing homes are chronically understaffed and do not pay enough to retain a sufficient number of employees, especially the nursing assistants who provide the bulk of residents’ daily care.
Studies have found that the worse a home’s staffing situation, the greater its use of antipsychotic drugs. That suggests that some homes are using the powerful drugs to subdue and sedate patients to avoid having to hire extra staff, or alternately to relieve already over-worked staff from the burden of caregiving. According to the NYT analysis of Medicare data, homes with staffing shortages are also the most likely to misrepresent the number of residents on antipsychotics.
Staffing shortages are extreme, and threatening, made worse by a pandemic that has battered the industry. Nursing home employment is down more than 200,000 since early last year and is at its lowest level since 1994.
As staffing dropped, the use of antipsychotics rose.
Recent vaccine mandates further threaten industry staffing. In fact, following an announcement from President Biden that all nursing home staff will be required to be fully vaccinated against COVID-19 in a forthcoming regulation, the nursing home industry warned about the potential impact on the profession’s already challenging workforce situation. Industry leaders are deeply concerned that it may cause a "mass exodus" from the nursing home profession, leaving frail seniors without the caregivers and access to care they need.
In Ohio, only 54.3% of nursing home staff have been vaccinated, according to federal data. Pete Van Runkle, head of the Ohio Health Care Association, which represents the state's for-profit long-term care facilities, fears additional staffing shortages. A facility in Ohio on average has 19 open positions it can't fill, according to a recent Ohio Health Care Association survey. The mandate could make things worse, Van Runkle has said.
"I'm scared to death of what that's going to look like," he said.
Van Runkle noted there was one large long-term care company that voluntarily mandated vaccines, only to walk it back later after workers threatened to leave.
Staff exodus will only increase the already strong incentives to misuse and abuse drugs as chemical restraints. According to the NYT, the country’s leading experts on elder care are already "taken aback" by the frequency of false diagnoses and the overuse of antipsychotics. Barbara Coulter Edwards, a senior Medicaid official in the Obama administration, told the NYT she discovered that her own father was given an incorrect diagnosis of psychosis in the nursing home where he lived even though he had dementia.
“I just was shocked,” Ms. Edwards said. “And the first thing that flashed through my head was this covers a lot of ills for this nursing home if they want to give him drugs.”
In 2019 and again in 2021, Medicare said it planned to conduct targeted inspections to examine the issue of false schizophrenia diagnoses, but those plans were repeatedly put on hold because of the pandemic.
In an analysis of government inspection reports, The NYT found about 5,600 instances of inspectors citing nursing homes for misusing antipsychotic medications. Nursing home officials told inspectors that they were dispensing the powerful drugs to frail patients for reasons that ranged from “health maintenance” to efforts to deal with residents who were “whining” or “asking for help.”
"Asking for help." Let that sink in.
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