Medicare Ratings Fall for Short-Staffed Nursing Homes- One-Third of Nursing Homes See Ratings Drop

Aging in Place as a discreet planning objective is well justified and documented. Recent improvements to government reporting of data regarding quality of care at nursing homes, while welcome, only underscore the benefits of Aging in Place planning.

According to Kaiser Health News (KHN), the Centers for Medicare & Medicaid Services (CMS), gave its lowest star rating for staffing, one star on its five-star scale, to 1,638 homes, in its update to Nursing Home Compare,  According to a recent KHN article, most nursing homes were downgraded because their payroll records reported no registered-nurse hours at all for four days or more, while the remainder failed to submit their payroll records or sent data that could not be verified through an audit.  KHN characterized the recent action as an "acceleration" in the federal government's "crackdown on nursing homes that go days without a registered nurse by downgrading the rankings of one-tenth of the nation’s nursing homes on Medicare’s consumer website"

According to KHN:

"CMS has been alarmed at the frequency of understaffing of registered nurses — the most highly trained category of nurses in a home — since the government last year began requiring homes to submit payroll records to verify staffing levels. Before that, Nursing Home Compare relied on two-week snapshots nursing homes reported to health inspectors when they visited — a method officials worried was too easy to manipulate." 

CMS announced the changes last March:

"CMS is setting higher thresholds and evidence-based standards for nursing homes’ staffing levels. Nurse staffing has the greatest impact on the quality of care nursing homes deliver, which is why CMS analyzed the relationship between staffing levels and outcomes. CMS found that as staffing levels increase, quality increases and is therefore assigning an automatic one-star rating when a Nursing Home facility reports “no registered nurse is onsite.” Currently, facilities that report seven or more days in a quarter with no registered nurse onsite are automatically assigned a one-star staffing rating. In April 2019, the threshold for the number of days without an RN onsite in a quarter that triggers an automatic downgrade to one-star will be reduced from seven days to four days." 

“Once you’re past four days [without registered nursing], it’s probably beyond calling in sick,” David Grabowski, a health policy professor at Harvard Medical School, told KHN. “It’s probably a systemic problem.”

The American Health Care Association, a trade group for nursing homes, calculated that 36% of homes saw a drop in their ratings while 15% received improved ratings. AHCA has issued a response critical of the changes, and the accuracy and fairness of the ratings. 

KHN has an interactive tool, Look-Up: How Nursing Home Staffing Fluctuates Nationwide.  The tool reveals the rating Medicare assigns to each facility for its registered nurse staffing and overall staffing levels. The tool also shows KHN-calculated ratios of patients to direct-care nurses and aides on the best- and worst-staffed days.  Because staffing is closely related to quality of care, the KHN tool is useful for those investigating, comparing, and evaluating institutional care alternatives.  

Filial Support Laws Chaos: Pennsylvania and New Jersey Laws Clash

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Filial responsibility laws make family members legally responsible for the financial support of other indigent family members.  The statutes can require children to pay for the long term care costs of their parents who need nursing home care.  These same statutes can make parents responsible for their adult imdigent children. As more states adopt or enforce existing filial responsibility laws, there will be challenging questions of law regarding the application of different state laws.  If you are a child, and your parent enters a nursing home in another state, which statute will apply; the statute of the state in which you live, or the statute of the state in which your parent resides?  

In what is possibly the first case to confront such a question, the Pennsylvania Supreme Court held that Pennsylvania’s filial support statute applies to a support claim by a Pennsylvania healthcare provider against parents domiciled in New Jersey for care provided in Pennsylvania to their disabled adult son. The Court's opinion in Melmark, Inc. v. Schutt, et al., expands the application of Pennsylvania’s filial support statute, which was applied most notably by the Pennsylvania Superior Court in Health Care & Retirement Corp. of America v. Pittas to hold that a son was liable for his mother’s nursing care bill of nearly $93,000 (to read an article regarding the Pittas case on this blog, go here).

Pennsylvania’s filial support law generally provides that a spouse, child or parent of an indigent person has “the responsibility to care for and maintain or financially assist [such] indigent person, regardless of whether the indigent person is a public charge” if the non-indigent relative has “sufficient financial ability.”  23 Pa.C.S. § 4603(a)-(c).  In the Pittas case, the Pennsylvania Superior Court held Mr. Pittas responsible for the cost of his mother’s nursing home care because he had net income in excess of $85,000 and because he did not otherwise establish that he lacked sufficient financial ability to financially support her.  

The Pittas Court also determined Pennsylvania’s filial support statute does not require that other possible sources of income be considered before proceeding against any one of the financially responsible relatives listed in the statute.   The Superior Court suggested in Pittas that there is joint and several liability under Pennsylvania’s filial support statute, such that a claimant could proceed against any one of the statutorily responsible relatives regardless of the financial ability of any other relative, even if more sufficient.  This joint and several liability has complicated estate and financial planning for individual family members, and creates chaos within families. 

