By Thomas Goldsmith

Too often, frail and mostly older people in poor-performing skilled nursing facilities end up in unnecessary pain or distress. 

One example comes to light in the story of a resident of Accordius Health, a Statesville nursing home. State records show she was in such pain from a severe tooth abscess on Oct. 21, 2021, that a nurse practitioner there said she needed to see a dentist immediately. 

On Dec. 1, six weeks later, the woman identified in documents only as Resident #1 saw a dentist, who recommended extraction of all her teeth. But it was not until 315 painful days later, on Aug. 23, 2022, that her teeth were finally extracted, the records show. 

“Resident #1 opened her mouth and smiled, which revealed all visible teeth appeared to be yellow and brown stained, and jagged-irregularly shaped tooth fragments,” said an official report known as a statement of deficiencies and plan of correction, the federal form used to document inspections and their findings.

“Resident #1 vocalized she really needed to see the dentist to have her teeth extracted because she had multiple oral infections which had caused her pain, facial swelling, and at times, caused her to have difficulty chewing which made her not want to eat as much when this occurred,” the report continued.

The 10-month delay in addressing Resident #1’s oral health was among the causes cited by the Centers for Medicare and Medicaid Services (CMS) when the agency denied further federal funding to the Statesville facility in August. That move – often described as a last resort –  effectively shut down Accordius Health at Statesville.

For three months before the cutoff, the facility had been identified as a Special Focus Facility, the federal designation for a poor-performing nursing home that comes under federal scrutiny.

That’s just one example of the type of poor care federal authorities say they’re looking to crack down on. The White House recently announced that federal regulators will be taking a harder line in dealing with the country’s poorest performing nursing homes, such as the Statesville facility run by the for-profit Accordius Health chain. 

What are Special Focus Facilities?

According the Centers for Medicare and Medicaid Services, Special Focus Facilities are poor-performing homes with distinguishing characteristics that show that they have:

  • Roughly two times the number of deficiencies in performance in areas such as safety, resident care, and protecting resident rights;
  • Deficiencies that show more serious issues, including injury or harm to residents;
  • Persistent issues that occurred during a period of as long as three years since the nursing home was placed on the Special Focus Facilities list.

What changes are ahead?

The administration of President Joe Biden announced on Oct. 21 that CMS would heighten oversight of these kinds of nursing homes to increase the quality of care right away, shutting them down earlier if necessary.

“In a series of revisions to the Special Focus Facility (SFF) Program, CMS will toughen requirements for completion of the program and increase enforcement actions for facilities that fail to demonstrate improvement,” the department said in a statement. “CMS is also calling on states to consider a facility’s staffing level in determining which facilities enter the SFF Program.” 

The announced changes include:

  • Making improved quality throughout a facility, rather than a lower level of deficiencies, key to completing the program and escaping its penalties and stigma.
  • As in the case of Accordius Health at Statesville, pulling vital federal funding. Under new standards, this denial can take place at an earlier point, when a center is cited for two separate instances of “immediate jeopardy” of the life or health of residents.
  • Escalating enforcement, meaning a more severe regimen for SFF Program facilities that “have continued noncompliance and little or no demonstrated effort to improve performance.”
  • The new focus on staffing levels as a factor in the decision by state regulators on choosing a facility for the program.

The plans for stricter treatment have revived discussion about the best means to ensure the best care of the frail, mostly older people who live in places such as the former Statesville operation. Representatives of the long-term care industry call attention to the relatively small number of bad actors. However, principals in the public and nonprofit sectors say attention is warranted when a focus on profits affects the way residents are treated.

“Part of what is happening is that many of the nursing home corporations are looking at the bottom line and needing/wanting to make money,” Janice Tyler, director of the Orange County Department on Aging, said in an email. “We need to be looking at how much money these corporations are making after they cover their expenses.

“They obviously have to meet minimum standards, but could they provide better care if there was not a focus on profit? Could there be more staff training, more staff and better paid staff to reduce staff turnover, facility improvements, more engaging activities for the residents?”

Watching the money

Multiple studies over the past two decades have found that comparable residents in community or nonprofit long-term care settings have better health outcomes than those in for-profit facilities. And research performed in the past two years has shown that for profit nursing facilities had higher rates of COVID-19 infections and deaths during the pandemic than nonprofit facilities. 

However, particularly during and since the COVID-19 pandemic, operators are feeling increasingly squeezed. A recent report published by the nationwide industry group American Health Care Association and the National Center for Assisted Living notes that operators are finding that providing care costs more than the amount of reimbursement, to the tune of a “projected 4.8 percent negative margin.” 

