CMS imposed few penalties at nursing homes despite promises of tough enforcement

The federal agency and its state partners, Verma said, would conduct a series of newly strengthened inspections to ensure 15,400 Medicare-certified nursing homes were heeding long-standing regulations meant to prevent the spread of communicable diseases. It was another key component of a national effort, launched in early March, to shore up safety protocols for the country’s most fragile residents during an unprecedented health emergency .

But the government inspectors deployed by CMS during the first six months of the crisis cleared nearly 8 in 10 nursing homes of any infection-control violations even as the deadliest pandemic to strike the United States in a century sickened and killed thousands, a Washington Post investigation found.

Those cleared included homes with mounting coronavirus outbreaks before or during the inspections, as well as those that saw cases and deaths spiral upward after inspectors reported no violations had been found, in some cases multiple times. All told, homes that received a clean bill of health earlier this year had about 290,000 coronavirus cases and 43,000 deaths among residents and staff, state and federal data shows.

That death toll constitutes roughly two-thirds of all covid-19 fatalities linked to nursing homes from March through August.

Patient watchdog groups acknowledge that not every outbreak could have been prevented, even with adequate infection-control practices in place. But as the pandemic raged, the number of homes flagged for infection-control violations remained about the same as last year.

The facilities that were cited for breakdowns often escaped significant penalties, The Post also found.

Inspectors reported violations at about 3,500 homes, ranging from dirty medical equipment to a lack of social distancing. Though federal law allows CMS to levy fines of roughly $22,000 for each day a serious violation lingers, most providers were fined little or nothing at all.

For failing to ensure staff members wore masks, Sterling Place in Baton Rouge, with more than 80 coronavirus cases and 15 deaths, was fined $3,250.

For failing to separate residents in a common area, Heritage Hall in Leesburg, Va., with more than 100 cases and about 18 deaths, was fined $5,000.

For failing to use protective gear, the Broomall Rehabilitation and Nursing Center in Pennsylvania, with more than 200 cases and about 50 deaths — among the highest nursing home death counts in the country — was fined $9,750.

Broomall spokesperson Annaliese Impink attributed the lapses to “covid fatigue” and said staff members are corrected when concerns crop up. Officials with Sterling Place and Heritage Hall did not return calls seeking comment. In its written response to the inspection, Heritage Hall said tables had been rearranged and a nursing supervisor would monitor for compliance. Heritage Hall went on to suffer a second deadly outbreak last month, state records show.

The inspections follow a three-year push at CMS to ease rules long considered burdensome to the nursing home industry, whose lobbyists and leaders include former politicians and government insiders. Even before the coronavirus crisis, the agency took steps to limit the use of some

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Kansas nursing home faces severe federal penalties after deadly coronavirus outbreak

By the time the viral firestorm had finished sweeping through the nursing home, all 63 residents were infected and at least 10 had died. Medicare moved Monday to terminate the Andbe Home from its program, cutting it off from federal dollars and imposing thousands of dollars in fines.

Government inspectors found that infected residents were separated from their healthy roommates by little more than a privacy sheet. Communal dining continued for two days. Multiple staff members failed to wear masks — even after the outbreak took hold.

In an email Tuesday to The Washington Post, the nursing home administrator disputed some of the findings outlined in the report and stood by the response to the outbreak, saying the facility had immediately quarantined infected residents and that staff wore full personal protective equipment, including goggles, masks and gloves.

“This is a terrible virus, but I am proud of how our staff has battled COVID-19 over the course of the pandemic, coming to work every day under extenuating circumstances, and caring for all of our residents,” Mapes wrote. “I am also proud of and thankful for the mutual support between Andbe Home and our community during trying times for everyone.”

The Medicare report, however, said the facility’s failures had “placed all residents in immediate jeopardy by the spread of Covid-19 to all residents.”

The virus’s rampage through the nursing home came amid a surge of infections in Kansas’s Norton County, which led the nation in per capita case increases between Oct. 12 and Oct. 19 and ranked second this week, according to a Post analysis. Before Oct. 13, the county near the Nebraska border had been spared virus-related deaths.

