Overview of CMS Care Compare for Comprehensive at Williamsville Summary of Recent DOH Inspection and Repeat Deficiencies at Comprehensive at Williamsville

from Nursing Home Profiles - Comprehensive Rehabilitation and Nursing at Williamsville

Summary: The Need to Improve Quality of Care and Quality of Life

Halper’s involvement with facilities in Southwestern Pennsylvania, it is important to note that it may impact Comprehensive at Williamsville’s functions following the indictment.42

David Gast (33.33% member) has at least 5% or greater ownership in 13 nursing homes as detailed in Care Compare.43 Like with the other members of Comprehensive Management Services, this is an undercount as he testified he owns more than 40 nursing homes outside of NYS and also owns a share of Diversicare.44

Joshua Farkovits, the fourth member listed in the original CON, has at least 5% or greater ownership interest nationally in 26 nursing homes as detailed in Care Compare. Like with Mr. Lahasky, this is an undercount.45

On March 3, 2016, an application for transfer in ownership was received by the DOH.46 On December 12, 2018 the ownership change was contingently approved and the final public health council letter sent on May 10, 2018.47 As detailed in the CON document, the total purchase price for the 36% transfer of ownership from Lahasky, Farkovitz, Gast, and Halper to Debbie Korngut, Teresa Lichtschein, and Jeffrey Arem was $6. While DOH determined there was no negative information received concerning the character and competence of the added individuals, the CON document details that Meadow Park Rehabilitation and Health Care Center, where Teresa Lichtschein had ownership, incurred a Civil Monetary Penalty of $45,366.75 for immediate jeopardy from an October 19, 2016 inspection. On that inspection, the DOH found deficiencies under Quality of Care Accident-Free Environment, and Administration.48

Overview of CMS Care Compare

Care Compare allows consumers to compare information about nursing homes and other health care providers. 49 Care Compare provides information about providers and facilities. Specific to Nursing Homes, CMS created a Five-Star Quality Rating System. This Five-Star rating system is meant to help consumers, their families and caregivers compare nursing homes more easily and to help identify areas about which they may want to ask questions. Care Compare contains detailed quality of care and staffing information, as well as survey results, for all of the Medicare and Medicaid participating nursing homes. Much of the information discussed in this Profile is drawn from the Care Compare databases.

Care Compare shows an Overall rating for each nursing home; between 1 and 5 stars. Nursing homes with 5 stars are considered to have “much above average” quality and nursing homes with

42 Id., see also AG Verified Petition at #39 https://ag.ny.gov/sites/default/files/orleans_nh_petition.pdf

43 CMS Provider October 1, 2022 44 AG Verified Petition at #89 https://ag.ny.gov/sites/default/files/orleans_nh_petition.pdf. 45 AG Verified Petition at #42 https://ag.ny.gov/sites/default/files/orleans_nh_petition.pdf 46 Project # 161122-E https://apps.health.ny.gov/facilities/cons/nysecon/ProjectInformation.action 47 Id. 48 Id. 49 https://www.medicare.gov/care-compare/

1 star are considered to have “much below average” quality. CMS advises consumers to use Care Compare together with other sources of information for the nursing homes, especially including a visit to the nursing home. It is the opinion of CELJ and others that the Five-Star rating system is better at identifying bad nursing homes than it is at identifying good ones.50

In addition to the Overall rating, Care Compare also gives a separate rating for each of the following three measures that determine the Overall rating:51

• Health Inspections – Ratings for the health inspections domain are based on the number, scope and severity of deficiencies identified during the three most recent annual inspection surveys, as well as substantiated findings from the most recent 36 months of complaint investigations and focused infection control surveys. All deficiency findings are weighted by scope and severity. The higher the points score means the worse the facility did on inspection. The health inspections rating also takes into account the number of revisits required to ensure that deficiencies identified during health inspection surveys have been corrected.

