Source: Long Beach Press-Telegram
California’s nursing homes have received $880 million in additional funding from a 2004 state law designed to help hire more caregivers and boost wages.
But 232 homes did just the opposite. They either cut staff, paid lower wages or let caregiver levels slip below a state-mandated minimum, a California Watch investigation has found.
The homes that made these cuts collected about $236 million through 2008, the last year of available data. That’s more than a quarter of the total Medi-Cal funding increase shared by the state’s nursing homes. But the law that made the extra money possible included few safeguards to ensure that patient care improved.
Many nursing homes appeared to use the cash infusion to help bolster their bottom lines, according to a California Watch analysis of state nursing home data. Among the 131 homes that cut staff by 2008, the median profit was 35 percent more than other homes in the analysis.
At the same time, the analysis shows, about two dozen homes that made the deepest caregiver cuts had about one-third more deficiencies than other state facilities. State inspectors noted a litany of violations that included neglecting bedsores and giving patients the wrong drugs.
“There was an implicit good faith agreement that things would get better and that was broken,” said state Sen. Elaine Alquist, D-Santa Clara, chairwoman of the Senate Health Committee. “It was broken for the people of California and for a very vulnerable population – those that need the greatest care and those that can’t advocate for themselves.”
James Gomez, the chief executive of the state’s nursing home trade organization, said the 2004 law has led to a 5 percent increase in staffing rates for the state’s 1,100 nursing homes and an overall decline in turnover among caregivers – from 54 percent to 47 percent. California’s homes now exceed the national average for meeting the staffing minimum, Gomez added.
“Is it working in every facility every day? No,” said Gomez, leader of the California Association of Health Facilities. “But is it working in total? Absolutely.”
Of the homes that cut staffing, 13 owned by Orange County-base Covenant Care stand out. The homes pared caregivers even as they got $15 million in additional funding.
The average profit at those 13 homes reached more than $900,000 in 2008 – three times higher than the remaining 632 homes analyzed by California Watch.
The chain’s chief operating officer testified last year in a deposition that part of the company’s business plan called for housing more medically fragile patients. The strategy opens the door to higher reimbursements, according to critics, who say it can be dangerous to combine lower staffing rates with patients who need more attention. Patients such as Charles McGrew. The Texas-born janitor was admitted to the chain’s Long Beach home, Royal Care Center, in early 2006.
McGrew, a diabetic with high blood pressure and a history of infections, began to develop pressure sores on his ankles and tailbone at the home. But little was done to help him, according to court records filed by his family. One sore got so deep it exposed the bone. Another became severely infected, court records show.
Meredith McGrew, 24, said one sore was like a hole in his father’s back. Seeing it pained the younger McGrew, who remembers his father as a meticulously neat man.
“My family took it really hard,” McGrew said. “My father was the one who looked out for a lot of them and raised them, so they were devastated by the care he was getting.”
McGrew’s left leg needed to be amputated due to one sore, the family alleged. When he died three years ago at age 70, McGrew’s family blamed his death on mistreatment. Attorneys for Covenant said the family failed to prove that the facility caused McGrew’s problems. The case was settled and the terms are confidential.
Since his death, the home’s staffing level sank below the state-mandated staffing minimum set in 2000. Royal Care’s total profits, though, reached $540,000 in 2008 alone.
The Covenant Care chain, meanwhile, rewarded top administrators and nursing supervisors with bonuses based, in part, on how much profit each home generated, records show. Around the same time, a family trust associated with the company’s CEO, Robert Levin, paid $4.76 million to purchase an Irvine estate, complete with a theater and outdoor living room.
Levin would not comment about funding and staffing levels for this article. He asked in January for questions to be sent to him in writing, but he did not respond to the written questions or several follow-up phone calls. When finally reached by a reporter late last month, Levin again declined to comment.
The funding increases for nursing homes were made possible by the 2004 law that helped the state draw more money out of Washington, D.C., gradually boosting government spending from $3 billion in 2004 to nearly $4 billion in 2008.
The infusion of state and federal money has done nothing to slow the pace of violations and complaints.
State regulators documented nearly 1,000 deficiencies for inadequate care in 2008, a 65 percent increase compared with 2005.
Regulators maintain that the state hired more inspectors, which may account for the increase. But that doesn’t explain the 23 percent rise in complaints filed by patients, advocates or their families.In 2004, before the law was enacted, nursing homes registered 4,499 complaints. In 2008, patients, their loved ones and advocates filed 5,549 complaints.
Despite mounting complaints and citations, state officials in charge of carrying out the new law granted nursing homes a powerful weapon to fight claims of inadequate care: more money. They allowed homes to bill the state for legal costs spent to fight fines, citations and lawsuits alleging abuse and neglect.
“The policy is outrageous,” said Michael Connors, an advocate with California Advocates for Nursing Home Reform. “By paying the legal fees of nursing homes that are neglecting and abusing residents, the state is subsidizing their mistreatment. They’re directly undermining the whole purpose of the citation and enforcement system.”
State officials could not identify exactly how much they spent reimbursing nursing homes to fight penalties. But records show that since the 2004 law passed, nursing homes are challenging twice as many citations. Homes challenged 110 citations in 2005 and more than 220 in 2008, records provided by the Department of Public Health show.
Oversight lacking
The Nursing Home Quality Care Act of 2004 was designed to fix a glaring problem: Daily Medi-Cal rates paid to nursing homes in California were among the lowest in the nation.
