By Amy Silverman
By Olivia LaVecchia
By Monica Alonzo and Stephen Lemons
By Chris Parker
By Michael Lacey
By Weston Phippen
The Department of Health Services says no fines were levied in any of these cases because violations were considered isolated incidents. "That has changed," says Catherine Corbin, program manager in the department's enforcement section. The department now considers fines when just one resident is injured or killed, she says. But punishment still isn't certain, even in homes with histories of not meeting standards.
Life Care Centers of Scottsdale, for instance, had 20 violations between July 2003 and September 2004, twice as many as the statewide average. The home had 18 violations in each of the two previous inspection periods, which can last as long as 15 months. Since July 2001, inspectors have cited Highland Manor for 50 violations.
Yet neither of these homes has been punished, even after the state documented real harm to residents.
Nursing homes are big business in Arizona. All told, the state has 16,104 beds in 134 nursing homes that collect more than $30,000 a year for each Medicaid resident. If every bed was filled, with Medicaid paying the bills, that works out to a conservative $483 million a year.
Until last year, Arizona relied on someone else to punish nursing homes, referring the worst violations found by state inspectors to the federal government for sanction. It was a haphazard way to hold homes accountable.
The federal system has long been criticized for going light on bad nursing homes. For one thing, the federal government doesn't always follow state recommendations for sanctions. For another, the feds give grace periods: If violations get fixed within 30 to 60 days, no punishments are levied. And homes that pay fines without appealing receive a 35 percent discount.
Furthermore, the federal system is reactive rather than preventive. In most cases, someone has to be killed or hurt before the federal government takes action. Even then, the feds don't require states to refer cases for sanction if only one person dies or is injured. Homes on the brink are rarely punished at all for violations that have the potential to injure or even kill.
Besides issuing fines as large as $10,000, the federal government can terminate a home from the Medicaid program or temporarily stop a home from accepting new Medicaid or Medicare patients. A ban on new residents is a huge hammer, given that the government pays about 60 percent of nursing home costs in the United States.
Since 2000, the federal government has banned new admissions to homes within Maricopa County on just eight occasions, and for periods as short as two days, even when poor care has led to death. During the same period, the feds have levied $180,600 in fines against 14 nursing homes in the county. Three homes still haven't paid fines totaling more than $76,000 that were levied as long as two years ago.
"There's so little enforcement going on," says Toby Edelman, an attorney with the Center for Medicare Advocacy in Washington, D.C. "We don't say, 'Yes, you have to fix it for the future, but there's also a consequence because this person died.' If you don't pay your taxes, they might prosecute you if it's really bad. You can't just say, 'But I paid my taxes last year.' So what? You have to pay your taxes every year."
Since 1997, the Government Accountability Office (formerly the General Accounting Office), which audits federal agencies to determine whether they're doing good work, has been pointing out cracks in the system. Five years ago, the GAO found that the threat of sanctions doesn't force change in bad nursing homes because the homes fix things during grace periods, then lapse.
In July 2003, the GAO cited Arizona as one of several states that underreport serious problems, allowing problem homes to escape punishment.
The GAO looked at state and federal records from between 2000 and 2002, when the state boasted a 25 percent reduction in the number of serious violations found in nursing homes, the biggest drop of any state in the nation. On the surface, the statistics showed that the state's nursing homes had improved dramatically. But a closer look showed that the state wasn't doing its job.
According to the GAO, Arizona was letting nursing homes off the hook by not telling the federal government about homes with a pattern of harming residents. States are supposed to notify the feds when inspectors find two or more incidents that resulted in injury or death within two years. The feds are supposed to follow up with immediate sanctions. Arizona made 24 referrals to the feds during the two-year period, but the GAO found that an additional nine cases should have been sent to the federal government.
The GAO also determined that the state was downplaying the seriousness of violations, ruling that no one had been harmed in homes with a history of problems when, in fact, residents had suffered real injuries. In one case in which the state found no harm, a resident who was supposed to be turned every hour to prevent her bedsore from worsening went as long as eight hours without being turned. The charge nurse told inspectors she didn't know a doctor had ordered frequent turning. The woman's bedsore progressed from relatively minor to a wound deep enough that muscle or bone suffered permanent damage.