• Staffing – Ratings for the staffing domain are based on six measures. This includes three nurse staffing level measures (hours per resident per day) and three measures of staff turnover. The staffing measures are derived from data submitted each quarter through the Payroll-Based

Journal (PBJ) System, along with daily resident census derived from Minimum Data Set,

Version 3.0 (MDS 3.0) assessments. The nurse staffing level measures are case-mix adjusted.

For example, a nursing home with residents who had greater needs would be expected to have more nursing staff compared to a nursing home with lower needs. The turnover measures use six consecutive quarters of PBJ data to define annual turnover for nursing staff and administrators. Once points are assigned for each of the six staffing measures a total score is calculated giving the star rating.

• Quality Measures (QMs) - Ratings for the quality measures are based on performance on 15 of the QMs that are currently posted on the Care Compare website. These include nine longstay measures and six short-stay measures. Note that not all the quality measures that are reported on Care Compare are included in the rating calculations. In addition to an overall quality measure rating, separate QM ratings for short-stay measures and long-stay measures are also reported.

50 See i.e., Phillips, C., Hawes, C., Lieberman, T., Koren, M, “Where should Momma go? Current nursing home performance measurement strategies and a less ambitious approach.” BMC Health Services Research (February 2007)Accessed https://www.researchgate.net/publication/6244110_Where_should_Momma_go_Current_nursing_home_performan ce_measurement_strategies_and_a_less_ambitious_approach . See also Elder Justice Newsletter https://nursinghome411.org/news-reports/elder-justice/ ; and https://healthjournalism.org/blog/2016/07/whatquality-measures-can-tell-us-about-nursing-home-ratings/ 51 https://www.cms.gov/medicare/provider-enrollment-andcertification/certificationandcomplianc/downloads/usersguide.pdf

Since taking control over ownership in 2015, the CMS ratings for each of the measures have decreased, as detailed by the below table:

CMS Care Compare Star Rating52

Overall Health Staffing QM (SS/LS)53 2022 1 1 2 2 (2/2) 2021 1 1 1 3(4/2) 2020 1 1 2 1 (1/2) 2019 1 1 2 1 (1/1) 2018 1 1 3 2 2017 1 1 3 3 2016 1 1 1 2 2015 4 2 4 5

2014 5 2013 2 3 2 4 3 5 4

Summary of Recent DOH Survey Visits to Comprehensive at Williamsville

Congress set minimum health and fire safety standards for nursing homes that choose to be part of the Medicare and Medicaid programs. In return for these government payments, nursing homes agree to follow the minimum health and fire safety standards and cooperate with an on-site survey process that is conducted about once a year. The DOH conducts these periodic inspections and investigates complaints about nursing home care filed by residents or others. DOH does not give prior notice to the facility as to when the survey team will arrive.54

CMS calculates a weighted score for each survey health inspection based on the scope and severity of the deficiencies that the DOH identifies. More serious, widespread deficiencies receive more points. If the DOH has to conduct repeat visits to confirm that deficiencies have been corrected, more points are added to the score.55

52 See the table on page 13 of this report for additional details on the data 53 SS= Short Stay; LS=Long Stay 54 For additional information on the survey inspection process visit: https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/SurveyCertificationGenInfo/index.html 55 See CMS Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users’ Guide (October 2022) https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/Downloads/usersguide.pdf

The below tables show how the points are assigned:

CMS bases the health inspection rating on the relative performance of facilities within a state. The top 10% (with the lowest health inspection weighted scores) in each state receive a health inspection rating of 5 stars. The middle 70% of facilities receive a rating of 2, 3, or 4 stars, with an equal number (~23.33%) in each rating category. The bottom 20% receive a 1-star rating. In calculating the total weighted score, more recent standard surveys are weighted more heavily than earlier surveys with the most recent period (rating cycle 1) being assigned a weighting factor of 1/2, the previous period (rating cycle 2) having a weighting factor of 1/3, and the second prior

period (rating cycle 3) having a weighting factor of 1/6. The individual weighted scores for each cycle are then summed (after including complaint surveys, focused infection control surveys and revisit points) to create the total weighted health inspection score for each facility.

