Assisted Living: The experts answer your questions

July 23, 2010

A recent "Aging in Iowa" Opinion package on assisted living centers solicited questions for Dean Lerner, director of the Iowa Department of Inspections and Appeals. Below are readers’ questions and Lerner’s answers.

Question:

I’ve known nursing homes to take expedient measures to solve issues, like pulling the plug on a nursing home patient’s phone, or using a feeding tube on a patient to save time. Fear of reporting by patients as well as their families includes the thought it may get worse if complaints are lodged. How do you protect the elderly when people are afraid to report problems because they fear retaliation or being kicked out?

Answer:

There are two statutes in Iowa law that protect residents and staff who complain about the conditions in a nursing facility from retaliatory acts. Iowa Code section 135C.46 permits the Department of Inspections and Appeals (DIA) to issue state fines against a nursing home when it determines that a facility has retaliated against a resident or staff member who complains about care in a nursing home. Additionally, Iowa Code section 135C.21 allows a county attorney to pursue charges against a facility or a facility employee who retaliates in response to a complaint being filed with DIA.
The Department also takes a stronger position on retaliation by pursuing criminal charges against long-term care facilities that attempt to influence resident or staff behavior by threatening punitive actions. Most recently, Des Moines Register reporter Clark Kauffman wrote about two facilities – Granger Nursing & Rehab Center, and Windmill Manor – that received state fines for threatening their employees if they cooperated with an investigation. Such actions by a nursing home are unthinkable, and we assure you that the Department will pursue appropriate action to the fullest extent of the law for each complaint it receives.

Individuals who are concerned about the care being provided to a loved one in a long-term care setting may file a complaint with the Department by calling the toll-free complaint hotline at (877) 686-0027. Complaints may be made anonymously; however it is best to provide contact information so that staff may contact the complainant if additional information is needed to process a complaint. In any case, the name of a complainant is not released by the Department except when compelled by law.

Question:

How can in-home day care be supported and expanded in Iowa?

Answer:

Like most service-driven industries, in-home day care will be expanded when consumers demand more services. Overall, the health care environment in Iowa is evolving rapidly. Ten years ago, there were a handful of assisted living programs in Iowa; today there are more than 300 programs serving elderly Iowans. Likewise, we have seen a significant increase in the number of home health agencies and other alternatives to institutional care settings.

While DIA does not have specific authority for in-home day care programs or services, we urge Iowans to express their desire for this type of health care by contacting the Department of Human Services, which does have some oversight for consumer-directed health care, and the Department on Aging, which promotes these alternatives for elderly health care.

Either way, DIA’s role in this process – the expansion of in-home care – would be to assure that appropriate regulations are developed and implemented to protect the public.

Question:

How many nursing facilities in Iowa are there, and how many are for-profit vs. not-for-profit? Do you know generally how much money is being made by those facilities that are the for-profit facilities, and how do they spend their money differently than those facilities who are not-for-profit?

Answer:

There are 410 certified nursing homes in Iowa. These are facilities that participate in the Medicare or Medicaid Programs. Approximately 60 percent of these facilities are for-profit operations. Fourteen corporations own five or more facilities each, with the largest corporation operating a total of 45 nursing facilities.
DIA does not have any data on the spending patterns of nursing homes, but in 2007 it was suggested that nursing homes in Iowa represent a $1.4 billion industry (see attached chart).

Approximately 55 percent of all nursing home revenue comes from Medicare and Medicaid reimbursements, as well as client participation fees. As such, many nursing homes are essentially tax-supported operations.  The Department has long sought greater transparency in the business operations of nursing homes so that residents, their families, and the general public better know how their tax dollars are being spent.

Spending on care for our loved ones has to be the absolute priority.
An analysis by the New York Times (September 23, 2007) concluded that more profit often equated to less nursing:

“After such investors have acquired nursing homes, they have often reduced costs, increased profits and quickly resold facilities for significant gains.”
“But by many regulatory benchmarks, residents at those nursing homes are worse off, on average, than they were under previous owners.”

Question:

My mother was in an assisted living center and is now in a nursing facility. Her main complaint is about having a different caregiver every other day. Why isn’t there more consistency in the staff, how big of a problem is it and what’s being done about it?

Answer:

The Department has long supported the concept of consistent staffing, where residents get to know the individuals who are providing their care on a daily basis. Consistent staffing not only reduces a resident’s anxiety about the care being provided, but also “keys in” the caregiver to changes in the resident’s physical or emotional condition. In some cases, the caregiver is a resident’s closest friend, someone with whom the resident can confide.

In April 2008, the Department cosponsored a one and one-half-day training session for long-term care providers that, in part, focused on the benefits of consistent staffing. The featured speaker at this session was Barbara Frank who, for 16 years, worked for the National Citizens’ Coalition for Nursing Home Reform in Washington, D.C. The ABCM Corporation of Hampton, IA, which owns 31 nursing homes in Iowa, is also an avid supporter of consistent staffing. The corporation recognizes the benefit of consistent staffing to not only the residents, but to the nursing homes it operates, as well.

Any change to the nursing home environment, whether it is consistent staffing or expanded in-home care, will only occur when residents, family members, and advocates express their desire for these services. As mentioned above, the health care industry is a service-driven industry and will evolve to meet the needs of their customers. Likewise, regulatory oversight of new and expanded services must also be present to assure that residents receive the absolute best care appropriate to their condition.

Question:

What does the law say about how many direct care workers there should be on duty for each resident in an assisted living or nursing facility?

Answer:

There really is no law governing the number of direct care workers on duty at any given time. Federal requirements require that certified nursing homes have sufficient staff to meet the needs of the residents. The term "sufficient staff" is often the subject of debate and interpretation. The Department has explored and will continue to explore the need for statutory language mandating an established staff-to-resident ratio.

However, having a higher staff-to-resident ratio can be misleading. Experience shows us that it is not necessarily the number of staff present in a facility that matters. Rather, the dedication, the experience, and the training of the staff is even more important than the numbers alone.

The Department suggests that policymakers focus more on a better trained, better paid, tenured workforce than on sheer numbers. Iowa is fortunate in that it has many dedicated caregivers, but unless this workforce can be protected and encouraged to grow, no ratio alone will be "sufficient" to meet the needs of residents.