“Indigent” as used in the filial support statute “includes, but is not limited to, those who are completely destitute and helpless…” and that “also encompasses those persons who have some limited means, but whose means are not sufficient to adequately provide for their maintenance and support.”

In Melmark, the Pennsylvania Supreme Court addressed a conflict between the filial support law of New Jersey, the state where the indigent son and his parents were legally domiciled, and Pennsylvania’s filial support law. New Jersey’s filial support law does not impose liability for individuals younger than 55 years of age unless the indigent person is the party’s spouse or minor child. 

Alex Melmark suffered from severe mental and physical disabilities and needed assistance with nearly all activities of daily living.  He and his parents, Dr. Clarence and Barbara Schutt, lived in Princeton, New Jersey.  However, in 2001, Alex’s parents, who were also his court appointed guardians, placed him in the Melmark non-profit residential care facility for intellectually and physically disabled persons located in Delaware County, Pennsylvania.

Due to a protracted dispute over public funding for Alex’s care, Melmark filed a filial support claim against Dr. and Mrs. Schutt in Pennsylvania under its filial support law. 

On appeal, the Pennsylvania Supreme Court addressed the conflict between Pennsylvania and New Jersey’s filial support law.  The Schutts could not be liable under New Jersey law because Alex was under age 55 and not a minor at the time care was provided, while the Schutts could be liable under Pennsylvania law because does not apply such age restriction.

The Supreme Court held that Pennsylvania’s filial support law applied and that the Schutts could be liable under this statute. In its conflicts of law analysis the Court noted, in pertinent part, that Pennsylvania had a stronger interest in applying its law as all of the relevant facts occurred in Pennsylvania, notably that the Schutts voluntarily brought their son Mark to reside at the Melmark facility in Delaware County and personally funded other services for his benefit in Pennsylvania.

Ohio is a filial responsibility state, although it does not enforce the law, at the time of this writing, in Medicaid resource recovery.  Missouri is not, at least since 2014, a filial responsibility state.  

More:

Filial Responsibility- Complicating Estate, Retirement and Asset Protection Planning

Filial Responsibility Laws Lead to Chaos

Filial Responsibility Laws Complicate Estate and Financial Planning

Conveyance to Son Was Fraudulent, But His Siblings May Also Be Liable Under Filial Support Law

Elderly Couple May Be Responsible for Adult Son's Unpaid Medical Bills

Man Can't Challenge Discharge of Brother's Debt for Mom's Care under Filial Responsibility Law

Use of Filial Responsibility to Collect a Nursing Home Debt Survives Federal Challenges

Security Risks while at Nursing Homes and Assisted Living Facilities

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Among the reasons suggesting Aging in Place as a discreet objective of any estate and financial plan is security. Most people find their homes well secured and safe. Further, home invasions are rare, and security threats easily and inexpensively managed.

Security while at any institution is always an additional concern, and the risk is out of your control.  Of course security from other residents and even from staff, is a concern of which most are aware.  Violence is visited on residents from both staff and other residents, and this violence is entirely avoidable if non-institutional care is an option.  One research study concluded:

"Common violence encountered in the long-term care service industry is residents assaulting staff or each other. Maintaining adequate security in these facilities can be challenging for a variety of reasons including campus design, residents who may suffer from dementia or other cognitive impairments, the potential for criminal activity due to patient valuables and residents’ inability to recall details."

Most aren't aware, however, that there are existential security threats to any institution, simply because it is a place where people and things of value are aggregated.  Whether from the possibility of terrorism, or robbery, institutions must consider, confront, and protect against unique security risks, risks that are distinct from those you face at home.  

Nursing homes and assisted living facilities also present unique security challenges in confronting the risk:

The armed intruder or active shooter is an external threat that has occurred in assisted living and skilled nursing facilities in multiple geographic locations. Of concern in this type of incident is the limitations of the traditional response of Run, Hide, Fight, when considering the resident population of skilled nursing and assisted living facilities. Aside from the ethical issues of many nurses and other healthcare providers not wanting to leave their patients or residents, the residents themselves will be vulnerable due to conditions such as mobility issues and cognitive functioning. Numerous types of violence should be considered from a security perspective when examining the threat of an armed intruder or active shooter such as; violence directed toward a group or person (administrators, medical staff), domestic violence, and mercy killings. This type of violence may begin at another location and end on the campus or inside the facility.

Dean Conner, Violence and Security in Skilled Nursing/Assisted Care Facilities (IAHSS-F RS-18-04, December 3, 2018).

The objective of breaching the security of a single home is obviously less, and ordinarily would suggest there is no sufficient incentive for invasion.  Hence, homes are generally less attractive targets.

