Nursing home fixes prove to be elusive

Florida pays nursing homes between $190 and $250 per Medicaid patient per day. In most cases that's not enough to cover costs, said Thomas Parker, director of reimbursement for the Florida Health Care Association.

Two months after 12 people died inside a South Florida nursing home left without air conditioning after Hurricane Irma, state Sen. Gary Farmer joined a chorus of lawmakers proposing ways to make the state's 684 skilled nursing facilities safer.

The Broward County Democrat's legislation was a sweeping proposal that included giving nursing homes priority for power restoration after an emergency; allowing residents to put surveillance cameras in their rooms; forcing the homes to carry liability insurance; authorizing undercover inspections; and requiring homes to hang large signs on their doors if they are placed on a state watch list because of poor performance or bankruptcy.

Farmer's bill never got out of committee and died without a hearing, a possible sign that Florida leaders aren't confronting problems with the state's nursing home industry.

"A lot of my colleagues feel a lot of frustration," Farmer said. "We're never going to improve the system if we can't have an open discussion and consideration of ideas."

That system allows dozens of Florida nursing homes to limp along for years, providing poor care and abusing, neglecting and even killing patients while the state rarely takes serious action against them, a USA TODAY NETWORK – FLORIDA investigation has shown.

Florida's largest owner of nursing homes faced a huge judgment of $347.8 million by a federal jury that found its homes had bilked state and federal programs, only to have a judge overturn the verdict in January. His order reasoned, in part, that nothing the homes did triggered state or federal action. The judge's decision is on appeal.

As the judge ruled, Florida'sAgency for Health Care Administration threatened to yank the licenses of 53 of the homes owned by Consulate Health Care. But the agency backed off, agreeing to place only eight of the homes under closer supervision.

Enforcement

Enforcement and oversight by AHCA, the state agency that regulates nursing homes, "doesn't have a strong enough deterrent effect on bad actors," Farmer said.

Although AHCA regularly cites nursing homes for violations, the fines it imposes are typically small, as low as $250. The average state fine from 2013 to June 2017 was just over $4,500, according to an analysis by USA TODAY NETWORK – FLORIDA.

State law sets the largest AHCA fine for a single violation at $15,000, although that can double if a home is cited for a severe violation during its previous inspection.

"When you look at a facility that is a corporation that's getting this fine, it's a slap on the wrist," said Robyn Grant, director of public policy and advocacy at The National Consumer Voice for Quality Long-Term Care, a Washington, D.C., nursing home advocacy group.

AHCA leaders declined multiple interview requests for this story. In a prepared statement, they defended the agency's record, noting that federal data shows Florida's nursing homes as a whole have improved in recent years, including declines in infection rates and patient falls.

In addition to higher fines and making it easier for AHCA to suspend a chronically bad home's license, Farmer is calling for higher standards for who is allowed to operate a nursing home, stricter requirements for nursing homes to report problems, and greater power for the state's Long-Term Care Ombudsman program, which helps police homes for the elderly with volunteer inspectors.

"The ombudsman program has been gutted over the years to be just a shell of its former self," Farmer said.

Poor-performing nursing homes should be required to improve, said state Sen. Kathleen Passidomo, R-Naples, vice chair of the Senate's health policy committee.

"If a nursing home is subpar, it has to be dealt with," she said.

Passidomo said she she was not aware of findings in USA TODAY NETWORK – FLORIDA's investigation that many nursing homes in the state continue to operate despite a long history of violations found during AHCA inspections.

"If you find that, then it's important for us to know about it and it's important for the governor to know about it," she said.

Gov. Rick Scott has said he has confidence AHCA provides close oversight to nursing homes.

State Sen. Denise Grimsley, R-Lake Placid, a registered nurse and hospital administrator in Wauchula, said her experience shows AHCA aggressively regulates the medical facility where she works. A U.S. Department of Health and Human Services report in April, however, pointed out that AHCA didn't always check to make sure corrections were made after documenting hundreds of violations in nursing homes in 2015.

"It's a two-way street," Grimsley said. "AHCA has to give the provider the ability to make improvements, but they also have to hold their feet to the fire."

AHCA needs to act more aggressively to prod poor-performing nursing homes to improve, said state Sen. Darryl Rouson, D-St. Petersburg, a member of the Senate's health and human services appropriations subcommittee.

"I'm not comfortable with their assertiveness," Rouson said, "because these issues keep cropping up and the complaints continue to come."

Nursing home money

Grimsley said she believes a new, performance-based payment system for nursing homes will improve care.

Under the system that goes into effect this fall, state Medicaid reimbursements – which pay the bills for the bulk of Florida's nursing home residents – will be based on how well homes meet quality measures.

"I think that's going to drive them to raise their scores or go out of business," Grimsley said.

But the quality measures used in the performance-based system are so low that they threaten to reward poor quality at nursing homes and funnel money away from the state's best providers ranked the highest on a five-star quality scale, critics argue.

"Many four- and five-star providers will be losing hundreds of thousands of dollars," said Elliott Palevsky, CEO emeritus of River Garden Senior Services, which includes a five-star Jacksonville home.

If Florida leaders want to improve care at low-rated nursing homes, they need to increase Medicaid payments overall, said Tom Edwards Jr., a Jacksonville lawyer specializing in nursing home neglect cases.

"We are failing to provide proper care to elders with the level of funding they're using," he said.

Florida pays nursing homes between $190 and $250 per Medicaid patient per day. In most cases that's not enough to cover costs, said Thomas Parker, director of reimbursement for the Florida Health Care Association, an industry trade group.

"I certainly think having adequate funding is connected to the ability to have high-quality care," said Kristen Knapp, the association's spokeswoman.

State lawmakers did bump Medicaid payments to nursing homes by $50 million this year, which is expected to draw an additional $80 million in federal money.

"That's huge," Parker said. "That's additional staff. That's additional activities that you can do. You can make some renovations to the building. You can upgrade therapy equipment."

Yet there is no guarantee higher Medicaid payments would lead to better results.

"Just because you pay them more doesn't give them the impetus to spend more on care," said Erwin Bodo, a reimbursement specialist with LeadingAge Florida, an association of elder care organizations. "Show us where the money goes."

Eye to the future

Passidomo said state leaders can help increase the quality of nursing homes by enticing more people into nursing careers.

Legislative efforts to increase the number of nursing education programs in Florida have had mixed results, according to the Florida Nursing Center. There are more job vacancies for nurses than for any other profession in Florida.

Passidomo said Florida will need to train and recruit millions of new nurses in the next 30 years.

"We don't have enough nurses for anything," she said, "so we need to make sure we get people on that path that are interested in doing it."

Passidomo also said she is a proponent of diverting patients away from nursing homes in some cases, and setting aside state money to cover more at-home care.

"A lot of our older folks want to stay at home," she said. "They can't live by themselves, so we have to make it feasible for them to age in place."

Florida pays nursing homes between $190 and $250 per Medicaid patient per day. In most cases that's not enough to cover costs, said Thomas Parker, director of reimbursement for the Florida Health Care Association.