The NursingHome411.Org website is a useful resource for anyone looking for a nursing home or interested in current issues in nursing home care. In today’s episode, attorneys Rob Schenk and Will Smith discuss how to utilize the nursing home 411 website to find or evaluate a nursing home with guest Richard Mollot, Executive Director of The Long Term Care Community Coalition.
Schenk: Hello out there. Welcome back to the Nursing Home Abuse Podcast. My name is Rob Schenk.
Smith: And I’m Will Smith.
Schenk: This is going to be another special episode of the Nursing Home Abuse Podcast. This is going to be one of those picture pages, except that’s probably not a good reference now. This is going to be something – I don’t know, I’m having difficulty thinking. This is the fourth episode I think we’ve taped in the past two hours.
This is an episode that will be enhanced if you are watching it, because we are going to have a special guest, Richard Mollot, take us through how to use a website located at NursingHome411.org for the purposes of getting information about nursing homes in Georgia and elsewhere and getting just information on how to prevent neglect and abuse of all types.
Smith: Yeah, Richard’s one of our favorite guests. I first met him at a Consumer Voice conference last year, and he is the director of the Long-Term Care Community Coalition, the LTCCC, a nonprofit organization dedicated to improving care for seniors and the disabled through legal and policy research, advocacy and education. It’s just a bunch of research scientists who have a real heart for the elderly, and they get together, and the statistics that they come up with, the data that they come up with, is absolutely invaluable.
He addresses everything from dementia care, nursing home and assisted living standards, mandatory managing long-term care, nursing home financing and quality improvement. He’s written and presented trainings on everything from nursing home laws and regulatory standards, assisted living law and policy, dementia care and the use of antipsychotic drugs, caring and planning for aging persons. He’s a graduate of Howard University School of Law and he’s an actual attorney. He’s a member of the Maryland Bar.
Schenk: And this marks his fifth appearance of this show.
Schenk: But before we get him on, thank you for that introduction, Will, but before we get him on, again, I just want to make sure that if you’re listening to this, you will still get benefit from the episode, no doubt. However, sometimes if you’re visual like I am, it’s better to watch because he’s literally going, we’re going to have Richard take over the screen and navigate through his website as he talks about where the information is located as we’re navigating through there. And with that being said, we will go ahead and have Richard standing by, we’ll go ahead and have Richard onto the show. Richard, welcome to the show.
Richard: Well thank you for having me again. I appreciate it.
Schenk: All right. Well Richard, let’s just do this. Let’s dive right into it. What is Nursing Home 411, how long has it been around, and if you could just take us through it?
Richard: Sure. Well as you know, we are a nonprofit organization, Long-Term Care Community Coalition, and we are dedicated to improving care and quality of life for residents. And what we wanted to do was have a website that provided a good resource with information about quality, information that residents and families and those who work with them could use to improve care and to know what to do if they weren’t getting the care, the quality of life, treatment with dignity that they need and of course deserve.
So we put together this website, I’d say about eight years ago now, and we had a website earlier, but this was something that was really dedicated to providing that kind of information and those resources. And you can see the screen now?
Smith: Yes sir.
Richard: Okay, good. So we’re on the homepage. On the left-hand side, you’ll see this left-hand side always shows up on every page. We have a learning center, we have nursing home information and data, an action center and some of our news and reports on assisted living, and some information for our home state, which is New York, and we have a local ombudsman program here.
So I’ll go just very quickly – the learning center has information – we have fact sheets, we have issue alerts, we have our webinars, we do monthly webinars for families and residents and advocates on nursing home issues. We have a dementia care advocacy toolkit and we have a family and ombudsman resource center. So I will go there first just to give you – it’s a good starting point, actually.
Here, we have on the left-hand side some of the things that are new. So here is our announcement for the upcoming webinars on nursing home care and resident-centered advocacy, our most recent issue alert, which is on baseline care plans.