Now, there are clusters of cases at the nursing home, where 55 of 70 staff members tested positive for the virus, as well as at a correctional facility and a bank. City offices are closed to the public, municipal court is postponed and multiple businesses have temporarily shut their doors. The funeral home has posted a wave of obituaries for people who lived at the Andbe Home: a stained glass artist with pieces displayed around town, a onetime staffer turned resident, a skilled home cook known especially for “fried chicken with all the fixins.”

Like many parts of rural America, the county of about 5,000 had resisted masks and other measures aimed at preventing the spread of the coronavirus. The city police department was cheered in June after announcing it would not enforce a mask mandate imposed by Gov. Laura Kelly, a Democrat.

“For months, many have mistakenly shared the idea that this virus would never reach our rural and lower-population communities,” the governor said during a news conference last week. “Now, it is worse in those towns and counties than it is in our cities.”

She called the deaths at the Andbe Home “a stark reminder” of the threat posed by the virus.

Medicare inspection reports suggest resistance to masks at the nursing home, a sprawling, single-story facility that was rated as

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Acute Care Measure Could Reduce Hospital Readmission Penalties

About one in four hospitals would see their penalty status change under the Hospital Readmissions Reduction Program (HRRP) if penalties were determined using “excess days in acute care” (EDAC), a more comprehensive measure of hospital use after discharge, instead of looking only at 30-day readmissions.

The EDAC measure captures all days spent in acute care settings within 30 days of discharge, including emergency department (ED) visits, observation stays, and unplanned readmissions.

In the study, published online October 13 in Annals of Internal Medicine, half of hospitals in the highest-performing group under the more blunt 30-day readmissions measure would fall to a lower-performing group if EDAC were used.

Conversely, a similar number of low-performing hospitals would jump to a higher stratum.

“We know that linking the 30-day readmission measure to penalties under the HRRP has led to intensified efforts to treat patients in the ED or as observation stays,” said lead author Rishi Wadhera, MD, MPP, MPhil Beth Israel Deaconess Medical Center, Boston. “While this makes hospitals’ readmission rates look lower, it’s not clear that these shifts are actually good for patient care.”

Given the $3 billion in penalties assessed by Centers for Medicare & Medicaid Services (CMS) under the HRRP since its implementation in 2012, a switch to EDAC could help pull some struggling hospitals back from the brink.

Of particular concern, said Wadhera, is evidence showing that small rural and less resourced hospitals might be taking the brunt of those penalties.

“Large hospitals have the capacity and infrastructure to treat patients in the ER or place them in observation status, such that these encounters won’t count as readmissions. Small rural hospitals don’t have that capacity and may be unfairly penalized,” he suggested.

This new study compared the impact of the standard 30-day readmissions measure with the EDAC measure in 3173 hospitals that participated in the HRRP in 2019.

Because of ongoing concerns regarding unintended consequences associated with the 30-day readmissions measure, including a possibility of increased mortality among patients admitted with heart failure and pneumonia, there have been numerous calls from the clinician and health policy communities, including a recent one in JAMA from Ashish K. Jha, MD, MPH, Brown University School of Public Health, Providence, Rhode Island, to replace the metric with a more comprehensive measure of hospital use.

EDAC was developed for CMS and has been publicly reported since 2017, but is not included in the HRRP. Like the 30-day readmissions measure, however, it does not fully adjust for risk factors like frailty and medical complexity.

The EDAC measure would diminish the perverse incentive to avoid readmitting patients who come back to the hospital.

“One advantage of the EDAC measure is that it’s comprehensive and less gameable, because it counts all hospital encounters after discharge, including ED visits, observation stays, and/or readmissions. The EDAC measure would diminish the perverse incentive to avoid readmitting patients who come back to the hospital and allow for fairer comparisons of hospital performance,” said Wadhera.

“But at best, switching from 30-day

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