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News August 2017

Washington Watch

Nursing Home Patient Care Problems Continue Despite Oversight

By Alan M. Schlein

The number of nursing homes under special focus at any given time has dropped by nearly half since 2012, because of federal budget cuts. In 2017, the federal government designated 88 nursing homes with this designation and put $2.6 million devoted to fix the issues. But federal regulators identified 435 facilities as warranting scrutiny.

Despite efforts at stricter oversight by the federal government, nursing homes that have come under intense scrutiny often slide back into providing dangerous care, a new analysis of federal inspection data reveals.

Federal inspectors look for repeated safety violations, and when a nursing home facility is deemed dangerous, it is labeled a "special focus facility" (SFF). Since 2005, there have been 900 nursing homes that have been put on this watch list and are deemed some of the poorest facilities. Designated as a special focus facility requires the nursing home to either fix lapses in care while under increased inspections or be stripped of federal funding by Medicare and Medicaid – a financial deprivation few homes can survive.

The number of nursing homes under special focus at any given time has dropped by nearly half since 2012, because of federal budget cuts. In 2017, the federal government designated 88 nursing homes with this designation and put $2.6 million devoted to fix the issues. But federal regulators identified 435 facilities as warranting scrutiny.

An analysis by reporter Jordan Rau at Kaiser Health News (KHN), found that even with this high-risk designation, many of these facilities lapse back into problems years later. The Centers for Medicare and Medicaid Services (CMS) defends the program saying it is working to ensure nursing homes do not regress in their performance.

Of the 528 nursing homes that graduated from special focus status before 2014 and are still operating, slightly more than half – 52 percent –  have since harmed patients or put patients in serious jeopardy within the past three years, the KHN analysis showed. These nursing homes are in 46 of the 50 states. Some of the nursing homes failed to tell families or doctors about injuries that happened to the patient, gave a patient the wrong medicine, and/or did not stop violent and bullying residents. Years after regulators conferred clean bills of health, levels of registered nurses tend to remain lower than at other facilities, the analysis noted.

With an SFF designation, these facilities receive special attention from state survey agencies with at least two surveys each year (instead of one) and enhanced enforcement activities. While SFFs may not necessarily be the very poorest quality facilities in the country, they are, by definition, among the facilities nationwide that provide the poorest quality of care, according to Medicare. Nonetheless, despite recurrences of patient harm, the federal government has rarely denied Medicare and Medicaid reimbursement. And of course, the consequences for patients can be dire.

Take the case of Parkview Healthcare Center, in Bakersfield, Calif. In 2012, Parkview's history of safety violations led California regulators to issue the SFF designation. After 15 months of scrutiny, the regulators deemed Parkview improved and released it from the extra oversight. But a few months later, 74-year-old Elaine Fisher, who had lost the use of her legs after a stroke, slid out of her wheelchair at Parkview. Afterward, the nursing home promised to place a nonskid pad on her chair, but did not, inspectors later found. Twice more, she slipped from her wheelchair, fracturing her hip the final time. The violation drew a $10,000 penalty for Parkview, one of 10 fines totaling $126,300 incurred by the nursing home since the special focus status was lifted in 2014.

Fisher's remedy, her son-in-law told Kaiser, was to move to a different nursing home for better care. She used to be very involved with friends and bingo at the facility, he said. But "after this whole thing, she has to be on painkillers. She's mainly in her room all the time. It's the saddest thing in the world."

Parkview's owner at the time of the violations, LifeHouse Health Services, did not respond to requests for comment. Dr. David Silver, who purchased Parkview last fall, said he had replaced top management and staff members who resisted a new approach. "We were not happy with the level of patient care," Silver said.

Unfortunately, regulators rarely return to homes on the watch list, instead issuing fines for subsequent lapses. Some nursing homes continue operating despite multiple penalties. Special focus facility status is reserved for the poorest-performing facilities out of more than 15,000 skilled nursing homes. CMS assigns each state a specific number of slots based on the number of nursing homes and then the state health regulators pick which facilities to include.

What is particularly troubling, the Kaiser Health News analysis pointed out, is that more than a third of operating nursing facilities that graduated from the watch list before 2014 continue to hold the lowest possible Medicare rating for health and safety – one star of five. But CMS officials defend the program. They say that nursing homes on the watch list showed more improvement than did comparably struggling facilities not selected for enhanced supervision.

So they improved more than others that are not quite as bad, and that's good enough? Many people still wonder.


Medicare Advantage Patients Leave Seniors Sicker

Some Medicare Advantage (MA) plans may leave sicker patients worse off, according to a new Government Accountability Office (GAO) report. Most of the 19 million Americans that have privately-run Medicare Advantage plans are satisfied with them because they offer good value. These plans try to keep patients healthy by coordinating their medical care through cost-conscious networks of doctors and hospitals.

