Q&A with New York Medicaid Inspector General Jim Sheehan: Watchdogging Nursing Homes

New York state has an interesting job that is foreign to most other states, the office of the Medicaid Inspector General. Lucky for health writers, the Inspector General there, James G. Sheehan, believes not only in rooting out people who are ripping off taxpayers, but in sharing his techniques and tactics with reporters.

He calls the Association of Health Care Journalists, whose conference he recently attended, his "favorite group of people." In 2007, he helped recover about $7 million in duplicate claim payments from two managed care companies, and he has made it part of his mission to stop low-quality nursing homes from harming their residents.

I reached him by phone at his office in Albany. A recap of our conversation below has been edited for space and clarity.

Q: First, thanks for the great talk you gave at the AHCJ conference in Seattle.

A: I really liked what you wrote about the DEA. That went well beyond anything I had talked about. I thought it was very interesting.

Q: Thanks. You spent a lot of time in your talk on nursing homes. Let's say you are considering putting a family member in a nursing home.What are the first three things you are going to look for to find out whether that place is actually providing the kind of care it describes in its brochures?

A: You cannot emphasize enough the importance of personal contact and a personal relationship with the people who are most important in the care for your relative. For an awful lot of people, the first exposure to a nursing home comes when a relative or friend is being discharged from the hospital. Before they are discharged, you need to talk to the discharge planner at the hospital and make sure they are aware of the specific needs of the patient. Dietary needs. Medications. Their ability to get around by themselves. That personal contact with the discharge planner is crucial. The second thing is to visit the nursing home and talk to the people who work there.

Q: But don't they mostly look the same?

A: My experience is when you walk into a nursing home you pretty quickly have a good sense of what kind of place it is. You can tell by how the staff treats you when you walk in, how they treat the residents you see, how they treat each other. Does the place look like it's being kept up, and not just the lobby? The next thing I would do is look at Nursing Home Compare by CMS (Centers for Medicare and Medicaid Services). It won't give you everything you want to know about what might have gone wrong at a specific facility, but our state and several others also have our own review sites that give you a sense of what the circumstances are.

Q: What about the special focus facilities (SFF)? Medicare added this list to its site in 2008 as a way to encourage nursing homes that had been in trouble to improve more quickly.

A: If I saw a nursing home that was on the special focus facilities list, I would think very hard about sending a relative or friend there. There are 135 of those around the country. It doesn't mean they're not working hard at fixing their problems, but the problems are severe enough that they are on this list.

Q: It sounds like from your work that nursing homes have shifted away from actual physical restraints, the use of which has dropped from 40% to 4% over the past decade and a half. But have nursing homes replaced those physical restraints with, in effect, chemical restraints, by drugging patients just to keep them docile?

A: If you look at the record, the improvement in physical restraints has been tremendous, and there has been an uptick in drugs that might look like they are replacing physical restraints. On the Nursing Home Compare site, you can see the number of physical restraints used, but not chemical restraints.

Q: How would you find out if that's really happening or just a coincidence?

A: It requires some work. The first is knowing who is responsible for prescribing those drugs. Although the patients are in the nursing home, the prescriptions are written by the medical director or attending physician. You want to develop a personal relationship with the attending physician and the nurses and the aides. The thing to remember in nursing homes is if a patient is there for the long term, the doctor is only going to see the patient once every 60 days. Most of the orders are written in the chart by the nurses, and the doctor comes by and approves the continuation of those meds. The critical people are the people on the nursing staff. The vast majority of the notes in the chart are written by the nurses.

Q: You talk about poor care being no care. How do I decipher a 2567 report (CMS Statement of Deficiencies and Plan of Correction Report) to find out how a nursing home or hospital is providing less than the right amount of care?

A: It's very difficult. If you see five stars on the Nursing Home Compare site, for example, those five stars are not always a guarantee of good quality. The quality measures are self-reported. The overall rating is a mix of self-reporting and objective information. The health inspection information is entirely external. Nursing home staffing numbers are self-reported. Quality measures are a mix. I'm looking at one of these 2567's now. Here's a mistreatment deficiency. It says they were supposed to hire someone with no history of abusing residents but they hired someone with that history. That's a pretty serious violation. If you look at that report it goes through the level of harm from 1 to 4. Fours almost never happen. Ones are not a huge deal. It's the twos and threes you want to take a close look at. Here's another one in this particular home. The nursing home failed to make sure the residents were safe from serious medication errors. One thing you have to know is that the rate of medication errors that is assumed for purposes of an inspection is pretty high. So if they flunk that one, they're not doing well.

Q: How do you compare notes between records to see if there has been falsification or to see if the right hand doesn't know what the left hand is doing?

A: We have a variety of techniques that we use. One of them is handwriting analysis. But you can eyeball the documents as a lay person and see problems. For one, does it look like the same handwriting in same ink even though it's documentation of every three hours across 14 days? Nobody works that kind of shift. So that's a very bad thing. The second thing when patients are transferred between a hospital and back there are records that travel with them. If you look at something that has gone back and forth a couple of times you want to see what the charts looked like when they first left the facility. People are making copies all the time, and if someone has altered a record after the fact, you usually can find the original document.

Q: But less and less is copied to paper and more and more of these documents are generated on computers and stored on computers.

A: For electronic records, you might think that they could hide changes more easily. But some programs lock the reporting down after a day or two days or 30 days and require you to show that these changes were made after the fact. Believe me, if people are making things up, there is usually a way to find out.