------------------------------------------------------------------------------ NewsBank, inc. - The Commercial Appeal - 1998 - Article with Citation ------------------------------------------------------------------------------ Headline: NURSING HOMES They're better, but state can't relax vigilance Headline: FEWER FINES ARE PUZZLING: IS CARE BETTER OR IS PUBLIC BEING DUPED? Headline: CARE NOT AS GOOD AS IT LOOKS, CRITICS SAY. FINES, THEY SAY, TOO OFTEN DROPPED WITH LITTLE CHANGE Date: October 25, 1998 Section: METRO Page: B 1 Edition: Final Dateline: MEMPHIS Author: Marc Perrusquia The Commercial Appeal Index Terms: NURSING HOMES MEMPHIS DISABLED Text: Headline: NURSING HOMES They're better, but state can't relax vigilance WHY ARE state regulators assessing far fewer fines and other citations against the 34 nursing homes in Shelby County than they did just a few years ago? Has the quality of care these homes provide their elderly and frail residents improved that much that quickly, as nursing home industry officials assert? Or has the politically influential industry, which makes generous campaign contributions to Nashville politicians of both parties, persuaded the state to go easy on inspections - and to block alternatives such as home-based long-term care - as advocacy groups argue? A special report that begins today in The Commercial Appeal, "Nursing Homes: Challenged Care," suggests that the answer to both questions may be yes - in part. For Tennessee families who must contemplate placing a loved one in a nursing home, the overall quality of care in the state is still not where it needs to be. Until it is, the state cannot relax its vigilance in inspecting the state's 350 nursing homes, maintaining standards, securing correction of deficiencies, and fining offenders. It cannot defer those responsibilities to Washington or to the homes themselves, despite home operators' complaints of overregulation. If state regulators need more money to pay for an expanded inspection system, that would seem an investment in the quality of life of older Tennesseans. State and federal enforcement policies generally are aimed less at punishing nursing homes for poor conditions than at encouraging them to improve. They also tend to concentrate on a few immediate, major or chronic violations rather than a lot of smaller ones. Regulators say such an approach has greatly diminished the abuses that previously afflicted many homes, locally and across the state: patient injuries and neglect, misuse of restraints and drugs, unsafe and unsanitary conditions. But the newspaper's investigation found recent examples of unacceptable care that would seem to warrant stronger sanctions than were imposed. In some cases, critics say, second-chance enforcement policies allow nursing homes to paper over dangerous problems temporarily instead of correcting them permanently or working to prevent them. A recent federal report concluded that Tennessee rarely cites nursing homes for substandard care. The state generally avoids levying fines against homes that also are subject to federal sanctions. Fines should not be used primarily as a revenue-raising device. Yet there seems no reason that the state cannot levy its own financial penalties against nursing homes that violate accepted standards, independent of what the federal government does and without waiting for federal approval. At the same time, some problems affecting Tennessee nursing homes are not essentially matters of government regulation. Proprietors of many for-profit homes insist they are hemmed in by tight budgets, increased competition from so-called assisted living facilities, the effects of stock market changes on their parent companies, and what they say is inadequate federal aid from the Medicare and Medicaid programs. These constraints force nursing homes to pay workers low wages, despite the difficult, stressful and often unpleasant nature of the jobs, operators argue. That can make it nearly impossible to attract and keep qualified and well-trained employees, especially registered nurses. If state or federal agencies seek to mandate greater staffing by licensed or registered nurses at nursing homes, it would seem reasonable to earmark enhanced public funding for that purpose. Such circumstances make it incumbent on families to investigate nursing homes thoroughly before committing relatives to their care, and closely monitor the quality of - and even participate in planning - that care. But they have a right to expect that the state agencies that license and inspect nursing homes will do their part to protect residents as well. Until the state provides adequate financial support for home-based long-term care, Tennessee will continue to rely disproportionately on nursing homes to care for its elderly citizens. That situation calls for a