Monday, October 22, 2007

Nursing homes warehouse homeless, mentally ill - Cleveland (OH) Plain Dealer

Medicaid pays millions in Cuyahoga Country for patients who don't qualify, records show

Sunday, October 21, 2007
By Harlan Spector

Some Cuyahoga County nursing homes have become warehouses for the homeless and mentally ill, using millions of taxpayer dollars to house patients who often don’t qualify for the care. Medicaid pays nursing homes to take in hundreds of Cuyahoga patients discharged every year from hospital psychiatric wards. The mentally ill are eligible for admission to nursing homes only if they need 24-hour supervision or hands-on assistance. But 60 percent of the psychiatric patients admitted into Cuyahoga nursing homes, most on Medicaid’s dime, don’t need the care, the state found.

Many linger in the homes for months or years anyway, each costing Medicaid about $148 a day. That prompted William O’Boyle, who evaluated nursing home patients for the Ohio Department of Mental Health, to resign in protest in June.

O’Boyle filed a Medicaid fraud complaint against Saber Healthcare Group, a nursing home company that visits Cleveland homeless shelters seeking potential admissions.

The Bedford Heights company denies O’Boyle’s allegations. The fraud complaint concerns three East Side nursing homes owned by Saber — Cleveland Rehabilitation, University Manor and Rudwick Manor.

Some residents depend on the homes for room and board but little else, according to O’Boyle, nursing home staff members and residents themselves. Patients sleep away the days. Reports of fights, sexual assaults and illegal drugs emerge from public documents and interviews.

At Cleveland Rehabilitation on Carnegie Avenue, some residents are able-bodied enough to sign themselves out to earn a few bucks at a local car wash. “They smoke crack and weed and drink beer in their rooms,” said three-year resident Willie Rembert, who said he needs assistance because of physical disability from a stroke. “This is a bad place. You got fighting and cursing and stuff. I stay in my room.”

Saber co-owner William Weisberg said he was not aware of employees visiting homeless shelters to boost admissions, and he denied that the nursing facilities house patients improperly.

Weisberg also said illegal drug use is not tolerated. Medicaid paid the three homes $59 million from 2005 through August 2007, according to the state office.

Nursing homes help out hospitals, shelters and mental health agencies because not enough group homes or other housing exists for the mentally ill. Psychiatric patients move from hospitals to nursing homes under a Medicaid rule that allows 30-day convalescent stays, without rigorous screening usually required. The rule is like a free pass to nursing home care.

Numerous state and county agencies have a hand in the placements, but nobody polices the system, The Plain Dealer found. The neglect has cost Medicaid more than $2.5 million since 2006 in Cuyahoga alone for patients who the state determined didn’t qualify for the care. The figure is the newspaper’s estimate based on calculations made with data provided by state agencies. Medicaid officials, asked to comment on the estimate, provided a lower figure of $1 million to $2.5 million improperly spent.

O’Boyle calculates the Medicaid waste at $30 million over six years he assessed Cuyahoga patients. He said half the patients he reviewed — about 1,500 of 3,000 — were fraudulent admissions from the start and should not have been eligible for 30 days convalescence.

State officials acknowledged the system is being abused. They vowed to crack down. “We know there are people getting into these places who should not,” said Erika Robbins of the Ohio Department of Job and Family Services, which manages Medicaid. “We don’t know how many come in who never come out.”

A bureaucratic black hole

Every year in Ohio, about 1,300 psychiatric patients are admitted to nursing homes under the convalescent rule. Forty percent of those patients are in Cuyahoga. The rule allows patients to get in on a doctor’s signature, bypassing independent, face-to-face admissions reviews.

The nursing home industry, with the help of lawmakers, fought to keep the rule intact, even as officials saw signs that the system was being abused. The state Mental Health Department hires private mental health agencies like the Center for Families and Children in Cleveland to assess patients admitted for 30-day convalescence and to determine whether they qualify to stay longer. The assessments raised concerns in Columbus, after hundredsof patients every year were found not to require nursing home care. That includes most of the people admitted into nursing homes through the program in Cuyahoga.

At the end of the 30 days, the Mental Health Department sends letters to patients, nursing homes and the county to terminate the nursing home stays. But the letters have tumbled into a bureaucratic black hole. State and county agencies have not followed up to see that patients are ordered out of the nursing homes, leaving oversight responsibility to nursing homes themselves.

The Department of Job and Family Services, which pays the Medicaid bills, wasn’t even notified that the Mental Health Department had disqualified patients 885 times in Cuyahoga alone since 2005, The Plain Dealer found. O’Boyle, a licensed clinical counselor, said that early in 2006 he warned his bosses at the Center for Families and Children that 80 percent of those he evaluated didn’t belong in nursing homes.