Under the new federal regulations, nursing homes have to develop a baseline care plan for residents within 48 hours of admission, and the baseline care plan is really important. What studies have shown, what the Inspector General of the United States, Department of Health and Human Services found was that there is a significant amount of resident harm within the first couple of days of entering a facility. And this is true for people who go in for rehab as well as people who go in for long-term care. And too often we hear that medication did not accompany a resident, medications aren’t ordered by the facilities for a couple of days, that facility staff don’t know what to do, and as a result, residents, as you can imagine, are extremely vulnerable in those first few days.
And what the federal government did, CMS, the Centers for Medicare and Medicaid Services, in the new regulations, they said, “Look, we don’t expect you to do a full care plan, but you at least have to have within the first 48 hours a baseline care plan to make sure you’re identifying the resident’s needs and that he or she is not going to be subject to the vagaries of people not knowing that kind of care they did, what kind of medication they need, etc.
And then we also have fact sheets and other issue alerts. I’ll take you to one very briefly, but I wanted to show on the right-hand side, we have an upcoming webinar program, and you can watch past webinar programs as well. There are a few different buttons. We record every webinar that we do and it’s on our YouTube channel so you can access it there.
And then here you can see some of those resources I mentioned before: the free fact sheets on the middle line of buttons, the dementia care advocacy toolkit, and then we also provide some useful data.
So very quickly, I’m going to go to the learning center and the fact sheets, and I just want to pull up an example. Here are bedrails, which is the most recent, one of our most recent fact sheets. And so for every fact sheet, what we do is we identify as a consumer group issues that are affecting residents and their families have identified or advocates and attorneys have identified as affecting residents.
Bedrails is a very serious issue for residents, in fact, and people don’t realize that it was once thought that bedrails protected a resident because they, by their nature, are supposed to stop a resident from rolling out of bed and hurting him or herself. In fact, for most people, bedrails are extremely dangerous, and there are many, many incidents, unfortunately, very heartbreaking incidents across the country, of a resident who tried to get out of bed, resident may have dementia as most residents do have a little bit of dementia, they’re confused in the middle of the night. They try to get out of bed and they’re caught up in the bedrail. Sometimes they choke. Sometimes they even die as a result.
So in addressing this, the federal regulations talk about what should be done as alternatives before using a side or a bedrail, and then they talk about – we talk about the need for informed consent, and some other standards here regarding respect and dignity and resident beds in general.
So as this is just one example, but for each of these fact sheets – and they’re all free, you can print it out, they’re easy to access and download and you can print this out as you can see down here and use it in any way you like. So we hear and we’re very grateful to hear from families and people who work with them that they distribute them to families and to residents, they use them in resident and family counseling, etc.
Schenk: And Richard, I see obviously you’re getting the code from the federal code. Where is the content coming from in terms of that analysis that are in these fact sheets?
Richard: Thanks, that’s a really good question and I’m sorry I didn’t mention it before. So what we have here, we explain it very briefly at the top of every single fact sheet is we have the title, which is “Bedrail Standards,” so people know. So you go to our website, you have a concern, say your loved one has a pressure ulcer or your loved one, you’re concerned about the medication they’re receiving – are they correct? – or here, we’re talking about bedrails, you can search on the website about the issue of what’s your concern.
This fact sheet will come up, and here you can see in purple, we include, it’s 32-C.F.R., it’s a code of federal regulations, and we also include a number, an F-number. Those are both important for two different reasons. One is that the code of federal regulations is included not because everyone is expected to be a lawyer – of course, and that’s why lawyers are so important is because that lawyers have that kind of expertise. What I want families and residents and advocates to have is that they know that there is a citation to this. It’s not just LTCCC thing, this is something that you should have – it’s actually in the code. And everything that we include in italics here in the language, that comes directly either from the code or from the federal guidance, the federal guidance for how the code should be implemented.
And then lastly, very quickly, the F-number is very important, and that’s what’s called an F-tag. Whenever there is a citation for a failure to meet a section of the code, the regulatory standard, it is assigned an F-tag. What does that mean for families and residents and lawyers is that you can look for any nursing home, you can see, if you go to the nursing home itself, it should be available at the front desk or upon request, or if you go online to the federal Nursing Home Compare website, you can download or view the latest inspection reports for at least the last three years. And you can see, it’ll designate what the F-tag was, what the citation was, and this gives you a way to connect that to the quality standards. This can be really useful for families and for residents.
