Nursing homes operate on the honor system - pretty much the same way that all medical care is provided.  They are able to put their own spin on anything, making it difficult to hold them accountable.  
     Take a recent family member's situation.  He was in his mid 50's, with one leg amputated and in need of 24-hour care.  When we walked into the room to visit him, the staff was rude as hell.  One nurse threw away the power of attorney (healthcare) form he had completed and the family had to scramble to get another one faxed to them when he was signed onto hospice.  The nursing home social worker then refused to honor the document and completed another one with him, naming a friend as his decision-maker - even though he wasn't able to make decisions at that point.  They treated the family like shit, gave him full meals even though he had no teeth and was dying.  We walked into the room to find this cold meal:

He had bedsores, he was in pain and the staff was apathetic, and when I pointed out he wasn't able to eat the meal (above) they told me that "dietary services decides who gets what."   I pointed out to them that not only was it obvious the food had been sitting there for some time and he wasn't able to chew it, the grizzle on the meat was disgusting and inedible.  They told me it wasn't their problem and pretended to take a phone call.  
     Another friend had a family member there and they said that their experience was worse - and that they hadn't had one positive encounter with the staff there.  This nursing home received a "Two star = below average" rating from Medicare.  Yet it receives the same reimbursement from Medicare and Medicaid and other than paying a few fines, are allowed to continue to provide shitty-ass care.  It's cheaper to pay the fines than it is to provide quality care from caring professionals. 
  This week's theme is HMO's and nursing homes.  HMO's are Health Maintenance Organizations, and they are a method of holding down costs.  The government pays the HMO a set amount every month for each patient enrolled, and the HMO is also given bonuses for getting good grades and extra money for the super expensive patients.  Plus they receive grants for other stuff like upgrading equipment, teaching, etc.  Yet in many areas, HMO premiums have sky-rocketed. 
     But does all that money translate into better care for the patients?  Nah.  
     Let's take a look at nursing homes and HMO's.  If a patient who has Traditional Medicare A&B is admitted to a nursing home, Medicare pays in a very bizarre way for the patient to receive rehabilitation services and medical care.  That's another story for another time.  However, It's substantially easier to be admitted to a nursing home under Medicare Part A than it is to be admitted with an HMO.  Nursing homes have the freedom to provide as much therapy as they can for as long as they believe that the patient is benefiting.  I've seen this abused, but for the most part the patients benefit from the care.  
     HMO"s require preauthorizations and weekly updates for each patients - and they funnel their patients to contracted facilities rather than ones that are convenient to the patient and family.  If the patient isn't doing well enough in the case manager's opinion, HMO's terminate the services.  I've seen HMO's force patients to be discharged home even though there was no caregiver available, with little or no notice.  But that's not all.
    Nursing home patients with HMO's who are there for the long run are often required to go out to medical appointments even though there is a doctor willing to see the patient in-house. They micro-manage patient medications and make it difficult to receive ongoing therapy to keep the patient at their level of functioning (provided by Medicare Part B on the Traditional Plan).  
     And patients can only go to nursing homes that are contracted with the HMO. In small towns that might not be a problem - but in a larger town, the nursing homes that contract with HMO's are often the ones that are least desirable.  In my city, the company that contracts with HMO's has the very worst of care (as reported by Medicare).  They smell like urine (my observation), are not as nice as the other facilities and the care is left to be desired.  The company rakes in profits but rarely do they trickle down to paying for upgraded facilities and better trained staff.  The buildings are elderly and the air conditioning systems barely work - but patients continue to be shoveled there by HMO's.
    Patients who have HMO's have a tough time being admitted to the better nursing homes (even if they have a contract) because of the hassle of dealing with the HMO's.  
     HMO's might be the right choice for the senior who wants to save money, but limited physician choice, facility choice, less than desirable care and denials for services might make you think twice before you choose to enroll in one.  
The links on the front page today are all about Private Guardianship in Nevada.  The laws in Nevada are pretty lax - and I've heard that they're much the same in other states.  This opens the door to abuses such as those discussed in the links.  The courts require that Guardians submit annual accountings of how monies were spent - but they don't enforce this rule.  Nor do the courts question the charges, which are supposed to be reasonable.  

Essentially, all it takes in Nevada to become a Guardian is to pass a test and be able to show up in court.  One of the links (Ripoff Reports) discusses the hearing master flirting with a Private Guardian and totally ignoring the objections of the Ward's family.  And it gets better: one of the court-appointed Guardians actually charged his Ward thousands of dollars to read the complaints on the Ripoff Reports website.  He threw all of his business to one law firm and paid them extremely well for helping to strip people of their rights.  Not sure what the lawyer was doing the day in school that they discussed abuse, exploitation and 

The abuses have been ongoing for years, and only after a local newspaper wrote an investigative report did the courts even acknowledge there are problems with the system as it currently exists.  Hopefully this shit will be addressed and some real change will take place - and it's important to acknowledge that not all Private Guardians are worthless slime who view their Wards as little more than a mean ticket (in the most expensive of restaurants...).  I've met a few who are ethical, moral people who strive to help seniors and handicapped Wards have a better life.  

