“We’re not motivated to do a good job so that we can avoid fines; we do it as part of our profession,” said Bruce Gendron, regional administrator for the organization that since October 2014 has run the Guilderland Center nursing home.

“Fines were put in place for a reason. They’re intended to act as an incentive … and also as a deterrent,” said Jennifer Freeman of the New York State Comptroller’s Office.

They were talking about whether fines for violations are an effective way for the state’s Department of Health to oversee nursing homes.

On Feb. 19, the Comptroller’s Office released an audit, noting the percentage of violations for which the DOH issues fines is very small, at about 4 percent of citations, and,  even when it does levy a fine, the length of time between identifying violations and assessing fines can be as much as six years. This gap, Freeman said, “can render the fine meaningless.”

Special focus, but improving

The Guilderland Center nursing home has since June 2015 been on the national government’s list of the worst nursing homes in the country. The “special focus facility” list of the Centers for Medicare and Medicaid names  nursing homes that have had had more problems than others, more serious problems than others, and a pattern of problems that persists over time. A spot on the list means additional on-site inspections and a demand that facilities improve within 18 to 24 months or see their eligibility for participating in Medicare and Medicaid withdrawn.

The ranking is based on the facility’s performance over the three-year period before it is named to the list.

Guilderland Center Rehabilitation and Extended Care Facility — commonly referred to as the Guilderland Center nursing home — is currently listed as having “shown improvement.”

The 127-bed facility has been under new management since October 2014. It is currently being operated by The Grand Healthcare System, which is in the process of taking over ownership of the facility, according to the organization’s regional administrator, Bruce Gendron.

Gendron and the company’s regional census director, Gary March, took an Enterprise reporter around the facility Tuesday, showing off the many newly renovated common areas, including the lobby, the activity room, the dining room, and all the hallways.

March noted that an outdoor patio and a wide green area with pergolas had previously been inaccessible because of the fear of “elopement,” but had been made accessible to residents, with the addition of a chain-link fence around the perimeter. He added that events will also be held there when weather permits.

“We’ve put a bigger focus than before on getting people home,” Gendron said about the expanded and updated rehabilitation room. To create the 2,000-square-foot space, the company knocked down a few walls and incorporated adjacent space and then invested more than $15,000 in new exercise equipment. The company also implemented new hiring practices for the room, starting with hiring a director who then hired staff; instead of outside contractors, as before, everyone in these positions is now an employee, making for better continuity of care, Gendron said.

The plan is also to remodel all of the residents’ rooms, including new flooring, wall coverings, and curtains. For now, they have begun, Gendron said, by putting in a new phone system and new electric beds, privacy curtains, and flat-screen televisions in every residents’ room.

Half of the facility’s beds were still the old hand-crank types, Gendron said. “And what that does is take away patient independence.”

Previously, residents were responsible for providing their own phones and televisions. They had to have them hooked up in their rooms, so there might be an initial period of days or weeks when they had no phone or TV. If they moved to a different room in the facility, they had to disconnect and reconnect both phone and television. They had to pay the monthly fees themselves; the facility pays the fees now.

“When a resident moves in, they can use the phone and TV immediately,” Gendron said.

Further increasing the isolation, there was no Internet access before, the administrators said. The only Internet in the building came into a couple of front offices, and was very slow. Grand Healthcare  brought in wifi, for guests, residents, and staff to use.

The company also bought 32 computers, many hung on hallway walls for nurses and other staff to record data on residents’ health, medication, and activities of daily living. All of this record-keeping had previously been done by hand. The new computerized records are instantly available to other staff, ensuring that information is up-to-date and possibly preventing harm, the administrators said.

“We wanted to bring the system up, if not to the 21st Century, at least to the 20th,” quipped Gary March, regional census director.

Gendron added that a “community computer” for residents will be set up in the activity room soon. He also said that, once the Guilderland Center facility transitions to Grand Healthcare ownership, the company will roll out the iPad program it already has in place at its other nursing homes. Residents who want one will receive their own iPads that they can use to access the Internet, watch movies on Netflix, or talk to family on FaceTime.