Critics warn that these plans can prove more risky than traditional Medicare for seniors especially those in poor or declining health or those who need to see specialists – because patients often face hurdles getting access.

GAO researchers looked at 126 Medicare Advantage plans and found that 35 of them had disproportionately high numbers of sicker people dropping out. Patients cited difficulty with access to "preferred doctors and hospitals" or other medical care as the primary reason for leaving.

GAO's findings raise red flags for David Lipschutz an attorney at the Center for Medicare Advocacy, who says the report should prompt more careful government oversight. "A Medicare Advantage plan sponsor does not have an evergreen right to participate in and profit from the Medicare program, particularly if it is providing poor care," Lipschutz told KHN. While the GAO didn't name the specific 35 health plans, it recommended that federal health officials pay attention to large numbers of people leaving their plans as a possible sign of substandard care.

But Kristine Grow, a spokeswoman for America's Health Insurance Plans, had a different take on why people are leaving plans. She said many patients in the study switched from one health plan to another because they got a better deal, either through cheaper or more inclusive coverage. She suggests that MA plans do a better job for their patients than traditional Medicare does, because they want to keep their members long term and by coordinating medical care and offering extra wellness benefits like fitness club memberships.


States Lag in Keeping Medicaid Enrollees out of Nursing Homes

Every day, 10,000 people turn 65 and the eldest baby boomers will begin to turn 80 in 2026, so the demand for long term care services is about to explode in the near future. Already 1.4 million seniors live in nursing home facilities in the U.S. But states are only making lukewarm progress helping millions of seniors on Medicaid avoid costly nursing home care by arranging home or community services for them instead, a new AARP report finds.

Overall, AARP says states have made "incremental improvements" since its 2014 Scorecard, but calls the pace of change "slow and uneven." That's especially disturbing since many state budgets are healthier than they were three years ago.

While most states made modest improvements, "the pace of change is not keeping up with demographic demands," according to the report, which compared state's efforts to improve long-term care services over the past several years. Previous AARP reports on the same subject were issued in 2011 and 2014.

"People need to understand how this is playing out close to them, because changes often occur at the state and local level. There is no national long-term services and support federal policy, aside from Medicaid, which is administered by the states," says Susan Reinhard, senior vice president and director, AARP Public Policy Institute, which produced the report.

AARP ranked state's performance on long-term care benchmarks such as supply of home health aides, nursing home costs, long nursing home stays, the employment rate of people with disabilities and support for working caregivers.

The top-ranking states in the 2017 scorecard were Washington, Minnesota, Vermont, Oregon and Alaska. The states at the bottom were Indiana, Kentucky, Alabama, Mississippi and Tennessee. The most improved states since the 2014 Scorecard were Tennessee and New York. (Here’s a link to the entire chart so you can see how your state did: (

The report did find some progress though. For instance, 48 states (nudged by the federal government), have reduced the use of antipsychotic medications given "off label" for nursing home residents whose conditions don't support their use. The federal government started regulating the use of these medications for dementia patients in nursing homes three years ago.  That's also the same time that nursing homes started getting graded on the percent of their dementia patients receiving antipsychotic medications in Medicare's Nursing Home Compare online tool. (

Another significant area of progress was that 42 states have moved toward person-and family-centered practices that support family caregivers. AARP policy folks suggest that the impetus for this program was the passage of the CARE Act, (which stands for Caregiver, Advise, Record, Enable), which was developed and promoted by AARP.

The CARE Act requires hospitals to record the name of any family caregiver on the medical record of your loved one, inform the family caregiver when the patient is to be discharged and also provide the family caregiver with education and instruction of medical tasks he or she will need to perform the patient at home.

A downside of the Scoreboard report was a significant decline in the number of states where long-stay nursing home residents on Medicaid moved back to living in their communities. That number is now down to just 21 states. The top states are Utah, Oregon, Washington, Arizona and Idaho, where 12 percent of long-stay nursing home residents, on average, transitioned back to the community.

The report found wide discrepancies in how much state Medicaid spending went to long-term care directed to home- and community-based services for elderly and disabled adults in 2014, the latest year for data covering all states. Minnesota, the top-ranked state, spent about 69 percent, but Alabama, ranked last, spent less than 14 percent. Nationwide, the average ended up from 39 percent in 2011 to 41 percent in 2014. Only nine states and the District of Columbia spend more on home-and community-based services than on nursing home care, the report found. These services included home health care, caregiver training and adult day care.

AARP's Reinhard noted many states have struggled to expand home-based and community-based options for Medicaid enrollees needing long-term care because that is an optional benefit, while nursing homes are mandated under federal law.


Also contributing to this column were Kaiser Health News (KHN), Twin Cities Public Television and AARP.

Alan Schlein runs, an internet training and consulting firm. He is the author of the bestselling “Find It Online” books.

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