Long Term Care Law

Effects of Missouri Medicaid Cutbacks Offer Insights for Other States

The Journal of Health Affairs recently published a study prepared for the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured.  This study examined the results of Missouri's drastic cutbacks in Medicaid reimbursement and eligiblyty in 2005, resulting in loss of coverage for more than 10,000 citizens.  The cutbacks made by then Governor Blunt were in response to serious budget shortfalls during that time.  The study reports that as a result of the cutbacks, the number of uninsured people in the state increased, hospitals faced greater demand for uncompensated care and community health centers faced revenue shortfalls that forced staffing cuts and higher charges for patients.

MDS 3.0

According to Mary Pratt from CMS, MDS 3.0 is still on target to begin on October 1, 2009. Ms. Pratt confirmed during CMS's most recent SNF/TCL Open Door forum held on January 29, 2009. A new time line is being developed although as of this morning the time line had not been posted to CMS's MDS 3.0 web site.  

5 Star Ratings for Nursing Homes

CMS is now in the business of rating nursing homes.  Beginning December 15, 2008, CMS began notifying nursing facilities of the 5 star ratings.  The ratings will go public to consumers on December 18, 2008.  The ratings are based on survey data, which in my experience, is not alway accurate.  Nevertheless, that will be the basis for the ratings.

5 Star Rating System
A 5 star rating means that a facility ranks "much above average"; a 4 star rating means a facility ranks "above average"; a 3 star rating means a facility is "about average"; a 2 star rating means that a facility ranks "below average"; and a 1 star rating means a facility ranks "much below average", but still meets the minimum requirements for Medicare.  CMS will recalculate these ratings on a quarterly basis. 

 

Tap Water to Cleanse Wounds?

I highly recommend MedScape for all health care lawyers, but particularly those working with long term care facilities.  You have to register to get the information but it is free.  I frequently see interesting research that negates many  firmly held beliefs by surveyors (and many nurses).  The following is an example:

Normal isotonic saline is generally favored to cleanse wounds. Two investigators from Australia studied the Cochrane Controlled Trials Register and 4 other major databases to report in 2008[1] on 11 randomized and quasi-randomized controlled trials that compared rates of infection and healing with water and saline, as well as no cleansing. Tap water was statistically more effective than saline at reducing infection rates in adults with acute wounds and no different than saline in children. No statistically significant differences in infection rates were seen when wounds were cleansed with tap water or not cleansed at all. So you have lots of choices when confronted with an acute wound.

MedScape article

by George D. Lundberg, MD.

Robots May Provide Home Care

Federal Telemedicine News reported today on interesting research being conducted at the Center for Healthcare Robotics.  It reports the following:

The Center for Healthcare Robotics within the Health Systems Institute at Georgia Institute of Technology and Emory University are looking at ways that robots can be used to help when providing homecare for patients. The research team led by Charlie Kemp, Director of the Center has found a way to instruct a robot named El-E to find and deliver items it may have never seen before by using a laser pointer. The researchers are now gathering input from ALS patients and their doctors to use to prepare the robot to assist patients with severe mobility challenges.

The verbal instructions a person gives to help find an object are very difficult for a robot to use. These commands require the robot to understand everyday human language and a description of the object at a level well beyond the state-of-the-art in language recognition and object perception. According to Wallace H. Coulter, Department of Biomedical Engineering at Georgia Tech and Emory, “Robots have some ability to retrieve specific predefined objects but retrieving generic everyday objects is a challenge for robots.

Sparky & Robot Dog Tie for Affection in Nursing Homes

Sparky, a flop-eared golden colored pup could not beat out a robot dog when it came to cheering up nursing home residents.  In a study conducted by the University of St. Louis, researchers found that

a lovable pooch named Sparky and a robotic dog, AIBO, were about equally effective at relieving the loneliness of nursing home residents and fostering attachments.

The study, which appears in the March issue of the Journal of The American Medical Directors Association, builds on previous findings by the researchers that frequent dog visits decreased loneliness of nursing home residents.

Thirty-eight nursing home residents were divided into three groups: one got regular visits from Sparky, the real dog; the second got visits from the AIBO Entertainment Robot, a shiny robot dog formerly made by Sony that used artificial intelligence to interact with its environment and express emotion; and the third group got no visits.

The researcher, Dr. William Banks, a professor of geriatric medicine who worked on the study reported in the Journal of the American Medical Directors Association, said he had been sure Sparky would have the edge, but to his surprise, both dogs provided virtually equal comfort after seven weeks of visits.

While AIBO has been discontinued, Banks thinks similar robots could offer companionship for older people and might even be programmed to keep tabs on their owners, alerting emergency workers of a sudden fall.