Smith: Richard, just a quick question. Did I hear correctly that the F-tags were going to change or they were going to…
Richard: The F-tags did change.
Smith: Oh, they did change.
Richard: We talked about this in previous programs because I know they are on your website, but all the nursing home regulations changed in 2016. And so essentially, what we always say, the basic standards, all the residents’ rights stayed the same. What CMS did in changing the regulations is they basically just fine-tuned how they describe the different standards and what their expectations are for facilities in implementing those standards. So along with that, the F-tag numbers all changed as well, and we have updated them here in all of our fact sheets.
Smith: That’s my question. So they’re updated here.
Smith: The consumers looking at this don’t need to concern themselves with that then.
Richard: Say that again, I’m sorry.
Smith: The consumers looking at this website or this consumer fact sheet don’t need to concern themselves that the F-tags have changed then. This has all been updated.
Richard: Correct. So these are all up to date. The only issue would be that for previous years, so this is just the new survey protocols that were just implemented in November of 2017, so less than a year ago, since facilities are inspected on an average of a yearly basis, some of them, if you go to your facility’s listing, if you go into the nursing home and you asked for a statement of deficiencies, it would still have the old numbers there.
Smith: Got you.
Richard: But the standards are – and there’s some information out there that we can send if anyone is interested, crosswalks from the old to the new – but this is all new and this is all up to date.
If I could just mention before we move on, importantly in terms of having the baseline care plan, the issue we talked about before, I think that’s a good example to illustrate how the regulations are changed, that’s something new. So in the past facilities did not have to have a baseline care plan. However, facilities are always required to ensure the safety of their residents from the moment they accepted them in the facility, period. And the only reason why CMS said you need to have at least a mini, a baseline care plan at the beginning is because that safety we found was not happening. In fact, the U.S. Inspector General did a report in 2014 and found that one out of three people who go through a nursing home for Medicare rehab services are harmed within an average of two weeks. One out of three nationwide.
One of the most striking – I know this isn’t the subject of our discussion today – but one of the most striking reports that I’ve read in my entire career, because those are people, sometimes you’ll hear nursing homes say, “Oh, if we only got more money, we’d hire more staff, etc.” the Medicare rehab people are the rehab people that nursing homes get paid four, five, six, seven, even sometimes $800 per day to provide care for. The independent MedPAC, which reports to Congress, had found double-digit profits off of Medicare reimbursement rates for rehab.
So the fact that the staffing and the oversight and the monitoring and the appropriate care wasn’t there for these residents was honestly mind-blowing to me, because I worry, well what does that mean for residents with dementia? What does that mean for residents who’ve been in the facility for months or even years and depend upon the facility for significant levels of care?
So two important takeaways is, one, if anything, obviously the long-term care residents, residents with dementia, are even more vulnerable to those kinds of problems, and two, that families and residents and their loved ones should be very aware. When you go into rehab, it’s not necessarily something special. It’s not necessarily that you’re going to be getting a superior level of care, because as that study showed, one-third of people were harmed within, again, two weeks, and the study four 59 percent of that harm, the majority of that harm, could have been avoided and was likely the result of inadequate or inappropriate care.
Smith: Yeah. That’s too common.
Schenk: Yeah. Okay, so Richard, you’ve taken us through the learning center, or at least some of the learning center. We’ve learned there are a lot of fact sheets.
Schenk: There are a lot of webinars and I’ve already hyped this on other episodes, but those webinars are very informative.
Smith: Yeah, they’re very good.
Schenk: And they’re not – you know, some webinars, they drone on and on, but these are very informative and very to the point, so I would really recommend that our audience go out and check out, if anything, those webinars. Anyways, Richard, go ahead. What else?
Richard: Well thanks so much. Thank you very much. I appreciate it, and again, these invites to upcoming webinars is on the website in a number of places, here in the family and ombudsman resource center, upcoming webinars, “Nursing Home Care and Resident Centered Advocacy.” They’re always the third Tuesday of the month, pretty much, unless there’s a holiday or something. So we want to talk about some of the data that we provide, if that’s okay.