A recent drug robbery at an Alabama nursing home is an object lesson in the security threats faced by institutions, and the risks the elderly and their families must consider in selecting institutional care.  Two masked intruders recently invaded Consult America Cottage Hills, in  Pleasant Grove, Alabama, brandishing handguns and demanding the contents from the locked narcotic box.  Police estimate the pair made off with about $5,000 in narcotics, WBRC reported.  According to the report, Lieutenant Danny Reid told WBRC that such robberies usually occur in bunches, that he was convinced that the couple knew what they were doing, skipping over any blood pressure medications:

“Nursing homes are pretty soft targets,” he said Wednesday. “We have plenty of good leads I think. We’ll continue to work it. I’m actually reaching out to some local law enforcement in other cities to see what they have in regards to nursing home robberies ’cause usually this is going to be a pattern,” he added later.

Police are reviewing surveillance footage from the incident and believe that the pair are a man and a woman. An employee at Cottage Hills declined to comment to WBRC on the investigation when reached.  

"Soft target" assisted living facilities and nursing homes will only become more valuable and frequent targets as the nation battles the current opioid crisis, and as those who are ill-willed find success. It is only a matter of time before this lawlessness visits injury or death upon a resident.  

     

You May Soon be Able to Test Yourself for Dementia

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A new tool being developed by British researchers lets people test themselves for dementia. The new tool is promising and shows some initial success. 

The test, called “Test Your Memory,” or TYM for short, is a simple questionnaire that people can take and complete on their own. In initial trials, it is reportedly faster and more accurate than other current tests.  Researchers at Addenbrooke’s Hospital in Cambridge note that it has only been tried in one clinical setting, and many further studies are needed to conclusively prove  the test's efficacy. Also, the results of the questionnaire, while generally perceived as accurate and a good indicator of dementia risk, still need to be interpreted by a professional, according to the research team.

In the first trial, 540 healthy people aged 18 to 95 completed the questionnaire. As a control, researchers also asked 139 people with confirmed cases of either Alzheimer’s disease or mild dementia to take the test. The healthy cohort took about five minutes to complete the test, scoring an average of 47 points out of 50. Those with Alzheimer’s disease scored an average of 33 points, and took longer to complete to test. The exam comprises a series of word recall, verbal fluency and sentence copying questions. Interpretations of the results of the test identified 93% of those with Alzheimer’s, compared to 52% identified by the more commonly used mini-mental state examination.

Doctors at Addenbrooke note that, while the test can be an important part of identifying and diagnosis Alzheimer’s and dementia, physician evaluations and patient histories is nonetheless important. McKnight's Long-term Care News reported the existence of the test, but test results are scheduled for future publication in an upcoming issue of BMJ. 

Full-Time Nursing Home Doctors Less Likely to Medicate

Physicians employed full-time at a nursing home reduced prescriptions significantly, while community physicians tended to do the opposite, a new study finds. The information provided by the study, and more, the insights the study suggests regarding managing pharmaceutical care are invaluable in making decisions regarding institutional care and between competing institutional care alternatives.

According to an article in McKnight's Long-term Care News, researchers followed long-term stay residents for 12 months, with a goal of learning whether prescriptions were reduced after their first year at the facility, in an.effort to develop effective models for post-acute care for seniors. Results appeared last month in The Senior Care Pharmacist and were publicized last week by BRI. 

One of the reasons medication prescription, use, and management are of importance in evaluating alternatives is that so often medication mistakes or mismanagement lead to adverse health outcomes.  In fact, medications are a large part of the reason that persons discharged to nursing homes from hospitals are forced back to the hospital for additional care, or "readmissions," as they are identified by Medicare.  “Readmissions rates are a huge stressor, with 30% of readmissions due to medication issues,”  said LAJH Chief Medical Officer and Brandman Executive Director Noah Marco, M.D., as reported by  McKnight’s. “We said, ‘Let’s focus on medications first.’ Our hypothesis was that people will be coming in on a large number of medications and at the end of the year, their medications will be reduced.” 

But the mean number of scheduled prescriptions increased from 11.1 prior to admission to 13.3 by the end of the year, they found. Marco and team were shocked. When he and researchers dug into the data, they found that physicians employed full-time by the home ordered significantly fewer additional prescriptions. The home has five full-time geriatricians, with about the same number of community physicians also treating residents.

While more research is needed, Marco suspects that the on-staff geriatricians have a different philosophy with regards to medication.  Physicians employed full-time by the home get to know the patients, and the nursing staff.  "With that knowledge and alignment, we can create a plan,” he said.  The challenge is to find more avenues to study this patient population, he said. Marco also noted that pharmacists play a critical role in long-term care facilities.

“Just as they are playing a more important role in quality of care in the hospital, it’s incredibly important for more work to demonstrate the value of pharmacists actively involved in the day-to-day future care of this population,” he said. “I’m thankful I have such skilled pharmacists who are actively helping us create knowledge.”