Last month I had the opportunity to speak with Mark Kissinger, the New York State Deputy Commissioner of Long Term Care, and Jacqueline Pappalardi, Director of the Division of Residential Services in the New York State Office of Long Term Care. They answered some of my burning questions about the present and future of nursing homes.
I understand with the long term care restructuring going on in New York State, there’s a movement from nursing homes toward assisted living, but there will continue to be a need for nursing homes. How would you suggest nursing homes prepare for the future?
People will try to stay at home and at lower levels of care. The more client-centered nursing homes can be, the more helpful it will be to them. We’d suggest they diversify into rehabilitation care. More short-term rehab will help from a financial standpoint.
Are there efforts by the Department of Health to provide guidance for nursing homes? For example, is there anyone at the State Department of Health that nursing home staff can turn to for guidance if they want to start creative new programs?
Jackie meets regularly across the state to talk with the providers and with regional program directors. Regional staff are invited to these meetings and to the central office (in the Albany area). The staff at the Division of Residential Services, which includes nursing homes, assisted living, and intermediate care, can be reached via email. Every other week there are telephone calls with the Health Department about H1N1, for example. We also put out “Dear Administrator” letters to give guidance.
I see some residents and families afraid to say things to the staff, the line staff afraid of the administration, and the administration afraid of the DOH. Is the DOH afraid of the feds? If so, why?
No, we’re not afraid of the feds at all. We speak weekly with Annette Tucker-Osborne (Branch Chief at the Centers for Medicare and Medicaid Services). We work collaboratively with the federal government. The issue of people being afraid to talk to us is definitely out there, but we try to let them know they can call to talk. We have over 9000 calls on an annual basis.
Nursing home staff sometimes comment that State inspections appear to focus on arbitrary criteria. Staff are often puzzled about why certain issues are noted by the State, while others they expected to be problems aren’t seen as such. What’s your perspective on this?
Our staff are trained on state and federal guidelines. It’s not arbitrary, it’s a very set agenda. The nursing staff are very aware of what the guidelines are, and most administrators are very aware of what will be looked at. On a quarterly basis, we discuss the top five deficiencies surveyors find. While it might seem arbitrary to a staff member within one nursing home, things might be seen by surveyors as a systems problem after looking at several nursing homes.
How do you think nursing homes can be improved in general?
Through better management at the administrator level and better communication between certified nursing assistants, nurses, and administration. Examine systems and listen more to residents and staff. Constant quality assurance should be infused into the nursing home practice. The resident really should be at the center, and include their families. We encourage nursing homes to talk about best practices with each other. To facilitate best practices, for example, a chef could come in and talk to staff about meals. A spa-like environment could be created in the bathroom.
Dr. El,
Thank you, Mr. Kissinger and Ms. Pappalardi for shedding some light on the little known views of the New York State Department of Health. DOH is key in initiating systemic changes in long term care which will improve life for our residents and, ultimately, the younger, aging generations.
Sue, I was very happy to have an amicable, collaborative conversation with representatives of the DOH. I think there's a tendency within nursing homes not to make changes, especially if the home has done well during past surveys. In other words, there's a fear of messing with a good thing. If facilities felt they could discuss new programming ideas with the DOH and identify potential problems and ways to avoid them, then perhaps nursing homes could become more vibrant and creative in their care.
Want to improve nursing homes? Staff them adequately. Ask any stressed-out RN who's fled employment in long-term care. They're not staffed adequately. I'm still recovering from a year as the lone RN for 21 patients on a skilled unit at night. Frequently I was floated to work as the lone RN on an LTC floor with 42 patients. My situation was hardly unique. Many nurses (and patients) have it worse.
Anonymous, I've never seen a nursing home that was fully staffed, but I'm very curious about the results of doing so. I'd like to see a study comparing short-staffed to fully-staffed facilities (or units) that looked at resident/family/staff satisfaction, staff injuries, illnesses, and absences, incidents, fees for agency nurses, etc. If anyone knows of such research, please Contact Me via button in upper right corner of blog.
This was very informative. My mother entered a nursing home in October 2009 at the age of 101. She walked in, was eating, had some demential but still knew who I was (I am her daughter and primary care taker). One month later she fell out of bed and broke her hip, requiring surgery, that left her unable to walk and totally senile. It was only after her fall that I learned that my mother should have been in a "low" to the floor bed with mattresses surrounding the bed, so had she fallen she would not have broken anything. I was never informed that there was this option, but more important, the nursing home is not organized enough to make sure that all quality criteria are strictly adhered to. My mother came into this nursing home with one bedsore, she now has six. And is about to go on hospice care. All in four months. Of course her demise could have come at anytime, but this nursing home was supposed to take better care of her, instead what I did not know has almost killed her.
Sad Daughter
Dear Anonymous,
I am sorry to hear about your mom's situation.