Read the links - all of them - and feel free to post some comments here.  I love  hearing what you h

Healthcare providers compete for your healthcare dollars.  Every large city - and even the smaller ones - have multiple providers.  Take home health care and hospice providers, for example.  It seems like anyone can open a company, and they'll receive most of the referrals from their medical directors.  If they'e small enough to be flying under the radar of the Medicare auditors and have little or no ethics, they can pay kickbacks to private companies (group homes, professional case managers) and they'll get even more patients.
     Home Health providers make their money by providing skilled care to patients who need it.  If they can get a doctor to prescribe the care, they can fake all of the documentation necessary to bill thousands of dollars for care they never provided.  Years ago, one of my patients told me that an occupational therapist would come to her house and eat lunch with her and call it therapy.  She was happy to have the company, and when she was told that this was fraud she was afraid she'd get in trouble so so she refused to report it.  I hear rumblings about kickbacks, where companies give cash for patients.  It's wrong, it's illegal, but with all of the budget cuts from the recession there's no one watching to ensure this doesn't happen.
     Kickbacks can be in cash, or in the area I'm most familiar with it's common for group homes to use the supplies the hospice provides for all of their patients.  This can save the group home thousands of dollars each year in the cost of supplies (briefs, underpads, gloves, etc).  This makes it more difficult 
for those providers who operate lawfully to receive referrals - even if they're serving a patient once he moves into a group home it's common for the operators to have the patients transfer to the hospice of their choice - the one that gives them the most money or supplies.
     Companies bad-mouth each other, complain about workers who won't cooperate with their tactics, and if they're caught they either sell out or shut their doors.  Not every company operates this way, but plenty of them do.  
     I worked for a nursing home where the administrator would only allow referrals to a couple of home health or hospice providers - and if the patients chose not to use those companies the administrator conducted a witch hunt.  My first week on the job she bragged about firing all of the housekeepers on one hallway because patients from that hall chose another provider when they left.  I lasted 4 months in that job before I was "suspended" for narc'ing on her to corporate and to the state - but if you believe that this isn't going on all across the country, you are sadly mistaken, my friend.  Fraud happens anywhere.
     You have a choice in healthcare providers; make your own decisions and don't allow anyone to force you into accepting care you don't want or need.  
You might notice a common theme with this week's links - fraud.  Whether it's Medicare Fraud, Medicaid Fraud, or Exploitation of the Elderly, it's everywhere.  Whatever happened to honesty and helping people?

One of the links refers to "over payments" one company billed over the past year to Medicare - $35 MILLION DOLLARS in over payments.  Many Nursing Homes don't employ their own therapists, they contract with professional rehabilitation companies, which is the business model for RehabCare. Since Medicare pays close to $1,000 per day for a senior to receive the maximum amount of therapy possible for a nursing home patient, is the goal to perform as much therapy as possible or to help as many patients as possible?  

I've been present when patients are goaded into receiving more therapy, being forced to stay longer in a nursing home than they wanted to, simply because the patient had "days" left (Medicare pays up to 100 days in a skilled nursing facility).  If a patient has payment left, they'll receive rehabilitation whether or not they want it (and even be threatened with a report to Elder Protective Services if they want to leave before the nursing home wants them to.   But if the patient is out of "days," the nursing home will dump them out as fast as they can.  I've also seen more than my share of dying patients being forced into therapy because Medicare doesn't pay for a patient to die in a nursing home, only to receive physical therapy.

The amount of therapy provided to a patient is at the sole discretion of the rehab company; the more minutes billed, the more Medicare pays.  The system is flawed, because the chances of Medicare identifying fraudulent billing practices are pretty slim - and $35 million dollars is a drop in the bucket compared to the hundreds of millions of dollars that Medicare pays for therapy.  It's better to keep on keeping on the way they have been.  

I've seen a lot of rehab in my day, and whether it's under the Part A or Part B programs, Medicare is paying a shitload of money for therapies that often don't make a bit of difference to the patients.  Rehabilitation can be helpful, but when a company can repay $35 mill and not bat an eye, there's something wrong.  
I am part of the professional community that is able to place patients on a psychiatric hold against their will for up to 72 hours. To qualify for the free stay in a hard bed with shitty-ass food, they need to be a danger to themselves or others. A few years back I worked for a nursing home and the administrator wanted me to send a woman with dementia out to the psych hospital so that they could hold her for three days. After that, she would qualify for Medicare to pay $800 per day for her to receive physical therapy, occupational therapy and speech therapy. It didn't matter that she lacked the cognitive ability to retain anything that she might have learned and that the therapies wouldn't make a bit of difference because they weren't at all necessary... so I refused to sign the forms. She yelled at me, then threatened me with my job. She also threatened to file a report against my professional license. She insisted that the patient might wander out the front door into traffic - which doesn't constitute a "danger to herself or others," (although it did say a lot about a nursing home that admitted a patient who wandered without the ability to monitor her whereabouts). But I digress - her threats didn't work.

