Where Do Nursing Facilities Go Wrong? A View From the Grassroots.
Somewhere between media horror stories and organized long-term care's publicly stated devotion to "quality care" lies the truth. With some exceptions, nursing homes are neither as bad nor as good as advocates on both sides would have society believe. Accusations, excuses and explanations abound, but what are the real problems facilities face? How might they do better? Looking for answers at the grassroots level is a relatively small group of professional consultants who combine daily experience with facilities, objective assessment and a willingness to apply some "tough love" to help facilities succeed. One group that has specialized in this work for seven years--last year serving clients in 21 states and engineering 10 major turnarounds--is Consultants for Long Term Care, Inc. Company President Reta Underwood has nearly 18 years' experience in healthcare. In a recent interview with Nursing Homes/Long Term Care Management Editor Richard L. Peck, Underwood spoke frankly about some of the difficulties she has observed and the solutions considered.
Peck: What are the three or four most common serious problems you find facilities encountering that drive them to the point of turnaround?
Underwood: I'd say they were these:
1. The facility's relationship with the state survey agency has turned sour. The facility hasn't made its corrections, and it has lost credibility, or there has been a continuing cycle of citations and management hasn't changed.
2. There's been a lack of internal communications, whether between the corporate office and the facilities or among departments within a facility.
3. The resident population is too much to handle. Sometimes residents are placed inappropriately; I remember one facility that had a Huntington's chorea case it didn't know how to handle, and was cited for immediate jeopardy. In others, you'll see residents with Alzheimer's disease wandering about without appropriate monitoring systems in place.
4. There is high staff turnover. Staff is already stressed, and you add the stress of higher expectations after a poor survey, with no additional training, and they leave. You replace them with staff with even less experience or training.
There is an additional staffing-related problem: Facilities in survey compliance difficulties lose their ability to provide the 75 hours a year of certified nursing assistant (CNA) training, so they're forced to hire already certified NAs. These staffers often do a lot of job-hopping, and often bring their bad habits with them. One facility I visited was found by surveyors to be in the 75th percentile for urinary tract infections, and every CNA on the staff was providing inappropriate perianal care. This problem could have been avoided if the facility had had a quality assurance program in place to track their MDS assessments and catch deficiencies before the surveyors came.
Peck: Have you found there to be differences, or different patterns, in problems experienced by independent and chain operations?
Underwood: Decision making by the independents is usually quicker--they typically don't have to answer to stockholders. Some chains do empower individual administrators up to a certain dollar amount and certain types of admissions, but there's always a line for the administrator, even with the most flexible of chains. For example, the corporate office wants to review a member facility's plan of correction (POC) to ensure that no promises are made that they don't want made, such as for certain capital expenditures. From a business standpoint I can understand this, but the facility has time limits to be met, and sometimes they make them, and sometimes they don't. There are also several layers of responsibility in a chain and the bureaucratic politics that entail. I remember one regional manager who had two facilities in noncompliance but told corporate that "everything was fine." I asked him why, and he said, "Oh, they don't want to hear that stuff."
Peck: What about profit vs nonprofit?
Underwood: Nonprofits tend to have more staff, at least on the books; i.e., they're allotted, although whether they're actually available is not always certain. Another difference is that nonprofits sometimes have more flexibility in purchasing information management systems and might be more attuned to the necessary training of staff in using them. Nonprofits also, by definition, have a mission, a clear philosophy of care, although they can occasionally rest on their laurels.
Our experience with for-profits is that they have operational strategies and goals, but sometimes hire midlevel managers who don't understand that residents, not Medicare and Medicaid, are their customers. An initial facility walk-through with a regional or corporate manager during a tough turnaround is usually an eye-opening experience for these professionals. I've seen a few tender their resignations after one walk-through. All in all, though, there are many excellent operators, both nonprofit and for-profit. Quality management and good staff, not corporate tax status, are the keys to success.
Peck: To what extent are reimbursement shortfalls a contributor to facility problems, and what legislative or policy changes might be helpful along these lines?
Underwood: The one individual in the facility who is the key to reimbursement is not the administrator, it is not the DON--it is the MDS coordinator. This person drives the resident assessment, which determines the care to be delivered on the floor and, in turn, the reimbursement. However, it is not uncommon to find this position filled by an LPN, with the position changing hands two or three times a year. It's a wonder that we don't have more reimbursement problems than we do.
So I would say that, in these cases, I wouldn't blame the regulations or the reimbursement. I blame the operators for not spending the dollars to hire the appropriate person and to purchase an effective, user-friendly information management system.
Sometimes there is no MDS coordinator. We recently turned down a job with a facility that had been cited with two "immediate jeopardies" in four months, but where no MDS had been completed in six months. The facility is at risk of going into receivership.
Peck: What solutions do you find that you're recommending frequently on an individual facility basis?
Underwood: An important one would be documentation systems that are user-friendly and don't require a whole lot of mind power. I've seen facilities that use five or six different tools for documenting the same thing. Documentation should be standardized.
We also emphasize ways to help staff cope with stress by helping them do their jobs rationally. A very simple example: There might not be a shower schedule for residents. Either the showers don't get done, or the residents look "hit and miss"--some look fine, some don't. The staff ends up feeling confused and inadequate. Sometimes there won't be a 24-hour report for shift-to-shift communication. Again, staff is left in the dark.
Often training in the resident assessment process has to be done and redone. Assessments will be incomplete, or maybe a significant change in status is missed or not communicated. There are facilities that have never had an RAI Manual on the premises, or if they did, maybe it walked out the door with a departing staff member. Replacing it costs $30, but it sometimes takes "an act of Congress" to get the money. Perhaps the facility does have one, but the MDS coordinator guards it with her life and no one else can see it or use it.
Peck: What long-term care policy changes would you recommend?
Underwood: I wouldn't focus on staff salaries as an issue, for one thing. Nursing assistants in some areas are getting paid some very good money, comparatively--around $10 an hour--and I know of NAs who say they'd work for half that, if only working conditions were better.
I would favor abolishing the certificate of need (CON) process. Like virtually every other industry, let consumers drive the market and what services they want delivered and where. Force the industry to confront what consumers want, regardless of payment source. And if the industry becomes more proactive toward meeting these demands, and less reactive to regulations and reimbursements, it will find itself growing by leaps and bounds.
In my opinion, the perceived threat of "opening the Medicaid floodgates" is exaggerated. Whether we accept it or not, nursing homes are a placement of last resort not because the public resents the industry, but because this is a purely needs-driven healthcare service; people don't like to be in the hospital, either. My husband, John Underwood, who is executive director of the Kentucky Assisted Living Facilities Association, constantly relays feedback from 84-year-old assisted living clients who proclaim, "I don't want to live in a place with sick old people!"
I would add that there are a good many owners I know of who aren't complaining about regulations or reimbursement. They went into this business with open eyes, and they know that the real issue is how you deliver good care within the existing constraints.
I'd offer a little story that shows what a positive attitude can do. Recently we were conducting a training session for activities and social services professionals from 40 facilities. One of these facilities had been one of our toughest turnarounds yet. I asked at one point if anyone wanted to make any employment announcements for their organizations, and someone from this facility got up and said they had no staff openings whatsoever. This was a facility that, three months earlier, had been employing almost 100% agency staff, had received 24 survey deficiencies, including one immediate jeopardy, and had no administrator and no DON. Their corporation had all but given up on them. Now they were a star in the sky. Why? Because it turned out that this was a corporation, a state agency and a staff that truly wanted to change. We all worked together and did it.
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|Author:||Peck, Richard L.|
|Date:||Feb 1, 2001|
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