Long term healthcare, a history of changes

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Lafayette Health Care Center Administrator Rich Wisdahl explains changes in long term care. -Photo: Joyce Marie Taylor

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February 14, 2013

Long term healthcare, a history of changes

Joyce Marie Taylor Suwannee Democrat The Suwannee Democrat Thu Feb 14, 2013, 09:00 AM EST

Mayo — Lafayette Health Care Center Administrator Rich Wisdahl is well versed in the laws governing long term healthcare facilities and recently explained the complex process of patient admission assessment. He has been working in the nursing home administration field since 1974 and has seen a lot of changes over the years.

Paperwork

From about 1976 through 1988, Wisdahl said he noticed that most people entering a nursing facility did not have a complete health portfolio, which made it difficult for staff to know what to provide for the patient.

“There was no standardization to anything,” Wisdahl said. “Some facilities didn’t have anything, as far as a formalized assessment program. If an administrator or director of nursing had put something into place, it might have been a couple of pages of questions,” he added.

Since then, he said, a lot has changed, although the general public isn’t aware of just how much it has changed since the federal government stepped in around 1988 and decided a standardized admission assessment needed to be implemented for all nursing care facilities.

“So, they put in what is called an MDS, a Minimum Data Set,” he said.

Wisdahl remembers the uproar when, all of a sudden, they were forced to fill out about 10 pages worth of information for each incoming patient. He said he thought it was an okay idea, but he hoped they’d get reimbursed for their efforts.

“As time moved on, that process changed,” Wisdahl said.

Like any change, he said, things always seem to increase, including the amount of paperwork.

“For the most part it has been a very good change to have more detail,” he said.

About 10 or 15 years ago, he said, the admission assessment paperwork grew to about 30 pages.

When a new patient arrives at a nursing care facility, they are frequently unable to respond to or answer a lot of questions, he added.

“If I wanted an answer, I wouldn’t go to the individual, I’d go to the family member,” he said.

Oftentimes, he said, when you ask a family member about their parent or relative who is being admitted, they don’t know a lot of the answers because they haven’t been around the person in years.

“The accuracy to the answers probably weren’t the greatest,” said Wisdahl.

About two years ago more paperwork was added, along with a stipulation that answers needed to come from the patient, not a family member.

Once a patient is admitted another stack of papers have to be filled out identifying “triggers” for that patient. Then, as with all government paperwork, he said, there are meticulous instructions for filling out all the paperwork that can fill a four inch binder.

“You have no idea how things have changed within long term care,” he said. “It’s a much more thorough process.”

Wisdahl said probably about 99 percent of the general public doesn’t understand how much of a positive thing all these changes have been.

Penalties

Nursing care facilities are subject to annual inspections to ensure they are in compliance with federal guidelines. Twenty years ago if there was something substantially wrong with a facility, Wisdahl said there would be an “admission hold.”

“You were told that you’re not within compliance,” he said.

A penalty was assessed against the facility for however many days it took them to get into compliance.

About 10 years ago, he said, there were add-on’s to the penalty procedure using a graph system to deduce things, such as: Was there harm? Was there potential for harm? How many people were affected?

“The words harm and immediate jeopardy were starting to be utilized more,” he said.

Immediate jeopardy means that something actually happened. If it was serious enough the facility was placed on notice and told they had to immediately correct the problem. They would be fined until the immediate jeopardy issue was corrected.

In the last few years, Wisdahl said, there have been even more changes. He referenced a facility who was serving unpasteurized eggs to their residents and they were immediately placed in immediate jeopardy status.

“Was anyone sick? No,” Wisdahl said. “But it was immediate jeopardy.”

A few years ago, Wisdahl said his facility had a constipated patient and authorities wanted to place them in immediate jeopardy.

Psycho-social harm is another thing nursing care facilities have to be aware of. As an example, Wisdahl said if a patient has dementia, oftentimes they are yelling or exhibiting inappropriate behavior. In a group setting, if someone were to do that and another patient was sitting nearby getting agitated and then staying that way for the rest of the day, it would be viewed as psycho-social harm.

“Again, it could be cited as immediate jeopardy,” he said.

Non-payment

Another issue nursing care facilities face is non-payment for services from family members responsible for the patient’s bill and for following through with Medicaid applications. About one in five people don’t turn over the funds to the facility, he said.

Some excuses people use are 1) they had to get a new car, 2) they had to use the funds to fly the family to a funeral, and 3) they had to use the money to pay bills.

Wisdahl said non-payment of bills are less of an issue in smaller towns where small town values are adhered to.

Electronic medical and health records

Electronic medical records are specific to each facility versus electronic health records which are specific to a span of time for an individual. Electronic health records were supposed to have been put in place in 2011, but it has been pushed back to 2014, Wisdahl said.

If a person goes to an emergency room, he said, they most likely won’t be in the right state of mind to remember their past medical history, their surgeries, and all their diagnoses.

“In long term care, one of the frequent things that happens is the person has outlived three or four physicians,” he said. “They’re on medications that nobody has a clue why they were started or how long they’ve been on them.”

Electronic health records are a positive thing, he added, and if set up properly can save time.

Flu vaccinations

A hot button issue, Wisdahl said, is mandatory flu vaccinations.

“I’ve warned my staff,” he said.

Many people don’t wish to be vaccinated for various reasons, he said. Some say there isn’t enough evidence that they work, the vaccine is not for the current strain of flu, it contains mercury that can cause side-effects, and still others say they contain antibiotics that wipe out beneficial bacteria. Some believe flu shots can cause Alzheimer’s, due to the presence of aluminum, formaldehyde and mercury that can be more toxic when mixed together.

“Those are all technically good reasons not to take the vaccine, however, reasons people should take the vaccine is that it can prevent serious disease that can lead to death and hospitalization,” he said.

Estimates of annual deaths due to the flu varies, Wisdahl said.

“For people 65 years and older, 90 percent of the deaths occur in that age group that are related to flu,” he added.

Wisdahl said he has advised his staff that next year it may become mandatory for all healthcare workers to have the flu vaccine. Four states, he said, have already mandated it and one hospital fired four people because they refused.

“It’s coming,” he said.

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