Adam Sholar, president of the North Carolina Health Care Facilities Association, a statewide industry group, was unavailable for comment but referred NC Health News to a statement on proposed CMS changes by Mark Parkinson, president of AHCA/NCAL. Parkinson argued policy changes should stress facility improvement over punishment, as well as increasing reimbursement, particularly at a time when worker shortages are already at a peak.

“Nursing homes have experienced the worst job losses of any health care sector,” he said in the statement, issued in response to the White House announcement. “Analysts have projected that it will require billions of dollars to hire more than 100,000 more nurses and nurse aides if a federal staffing minimum moves forward.

“Long-term care needs a concerted and considerable investment to recruit and retain more frontline caregivers and address access to care issues for millions of seniors,” the statement continued.  

Similar concerns have been expressed at the North Carolina General Assembly, where lawmakers heard from industry leaders at the October meeting of several legislative oversight committees describe staffing problems in care facilities and the need to raise salaries for workers.

“There’s more awareness on the reality of where we are with the needs of North Carolina and the aging population,” said Sen. Jim Perry (R-Kinston). “As we talk about it more and people become more educated on the topic and you have a greater understanding of what we’re facing, and what’s coming, we’ve got to take bites at it.”

But the solutions – and the problems causing them – are not simple. 

Critics of the nursing-home industry, including some congressional leaders, have said that companies often structure a nursing home’s operation using multiple layers of financially related providers that make it difficult to determine profit levels.

“Experts have noted that the practice of nursing home parent companies using separate subsidiaries to service their operating companies may allow companies to obscure the true financial condition of a given nursing home facility,” reads a report from the Select Subcommittee on the Coronavirus Crisis, chaired by Rep. James E. Clyburn (D-S.C.).

North Carolina entries on Special Focus Facilities list

Facilities that have lost Medicare and Medicaid funding:

Facilities newly added 

  • Alamance Health Care Center, Burlington 

Facilities that have shown improvement (however the agency waits for at least 12 months before lifting restrictions)

  • Peak Resources, Shelby  

Facilities that have graduated (had sustained improvements for about 12 months)

  • Accordius Health, Clemmons
  • Macon Valley Nursing And Rehabilitation Center, Franklin
  • Richmond Pines Healthcare And Rehabilitation Center, Hamlet

— Centers for Medicare and Medicaid Services, updated October 26

“A more nuanced approach”

There’s long been debate about how much profit nursing homes actually make. That matters as the new CMS guidelines take hold because regulators will appraise staffing levels when deciding which facilities should go on the list. Somebody would have to pay for more staff, and operators say they’re not making enough profit as it is, so the bill for larger staffs should come from increased state and federal funds. However, information like the study by the U.S. House Select Subcommittee on the Coronavirus Crisis shows that owners can hide profits by routing payments through wholly owned but supposedly separate parts of the business like pharmacy or housekeeping.   

“They are largely for-profit, with absentee owners who may well be interested only in profit and not in care,” said Dr. Philip Sloane, a professor of family medicine and geriatrics at the University of North Carolina School of Medicine, said of the state’s nursing homes. “Those individuals may well only be motivated by punitive requirements. But the other aspects of poor performance need a more nuanced approach that includes evaluation, support, training, and, at times, resources.”

Sloane was one of the national experts who took part in an effort by the National Academies of Science, Engineering and Medicine to produce a report, “The National Imperative to Improve Nursing Home Quality,” that prescribes innovative remedies for nursing home ills.

Changes coming from CMS could bring about positive changes for residents, according to Linda Elizaitis, who works with clients as president of the Melville, N.Y.-based consultant firm, CMS Compliance Group.

“CMS’s revision to the SFF Program to include consideration of staffing is warranted,” Elizaitis said in an email. “A facility can’t deliver quality care and services without a sufficient number of competent and educated staff to carry out direct care and services, but it’s not just about a ‘number’ of staff on a shift.

“Frontline staff need to have appropriate oversight and be monitored by qualified staff members to ensure that the health care needs and safety of the resident population are being met.”

For Janice Tyler, at the Orange County Department of Aging, improvement can come from local interaction with facilities staff, even though that’s more difficult given the large number of absentee owners. Relatives and residents can get help from local government ombudspersons distributed throughout the state if they find issues difficult to address with nursing homes directly.

“We have had success in building relationships with the administrators, but when it is a corporate facility they get moved around a lot and then we have to start all over with a new staff person,” Tyler said. “We want to support the facilities and assist in recruiting volunteers to serve them to help create community and engagement.

“We think education on behalf of consumers and their families is important. They might not realize the basic protections and may fear retaliation when seeking support from ombudspersons.”

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Thomas Goldsmith

Thomas Goldsmith worked in daily newspapers for 33 years before joining North Carolina Health News. Goldsmith is a native Tar Heel who attended the UNC-Chapel Hill, and worked at newspapers in Tennessee...