Twenty-four cameras throughout the building and at the entrances provide security and also “allow us replay any incidents — if a resident falls or is injured — to make sure there  is no slippery floor, no abuse,” March said.

There have also been employment-related changes, Gendron said. The facility made wage scales more competitive for the local market, he said, and negotiated a wage increase with the Service Employees’ International Union, which represents the home’s employees, “that will allow us to continue to recruit qualified staff.”

They have also “improved the skill mix” by hiring additional registered nurses, including a full-time educator tasked with creating a training program for all staff, including nurses, certified nursing assistants, therapists, housekeepers, and kitchen workers. “It’s pretty comprehensive,” he said.

“Resolved for now,” says union  

In 2015, the Guilderland Center nursing home was picketed by employees who claimed that the facility failed to pay overtime and holiday pay, allowed workers’ health insurance to lapse by failing to pay premiums, and incorrectly recorded hours worked.

Gendron said that the state’s Department of Labor had stepped in to do an audit and that Grand Healthcare had “made whole” anyone whom the department identified as having been shortchanged. He said that the company may try to sort out the back payments later with the previous owner, but had wanted to resolve the matter quickly. The labor department then gave the facility “a clean bill of health,” he said.

The Enterprise made several calls to the Department of Labor to try to confirm that employees’ concerns were resolved, but did not receive calls back.

Mindy Berman, spokeswoman for 1199 SEIU, confirmed that the Guilderland Center nursing home did resolve employees’ complaints, “for now.” She often uses the phrase “for now,” she said, because “it’s always one thing after another with nursing homes, especially those that are for-profit, which this one is,” she said, referring to Guilderland Center.

Gendron responded to Berman through The Enterprise, saying, “Well, that’s the union’s perspective, obviously. We have not worked with SEIU here [in the Capital District] before. We have excellent relationships with SEIU in the other areas where we’ve been more established.” He added that the company expects “a long and positive relationship” with the health-care union.

Repeated studies have shown that quality of care at not-for-profit nursing homes is generally better than that at for-profit facilities, according to the Center for Medicare Advocacy website.  The website refers to a report by the Institute of Medicine that found, “For-profit and chain-operated nursing facilities tended to devote fewer resources to direct patient care, resulting in poorer quality of care for residents.” This same report also said, “Excellent facilities are found in each category, but truly wretched ones are almost always proprietary [as opposed to nonprofit facilities].”

March gave a different perspective, saying that his company’s expertise as the operator of several facilities is a resource for staff at the Guilderland Center nursing home.  “Before, when it was stand-alone, if the employees came up against a question they didn’t know how to handle, they didn’t have anywhere to go.”

Audit of the Department of Health

The report from the comptroller said that while the state’s Department of Health is “generally meeting its obligations” to conduct periodic inspections, including timeliness of inspections and accuracy of scope and severity of deficiencies found. But, the comptroller said, the department needs to strengthen its enforcement policies and procedures.

For instance, the report said, the DOH does not levy fines at all for certain categories of violations that comprise almost 85 percent of the problems found. It levies fines, the report says, only if a problem has already resulted in actual harm to an individual or if it is currently placing people in immediate jeopardy. Historically, the report says, this means that it levies fines for less than 4 percent of all violations.

And when the DOH does levy fines, it is sometimes very slow about it, the report found, because of inefficiencies in the department’s processes for issuing and tracking assessments, which undermines the sense of urgency about correcting deficiencies. In some cases, this resulted “in delays of up to six years between when a violation is cited and a resulting fine is imposed.” This gap has increased  “significantly” in recent years, says the report.

Communications Director Freeman said the comptroller’s office has “multiple concerns.” Most notably, she said, the office is concerned that “in some situations they’re not assessing fines for institutions where they’re finding repeat violations.” The concern, she said, is that “those repeat violations could ultimately escalate into something more significant and more serious.”