In interviews, O’Boyle said he saw many people living in homes after the state ordered them out. The breakdown, he said, isn’t just that denial notices are ignored but that the admissions are bogus from the start. Five current and former Saber employees in clinical and management positions also said in Plain Dealer interviews that the three Saber homes are filled with patients who don’t need the care.

Saber officials deny the allegation.

“They come in 30-day convalescent, and they stay for years,” said a social worker at one Saber home. The staff members asked not to be quoted by name because of employment concerns. The system was ripe for abuse, O’Boyle said.

Suitable housing hard to find

Psychiatric patients are a financial drain on hospitals. Housing for the mentally ill is in short supply. The nursing home admissions are a path of least resistance for hospitals and the mental health system.

But the system provides a windfall for nursing homes, at the public’s expense. “The nursing homes serve as a rescue,” O’Boyle said. “It’s not a proper solution. There’s no accountability.” He isn’t the only person to raise concerns.

Lila Jenkins, a psychiatric nurse who also evaluates Cuyahoga patients for the state Mental Health Department, wrote to state Medicaid officials in 2005 that the admissions were “rubber stamp” approvals and the vast majority of patients don’t need the care.

“The state is paying [an] average of $5,000 per month for a bed for someone to sleep on while not getting much of anything else,” said Jenkins’ letter, obtained through a public-records request. She could not be reached for comment.

O’Boyle, 53, said supervisors ignored his concerns. Mary Hull, O’Boyle’s supervisor at the center, said she told him to take it to the Ohio Health Department, which licenses nursing homes.

O’Boyle disputes that and said she “summarily dismissed” the complaint. Lt. Gov. Lee Fisher, executive director of the Center for Families and Children through early 2006, said that he was not aware of O’Boyle’s complaint but that allegations should be investigated. O’Boyle’s formal complaint to the Ohio attorney general accuses the Saber Group of recruiting “drug addicts and criminals” under the guise of the mentally ill to the three East Side nursing homes. It says Saber holds on to patients sometimes years after they are denied long-term care.

The company denies those allegations. O’Boyle’s complaint also says the company has kept patients on the roster, even after they left, to use up an allowance of “bedhold” days. Nursing homes can hold a patient’s bed for up to 30 days a year for absences and still receive partial reimbursement.

Several of the current and former Saber employees corroborated those allegations. Co-owner Weisberg denied them and said the nursing homes follow the bed-hold rules.

An investigator for the attorney general interviewed O’Boyle at his home in August. A spokesman said the office does not comment on investigations. A windfall for nursing homes Saber owns 25 nursing homes, the company’s Web site says. The firm specializews in turning around facilities struggling with empty beds and operating losses, according to the Web site of Focus Management Group, a Florida-based turnaround firm.

To boost admissions, Saber representatives visit Cleveland homeless shelters to market the services, according to staff members and shelter officials. Many of the homeless have drug, alcohol and psychiatric problems and cycle among shelters, hospitals and the nursing homes.

Two Saber representatives this summer asked the Cleveland women’s shelter on Payne Avenue to arrange direct admissions to the nursing homes, said Eric Morse, who runs the shelter for Mental Health Services for the Homeless Inc. The shelter turned them down. “That would be setting us back 30 years,” said Morse. “You’re reinstitutionalizing them.”

The state Medicaid office in recent years was prepared to crack down on convalescent admissions. State mental health officials said in interviews that they also wanted the “loophole” closed.

Angela Finney, a former official in charge of admissions reviews at the state Mental Health Department, said lobbyists derailed the effort in early 2006. “Everybody was ready to do it and then the nursing home lobby got involved and they all backed off,” said Finney, who ran the program from 1997 to 2006.

“They had the nerve to call it discrimination and they scared everyone away. That’s a moneymaker for them. Some nursing homes would just go out of business.”

A law firm for the Ohio Health Care Association, which represents nursing homes, protested the rule change in a December 2005 letter to the state Medicaid office. The association argued that the state proposal placed an unreasonable burden on nursing homes to verify patient eligibility.

State Medicaid officials said they yanked the rule changes after legislators raised objections. They did not identify the lawmakers. Health Care Association chief Pete Van Runkle defended the admissions in an interview with The Plain Dealer. “These people aren’t coming to these facilities because they’re being kidnapped. They’re coming because there’s no place else to go. We, to some degree, became the caretaker of last resort.”

State officials say the housing shortage is a problem for the local mental health system to grapple with. In the meantime, state medicaid officials, responding to Plain Dealer inquiries, said they have begun tracking patients who should be discharged and will warn nursing homes not to bill Medicaid for them.

To reach this Plain Dealer reporter:, 216-999-4543