An alliance of labor leaders and nursing home owners came up with a plan that wiped out a flat-fee system and replaced it with one that reimbursed nursing homes based on their costs.
The system allowed nursing homes to boost the amount of matching funds they got from the federal government. The homes first pay a fee to trigger the matching funds and additional revenues.
Not all homes benefited as much as others. Some homes even lost money, especially ones that serve fewer Medi-Cal patients. But most of the state’s homes analyzed by California Watch drew a windfall of new money.
Homes could spend the new money on a variety of services. But reimbursement rates increased if they spent the money on labor. Homes also got additional bonuses meant to boost hiring and wages.
Patient advocacy groups cried foul over the added payment, noting the nursing homes could ultimately spend it any way they wanted. And some advocates bristled over the lack of get-tough measures in the proposal. The California AARP ran full-page newspaper ads that said, “No blank check for bad nursing homes.”
Still, the bill flew through the Legislature. When Gov. Arnold Schwarzenegger signed it, he directed the Department of Health Services to “reward quality care.
“We are making this investment in nursing facilities to ensure better care, and I intend to hold the industry and caregivers accountable for this critical responsibility,” Schwarzenegger’s 2004 signing statement said.
Despite the governor’s directive, the Schwarzenegger administration failed to follow through. Instead, California Watch found, state regulators lavished new money on homes where findings of lax care mounted, where administrators failed to pay fines for poor care, and where corporate executives cut staff in California and expanded chains elsewhere.
The Governor’s Office declined to comment for this story, referring questions instead to agency officials.
Toby Douglas, chief deputy director for health care programs at the Department of Health Care Services, conceded that some homes may have cut staff. But he said that most have invested more heavily in caregivers. His office repeatedly attempted to route questions about nursing home accountability to another state agency that inspects the homes.
While Douglas’ agency sets rates and reimburses nursing homes, a second agency, the Department of Public Health, issues and collects fines for substandard care. Even if one agency cites a home for egregious and repeated violations, the other agency may reward it with more funding.
“Our responsibility is to develop a rate method that tries to meet the goals the governor laid out in his signing message,” Douglas said. “That means we have to set a methodology and hold that methodology accountable. In that area, yes, we believe we’re doing a good job.”
Douglas said the Governor’s Office has “made it clear that (the funding law) could be improved” by linking nursing home pay to factors such as patient satisfaction, reduction of bed sores or payment of fines for inadequate care. His department is in the “very preliminary” stages of creating such a system, Douglas said.
The revenue increases to nursing homes were not renewed last year due to opposition from patient advocates, but nursing home executives have been pushing to restore the funding. Alquist, the state senator who heads the health committee, says the law will be scrutinized during a scheduled legislative review this year.
Staffing lags
The Golden State has about 1,100 licensed nursing homes that each year care for an estimated 100,000 people – including the elderly, disabled and those recovering from surgery.
California Watch reviewed financial and staffing data for the 645 nursing homes that serve the largest number of low-income Medi-Cal patients who need 24-hour care. The 2004 law was set up to benefit these homes the most.
Of that group, 232 homes either cut staffing or wages or fell below the statewide staffing minimum – even as they received more money from Medi-Cal. The analysis found that 27 other homes fell behind in wages and staffing but saw a reduction in funding.
Since the legislation was enacted, the California Department of Health Care Services gave the 645 homes analyzed by California Watch a total funding increase of nearly 25 percent over five years
But the lowest-paid workers who perform the vast majority of the patient care in nursing homes did not see that kind of raise. Only 76 homes in the state gave nursing assistants a 25 percent pay increase. Adjusting for inflation, average wages in more than 400 homes went down, the California Watch analysis shows.
In 2008, dozens of homes also operated beneath the decade-old staffing standard – which is set at three hours and 12 minutes of caregiver attention a day for every nursing home patient. At Cloverdale Healthcare Center in Sonoma County, staffing was down 8 percent in 2008 compared with 2004, despite the home’s $1 million increase in state funds. Regulators found problems there in the beginning of 2009, including one patient who had been left wearing a dirty diaper for five hours.
Cloverdale officials did not return calls seeking comment.
New Jersey home health care providers, and others like it are benefiting from the shift from long-term care to home-based care. But across the country, from Ocean County NJ house call doctors, and in-home care providers in Texas, everyone is uncertain about the future of medicare funding and reimbursements under guidelines set out in recently passed healthcare reform legislation.
Gomez, of the California Association of Health Facilities, said the state should aggressively investigate the homes that operated in 2008 with staffing levels below the state standard.
“I don’t have an issue with them looking at those facilities today,” Gomez said of the 68 homes below the nursing-hour minimum. “That would be the right thing to do.”
The state, however, has not issued staffing-related fines to any of the homes that failed throughout 2008 to reach the minimum staffing level, records show.
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My Take: Nursing homes have to be among the most depressing places on the planet, unless you’ve got the luxury of putting a relative in one that costs a fortune. I’d rather take a five week course on how to pick locks or work for minimum wage for a computer service provider than work in a nursing home. I frankly don’t see how people do it. I know they are a necessary part of our society, as most people can’t afford in-home care or a fancy “rest home” as they used to call them back in the day. But so , many of them are smelly and dingy and seem neglected from the aesthetic perspective, and I wouldn’t want to have to visit a relative in one if there were other choices.
But what choice do we have if we are among the low-wage earners who for example, sell lockpick tools or do provide that computer help in New York? We rely on the government for support and when we do that, we have to take what we can get.
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