regulatory system that is as unobtrusive as possible, but as tough as necessary. That system has yet to be realized. Copyright 1998 The Commercial Appeal, Memphis, TN Headline: FEWER FINES ARE PUZZLING: IS CARE BETTER OR IS PUBLIC BEING DUPED? State regulators are reporting few problems in Shelby County nursing homes and are handing out even fewer fines. Whether that's the result of lax enforcement, as critics contend, or the fruit of improved care, the situation has created a fierce debate. Critics also claim nursing home interests, which contribute heavily to state and local politicians, have compromised state enforcement. Industry spokesmen deny they wield such influence and say they are simply participating in the electoral process. "We don't have any undue influence whatsoever," said Richard Sadler, executive director of a group that represents most of Tennessee's 350 nursing homes. Whatever the reasons, annual inspection reports show violations in Shelby County's 34 licensed nursing homes have slowed to a trickle, down by three-fourths since 1996. For a synopsis of the most recent deficiency reports, visit The Commercial Appeal's Web site: http://www.gomemphis.com Fines, which once averaged eight per year in the county, have dropped to about one a year, though individual dollar amounts are much higher. Some nursing homes have avoided paying any fines, despite deplorable conditions, under a federal second-chance policy. A handful of states, including Tennessee, rarely cite for substandard care - a severe violation that nursing homes dread, a federal study says. Improved care alone cannot account for such drops, a federal regulator said. While questions about enforcement abound, a three-month examination by The Commercial Appeal found that, overall, nursing home conditions have improved in recent years. Gone for the most part are the injuries, filth and overuse of mind-numbing drugs that evoked public horror in the past. One of the biggest challenges facing nursing homes is retaining qualified staff in order to offer quality care. Certified nurse aides provide most of the care nursing home residents receive, yet starting pay for many is only slightly better than minimum wage. Although they are considered unskilled laborers, aides must take 75 hours of training and pass a state test. Job turnover approaches 100 percent at some homes. And Tennessee lags other states in requiring longer duty periods for registered nurses to help stabilize nursing staffs. Stories today and Monday explore these issues and offer tips on choosing a home. By Marc Perrusquia Copyright 1998 The Commercial Appeal, Memphis, TN Headline: CARE NOT AS GOOD AS IT LOOKS, CRITICS SAY. FINES, THEY SAY, TOO OFTEN DROPPED WITH LITTLE CHANGE If nursing home conditions are truly improving, Donnie Burch should know. He's spent the past decade in nursing homes since breaking his neck in a car wreck. "They've got a stressful job,'' Burch, 47, said of his caregivers at county-owned Oakville Health Care Center. This is Burch's second nursing home: He spent eight years at Shelby County Health Care Center. "It's a much neater place than when I first came there,'' he said of Shelby. But is patient care improving? Does the staff really help patients? Burch shrugged, then shot a knowing glance. "Some of them are true-blue dedicated to their patients,'' he said. "Others are making a paycheck.'' Nationwide, residents, reform advocates and government officials also are pondering the quality of nursing home care as government inspectors report sharp declines in violations. In Tennessee last year, about 1 percent of the state's nursing home inspections reported severe findings known as substandard quality of care, a federal study found. The percentage was down from 13 percent in 1995. A substandard care designation triggers automatic sanctions. For example, a nursing home can lose the right to train nurse aides for two years. Physicians and the nursing home administrator licensing board also are notified. A similar decline in substandard-care findings and other violations has occurred locally, state inspection records show. In 1996, Tennessee Health Department inspectors found on average more than 12 violations in the delivery of patient care at each of Shelby County's 34 nursing homes. This year, they are uncovering about three violations per home. Increasingly, inspectors are filing reports with no violations. "Enforcement has all but collapsed in the state," charges Gordon Bonnyman, an attorney for the Tennessee Coalition for Nursing Home Reform. Richard Sadler, executive director of the Tennessee Health Care Association, attributes declining violations to improved care and sensible policies that focus regulation on severe problems, not petty ones. Improved care alone, however, cannot account for such a drop, said Marvin