By Thomas Goldsmith and Riley Davis
North Carolina’s state-owned veterans nursing homes became the place where 36 ailing men caught COVID-19, then died, after surviving tours in places such as Pearl Harbor and Korea, according to federal records.
According to the Centers for Medicare and Medicaid Services, the death totals mean North Carolina ranks third nationally in COVID-related deaths in state veterans nursing homes.
The Georgia conglomerate PruittHealth has run North Carolina’s four veterans nursing homes for 22 years, under a contract which has had little public attention and pays Pruitt 9.25 percent of annual state funding of about $38 million, a cost projected to rise to $47 million in 2021.
Pruitt has chalked up mid- to top-ranked reviews from CMS but has also gotten the federal oversight agency’s attention with citations for dozens of deficiencies. Most recently, for 10 days in June, the PruittHealth managed nursing home for veterans in Salisbury allowed dozens of relatives to make drive-up visits to residents, according to state records.
The visits came despite multiple recent COVID-19 deaths in that facility and in two equivalent veterans homes also run by PruittHealth.
Fifteen residents had already died of COVID-19 in the Salisbury skilled nursing facility. The inspection and citation at the Salisbury center came after a total of 36 veterans had died of COVID-19 at three of North Carolina’s four state-owned veterans nursing homes managed by PruittHealth.
Anna Amirkhanyan, an associate professor of public administration and policy at American University, and an expert in nursing home care and public-private collaborations, noted the perilous circumstances of nursing home residents, including those with neurocognitive orders such as Alzheimer’s disease.
“Even one death is one too many in the context of nursing home care, particularly because this is a vulnerable population,” Amirkhanyan said in a phone interview. “These are our American elderly, and they often lack the ability to complain.
“Not all of them are able to switch their residence promptly if they’re not happy with care and many of them are not even able to differentiate between good and bad.”
Pending any further investigations or post mortem, it’s not possible to know what responsibility Pruitt may hold for the COVID-19 deaths among what are now 342 men in North Carolina’s four veterans nursing centers. The numbers of dead are higher than those in veterans nursing homes in neighboring states according to a database maintained by the federal Centers for Medicare and Medicaid Services.
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Pruitt’s communications department said they would not discuss any details of the deaths because of their respect for residents’ privacy.
“We offer our sincerest condolences to the veterans’ families and loved ones during this difficult time,” a representative of Pruitt’s communications staff said in a statement.
An NCHN analysis of Centers for Medicare and Medicaid Services data shows that no veterans have died of COVID-19 in state-run nursing homes dedicated for their use in neighboring states of Virginia, Tennessee and South Carolina.
A July 9 state Department of Health and Human and Services inspection report faults the State Veterans Nursing Home in Salisbury for failing to have a plan for controlling and preventing infection, as required under state law.
According to that report, Salisbury staff members scheduled between four and six visits for residents each weekday during a period when countless North Carolina families were turned down when they asked for more time with their relatives in nursing homes across the state.
Bringing ‘peace to residents’
“The Director of Nursing stated visitation was started as it was the only way to bring peace to the residents and they had not broken any codes,” the inspectors wrote of the visits. “The administrator noted that they had stopped the family visitation effective 06/18/20.”
That was the day state inspectors talked to staff and walked through the facility.
The core citation alleges failure by the nursing home to create and run an effective infection control and prevention program, meant to “help prevent the development and transmission of communicable diseases and infections.”
PruittHealth offered a bristling rebuttal of the charges.
“The suggestion that there was no plan for infection control and prevention in place at North Carolina State Veterans Home – Salisbury is categorically false,” a statement from the PruittHealth communications staff said in part in an email to NCHN.
“As part of our Commitment to Caring, we recognize the importance of addressing veterans’ emotional well-being and mental health needs resulting from months of separation from loved ones.”
Of the three dozen North Carolina military men lost to COVID-19 in PruittHealth-run nursing homes, 20 died after contracting the disease in the State Veterans Nursing Home in Fayetteville, 15 in the State Veterans Nursing Home in Salisbury and one at the State Veterans Nursing Home in Kinston. That’s according to the most recent data from the federal Centers for Disease Prevention and Control.
For its management role, Pruitt receives 9.25 percent of each facility’s revenue. The $1.2 billion company won the contract for the first time in 1998 and has received a cut of the taxpayer-funded revenue since. Pruitt now works under a one-year extension of a five-year contract signed in 2014, with four more potential one-year extensions.
Representatives of PruittHealth would not answer questions from NCHN about the percentage of revenues the company receives from North Carolina.
Is a 9.25 percent commission fee fair?
“Nine percent is awfully high,” said Dr. Philip Sloane, a geriatrician and distinguished professor of family medicine at the University of North Carolina-Chapel Hill. “My understanding of it is in the more like the four to five percent range.
“The thing is, they can tolerate a low percentage because they basically have a captive population that’s supposedly relatively guaranteed.”