New Study Finds Risk Factors for Increased Falls in Elderly Diabetics

Medscape featured an article today in which 446 elderly persons with Type I and 2 diabetes were studied for fall risks.  The study found that:

An HbA1c level of 6% or lower vs 8% or higher is associated with falls in older patients with diabetes who use insulin but not in those who use oral hypoglycemic agents.

Predictors of falls in older patients with diabetes are reduced peripheral nerve function, poor vision, weight loss, and poor renal function.

Other interesting findings include:

• In the first year, 24% reported falling and the rate of falls was 22%, 26%, 31%, and 30% in the subsequent years.
• In patients who did not use insulin, an HbA1c level was not associated with fall risk.
• In those who used insulin, HbA1c level of 6% or lower was associated with an increased OR for falls of 4.36 vs an HbA1c level of more than 8%.
• Low peroneal nerve response amplitude at the popliteal fossa was independently predictive of falls.
  
• Peroneal nerve conduction velocity between the ankle and popliteal fossa or fibular head was not associated with higher risk for falls.
  
• Seated or standing blood pressure was not associated with falling, but diastolic, and not systolic, change in blood pressure was associated with increased fall risk.
  
• Weight loss, but not BMI, was associated with increased fall risk.
  
• Grip strength; knee extensor strength; standing balance time; chair stands; and the 6-meter walk, but not the 6-meter narrow walk, were associated with falls.
  
• Higher cystatin-C level (OR, 1.38), poor contrast sensitivity (OR, 1.41), and reduced peroneal nerve amplitude (OR, 1.50) were associated with falls.

The study, "Risk Factors for Falls Identified in Older Adults with Diabetes," was conducted by Laurie Barclay, MD and Désirée Lie, MD, MSEd.

Many physicians test the HbA1c routinely for their diabetic patients, which tells how well the person's diabetes has been managed over the past 2-3 months.  This study may help reduce the number of falls through better diabetic management.

CMS Surveyor Training on Documentation

On CMS's Survey and Certification Online Course Delivery System of web based training, CMS has scheduled a non-mandatory survey web based training titled: SCG News Magazine: Legal Ramifications of Surveyors’ Failure to Use Best Practices in Documentation, Investigation and Deficiency Writing scheduled for Friday, February 29, 2008 from 1:00 to 3:00 EST.  The target audience is the CMS Regional Office and State agency nursing home surveyors.  According to the material,

[a]s a result of participating in the satellite broadcast, the viewing audience will be able to describe the legal repercussions that can occur when survey documentation and investigation are not handled correctly by surveyors, as well as how common errors in the process can be avoided.

If you register at the website, you will find the course outlines of:

broadcast promo2-29.doc: Microsoft Word (DOC), 78.0 KB

Brookridge Edited Opinion for CMS Webcast.pdf: Adobe Acrobat (PDF), 38.1 KB

Emerald Shores edited opinion for CMS webcast.pdf: Adobe Acrobat (PDF), 36.1 KB

Glenburney edited opinion for CMS webcast.pdf: Adobe Acrobat (PDF), 51.9 KB

Heron Pointe Edited Opinion for CMS webcast.pdf: Adobe Acrobat (PDF), 37.2 KB

Lake Mary edited opinion for CMS webcast.pdf: Adobe Acrobat (PDF), 43.4 KB

Advance Announcement: Microsoft Word (DOC), 30.5 KB

Lisa Tripp, who used to work for one of the CMS Regions and now on staff at the John Marshall Law School, will present the material with the course objectives for the participants to be able to describe several sources of surveyor error; recognize the potential legal consequences of errors in the survey process and identify best practices that should be used to avoid legal issues.

CMS Surveyor Training on Documentation

On CMS's Survey and Certification Online Course Delivery System of web based training, CMS has scheduled a non-mandatory survey web based training titled: SCG News Magazine: Legal Ramifications of Surveyors’ Failure to Use Best Practices in Documentation, Investigation and Deficiency Writing scheduled for Friday, February 29, 2008 from 1:00 to 3:00 EST. The target audience is the CMS Regional Office and State agency nursing home surveyors. According to the material,

As a result of participating in the satellite broadcast, the viewing audience will be able to describe the legal repercussions that can occur when survey documentation and investigation are not handled correctly by surveyors, as well as how common errors in the process can be avoid

ed. If you register at the website, you will find the course handouts at http://cms.internetstreaming.com/courses/95/ Lisa Tripp, from the John Marshall Law School in Atlanta will present the material with the course objectives for the participants to be able to describe several sources of surveyor error; recognize the potential legal consequences of errors in the survey process and identify best practices that should be used to avoid legal issues.

Balloon Man is a Big Hit

At last year's Long Term Care & The law Conference we had a balloon clown make balloon hats for us at Jimmy Buffett's Margaritaville.  However, our balloon man fell far short of the creations made by this expert.  It looks to me as the residents in this video are having a good time and are enjoying their hats.   

In fact, they looked like they were having as much fun as we did.