Two weeks ago the NYT had an article about nursing homes and and profit factor. I was pretty damn PISSED when I read it; so much that I could not blog about it. Time has calmed me down a tad or two, and I have some thoughts about this.

This post is an essay- quite long but well timed right about now.

Habana Health Care Center, a 150-bed nursing home in Tampa, Fla., was struggling when a group of large private investment firms purchased it and 48 other nursing homes in 2002.

The facility’s managers quickly cut costs. Within months, the number of clinical registered nurses at the home was half what it had been a year earlier, records collected by the Centers for Medicare and Medicaid Services indicate. Budgets for nursing supplies, resident activities and other services also fell, according to Florida’s Agency for Health Care Administration.

The investors and operators were soon earning millions of dollars a year from their 49 homes.

We have to go back in time a little, to see how this is relevant now.

In the early 1960’s America had very few “nursing homes”…in those days before the Flower Power ME ME ME generation took hold of our culture and society, people looked after their own. We had small hostels where the homeless or those who had no family were housed in their elderly years; we had institutions where mentally ill and disabled were housed (like cattle I might add…)
After the roots had been planted by the selfish baby boomers, the family began to suffer. The first casualties of that generation were the older folks. It suddenly became inconvenient to take care of Grandmah or Grandpa. Our great industrious country came up with the perfect solution: Nursing homes- the place where we would place our elderly family members, where nursing and other services could be provided. The idea was great for the flower powered set; and it became common for the older people to NOT want to be a “burden” to their younger relatives.

These nursing homes were questionable- there were hardly any nurses providing care. Nurses aides were unheard of at these places; they hired just about anyone to perform those tasks- and the resulting problems were tremendous. Poor care led to disability and early deaths- often cruel and nasty deaths. Abuse was rampant. Neglect was common as well. The people employed at these facilities were not trained or educated in the arts and sciences of caregiving. The private sector really blew it in those early days. They could have capitalized on the bad things by offering much better services- for whatever reasons, they did not. It became a huge profit machine- nursing homes. And the elderly paid the ultimate price.

The generation gap grew wider as the baby boomers sued the nursing homes for the gross neglect and abuses; they cried foul and demanded the federal government step up regulation and oversight. The private sector was never given a chance to correct itself. Our government created the second most highly regulated “industry” in America: Nursing homes. Called OBRA 1987- the Omnibus Reconciliation Act of 1987 had far reaching arms that still touch us today.

As previously written here, nursing home oversight is ridiculous at times. The manual is 6 inches thick and weights about the same! The federal government empowers each state to figure out if the nursing homes are in compliance with the standards; each state must inspect every nursing home that receives federal funds, once every 15 months. One of the regulations provides that nursing home management must be open and registered with each state; the shareholders and other vested parties must be known: This is to keep things honest and, to provide the private sector with some opportunity to gain profit if it can be done. Profits must be reported to the federal government and taxed of course; but the nursing home MUST stay within regulation and care must meet minimum standards no matter what.

Until now. We have special interest investors pooling funds and buying out entire chains of nursing homes. A clever and manipulative and elaborate system of ownership is happening: The building is leased; the staff are hired and employed through an employment agency (NOT through standard nurse staffing agencies); medical services from doctors are contracted out; supplies are purchased through large group plans. The actual owners, and investors, are not known. Each facility has an Administrator who works for a chain, and the chain is owned by corporations that buy up other services from many different industries.

What does this have to do with anything??

Residents fared less well. Over three years, 15 at Habana died from what their families contend was negligent care in lawsuits filed in state court. Regulators repeatedly warned the home that staff levels were below mandatory minimums. When regulators visited, they found malfunctioning fire doors, unhygienic kitchens and a resident using a leg brace that was broken.

“They’ve created a hellhole,” said Vivian Hewitt, who sued Habana in 2004 when her mother died after a large bedsore became infected by feces.

Habana is one of thousands of nursing homes across the nation that large Wall Street investment companies have bought or agreed to acquire in recent years.

Those investors include prominent private equity firms like Warburg Pincus and the Carlyle Group, better known for buying companies like Dunkin’ Donuts.

As such investors have acquired nursing homes, they have often reduced costs, increased profits and quickly resold facilities for significant gains.

It means that profit once again rules over nursing care. It means that people, elderly and disabled, are being neglected and therefore abused, not intentionally by their staff, but by the lack of supplies and caregivers. It means there is no recourse for the families. We’ve gone backwards here. Where there is a way to make a quick buck, there are always shady and unethical people who will take advantage of this opportunity.

But by many regulatory benchmarks, residents at those nursing homes are worse off, on average, than they were under previous owners, according to an analysis by The New York Times of data collected by government agencies from 2000 to 2006.

The Times analysis shows that, as at Habana, managers at many other nursing homes acquired by large private investors have cut expenses and staff, sometimes below minimum legal requirements.