Richard: One of the biggest issues that I think virtually everyone I speak with about nursing homes comes to staffing, staffing, staffing, staffing. And that is also what I find in my own advocacy and work when I look over some of those deficiency reports. It’s almost always staffing. But what we’ve found in the research that we’ve done is that staffing is very infrequently cited by the state agencies, and because of that, because it’s not cited, even though it’s a problem in so many nursing homes, the fact that it’s not cited means that nursing homes are not penalized too often for having low staffing, and in essence for the nursing homes and the nursing home industry, your low staffing levels are okay.
And that is not only a good thing for the so-called, as we would say, the bad providers, it’s also a bad thing for the good providers because it makes it much harder for the good providers to do a good job when they’re under this pressure and bad providers are able to get away with having very low staffing.
So we have advocated for many years, we and many other organizations, for CMS to collect better information on nursing home staffing because it is so important. So up until last year or actually the year before last, up until 2016, all the information on Nursing Home Compare, which is the federal website for nursing home information, all the information on facility staffing was self-reported by the facility at the time of their annual inspections for the two-week period prior to the inspection. So when I talked to family members about this, they nod their heads because they all know when the facility is expecting its annual inspection, it will oftentimes beef up staff. They often see that.
In addition, even if they’re not doing that, these staffing data were self-reported and completely unaudited by either the state or the federal government, so nobody ever checked to make sure nursing homes were reporting accurately.
Under the Affordable Care Act in 2010, that required nursing homes to report their staffing for every single day of the year, and to divide up that staffing between who’s assigned to provide care, who’s assigned to provide administrative duties, for direct care staff, and also to report other staff who are not direct care, and in addition, because this is a big issue as well, to report staff who are actually facility employees versus contractor agency staff, because that could be a big issue.
So that was required in 2010. It actually wasn’t implemented until 2016, so facilities did not change their action until then, and it was reported for the first time at the end of 2017, and it’s actually only since August of this year that CMS has reported all of the information that I just described on its website. Now some of this information is now being integrated into Nursing Home Compare when you go there to look at a particular facility, however, a lot of it is not. So what we’ve been doing is we’ve been collecting this data and trying to connect them together in a way that’s as useful as possible, and I’ll talk about that next.
So if you go back to our homepage here and then go to “Nursing Home Info & Data,” staffing is the first thing that we put up. I’m opening up that page and here’s the latest data. So the nursing home’s report for every single day of the year, CMS reports that to the public on a quarterly basis. The most recent data that CMS has reported is for 2018 Q1. So for your audience, particularly in Georgia, you can go there, you can click on that page, we’ve discussed briefly what’s included here, and then you can just scroll here and go to Georgia, click on it, and that should download Georgia. Now are you able to see that? If not, I will open up that page for you.
Schenk: Open up the page because we can’t see the Excel spreadsheet.
Richard: Let me just do that. There we go.
Schenk: Got it.
Richard: Great. So what we have done is we do a state file for every single state in the country. About 97 percent of facilities are now compliant with this requirement, but not every facility is, so you may not see your facility here because if it is not here, it means it’s either not in compliance, or the data that it provided to CMS was not sufficient or looked suspicious, sure.
So we have direct care staff. We also include the select non-nursing staff in this file, in this tab, and we include notes, so you can find out the information. Again, you can see the links exactly to where we got the data. Those data tools are very, very complex, which is why we make it a little bit shorter, a little bit easier here.
We also include – try to make that bigger here – the national care staff averages and Georgia’s care staff averages. So here you see the average staffing, and we only have here the direct care staff that is assigned to provide care. As I said to CMS a number of times, nobody cares if the administrator also has an RN license. He or she being in the building is not providing the supervision, the medical care, etc., to a resident that we talk about when we talked about what the need is for residents.