Feuerberg, an analyst with the U.S. Health Care Financing Administration (HCFA). Nursing homes that receive Medicare and Medicaid funds operate under HCFA (pronounced hick-fah) rules. States, which license nursing homes, enforce those rules. "It's gone down to virtually nothing," Feuerberg said of Tennessee's declining substandard care findings. "We find it extremely implausible that the quality of care in any state could have improved to (that) point." So does Sandy Smegelsky, who regularly witnesses nursing home conditions in her role as the Memphis representative of the Tennessee Long-term Care Ombudsman Program. Smegelsky, whose job is funded through the federal Older Americans Act, hears complaints on care and helps resolve disputes. "They just slacked off, I'm sorry," Smegelsky said of the state's nursing home enforcement. A chief concern involves a substantial drop in the number of fines issued statewide and in Shelby County since 1995. Facing growing calls for reform, state officials say they plan to beef up enforcement and levy more fines, but some question whether the state could have done more earlier. "I know we have a lot of problems out there," Smegelsky said. "I just find it hard to believe that everything's gotten to be real hunky-dory and no fines need to be handed out." Big drop In some instances, decreases in reported violations have been dramatic. At Graceland Nursing Center, for example, inspectors in 1996 wrote up nearly 40 violations, called deficiencies, in a hefty 66-page report. Deficiencies that year ranged from improperly tying down a patient's hands to accuracy problems in patient records. Inspectors also reported dirty linens, strong urine smells and inadequate care on weekends, when some patients were left in bed for days. In a two-page report last year, inspectors listed one deficiency at the 240-bed home on Farrow Road. The finding involved a series of minor, yet potentially life-threatening problems in the care for seven dialysis patients. "We made great strides and improvements," said Allen Curtis, management division vice president at ServiceMaster Diversified Health Services, the for-profit firm that manages Graceland. A change in administrators and more staff training has helped reverse fortunes at the facility, Curtis said. Overall, disagreement is wide on why the number of deficiencies is dropping. Judy Eads, Tennessee's assistant health commissioner, said she's aware generally that reported deficiencies are down statewide but said the situation hasn't been studied. Industry spokesman Sadler interprets the trend as a reflection of improved care. He's proud of federal statistics that show 33 percent of all Tennessee nursing home inspections last year revealed no deficiencies. Nationwide, 23 percent of inspections in 1997 were deficiency-free. "We're doing a better job," he said. "I don't want to suggest to you that the nursing home industry doesn't have problems. It has problems every day. But maybe we're doing a better job." Federal officials agree nursing homes are better but question whether states are properly scrutinizing conditions to protect residents. In a July report to Congress, HCFA urged more reforms, finding that too many nursing home residents suffer from bedsores, malnutrition and dehydration. The report found that state-run inspections are too predictable, noting that a handful of states, including Tennessee, rarely cite nursing homes for substandard care. HCFA will target states with weak inspection systems. States that can't properly enforce federal regulations will lose inspection contracts, and HCFA will contract with "other entities" to "do the job right," HCFA deputy administrator Michael Hash said. In response, Tennessee began Oct. 1 retooling inspector workweeks to give them time to focus on individual homes, Eads said. The state also plans to crack down on repeat offenders and conduct more weekend and evening inspections, Eads said. The inspection changes could trigger a request for a budget increase, she said. No state fines The state also is seeking permission from HCFA to resume levying state fines. The state stopped issuing fines on federally regulated homes in 1995 when HCFA required states to use its fine schedule. Reform advocate Bonnyman said Tennessee could have been levying its own fines as well as the federal fines and does not need federal approval. From 1992-94, the state fined as many as 60 nursing homes a year throughout Tennessee. In Shelby County, the state handed out 26 fines in the period, ranging from a $1,000 assessment against Allenbrooke Health Care Center for alleged neglect in 1993 to $225 against Methodist Hospital Skilled Nursing Facility for improper medicine storage in 1992. Since 1995, Tennessee has reserved state fines for six nursing homes that are not governed by HCFA rules because