I don't know the specifics of your mom's situation, however, I do know residents are not automatically placed in a low bed with mattresses surrounding it, as not everyone is at risk for falling out of bed (although this can always happen). For some, the low bed with mattresses surrounding it pose a far greater risk for accidents. Some facilities conduct a risk assessment on admission.
Thanks, Sue, for addressing Sad Daughter's concerns. SD, this must be a very difficult time for you. It's hard for anyone new to a situation to know all the "right" things to do or ask about, and as Sue pointed out, things that are appropriate for some residents are not appropriate for others.
Here are some good tips to increase your Case Mix Index and Revenue
http://blog.harmony-healthcare.com/blog/bid/44782/Increase-your-Medicaid-Case-Mix-Index-Part-II
CMS and State Department's of Health must mandate proper staffing ratios in SNF's in order that they can successfully comply with the infastructure of regulations/best practices that they require.
Paper compliance, MDS.3 documentation are added time/labor intensive requirements that take TIME and attention AWAY from Residents.
CMS should mandate and manage Volunteer Centers for individual states to draw from in order for facilities to afford added manpower.
Blaming individuals for mistakes/oversights on Surveys that can result in citations is shameful. Often times it is not the Individual BUT the SYSTEM that is to be blamed !!! Sorry for the vent
Anonymous, it's clear you care deeply about these issues. A Volunteer Center is an interesting idea. I was just discussing the staffing problem with K. Tree, CNA on her blog, saying I'd like to see a study that compared working full-staffed with working short-staffed on a variety of measures, including resident and family satisfaction, staff injury, turnover, and absenteeism, and clinical indicators such as pressure sores, etc. I'm guessing we, as a system, are often penny-wise and pound-foolish.
I, too would be interested in this sort of study. I want to be optimistic. Appreciable differences in all of these indicators and measures resulting in a better life for Residents could finally be attributed to increased staffing. My only fear is that the only improvements would be seen in paper compliance/charting. The charting would reflect increased accuracy, timliness and authentic observations and conclusions. I hate to say this, but sometimes I feel no one ever is able to apply "textbook" standards to their charting in all disciplines. Charting is a time sucker. Unfortunately, many in healthcare do percieve it as a necessary evil, but sometimes I think charting is a way to escape and avoid Resident "hands on" contact. Somehow, doing the right thing is always sabatoged by this. Over our heads is this persistent fear of the State's " Gottcha Mentality ". The State needs to be perceived as a collaborator not as an enemy. The State needs to say "these are the areas where we found some problems, here is what we can do to help you, not punnish you!"
P.S. I admire your courage in turning Grey. I'm trying, but the peer pressure, not to, is great!
Anonymous, while I think my job would be a lot more fun and I'd get to spend more time with residents if I didn't have to chart every contact, etc, I fall into the "necessary evil" camp. "If it's not written down, it didn't happen." On the other hand, I agree that collaborative interactions with the State would be far more productive than a fear-based relationship between surveyor and those surveyed. After my interview with Mark Kissinger, I anonymously phoned the NYS Dept of Health to ask them a question (Dr. El Goes Undercover with the NYS Dept of Health) and they were helpful and collaborative, just as Mr. Kissinger suggested they'd be. Perhaps there's more room for a positive interaction than we, as providers, have explored.
PS — Regarding the gray, it's not for everybody, but so far I'm enjoying it. Thanks for the encouragement.
But you see, this is what I think is absurd, at least from the Therapeutic Recreation point of view: Many effective, result based interractions/interventions happen that are NOT written down. All disciplines may informally participate in making that happen. Do I have to anticipate a method of documenting this in order to proove it, or even take credit for it? How tedious, and how grandiose. This is a Resident's HOME, not an elementary school! Measurung quality of life in "scientific" terms, I think does not work.
When I worked in the State Psychiatric Center, Anonymous, we used to write notes on a monthly basis that I felt captured the flow of the patient's progress very well without being overly cumbersome. Now, as a psychologist, I'm working fee-for-service, so every service has to be documented, but that's not the case with the Recreation Department. I look forward to more computerization of charting that will reduce redundancy and speed up the process. You are, of course, correct that many important clinical moments take place without documentation, and I know my notes don't fully reflect the amazing things happening in my sessions.
So, according to the State, those "amazing things" that happen in your sessions did not happen. The irony: "Amazing things" happen when the state surveyors enter the building. Increased teamwork among staff, best practices REALLY being practiced. The Cover your A_ _ mind set is what needs to GO. Simple authenticity/less regulations/common sense needs to replace it. I know I am being unrealistic, but this is what drives the good, quality people out of the biz and expedites burnout.
Anonymous, when I'm having those tough days, I try to remember the saying, "God is my employer." This shifts my focus from the day-to-day frustrations to my higher purpose in working in long-term care.