Richard: So that’s what we include here. So you can see national care average is 3.4 hours of total direct care staff time per resident per day. The Georgia is 3.3, so it’s a little bit lower than the national average. And then let me just note that there was a report that came out 16 years ago that found that you need to have a minimum of 4.1 hours of direct care staff time per resident per day in order to just to meet the clinical needs – forget about dignity, forget about quality of life, which you shouldn’t – those things are extremely important, but just looking at clinical measures, at least 4.1 hours of direct care staff time was needed. And actually now, because resident acuity has increased, people are living longer, they’re staying at a nursing home longer, it’s actually more like 4.6 to 4.8 hours of direct care staff time would be a good number – 3.4 is average.
Smith: Richard, can you go back to the direct care staff label?
Smith: I just want to make sure I understand something.
Smith: So the numbers that we’re looking at, the first one is the number of residents or patients, right? The MDS census?
Richard: Yes. Yeah, so I do want to go – so here you see we include the provider name here, the county where it’s situated, the city, so that you can look up by your city and see what nursing homes are there, you can look it up by your county, see what nursing homes are there if you’re comparing. And then then first column here of the MDS census, that’s what the facility has reported as the number of residents in the building.
Smith: And then the second one is hours per what?
Richard: Yeah, so the second one is so what we’ve done here is as I’ve said, the facilities report for every day of the quarter. What we do, what I do is we average them out. So this is the average for the quarter – let’s just look at the first facility, Abercorn Rehabilitation Center. They had an average census of 75 residents and an average RN hours of 19.3, which is care staff time.
Smith: Oh 19.3 for the quarter?
Richard: For the quarter per day.
Richard: And then LPN hours and then CNA hours, this is the total care staff time, this is probably not as interesting to people, but I need to include it so people don’t think I’m just making up what I’m going to talk about next, which is the average total staff hours per resident per day. That’s the important number that people should be looking at.
Smith: I got you.
Richard: So what we do is we essentially calculate based upon the census and the care staff hours reported here. These are the data reported by the facility. The last two columns are what are important based upon those reported data from the facility who they paid to provide care, this is what we’ve computed, that this facility had an average of 3.1 total staffing hours per resident per day and average RN hours per day of 0.3.
Now as I was just saying before we move back to this, the total staffing time that is needed is minimally 4.1 but it really should be at least 4.6 or 4.7. And then for RN hours, the 2001 report that I mentioned earlier, they found that you need to have at least 0.75 hours of RN staff time, 0.75. And the new data, based upon – it’s more updated with what residents’ needs are now – is saying it’s at least it’s really 1.15 hours, so over an hour.
Smith: Let me ask you this – so where do LPNs fall in that? Do they go to total care staff?
Richard: Yeah, so the LPNs go to total care staff, so really we’re looking at – and generally, researchers look at two things: how much total care staff time is needed, but studies over the years have found that RNs themselves have a very significant role and they’re very, very important. That’s actually now that these data just came out, we have almost a year since they were published, they were published last fall, that we’re seeing and researchers are seeing a tremendous correlation between higher RN staffing with better resident outcomes.
Smith: Got you.
Richard: Period. So that would be – total staff times are important. CNAs, as I’m sure you guys know, provide the vast majority of care, so they are extremely important, and LPNs, or LPNs are important as well, but it’s the RNs who provide the supervision, that provides the training and monitoring of what the CNAs and LPNs are doing if they’re there. What we’ve found is that a lot of facilities don’t have an RN providing any kind of oversight, and that would be extremely alarming to me.
Smith: Got you.
Richard: Very quickly, I know we don’t have a lot of time, I want to just mention the non-nursing staff as well, and this is brand new. CMS reported this for the first time in this quarter in August this year. So again, we have the provider information, the city, the county, provider name, but you can see how many administrative hours on average per day are provided, how many medical director hours, how many pharmacist hours. Pharmacists are important because if your resident has dementia and is receiving drugs, it’s important for the pharmacist to be overseeing that and to be providing input.
Dieticians, activity staff – so what we’ve found was we looked at the total activity staff, we looked at the total social work staff and then we computed average staffing hours to those per resident per day, and you can see here for this facility, there was only an average of activity staff of a tenth of an hour per resident per day.
Schenk: Oh wow.