She concluded, “And then, of course, if in fact they do decide to assess the fines, they’re waiting so long that it diminishes the power of that fine.”

The comptroller’s office wrote in the report that the backlog was caused by having just one part-time employee working on fines.

The report notes that the DOH has addressed the backlog by reassigning two more staff members to assist with this task and has also revised its enforcement procedures, and that the DOH says it has “significantly reduced” its backlog. DOH has addressed the backlog by reassigning two more staff members to assist with this task and has also revised its enforcement procedures, and that the DOH says it has “significantly reduced” its backlog.

Freeman said that the staff reassignment was temporary and asked, “But the question is, ongoing, what’s going to happen, if there’s still a staff shortage, or not enough people processing some of these violations, are they going to find themselves in a similar position not that far into the future? … It’s unclear from their response how they intend to fix the problem long-term.”

Department of Health spokesman James Plastiras said, “Let’s be clear: The comptroller’s audit found DOH to be in compliance with federal regulations governing the inspection of nursing homes, and the agency acts quickly on serious complaints. To further improve the process, a new enforcement process was implemented by the DOH Nursing Home Division in April 2015 and we are continuing to work to ensure that fines are assessed in a timely manner.”

Freeman was asked if fines should be levied for a wider swathe of violations. She said that they should, because “we think this is a strong deterrent to preventing this behavior.”

Would more fines just be a burden on already-struggling nursing homes?

Freeman answered, “I think what this report raises is, if institutions are operating as they should be, and the Department of Health is in fact fulfilling their full role when it comes to inspections, institutions would be operating better, there would be fewer incidences that are occurring with residents, and ultimately the program would be working as intended. What this audit finds is that it does not.”

The fines are intended to be levied against institutions that are putting patient care and safety at risk, she said. More than the financial impact on institutions, her office’s biggest concern, she said, “would be on making sure those individuals are protected.”

Freeman also noted a need for legislative action. She highlighted a point made in the report that, prior to 2008, the maximum fine allowed for a violation was $2,000 per incident, even if those incidents resulted in physical harm or death. The law was amended to increase the fine, to $5,000 for a repeat violation, and to $10,000 for a violation that caused serious physical harm. But the amendment will expire in 2017. Asked if the amendment should be extended, Freeman said that it “absolutely” should be.

Asked if he thought fines worked as a deterrent, Gendron said, “Any time any time a fine is levied, operators of nursing homes certainly have to want to avoid that. But I don’t think avoiding fines is what motivates most of us who are in this industry. People who work in hospitals and people who work in nursing homes have dedicated their careers — we’ve gone to school, we’ve gone to college, because we want to help people. And I think sometimes people lose sight of that. The nurses and the aides and the LPNs and the administrators, this is what we’ve dedicated our lives and our careers to. We’re not motivated to to do a good job so that we can avoid fines; we do it as part of our profession.”

People who are considering a nursing home may access a great deal of information about individual facilities online, at the state’s website profiles.health.ny.gov. Go to “nursing homes” and select “search by county/region,” then “Capital District.”

For each individual nursing home, categories that come up such as “Administrative” or “Statistics” can be clicked, and will bring up more information. The word “Inspections” near the top of the page may also be clicked, and will bring up the option “Citations”; clicking on Citations brings up detailed looks at that facility’s recent inspections.

Guilderland Center wants off the list

Gendron noted that the minimum requirement for getting off — “graduating from,” it is called — is to have two inspections in a row that at least meet minimum standards. He said that he believed that the Guilderland Center facility had already done that, since it passed an inspection in September 2015; he thought that the most recent inspection, conducted on March 7, had also been successful, although he has not yet received a written report from the Department of Health.

“Our record is getting better,” Gendron said. “We didn’t get in this position overnight, and we’re not going to fix it overnight. Our goal is to take one step at a time.”

March added, “You get the collar of the facility’s predecessor, you get the history. It’s like when you buy a house and then, two months later, the water heater goes. You can’t go back to the previous owner and say, ‘Pay for this.’ You have to fix it yourself.”