Regulators say residents at these homes have suffered. At facilities owned by private investment firms, residents on average have fared more poorly than occupants of other homes in common problems like depression, loss of mobility and loss of ability to dress and bathe themselves, according to data collected by the Centers for Medicare and Medicaid Services.

The last US census showed that we have over 1.8 million people residing in nursing homes- or just over 6% of those over 65. Not a lot. Most of our older folk live at home or in other community type housing- assisted living, group home residences and the like. It’s pretty uncommon these days to see family taking care of their own.

Once an elderly person runs out of money to live on their own, or pay the assisted living fees, they become eligible for Medicaid. This determines nursing home placement. Most all nursing home residents depend upon Medicaid to pay the bill. I have known nursing home residents who worked hard all their lives; who saved every penny they could towards their retirement. Many had MILLIONS saved. They retired and lived the good life for several years; they traveled and explored. They could not afford the health insurance though- so they depended upon some of these savings to get them through medical needs. Until that need turned into a stroke or a heart attack. Suddenly all that money was gone; the house is sold (by federal law) to pay up some of those bills as well…the disabled grandpa must be admitted to a nursing home. Often his family had no choice as to WHAT nursing home either- wherever there was an open “bed” is where he would go.

This is common. Good, honest hard working older people get sick and find themselves totally broke. Uninsured. Unable to take care of themselves. And they have become a “burden” to their own families- who conveniently have no resources either, to care for their elders. What’s the “option”? The nursing home, of course. Where death begins. Sometimes a long painful death…as a people we Americans should be ashamed of ourselves. For allowing the mentality of this “burden” rule the life of the very people who gave us what we have…I won’t get into the morals and values of all this here, but it is a very BIG FACTOR in all this.

The last 20 years of the nursing home industry have proven to be lacking at best, although they have gotten better in small steps. Some facilities are really good- they operate with a mission that places the person first and not the profit. Overall though, nursing homes have not improved. The government pays for everything: the bed, the meds, the food, the clothes, the supplies. The government sets the price it will pay for services provided; the price has barely increased in the past ten years. So, we have nursing homes operating in the red. They cannot afford to pay the staff competitive wages or offer decent benefit packages- hence we have a huge shortage of trained, caring nurses and aides. We’re resorting to hiring legal and illegal immigrants to fill these positions and we’re seeing poor care continue because of this.

It baffles me how ANY group of private investors CAN MAKE A PROFIT these days. But they do- at the cost of lives though.

But private investment companies have made it very difficult for plaintiffs to succeed in court and for regulators to levy chainwide fines by creating complex corporate structures that obscure who controls their nursing homes.

By contrast, publicly owned nursing home chains are essentially required to disclose who controls their facilities in securities filings and other regulatory documents.

The Byzantine structures established at homes owned by private investment firms also make it harder for regulators to know if one company is responsible for multiple centers. And the structures help managers bypass rules that require them to report when they, in effect, pay themselves from programs like Medicare and Medicaid.

Investors in these homes say such structures are common in other businesses and have helped them revive an industry that was on the brink of widespread bankruptcy.

And:

The graying of America has presented financial opportunities for all kinds of businesses. Nursing homes, which received more than $75 billion last year from taxpayer programs like Medicare and Medicaid, offer some of the biggest rewards.

“There’s essentially unlimited consumer demand as the baby boomers age,” said Ronald E. Silva, president and chief executive of Fillmore Capital Partners, which paid $1.8 billion last year to buy one of the nation’s largest nursing home chains. “I’ve never seen a surer bet.”

For years, investors shunned nursing home companies as the industry was battered by bankruptcies, expensive lawsuits and regulatory investigations.

But in recent years, large private investment groups have agreed to buy 6 of the nation’s 10 largest nursing home chains, containing over 141,000 beds, or 9 percent of the nation’s total. Private investment groups own at least another 60,000 beds at smaller chains and are expected to acquire many more companies as firms come under shareholder pressure to sell.

This means that many of US will become victims here. As we steadfastly proclaim it will NEVER happen to us, a nursing home admission is almost certain for a great majority of those of us born after 1965….we live in a society that shuns personal responsibility and willingness to sacrifice. Many people have raised their kids to be selfish people who will NOT take care of their aged parents. Family comes last in the long list of things to do.

These horrible nursing homes have figured out how to circumvent the regulations and oversight; they have figured out how to effectively be immune from lawsuit or other means of accountability for poor care and death; they have made BILLIONS in profit as well. Just how to they do it?