For those of you who are movie buffs,,. think of the bank scene from "Leaving Las Vegas." I simply couldn't sign the forms.

The Administrator got a nurse to sign the forms, sentencing the patient to 3 days in a psych ward, and in appreciation she suspended me a couple of weeks later. She was fired soon after that, after I reported her both to the company and to the State for her behaviors.  But she still works in the industry, ruining people's lives and controlling the elderly by ignoring their rights and treating them subhumanely.  It just ain't right.


Financial Exploitation of the Elderly

Financial Exploitation is a complicated issue.  My experience has been that the police often view this as a civil matter, which means that there is no one to stop a person from draining a senior's bank accounts while the case winds its way through civil proceedings.  I've seen people scam seniors out of hundreds of thousands of dollars because of this.
     This is frustrating for social workers.  If we're lucky, we can get the banks to freeze accounts while it's figured out - which makes it harder for the senior to pay his bills, considering his monies aren't available to him either.  And that doesn't even take into account that "while it's figured out" could be years, could mean the senior going through mental evaluations, possible guardianship, nursing home or assisted living placement - all at their own cost.  If the suspected exploitation doesn't get them, the cost of proving that they are competent to make their own decisions will.  And if a Court-appointed guardian is allowed to act however they want to, the senior is victimized repeatedly.  
    The elderly are easy targets - but it needs to be easier to help them from being victimized by the system all over again.  Below is an excellent example of the system working against the seniors.  I invite you to read all of the links provided in these stories.  It'll curl your hair.
Public Guardian Retires in 2002, Editorial Says Time to Clean House
Public Guardian Opens Private Agency, Multiple Complaints of Exploitation.  

     A nursing home I know of has a staff member who wields way too much power.  How much?  All he has to do is say that a patient is "unsafe" to live alone and the nursing home will do everything possible to block the patient from returning home. The nurses will tell the doctor that the patient can't leave, and the doctor will refuse to discharge him.  If the patient wants to leave, he will have to leave "AMA" (Against Medical Advice). That means no after care, prescriptions or equipment will be provided.  It's common in these situations for the staff to threaten to call Elder Protective Services (EPS).  This often scares the hell out of the patient/family, and so the patient remains in a nursing home until his death, lonely and miserable.
     Sometimes the nursing home's assessment is correct - that the patient probably shouldn't return home.  But other times it appears that the decision is based on the fact that the nursing home has a low census and needs patients.  This is especially true when a patient requires expensive treatments and he has the ability to pay for them - such as g-tube feedings or specialty beds which can cost hundreds of dollars extra per day.  I've seen patients pay close to $15,000 per month for a shared room, which would pay for 24-hour care (and then some) in the patient's home.  
     Patients don't realize that they have the right to self-determination, which means that they have the right to return home if they wish.  EPS can't remove a patient from his home as long as he is able to make decisions and appears well-cared for.  We all have the right to make decisions unless a court says otherwise.  
     If the nursing home refuses to discharge your family member, it's always possible to call your primary physician for a Home Health referral, prescriptions and equipment.  For additional information, buy a copy of The Nursing Home Survival Guide
I worked for a nursing home that failed its annual survey. Then, it failed the re-survey. After that, it failed the 3rd go-round, causing admissions and federal/state payments to be held while a plan of corrections was developed, accepted and then implemented. 

Each time the inspectors came into the building, the administrator suspected that they knew exactly which charts to review. Of course, the more plausible explanation was that pretty much every chart included errors, fraudulent behaviors and/or blatant ignorance of even the minimal standards of care. 

So, I'm sitting in a meeting with the entire administrative team in yet another endless, useless meeting between the 2nd & 3rd inspections, and the administrator says that she feels like someone is sabotaging her... and one of the nurses declared her love and respect for the administrator in a most nauseating display of support.

After the nurse was done sucking up, the woman next to her agreed and added a few superlatives of her own. And then the next person, etc ad nauseum.

When it came to me, I simply looked at the person sitting on my right and said, "your turn." I was suspended later that day.

   It seems that Gentiva Hospice, formerly Odyssey Healthcare, is closing a bunch of offices.  I have looked all over the internet and don't see anything about it, but the Las Vegas office has closed (effective April 30th) and a former employee told me that they're closing many locations across the country.  If anyone knows any more about this, by all means comment or post in your blog. 
     I went to the Las Vegas office and it was a sad day indeed, watching employees pack up all of their offices and hugging each other as they left.