The nursing homes in Erie County are rated as follows: 20%(7 facilities) 1-star; 5.71% (2 facilities) 2-star; 22.86% (8 facilities) 3-star; 34.29% (12 facilities) 4-star; and 2.86% (1 facility) is 5-star.56 Erie County has one facility on the CMS Special Focus Facility (SFF) List.57

Because CMS bases the health inspection rating on the relative performance of facilities within the state, there will always be nursing homes rated at 1 star in the health inspection rating. Each nursing home has a legal responsibility to abide by the minimum federal standards of participation (i.e., the resident rights and protections standards). As such, the goal of each nursing home should be to meet these standards, meaning the health total points score should be at or close to 0.

The cut point for a 1-star health inspection rating in NYS is >40.667.58 Including the CMS SFF, there are 9 nursing homes in Erie County whose total points exceed 40.667. The range is 48-184.33, the average is 82.52, and the median is 62.33.59 Comprehensive at Williamsville has 71.67 total weighted points.

For the most current rating cycle, using the August 27, 2021 annual certification inspection, Comprehensive at Williamsville was cited for 11 health deficiencies for violating federal regulations, a total point score of 78.60 When taking into account state based deficiencies, the total number of deficiencies increases to 13. 61

The below table lists the health inspection scores since March 9, 2012, when Comprehensive at Williamsville was still under Catholic Health operations as “St. Francis” to the most recent report on August 27, 2021. August 20, 2015 is the first annual inspection under current ownership. As documented by the data, quality quickly decreased and overall, the private, for-profit ownership, has failed to improve resident safety and quality of care.

56 Note: during the COVID-19 pandemic, CMS stopped annual certification inspections. As a result, 8-facilities star rating are based on inspections 2+ years old. None of these 8 facilities have a health inspection rating of 1-star. Source: CMS Provider October 1, 2022. 57 Buffalo Center is the SFF, see https://www.cms.gov/medicare/provider-enrollment-andcertification/certificationandcomplianc/downloads/sfflist.pdf for more information. 58 Five Star state level cut point table (October 2022 Update) https://www.cms.gov/medicare/provider-enrollmentand-certification/certificationandcomplianc/downloads/cutpointstable.pdf 59 CMS Provider October 1, 2022 60 CMS Provider October 1, 2022 61 https://profiles.health.ny.gov/nursing_home/view/150369#inspections

DOH Standard Survey date

Health Deficiencies Including Complaints Cycle 1 08/27/2021 11 Cycle 2 11/04/2019 12 Cycle 3 10/16/2018 17 06/08/201762 13 06/08/201663 35 08/20/201564 30 Weighted score after revisits 78 56 84 64 428 270

12/18/2014 15 12/10/201365 5 01/17/201366 3 03/09/201267 12 68 20 16 60

While Comprehensive at Williamsville has not been cited at Actual Harm or Immediate Jeopardy over the current three survey cycle period, concerns about quality remain. For example, as detailed below, Comprehensive at Williamsville has a long history of repeat violations since the ownership transfer in 2015. When DOH issues a citation for violation of a regulatory requirement, the facility is supposed to rectify the issue. It is concerning when there are chronic deficienices cited by the DOH for the same regulatory violation.68

While we focus on infection control repeat violations, Comprehensive at Williamsville, based on the DOH annual inspection survey completed on August 27, 2021, was cited for numerous other regulatory violations that were repeat deficiencies from prior annual and complaint inspections. These include:

• F584: Resident’s Right to a Safe, Clean, Comfortable, Homelike Environment. Four citations since acquiring the facility in 2015: 10/28/2021; 11/04/2019; 1/17/2018; 08/20/2015.