Lets count the ways:

Staffing:
Two or three aides for 80 residents (human beings with heavy medical and nursing needs). Two or three aides who must bathe, dress, feed, toilet, reposition and hydrate- several times a shift. It doesn’t happen in these nursing homes. Nurses? If you’re lucky there is an RN in house, and if there is she is corporate whore who is on call for several homes owned by the big chain; LPNs and med techs do the med passes and dressing changes and supervision of the aides. The aides? Many are immigrants of various status who do not and will not speak English; who are trained by the corporation- to provide as little care as “humanely” possible. They are barely in standard, and the RN who works for the corp does the training and testing. And, the corp is reimbursed by our government for this “training”– how perfect this is. Caring for human beings is an art and a well documented science. We demand our nurses to be college educated; we develop standards of care and call it neglect when that doesn’t happen. Nursing polices itself- we hold ourselves to a higher standard than most other professions. For a reason- the value of life is extremely important to most of us. We recognize that in order to heal, the conditions our patients are in must be at a certain level. This goes with dying as well: While old people do die- it doesn’t have to be from bed sores and undernourishment. It should never be due to a fall and a broken hip. And it should never EVER be because some outside interest group lowers OUR standards. That’s exactly whats happening though.

Supplies:
Incontinent residents are common due to the lack of staff. Briefs, adult diapers? If you’re lucky you’ll have disposable ones. More common are the cloth variety which are uncomfortable when wet or soiled with feces. These nursing homes LIMIT the number of briefs a resident is allowed to use in a 24 hour period. Many allot TWO. I know many aides who purchase packages of briefs on their meek 8.00/hr salaries for their residents and sneak them into work…its against the law for aides to do this. The families can do this too- but it’s also against the law to USE the products…many aides DO use them in spite of the rules. Most aides simply cannot afford to do this and they shouldn’t have to. Allotting TWO damned diapers for a full grown adult to use in a 24 hour period is simply disgusting. But common at these shabby homes.

Food- government surplus is what is found in the kitchens. Plates of cottage cheese and jello are the staples for dinner. Watered down dry mix milk, cheap fruit juices and old stale coffee is the norm. The hot meal is served at noon and is often bland, boring, cardboard like slices of meat and instant potatoes. Bought in bulk these food items are cheap, have a long shelf life and add to the profits.

Linens:
Bet most people don’t think to much about the sheets they sleep on; or they divulge themselves in the sensual feeling of high counts and satin. In the nursing homes managed by these greedy scums, the sheets are plain polyester and are laundered once a week- no matter HOW often the resident urinates on them. When an aide finds a sheet wet- they are instructed to leave the bed unmade and open to air dry. Sweet eh? Grammie worked hard all her life to deserve this. Linen services are outsourced, and limits to the number of loads allowed per week are typical. Towels? Wash cloths? Ha. One set a week…for that one shower each resident is allowed. Some of the better nursing homes under these corps should be given credit: They do allow bed pads. One per resident per week. How generous.

I get these numbers from CNA’s and nurses who work for chains such as Life Care Centers of America; Manor Care; Beverly Enterprises- there are many. Sad thing is THESE chain managed homes are better than the ones described in this article. These chains are accountable and their ownership is as well. The homes in the article are as unaccountable as a ghost. They open up shop, provide a very very poor service knowingly; they get served with papers or cited by the government inspectors- and they close up house. And move along to the next town.

The gist of this is simple. These scumcorps are lowering the already low standards. They’re making profits off of US- the American people. I don’t give a wet rats ass what your politics are in this. Whether we like it or not, we have an entire generation of people we call the Greatest Generation- being neglected wholesale. And we have no one to blame but ourselves- each of us who has an elderly parent or Grandparent who WE placed into a nursing home…under some BS guise that it was THEIR choice, not ours….THEY don’t want be that awful BURDEN…we make the choice, not them.

Our society has placed less and less value on our most generous and honest people- our elderly. To get old is a bad thing. Old is terrible; old isn’t sexy; old means death. We need to get over ourselves and get back to whats important in life…and that is not living the good life at the expense and comfort of our elderly citizens. I totally blame US, society and the Flower Power assharts for destroying the value of FAMILY. My idea of family most certainly includes my elders. We get what we give in life folks. If we devalue the lives of our parents or grandparents, and place their last years in the hands of government, we have little business complaining about these issues. Yet, if someone DOESN’T speak up, we become enablers of elderly concentration camps- nursing homes. It shouldn’t be about profits and loss. It shouldn’t come down to supplies and two CNA’s. It should be about the personal sacrifices we SHOULD be willing to make in order to provide the home and care for those who need it at this time in life.

My good friend JD, a nurse, has a different take on this. Not too different though- and he points out some truths that must be known. ALL nursing homes cut staff and supplies, yes. ALL nursing homes operate in defensive nursing, yes. NO ONE is willing to pay the true costs of good nursing care- because it would bankrupt the country. JD is much more polite when it comes to placing the blame- he is subtle and drops little hints. NOT ME. This is OUR fault. We don’t want to be bothered with taking care of Ma and Pa when they get old. We’re too busy. We have too many bills and both MUST work…yaddah yaddah. But we will sue the hell out of a nursing home for poor care that we are not willing to make better by paying A HELL OF A LOT MORE taxes to fund it!

My advice to everyone: Keep your loved ones at home. Make the damned personal sacrifice. Lower the standard of living a notch or two. Drop the need for two incomes…Do the right thing. Take care of family. Otherwise you face the exact same fate these people who died untimely and neglectful deaths.