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No Place Like Home: Nursing home's fight for solvency, respect mirrors industry-wide woes

Monday, September 23, 2002

By Gary Rotstein, Post-Gazette Staff Writer

In his Collins Health Center office, Thomas Kalkhof stacks folders of correspondence complaining about how difficult the government is making his business.

At the Collins Health Center in Friendship, activities director Irene Missiriotis takes the task of feeding resident Virginia Sellers. (Steve Mellon, Post-Gazette)


No Place Like Home
Part Two

Related article:

Accounting gimmick that sends Medicaid funds to nursing homes is about to end

Graphic:

Collins Health Center


No Place Like Home:

Part One:
Nursing homes struggle with too few nurses, aides for growing elderly population

Part Three:
Nursing homes find "culture change" necessary to make patients happier, healthier

Part Four:
Avoiding nursing home horrors

The portly, talkative nursing home owner freely airs his troubles to the White House, governor, lawmakers and state and federal agencies, whether they want to hear from him or not.

His 65-bed facility in Friendship has been operating in bankruptcy since March, and he's uncertain if he can ever make it solvent again.

"It's hard to make great strides the way the business is at this time," said Kalkhof, a work-week commuter from Erie who spent his teen years working in a nursing home his father owned there.

A hallway runs from Kalkhof's office past a small nurses' station and turns right before dead-ending at room 110, where four elderly women occupy beds. That's where $9-an-hour nursing aide Sharon Best spends many days caring for a population that can be difficult, even on the best days.

On a cigarette break after washing and dressing one cantankerous woman who is confined to a wheelchair, Best says without a trace of hostility, "She cusses at you. She'll tell you she'll beat your ass. She hit me the other day."

Such is life on the top and bottom rungs of one of Allegheny County's 68 nursing homes, one of about 760 in the state and 17,000 in the nation. Collins is smaller, older and has more financial troubles than most, but many of its issues are the same, a joint Pittsburgh Post-Gazette/KDKA investigation has concluded.

Kalkhof, 55, complains of inadequate government reimbursements and difficulties in recruiting dependable staff members like Best. He wonders if there's any future for an urban nursing home with a high percentage of Medicaid-covered residents like his.

Best, 40, is unusual in that she's content with what she's doing in an industry handicapped by worker shortages.

She's up at 6 a.m. in her North Point Breeze home to prepare for the 7-to-3 shift at Collins. She's been a nursing aide since 1999, caring for eight to 12 people at a time, and before that, she worked in the facility's laundry for 10 years.

"If you come in here with a bad attitude, you're going to have a bad day. Most of the time I come in happy-go-lucky," Best said after a day spent cleaning, dressing, feeding, changing and chatting with a group of eight women in her care.

It's a job that carries little respect in society, in a setting that many people abhor. Nursing homes are commonly considered a way station to the funeral home. A patient's dignity is diminished by regimen and dependency. Almost any functioning person prefers to live at home as long as possible, or at least in the more open environment of a personal care home.

Yet the need for nursing homes persists, especially as medical advances push more people than ever into the 80-and-over population where debilitating health issues loom.

Collins remains in operation, for now, because 50 or so patients live there, a similar number of employees depend on it for paychecks, and Kalkhof says he doesn't want to let either group down.

How much longer that remains the case is uncertain.


More like family

A nursing home has operated since before World War II in the two connected turn-of-the-century mansions that make up Collins, located on busy Baum Boulevard near the edge of Bloomfield, East Liberty and Shadyside.

Collins nursing aide Sharon Best combs resident Marge Geston's hair. "If you come in here with a bad attitude, you're going to have a bad day," she says. "Most of the time I come in happy-go-lucky." (Steve Mellon, Post-Gazette)

Most nursing homes are in buildings constructed since the 1960s, when the onset of Medicare and Medicaid programs led profit-making ventures to enter an elder-care industry once dominated by charitable missions.

The newer nursing homes have wide and straight hallways, large elevators and nursing stations, spacious dining rooms and living quarters with no more than two beds to a room. They often resemble mini-hospitals.

Not so, Collins, which Kalkhof acquired in 1987. Its corridors are full of Gothic twists and turns, its rooms stuffed with three or four beds flanked by plain bureaus and chairs. Its wooden interior and stairways create a darker, less antiseptic atmosphere than modern counterparts.

The bathrooms are located along public hallways, instead of attached to bedrooms. Those halls are barely wide enough for a wheelchair and a mobile person to pass at the same time, but they're generally clean and free of odors.

As in some private homes, televisions flicker in rooms all day and into the evening, whether anyone is watching or not.

Collins is small enough that many residents and longtime employees learn one another's quirks and personal histories, as well as illnesses. If they are not part of any cutting-edge gerontology, they don't seem to mind.