Richard: So if I was looking at a facility, I would say – here some of them have zero. What is going on? Is it just going to be bingo in this facility? Are people just going to be planted in front of a TV and left to their own devices? Or is the resident being given time to take part in activities that are meaningful? This is the resident’s home. Residents generally can’t walk out to go and go to a movie or something or to participate in a prayer group or anything like that. Those things need to be brought in. Who’s doing that? It looks like no one in too many cases. Same thing with social work. We do that here as well.
Schenk: Well Richard, in the couple minutes that we have left, if you could go back to the main website and just kind of – what are the three most important sections of this website for residents or for family members of residents in nursing homes? Like what are some action items that you can give them today to go to the website and do?
Richard: Okay, sure. So I would say first, we talked about the learning center. If you are experiencing an issue, if you have a concern about care, check out the fact sheets. Go from anywhere – you can do a search. You see here at the bottom there’s a little search icon, so you can search for pressure ulcers, you can search for staffing, you can search for dementia care and it’ll come up with all these things, and the learning center has a lot of really good resources.
The data, so we put out information on anti-drugging rates for every nursing home, on staffing rates, and similarly there are state files that are fairly easy – we know it’s a lot of information, but we make it as easy as possible.
And then I would say that our action center that we’re putting together and we have information on there for people to speak out – we have national action alerts. You can speak out on let’s say staffing. You can speak out generally in support of nursing home residents. We’re putting together now a “Tell My Story” campaign so people will be able to tell their story, so that’ll be here as well.
Smith: Awesome. This is such a good website, Richard, it really is.
Richard: Thanks very much. I appreciate that.
Smith: Yeah, we’re going to try to get the word out there.
Schenk: Yeah, and Richard, do you all have any plans to convert this into an app?
Richard: That’s really interesting. Not off-hand. We do think about it being friendly for mobile devices and stuff like that.
Schenk: We got to talk then.
Richard: Oh really? Yeah.
Schenk: Yeah, okay. Well we can do that. We won’t bore the audience with that. But at any rate, Richard, thank you so much for this and we’ll definitely – we’ll have to have you back on again real soon because there are some of these things I want to go explore in breadth.
Smith: Yeah, there’s a lot of stuff.
Schenk: Yeah, but fantastic. Thank you so much, Richard, once again.
Richard: Thank you so much. You guys have a nice afternoon.
Schenk: You too.
Schenk: Bye-bye. So again, if you’re listening to this and not watching it, maybe bookmark this podcast. Go to your home or library or whatever you can get on the Internet, and watch the episode because you’ll, again, Richard, as he’s talking, he’s guiding us through where his website, how his website works and the information and where it’s available on the website. But at any rate, jot it down, NursingHome411.org. It’s just an extra special website.
Smith: A wealth of information…
Schenk: A wealth of information.
Smith: …and resources for people that have loved ones that are going to a nursing home, that are thinking about putting a loved one in a nursing home or who are in a nursing home. It’s one of the most informative if not the most informative place for you.
Schenk: And Will, do you know what Friday of this week represents? December 7th?
Smith: It’s a day that will live in infamy.
Schenk: Okay, that’s true, but I wasn’t talking about that. It’s infamy for another reason.
Smith: Oh, it’s also the day that we officially organized our law firm.
Schenk: That’s right. Schenk Smith LLC was officially formed under the laws of the state of Georgia on December 7th, 2000-when?
Schenk: 2012, a little off. This is like I feel like I’m the wife.
Smith: Forgetting the anniversary.
Schenk: Forgetting the anniversary.
Smith: Of course it is.
Schenk: “You’re going to sleep on the couch.” December 7th, 2012, another date that will live in infamy is that is the official date of the inception of this law firm.
Schenk: Anyways, we appreciate you making it this far into the episode. You can watch or listen to new episodes every Monday on our website, which is NursingHomeAbusePodcast.com or on our YouTube channel, or you can check us out on Spotify, Stitcher, iTunes, Google Play, Podcast Puppies, wherever you go to get your podcasts – you will find us there. And with that, we will see you next time.
Smith: See you next time.