A short survey of people with knowledge of the industry found some who believed the Pruitt commission is high, but others such as Jeff Horton, the executive director of the North Carolina Senior Living Association and a former state official, thought the share is warranted given regulatory burdens and other factors.
Before and since the onset of the pandemic, state and federal officials, advocates for older people, academics and family members have raised questions about the operation of several of the more than 130 such centers across the country, including some with privatized management.
The arrangement between PruittHealth and the state Division of Military and Veterans Affairs dates to 1998, but has received little attention beyond a small circle of industry and government leaders.
Drive-in visitors, but how close?
As many as four or five sets of relatives visited residents at the Salisbury nursing home each weekday from June 8 to June 18. The relatives remained in their cars and the ailing veterans in wheelchairs at what several staffers told DHHS was always within an appropriate social distance. But a DHHS interview with one of the center’s activity staffers told a different story.
“She noted the visits were done at the main entrance,” the DHHS inspection report says. Interviewees in DHHS inspection reports remain anonymous. “She said they would roll the resident outside almost to the car door so they could see their family and speak with them from a distance.”
PruittHealth’s communications team strongly denied any wrongdoing at the Salisbury nursing home in an emailed statement.
“When the clinical leadership team developed an idea to help improve veterans’ quality of life with a few, socially-distanced visits in which family members wore masks and stayed in their cars while speaking with their loved ones – also in masks – at the entrance of the building, we sought and obtained approval from epidemiologists at the VA before proceeding,” the statement said. “The visits in no way contributed to the spread of COVID-19 in the center.”
Federal Veterans Affairs spokeswoman Megan Heup painted the exchange between PruittHealth and the VA differently.
“As part of VA’s Fourth Mission, and through an official tasking from the Federal Emergency Management Agency (FEMA), VA simply conveyed CDC guidance that appropriately socially distanced outdoor events utilizing proper PPE would not contribute to COVID spread,” Heup wrote in an email.
The DHHS COVID Dashboard site lists both the Salisbury and Fayetteville veterans nursing homes as having ongoing outbreaks as of Tuesday.
Two more vets’ homes on the way
The decision by Pruitt to allow visits came among growing discontent about strict limits on nursing home visits that countless frail elderly people died without being able to spend their last minutes with loved ones. Bill Lamb, a long-time advocate for older people and former head of Friends of Residents of Long-Term Care, said PruittHealth likely had good intentions when it started the process that ended with a citation.
“There’s very heavy pressure from families, so you are seeing responses from some facilities, trying to stay as close to the line as they can,” Lamb said.
“My own orientation is that I worry when we privatize the public interest, going to the private market for things like prisons.”
For more than two decades, Pruitt has managed North Carolina’s state veterans nursing homes after submitting bids and signing a series of contracts. However, details of the early years of the arrangement remain murky because the state Department of Administration has been unable to provide any records earlier than 2014. NC Health News first requested them June 4 and submitted a formal public records request on June 17.
The state contract signed in 2014 projected that PruittHealth would be paid $207 million from 2014 to 2019 to run the veterans nursing homes. More than $19 million of that revenue became Pruitt’s 9.25 percent commission.
2014 Pruitt Executed Contract (Public Distribution Copy) (PDF)
PruittHealth CEO Neil Pruitt attempted, but failed, to increase the fee to 9.75 percent just before the 2014 contract signing, according to a Department of Administration document.
This privatized management arrangement got an extension this year, according to state officials. The deal will be up for renewal in December. The future management of planned veterans nursing homes in Raleigh and Kernersville is already written into the deal.
‘Does not constitute an admission’
The Salisbury car visits to veterans came when state and CDC guidelines had prohibited it and when Pruitt had announced that the facility had reached Code Red Alert, its highest level of warning.
As part of the DHHS deficiency process, Pruitt officials were obliged to respond to the report, but admitted no fault and described its required plan of correction as a “written allegation of compliance.”
The response continued: “Preparation and submission of the plan of correction does not constitute an admission or agreement by the provider of the truths of the conclusions alleged or the corrections of the conclusions set forth on the statement of deficiencies. The plan of correction is prepared and submitted solely because of requirements under state and federal law.”
Between Salisbury and Fayetteville, the PruittHealth-run veterans homes have reported132 cases of COVID-19, according to state DHHS. Six of the company’s other non-veterans facilities in North Carolina have had deaths, including a large outbreak of more than 80 patients at PruittHealth-Carolina Point in Orange County, with 20 COVID-related deaths among them.
Where sick veterans go
The most recent budget document from the NC Office of State Management and Budget projects that the state will spend $47.58 million in 2021 in support of the state veterans nursing homes. PruittHealth would earn $4.4 million in annual profit based on their contracted commission rate.
PruittHealth communications staff declined to comment on the deaths or the company’s contract.
“The health and safety of our veterans and staff are top priorities at PruittHealth,” one statement said. “We consider it an honor and a privilege to serve those who have given so much of themselves for our freedom and our country. As such, we are deeply saddened by the veterans lost to COVID-19.”