"It seems like a big family," said relative newcomer Carlenia Tillery, 87, a second-floor resident who moved from another nursing home, a newer one which she and relatives considered unsanitary, with awful food.

Collins' employees are known to mend or purchase clothing at their own time and expense for needy residents. Employees feel appreciation from the owner in the form of Christmas bonuses, recognition lunches and a vacation-and-benefit package that is generous by industry standards.

Virginia Buddish, the registered nurse assessment coordinator, has enjoyed her nine years at Collins more than many of her 27 years of work in nursing homes.

"This is more individualized, more like a home," said Buddish, a former administrator in Allegheny County's Kane system.


A fine and a ban

Just like all families, all nursing homes have their problems. Collins is no exception, and in some ways, it is more dysfunctional than most.

Rhonda Anderson, who's a certified nursing aide, hugs Ruth Banks in her room at the Collins Health Center. Despite the home's financial problems, there are employees and residents who like the sense of family they get from working and living there. (Steve Mellon, Post-Gazette)

On Feb. 13, 2001, the state imposed a rare "immediate jeopardy" citation on Collins indicating a threat to residents' health and safety. A resident's scalp was singed in a smoking accident when another patient tried to light her cigarette for her. Health Department officials considered it evidence that unsupervised smoking presented a major safety hazard.

While taking steps to provide better monitoring in a second-floor smoking room provided for residents, Kalkhof argued that the state exaggerated the seriousness of the problem. He believes he was targeted unfairly and has appealed the severity of the citation.

Collins was fined and prevented from admitting residents for 2 1/2 weeks. The penalty contributed to a five-fold increase last year in insurance costs. And the admissions ban compounded a critical problem Collins already faced: a declining census.

Occupany rates of nursing homes nationally have been dropping since the mid-1990s, when beds were occupied more than 90 percent of the time. Occupancy by 2000 had dropped to 87 percent, which industry officials generally attribute to more assisted-living residences and at-home services for the frail elderly population.

Kalkhof said Collins lost potential clientele from both the ban and a too-passive approach by a former admissions director who failed to draw new residents from nearby hospitals. The summer of 2001 found Collins less than 60 percent full at one point, with just 38 patients, though it has been back above 50 residents in recent months.

Collins has an additional problem because so many of its residents' stays are covered by Medicaid. Those payments to cover poor people's care are less than the reimbursements from Medicare or private insurance or from daily charges to patients who pay their own way -- a type of resident that Collins lacks.

Typically, about four of six nursing home residents are financed by Medicaid; at Collins, it's closer to five out of six. Kalkhof learned last week his state Medicaid reimbursements will rise to more than $158 per day per patient on Oct. 1, about $12 more than he's been receiving.

He described it as a surprisingly generous boost, but one that will still leave him short of actual costs.

Government reimbursements are partly tied to the costs experienced by a nursing home three to five years ago. Kalkhof and others in the industry decry that as a failure to recognize huge increases in labor costs and liability insurance in recent years.

Changes in the federal reimbursement system initiated in 1997 also made the rehabilitation of Medicare residents less lucrative.

After a delay of several years in some of the funding cuts, they're now to take effect Oct. 1, potentially reducing nursing homes' Medicare reimbursements by 10 percent. Kalkhof said that will swallow much of the benefit of the Medicaid boost.

"The government doesn't want to run health care, but they're squeezing providers to the point where we can't survive," Kalkhof said.

He said the lack of sufficient residents and reimbursements created debts that prompted Collins to file for Chapter 11 bankruptcy protection on March 8. The federal court filing reported net income losses exceeding $350,000 for 2000 and twice that in 2001.

Collins' debts tallied $4.5 million, including $120,000 owed to the Internal Revenue Service for failure to pay payroll taxes.

"What was more important, paying the IRS or making sure that [the residents] get food?" Kalkhof explains now.

In mid-July, he put Collins up for sale. He gathered his staff to explain the decision, just as he had when filing for bankruptcy.

He told them he was hoping a buyer with deeper pockets would rescue the facility and protect their jobs before he reached some crisis point of needing to shut down. But he also knows the property could have more value to potential buyers if used differently.

"I have an obligation to generate as much cash to pay off as many people as I can," Kalkhof said. No buyer has yet emerged.


Staffing -- the standard woe

Best has no intentions of leaving Collins despite its uncertain future. Sometimes, she even volunteers to work double shifts.

"They pay you for it -- they feed you, too," the short, round-faced aide said 12 hours into one recent workday, in which she cared for residents from 3 to 11 p.m. after arriving at 7 a.m. The extra shift paid about $15 an hour instead of $9.