• F656: Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured. Five citations since acquiring the facility in 2015: 08/27/2021; 11/04/2019; 01/17/2018; 06/08/2016; and 08/20/2015. It

62 CMS Provider 10/01/2019 63 Id. 64 CMS Provider 10/01/2016 65 CMS Provider 10/01/2014 66 Id. 67 Id. 68 For additional information on the issue of chronic deficiencies, see LTCCC’s report, “Chronic Deficiencies in Care. The persistence of Recurring Failures to Meet Minimum Safety & Dignity Standards in U.S. Nursing Homes. 2017. https://nursinghome411.org/wp-content/uploads/2017/02/LTCCC-Report-Nursing-Homes-ChronicDeficiencies-2017.pdf

should be noted that when the facility was owned/operated by Catholic Health System, it was cited for this deficiency on 12/18/2014.

• F688: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Four citations since acquiring the facility in 2015: 08/27/2021; 10/16/2018; 06/08/2016; 08/20/2015

• F908: Maintain all mechanical, electrical, and patient care equipment in safe operating condition. Comprehensive has been cited six times since acquiring the facility in 2015: 08/27/21; 11/14/2019; 10/16/2018; 06/08/207; 08/20/2015 and 06/11/2015. It should be noted that when the facility was owned/operated by Catholic Health System, it was cited for this deficiency on 12/18/2014.

Infection Control: F880 As detailed below, Comprehensive at Williamsville had issues with infection prevention and control prior to the pandemic and arguably because of these issues, set the stage for resident harm during the pandemic. For example, in October of 2021, federal officials sent a strike team to Comprehensive in response to a large COVID-19 outbreak, where 61 residents and staff tested positive for the virus between September 27 and October 17, 2021.69

Earlier in March of 2021, Comprehensive left residents without hot water for days after Legionella bacteria was found in the water.70 Legionella does not often affect most healthy people even if they are exposed to it, however Comprehensive’s resident pool is made up of many types of people who are at increased risk of sickness if exposed (those over 50, weakened immune systems or underlying illnesses).71 Processes and procedures must be proper and implemented. Otherwise, resident health and safety may be adversely impacted.

• August 27, 2021 Newly admitted resident was admitted and was not wearing a surgical mask while in the dining room. In addition, the resident’s room door did not have a sign that indicated the resident was on transmission-basedprotocols (TBPs) and there was no PPE set up on the door. During observation, an occupational therapist (OT) was in the resident’s room wearing a surgical mask and no other

PPE while in direct contact with the resident. The OT stated they were uncertain of the facility protocols for unvaccinated, newly admitted residents and didn’t know if the resident was on

69 “Williamsville nursing home: 8 people have died from COVID-19”, WGRZ (October 22, 2020, updated October 24, 2020). https://www.wgrz.com/article/news/health/coronavirus/report-federal-officials-visit-williamsvillenursing-home-after-covid-outbreak/71-c5c6607b-01d2-4b23-b3f5-6a557bc4f83c 70 McAndrew, Mike, “Williamsville nursing home without hot water for days after Legionella found in water,” Buffalo News, (March 10, 2021, Updated May 25, 2021). https://buffalonews.com/news/local/williamsville-nursinghome-without-hot-water-for-days-after-legionella-found-in-water/article_9e03c014-81d9-11eb-89c72b8d59df75fb.html 71 For example of the dangerous of Legionnaires in nursing home, see https://www.nbcnewyork.com/news/local/5deaths-at-nyc-nursing-home-blamed-on-legionnaires-disease/3956035/ , where 5 residents died.

precautions. The Director of Nursing was interviewed who stated that the resident was not vaccinated and should have been on precautions since their admission date.

• October 7, 2020 (COVID-19 Focus Survey)72 The facility did not ensure staff were checked for COVID-19 symptoms, including temperature checks every 12 hours while on duty. During interview on 10/7/20 the Administrator told DOH that the facility census was 98 with 49 COVID-19 positive residents who were cohorted on Unit 5. There were 18 staff and four agency staff out of work related to COVID-19 and stated Units One, Two and Six were yellow zones (residents that have been potentially exposed to COVID-19 due to outbreak in the facility).