Among more than 130 state veterans nursing homes across the United States, North Carolina’s death total in such facilities is outranked only by single, similar homes in New Jersey with 79, Maryland with 56 and another in Massachusetts with multiple deaths.
“Most veterans are vulnerable because most of them have underlying health conditions, and that if you have any underlying health conditions with COVID-19 you’re at much greater risk for hospitalization and death,” said Suzanne Gordon, an adjunct professor at the University of California-San Francisco School of Nursing and an authority on long-term care.
Questions from the top
Two U.S. senators asked in May for the General Accounting Office to look into the Department of Veterans Affairs’ oversight of the nation’s state-owned nursing homes following a COVID-19 outbreak that killed 76 people at a Massachusetts veterans nursing home.
Subsequently, family members and media accounts have described actions by the nursing homes that the kin found troubling and made public the names of a few of those who died after contracting COVID-19.
Among that group was retired Master Sergeant Harold Lee Brigman, Sr., 85, who had lived in the Fayetteville state veterans nursing home since 2017. He died May 23, 10 days after Pruitt announced a high-level Code Red Alert warning status for COVID-19 at the center.
Brigman loved his family and would go above and beyond for those in need, one of his daughters, Jennifer Brigman, said in a phone interview. He once drove halfway across the country without stopping to help her out of a dangerous domestic situation, she remembered.
His philosophy was “never to leave wounded,” meaning you should always go back for those injured in battle, she added.
‘They should have been more careful’
Brigman said that communicating with her father in his nursing facility was often difficult. They faced a large cell phone theft problem, and the phone she bought him disappeared the first day she gave it to him. The family wasn’t allowed in the hospital where Harold Brigman was admitted and eventually died.
“We would have never let him die alone,” Jennifer Brigman said.
Brigman praised two Pruitt employees for assisting her family in finding the paperwork needed to hold her father’s funeral with full military honors. But she also faulted some of the company’s care during the outbreak.
“I think that they should have been more careful,” Brigman said. “They’ve admitted that it was one of their personnel who brought the virus in.”
Another who died during the outbreak was Navy veteran Van Thomas Kluttz, who survived Pearl Harbor, contracted COVID-19 in the state veterans home in Salisbury, and died at age 95. His death came a day after a related trip to an emergency department, his granddaughter, Sally Nifong, told Charlotte television station WBTV.
“Had I known that he was going to be even exposed to it, I wouldn’t have brought him out,” Nifong told WBTV. “I would have brought him home with me, had I known. I thought he would have been safer there.”
Elected officials respond
State Rep. Grier Martin (D-Raleigh), who served in Afghanistan and continues in the U.S. Army Reserve, said his fellow veterans in nursing homes deserve the best possible treatment.
“It’s a tragedy all the lives we’ve lost and certainly my hope would be for any of my fellow veterans that they be able to enjoy the retirement and the care that they’ve earned, that our state and the federal government work hard to provide them,” Martin said in a phone interview.
At the federal level, U.S. Rep. David Price (D-NC) also said the country’s veterans deserve the best care.
“The deaths and COVID-19 spread at congregate care facilities, including state veterans homes, are alarming,” Price said in a statement.
U.S. Rep. Richard Hudson (R-NC), whose district includes Fayetteville, did not respond to a request for an interview.
Meanwhile, CMS appears to have started inspecting nursing homes specifically to uncover how COVID-19 spread to thousands of residents.
Recent information about COVID-19 spread in Long Term Care Facilities (LTCF) shows about half of residents testing positive for COVID-19 are not symptomatic. Spread of the virus could have been occurring undetected long before a positive test is reported, inspectors said in a report on the Southeastern Pennsylvania Veterans’ Center in Spring City, Pa.
Georgia-based PruittHealth has managed the publicly financed State Veterans Nursing Home since 1998. Here are totals of recent amounts paid to the company, part of these payments became profit for Pruitt: In 2019 PruittHealth Veteran Services received $41,456,079. In 2018 PruittHealth Veteran Services 2018 received $40,324,205, including $8,262 for equipment. In 2017 PruittHealth Veteran Services received $38,466,256. In 2016 PruittHealth Veteran Services 2016 received $41,810,166 in two contracts for $32,149,943 and $9,660,972)
Georgia-based PruittHealth has managed the publicly financed State Veterans Nursing Home since 1998. Here are totals of recent amounts paid to the company, part of these payments became profit for Pruitt:
In 2019 PruittHealth Veteran Services received $41,456,079.
In 2018 PruittHealth Veteran Services 2018 received $40,324,205, including $8,262 for equipment.
In 2017 PruittHealth Veteran Services received $38,466,256.
In 2016 PruittHealth Veteran Services 2016 received $41,810,166 in two contracts for $32,149,943 and $9,660,972)
Riley Davis provided assistance via the the NC News Intern Corps, a program of the NC Local News Workshop, funded by the North Carolina Local News Lab Fund and housed at Elon University’s School of Communications.