Like most nursing homes, Collins has staffing problems. Best had worked two mandated double shifts the month before.

And one of the two licensed practical nurses working the same recent shift as Best was recruited from an agency that provides temporary help.

Using agency workers costs Collins nearly twice as much per hour as using its own staff. It's also worse for residents to be cared for by temporary helpers unfamiliar with their needs, but nursing homes say the industry's high turnover rate and regular employees' illnesses and vacations make it a necessity.

"The toughest part of this business is finding enough bodies to fill the positions," said Kalkhof, noting he is in constant competition with better-funded hospitals to attract nurses.

He is offering up to $25 an hour to attract registered nurses, about 40 percent more than he was willing to pay three years ago.

Different problems accompany the recruitment of aides like Best. Applicants could earn the same money for easier work at the many fast-food restaurants right outside Collins' door.

With the increasing difficulty in recruiting competent, direct-care workers, Collins is finding that only half of its newly hired aides make it past their probationary periods.

Voluntary and mandatory overtime and agency temps help keep Collins above minimum staffing requirements set by the government, but Kalkhof acknowledges the numbers aren't optimal. Generally, 50 to 60 residents are cared for by a registered nurse supervisor, two LPN's and four or five aides.

On her double shift, Best seemed relaxed when trying to coax one man, Walter, into eating dinner. He was lying in bed with eyes closed, grunting, as she held a spoon with mashed potatoes in one hand and tapped his shoulder with the other.

"Wake up, Walter. Over here, Walter. C'mon, you ready?"

The elderly man was headed to the hospital the next day, in fact, to receive a feeding tube because he had become so reluctant to eat solid foods. Best persisted for minutes, and he eventually opened his mouth to chew and swallow.

"Any feeding here takes time," Best explained. "You can't rush through and say they don't want to eat."


An industry in microcosm

Kalkhof believes Pennsylvania officials have been harsh on him, in the smoking citation and otherwise, for criticizing a state funding scheme involving nursing homes and federal Medicaid dollars.

But he's also adamant that more and more nursing homes will be forced into bankruptcy or closure for some of the same funding problems he is experiencing. Some in the industry agree with him.

"You've got more Medicaid patients than you ever had, your costs are higher and your reimbursements aren't keeping up," said Peter Burke, a consultant from Brandywine Senior Care Inc. in New Jersey who has reviewed Collins' situation.

"Unfortunately, it's going to be a problem not only for Collins but a lot of places," he said. "The numbers just don't add up anymore."

There are eight other Pennsylvania homes in bankruptcy, and the number of facilities in operation is dropping rather than increasing. One South Side nursing home, the Sidney Square Convalescent Center, closed in April, and Pittsburgh Mercy Health System intends to close its 153-bed Mercy Senior Care: St. Joseph's nursing home in Garfield by Nov. 1

But some of the problems of local facilities could be the result of a surplus of nursing home beds at a time when people want other options.

"Nursing homes are still struggling, but doing better than they were," said Tom Scully, administrator of the federal Centers for Medicare & Medicaid Services, citing a government report that found publicly held companies have begun returning to profitability after numerous bankruptcies.

Scully acknowledged that Medicaid reimbursements are inadequate, a problem arising in part because the government never anticipated so many nursing home residents depending on it.

Ironically, the problems of other facilities could be Collins' silver lining. A few new admissions resulted from Mercy's need to relocate some 70 residents by closing nearby St. Joseph's.

For now, Collins' mortgage-holder is willing to forgo monthly payments to help Kalkhof keep it afloat. The home also has laid off non-nursing staff and dropped liability insurance to avoid a second straight huge increase.

Anyone filing a legal claim against Collins will have a hard time getting paid for any judgment against it.

"They'd have to get in line in bankruptcy court," Kalkhof said.

He believes a lot of other homes are only avoiding his difficulties by cutting corners on staffing or other expenses. He's prepared to continue running Collins, meanwhile, until a buyer emerges or the financial picture somehow brightens.

Best hopes he stays, or at the very least, that Collins remains in operation.

"I don't want to leave this place, because I started here," she said, figuring it will help her prepare to care for her parents someday.

She explained her desire to stay just before a tussle in a bathroom with Marge, a woman who objected to Best changing her diaper.

"I have rights!" Marge shouted in a slurred voice that could be heard outside.

"I have rights to clean you up, OK?" Best responded evenly. "You have rights, but you still gotta be clean, OK?"

She won the battle, and made her last act of the shift the disposal of the dirty diaper.


Tomorrow: A look at the efforts being made to improve nursing homes, including Allegheny County's Kane system.


Gary Rotstein can be reached at grotstein@post-gazette.com or 412-263-1255.

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