During an interview on 10/7/20 at 2:17 PM, with Administrator and Infection Preventionist Registered Nurse #1 (IP RN #1) present, IP RN #1 stated they were not aware of the 12-hour screening requirement until today and now they know it is supposed to be done every 12 hours, which they were not doing. The Administrator stated they have a bunch of regular staff that are always willing to help out and work overtime but have not been re-screening or taking temperatures after working 12 hours. The IP RN #1 also stated, when staff come in for the start of their shift they are screened, temperature is taken, and they sign the employee log sheet. They have some staff who pick up extra time and know that staff will be working over eight hours from the start of the shift but they do not get re-screened or re-temped when working over 12 hours

• May 20, 2020 (COVID-19 Focus Survey) The facility did not practice social distancing on two of four units, residents were not assessed for signs and symptoms of COVID-19 and there was a lack of proper hand hygiene. On May 19, DOH observed Activity Aide #1 was distributing crayons, pencils and paper to the residents sitting at the tables. The nine residents were seated in the same locations, were not wearing face masks and were not social distancing. The Activity Aide made no attempt to redirect or social distance the residents sitting at the tables. During interview on 5/19/20 at 11:26 AM Licensed Practical Nurse (LPN # 4) stated they try to make sure all residents are social distanced. "We try our best."

Observations of Unit 2 on 5/19/20 at 12:44 PM revealed Certified Nurse Aide (CNA) #4 entered a resident's room who was presumed positive for COVID-19 and delivered a meal tray without wearing gloves. CNA #4 exited the room without completing hand hygiene, went to the meal delivery cart parked in the hallway, removed another meal tray from the cart, and entered a resident's room who was non-COVID-19 positive.

CNA #4 exited the non-COVID-19 resident room and did not complete hand hygiene. During interview on 5/19/20 at 12:49 PM, CNA #4 stated the residents on Unit 2 were on precautions

72 Note: while not cited again on a 10/23/20 inspection, the report stated “the facility remains out of substantial compliance related to the 10/7/20 Focused Infection Control Survey.” Event ID: X6QT11

because they were new admissions to the facility and do not have COVID-19. CNA #4 was unaware that she should wash her hands in between delivering meal trays because she "didn't physically touch the patients."

• November 4, 2019 Based on record review and interview conducted during a Standard survey completed on 11/4/19, the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease for three (employees A, B and C) of 10 employees reviewed. Specifically, the facility did not provide documented evidence that education was provided to its employees on the risks and benefits of the pneumococcal vaccine. Additionally, the facility did not conduct a Legionella risk assessment, did not have a water management plan in place, did not complete quarterly sampling of the facility's water system and the facility did not report positive legionella water samples that exceeded New York State guidelines. This affected three (Unit 1-2, Unit 5, and Unit 6) of three resident units, one of one Second Floor (administration), and one of one Basement.

• October 8, 201673 Report notes that this is a repeat deficiency from the standard surveys completed on 12/18/14 and 8/20/15. One of four residents observed for infection control practices during personal care had issues involving the lack of proper hand hygiene after providing peri-care and prior to touching items in the environment. In addition, the laundry room observed for infection control had five washing machines with large amounts of sediment on the front of the washing machines; and the facility did not maintain a record of incidence of and corrective actions related to infections.

• August 20, 201574 Report notes that this is a repeat deficiency from the standard survey completed on 12/18/14.75 One of eight residents observed for infection control practices during personal care had issues involving the lack of proper hand hygiene after providing urinary incontinence care and prior to touching items in the environment. In addition, staff placed clean heel booties on the floor. During an interview with the resident’s daughter, she stated “she is always picking up soiled gloves and paper towels from the floor, the garbage cans never have bags and she is always wiping down surfaces. In addition, she does not feel staff wash her mother thoroughly.”

73 Event ID YV1O11 74 Event ID YL1O11 75 On 12/18/2014 Catholic Health Systems was the official operator of the facility. The facility was cited because a staff member that had not received the flu vaccine was not wearing a mask while providing direct resident care. The facility was also cited for the contamination of clean items and resident furniture after performing fecal incontinence care for a resident.