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Jacuzzi or Injury – How Medicare Handles “Dangerous” Nursing Homes

medicare

Imagine sitting in a large, luxurious arm chair next to a babbling waterfall fixed in Zen garden. As you look to your right, you can see a long hallway filled with rooms that lead to a relaxing Jacuzzi. To your left, another long hall lined with rooms leads to a lounge cluttered with every amenity you could think of (coffee, cookies, HBO access, the works).  The reception desk welcomes you to this inviting location.

While this scene appears to be one like a five-star hotel on Michigan Avenue, instead, a new trend among some nursing homes and other rehabilitation centers tries to lure new patients in order to gain Medicare benefits. However, although the amenities of the facilities seem top of the line and successfully entice patients, some nursing homes fail to provide the type of care comparable to their amenities.

Warning Signs

Although millions of Americans live at wonderful nursing home facilities with experienced and wonderful staff, some nursing homes give the rest a bad name. Several facilities hire unskilled nurses and workers and lack a sufficient number of doctors. Additionally, understaffing affects the rehabilitiation and medical care needs of the residents.

According to a study conducted in 2014 by the Department of Health and Human Services’ Office of the Inspector General, 22% of Medicare patients staying in a nursing home for a duration of 35 days or less experienced injury or harm from the medical care received. Additionally, 11% of Medicare patients endured some sort of temporary injury. The study stated that Medicare spent an estimated $2.8 billion on hospital visits and treatment for the injured Medicare recipients.

Hour to Hour Care

Most people typically picture a nursing home filled with older people needing hour to hour care. However, nursing home and rehabilitation centers alike welcome short term stays for anyone utilizing Medicare insurance. In fact, these centers are pushing to enroll more Medicare patients as opposed to Medicaid patients. Currently,  Medicare pays facilities 84% more for short term patients than Medicaid pays for long term residents.

With large percentage difference in payment, nursing homes and rehabilitation centers eagerly welcome Medicare recipients. But what is the difference between a Medicare recipient and a Medicaid recipient?

Medicare v. Medicaid in Nursing Homes

According to the Medicare.gov website, “Medicare is the federal health insurance program for people who are 65 or older.” Additionally, younger people with disabilities or for people with End-Stage Renal Disease can use Medicare

There are three kinds of Medicare plans:

  1. Hospital Insurance (Part A)
  2. Medical Insurance (Part B), and
  3. Medicare Advantage Plans (Part C).

In contrast, “Medicaid is a joint federal and state program that helps with medical costs for some people with limited income and resources.”

While these two benefit services are separate, it is important to note that a person can have both Medicare and Medicaid coverage. In terms of determining who pays first, Medicare.gov states that “Medicaid never pays first for services covered by Medicare.” Instead, Medicaid pays after Medicare and all other insurance coverage providers have paid.

Special Focus Status

Due to a growing number of Medicare recipients needing rehabilitation center and nursing home care, Medicare as begun to impose higher scrutiny on the facilities. Medicare officials note the number of Medicare recipients at a facility who have needed hospital care based on an injury. The federal government then places the facility on “special focus status.” This status is the highest and strictest forms of monitoring that is reserved for the poorest performing facilities in the nation. “Special focus status” facilities are required to either fix gaps in patient care while the government provides increased inspections or be threatened with losing Medicare and Medicaid funding. Facilities can also be punished with monetary fines.

Medicare Rights for Residents of Nursing Homes

The Medicare.gov website states that residents of nursing homes and rehabilitation centers have rights and protections under both state and federal law. Some of these rights and protections include:

  • Freedom from discrimination
  • Right of respect and dignity
  • Right to be informed on services and fees
  • Freedom from restraints
  • Right to manage money
  • Right to privacy, property, and living arrangements
  • Freedom from abuse and neglect
  • Right to proper medical care
  • Right to receive visitors
  • Protection against unfair transfer or discharge
  • Right to social services
  • Right to complain
  • The Right to see family and friends

Facilities must honor these rights granted to patients, and facilities that violate those rights that involve the proper care of patients are put on “special focus status.”

If you know someone who has had any of these rights violated by their nursing home, please contact the experienced nursing home lawyers at the Law Offices of R.F. Wittmeyer, Ltd. today for a free consultation.

How Does the Government Define a Dangerous Nursing Home?

The government puts a nursing homeon “special focus status” when

  • Giving a patient incorrect medication
  • Failing to protect patients from violent or bullying residents or staff members
  • Neglecting to tell the patient’s family or physician about injuries
  • Failing to provide adequate care by having a sufficient number of registered nurses and qualified doctors
  • Failing to conform to federal government regulations given to facilities to ensure safety of patients

Facilities can end their high watch status by fixing the issues stated by the federal government. However, of the 528 nursing homes in 2014 that lost their “special focus status,” 52% have relapsed into providing dangerous care, harming patients, or placing patients in serious jeopardy.

These relapsing violators are usually not placed back under “special focus status” and watch. Instead, the government imposes fines.However, facilities can continue to operate with unpaid fines and multiple penalties.

How to Research a Nursing Home

As a consumer, you can choose where you. Don’t just look at the Jacuzzis and Zen gardens. Ask about their hiring practices

And go to https://www.medicare.gov/nursinghomecompare/search.html to compare nursing home rankings and reviews and to make the best choice for you.

About the Firm


Ronald F. Wittmeyer, Jr. practices plaintiffs' personal injury law at his office in Arlington Heights, Illinois.

About Ron

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