they do not participate in Medicaid and Medicare. Only about seven federally required fines are levied annually statewide, records show. Four Shelby County nursing homes have been fined since 1995 under this system. Included among those fines: - A $4,350 assessment this year against Senior Care Inc., 1279 Peabody, where inspectors uncovered housekeeping troubles. - A recommended $51,500 fine in 1996 against Allen Morgan Nursing Center, 177 N. Highland, for problems with dietary services and quality of care. Allen Morgan disputes the fine, and it remains unpaid. In a March 24 letter, Tennessee Health Commissioner Nancy Menke told HCFA the state stopped levying its own fines three years ago because ". . . it was thought that the federal enforcement program was more strict and thus would include most if not all areas addressed in the state statute. "Time and experience has shown this is not the case." The state is waiting for a response from HCFA, Eads said. Some states, like Washington, already levy state fines without HCFA approval. "We don't have to ask anybody permission to use our state law," said Joyce Stockwell, administrator of nursing home quality for Washington's Department of Social and Health Services. Washington state does not levy federal fines in addition to state fines, but it could if it wanted, Stockwell said. The state considers its fines tough and aggressive - nursing homes can be charged up to $3,000 per violation. And unlike federal regulations, Washington's rules don't allow homes a chance to correct problems to avoid the fines. Second chance Despite deplorable conditions, some Shelby County nursing homes were never fined under a federal policy that gives them a chance to correct problems to avoid sanctions. Among those that didn't pay fines is Allenbrooke, 3933 Allenbrooke Cove, where inspectors in January found 11 violations, including a failure to properly treat bed and pressure sores. Inspectors identified 19 patients with pressure sores. Patients with sores did not receive adequate care, an inspection report said, listing a number of hygiene problems, including strong urine odors, dirty hair and fingernails and soiled bedding. Allenbrooke administrator Jeff Adams said the problems detected in January have been corrected. "We have made a lot of progress," he said. Adams doesn't agree with critics that enforcement has gotten lax. "I found the (inspectors) did a very thorough job," he said, calling nursing homes one of the more heavily regulated industries. Also not fined was Graceland Nursing Center despite reports of more than 30 violations in 1995 and again in '96. Under federal rules, if nursing homes correct problems by the time inspectors return for a follow-up visit, no fines or other penalties are imposed. This "free bite at the apple" perturbs critics. Reformers say prevention should be just as valued. Memphis ombudsman Smegelsky complained that a deficiency involving a potential wound was downgraded last December by survey supervisors visiting the county-owned Shelby County Health Care Center at 1075 Mullins Station. The report cited two residents lying on cloth pads saturated with urine, which could increase the risk of infection. The score gauging the severity of the deficiency was lowered to a level that did not trigger a penalty, Smegelsky said. Improvements The Clinton administration announced plans last summer to remove the free bite for serious offenders. "Enforcement efforts have focused on letting facilities correct problems to avoid sanctions. Far too often, improvements have been only fleeting," HCFA deputy administrator Hash told the Senate Special Committee on Aging in July. "Far too often follow-up surveys find residents in real danger once again." The administration plans changes in the coming months, Hash said. Repeat offenders no longer will receive a grace period but will face immediate sanctions. In its July report to Congress, the administration underscored improvements nationwide, including reductions in the overuse of anti-psychotic medicine and physical restraints, as well as a drop in the misuse of urinary catheters. Nursing home owners point to the same improvements. But critics and owners differ sharply over whether inspectors are truly reporting deficiencies. One concern involves an "outcome-oriented" enforcement approach, which holds that if a violation does not harm a resident, there should not be a severe finding. "We have a system that is looking not at the insignificant but the significant," said Sadler. By Marc Perrusquia Copyright 1998 The Commercial Appeal, Memphis, TN To reach reporter Marc Perrusquia call 529-2545 or E-mail perrusquia@gomemphis.com Copyright 1998 The Commercial Appeal, Memphis, TN Accession Number: 9811260146 ------------------------------------------------------------------------------