To see the
federal government’s inconsistent oversight of nursing homes, one needs only to
look at what happened after two residents died — one in Texas, one in
South Carolina.
At a nursing
home in the East Texas town of Hughes Springs earlier this year, a resident approached
the nurses’ station gagging on a cookie. Attempts to clear his airway failed,
and he died. Government inspectors determined that staff at the home were not
trained for emergencies and did not immediately call 911.
Months earlier,
in North Augusta, S.C., a resident pulled out her breathing tube and died. Inspectors faulted the home for failing to take appropriate
steps to keep the resident from harming herself, even though she had pulled out
the tube multiple times in the two months before she died.
In each
state, inspectors working on behalf of the U.S. Centers for Medicare and
Medicaid Services cited the homes for their failure to operate “in an
acceptable way that maintains the well-being of each resident.” Both homes posed
an “immediate jeopardy” to residents’ health and safety, inspectors determined.
But the
consequences were starkly different.
In the Texas
case, at the recommendation of state officials, CMS imposed a fine against The
Springs nursing home of $9,500. In the other, acting at the suggestion of South
Carolina officials, CMS required Unihealth Post-Acute
Care-North Augusta to pay a fine of $305,370.
These disparities aren’t unusual, it turns out. But they are
now much easier to spot using ProPublica’s expanded Nursing Home Inspect tool. We’ve mapped the differences among
states in finding serious violations and parceling out fines. Here’s more on how to use our updated tool.
The results support
what auditors and researchers have maintained for years: Federal
fines vary widely by state. Homes in some states pay a steep price for
misconduct while those in neighboring states don’t. See our state-by-state breakdown here.
The average
fine paid by a South Carolina nursing home in the past three years was $40,507.
The average fine in Texas: $6,933.
A Balkanized
System
CMS pays
states to inspect nursing homes on its behalf. It gives states guidelines on when
and how to impose penalties, and states recommend actions to CMS regional
offices.
Those
regional offices must approve sanctions before they are imposed, but CMS almost
always accepts the states’ recommendations. The federal government and states
share the fine money.
Despite its authority,
some experts say, the federal government has not done enough to standardize
punishments.
“The
enforcement system is broken,” said Charlene Harrington, a nursing home expert
and emeritus professor of nursing at the University of California, San Francisco.
“If you don’t go after these really bad violations and try to force these
nursing homes to improve quality, they’re going to continue to cause harm and
jeopardy.”
Harrington
was the lead author of a 2008 study that found enforcement disparities and
encouraged the government to “re-examine” the system of imposing fines, called civil
monetary penalties (CMPs) in bureaucratic parlance.
Federal
officials acknowledged inconsistencies identified by ProPublica and said they
are working to reduce them. Years ago, CMS came up with guidelines to advise
states and its own regional offices on when and how much to fine homes.
But the
guidelines give them wide latitude. States can choose penalties either by
incident, capped at $10,000, or on a per-day basis, which can quickly add up to
a much higher number.
Beginning
next year, CMS will test a new program that provides more specific guidance. “Our new tool reduces that latitude by a
fair degree,” said Alice Bonner, director of CMS’ division of nursing homes.
Bonner said some
flexibility is warranted because not every situation is the same. Factors
affecting the size of a fine could include a home’s past record of deficiencies,
the speed with which it corrects problems and whether too large a penalty could
force a facility to close, a hardship on residents, she said.
Some states
also have the authority to impose fines against homes under state law, but CMS
does not centrally collect and report them.
Tim
Thornton, administrator at The Springs in Texas, said his nursing home has retrained
staff since the resident choked on a cookie and died.
“With this
specific case, the nurse on duty showed a lack of leadership … There was kind
of a breakdown and maybe a little panic in the situation, and the nurse took it
all upon herself and didn’t ask for assistance from the others.”
The $9,500
fine against the home is not yet listed on the CMS website because it has not
been paid, officials said.
Calls to Unihealth-North Augusta were referred to the home’s parent
company, UHS-Pruitt Corp. in Norcross, Ga. Spokesman
Nick Williams declined to comment.
Unihealth-North
Augusta has received more federal fines than any other home in the nation, $736,580,
in the past three years, according to government data. Another of the chain’s homes, in
North Carolina, was fined $372,970 during the same period.
Fines vs.
Deficiencies, a Disconnect
To
demonstrate variation in enforcement, ProPublica mapped states based on their average
fine, the number of serious deficiencies per home, and on how often they
penalized homes with payment suspensions for new admissions – another
form of sanction that is less common than fines.
Officials in
several states — those with high fines and low ones — said they had
not compared themselves to others and were unaware where they stood. The
officials said that if CMS wanted to raise or lower their recommended
penalties, it has the authority to do so.
Texas has
the second highest number of nursing homes in the nation, behind only
California. While it had the most serious deficiencies of any state and imposed
more payment suspensions, its average fine placed it near the middle.
Cecilia Cavuto, a spokeswoman for Texas’ Department
of Aging and Disability Services, defended the state’s approach.
Texas chooses its actions based on
“the nature of the deficiencies identified, prior success or failure of
previous remedies, and staff’s professional judgment regarding what remedy
might best encourage a facility to come back into compliance with
Medicare/Medicaid requirements,” she wrote in a statement.
A South Carolina spokesman said the
state simply follows federal guidelines in issuing fines and that “there has been no change in the
philosophy for enforcement.”
Michigan has
426 nursing homes, the 11th highest in the nation. Yet, over the
past three years, Michigan homes paid more fines than any other state, nearly
$10 million, and regulators meted out 175 payment suspensions, second only to
Texas.
Officials at
the Health Care Association of Michigan, the nursing home trade group, said the
figures show that Michigan regulators have been unreasonably harsh.
“We just
don’t have any indication that we’re performing worse than other states” in
terms of the number of problems cited by inspectors, said David LaLumia, the association’s president and CEO. “The latitude
that states have to impose civil monetary penalties is very subjective.”
Kimberly Gaedeke, assistant deputy director for Michigan’s
Department of Licensing and Regulatory Affairs, defended the state’s use of
penalties. She said the state has seen an increase in the number of serious
deficiencies. Like other states, she noted, the final decision ultimately rests
with CMS.
In a written
statement, Graedeke said the state is re-examining
its penalty system to make “positive changes” so that penalties don’t impede a
home’s ability to provide quality care for residents.
Are States
Too Soft?
Advocates
for nursing home residents said they do not accept the argument that some
states are being too tough. If anything, they said, many states are going too
easy on homes.
“This is not
an easy issue to deal with,” said Richard Mollot, executive director of the Long Term Care
Community Coalition in New York City. “The states themselves are
subject to a lot of political pressure (from nursing homes). They have not been
subject to a lot of pressure from CMS to do a good job.”
CMS officials asked Minnesota to “step up our fines” a couple of years
ago, Darcy Miner, director of the health department’s Compliance Monitoring
Division, wrote in an email. The state’s average fine of $2,147 is one of the
lowest in the nation.
“I would have to say that I haven’t seen CMS modifying most of our
recommendations, so I have assumed that we are within the appropriate range,”
she wrote. Since CMS asked the state to increase its fines, it has tried to do
so, she wrote.
Brian Lee, executive director of
Families for Better Care in Florida, said residents and their families should
care about how well the government oversees the quality of care in nursing
homes.
“This is affecting all of us. It’s
affecting our families,” Lee said. “We’re relying upon the regulators to ensure
safety and quality care for our parents and grandparents.”
—
Jennifer LaFleur,
ProPublica’s director of computer-assisted reporting,
contributed to this report.
