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Incentive payments went to nursing homes with infection control violations, dozens of COVID deaths

See the nursing homes that received thousands of dollars in quality incentives after Medicare issued penalties for putting residents at risk of COVID-19

ST. LOUIS — In the span of a year, Annette Jansen has watched through nursing home windows as her mother’s health deteriorates.

“I have three pictures of her: one for May, one from September and one from just maybe two weeks ago,” said Jansen. “I see my mom deteriorate so much and, you know, it's from the isolation.”

At the start of the COVID-19 pandemic, 5 On Your Side interviewed Jansen about her concerns that her mother, Leona Behrens, was being exposed to the virus at Frontier Nursing and Rehabilitation. One thing she noticed in May was that her mother was housed with a roommate who had COVID-19.

Since the start of the pandemic, 22 residents at Frontier have died, according to their reports to the Centers for Medicare and Medicaid Services (CMS). Behrens, 76, survived her own COVID-19 diagnosis.

“I think COVID went so quickly through the nursing home and pretty much, at one point everybody had it,” remembered Jansen.

Credit: annette jansen

In June, CMS surveyors took note. Their inspection record indicated that staff failed to wear personal protective equipment, did not properly sanitize equipment and did not isolate COVID-19-positive patients. CMS issued civil monetary penalties related to infection control deficiencies in June and October, totaling $30,000, according to data on the CMS website.

“I'm glad they were fined,” said Jansen. “That's just a little over a thousand dollars per person that died. That doesn't seem worth their lives at all.”

As Frontier was being penalized by one part of the Department of Health and Human Services, it got an award from another. In October, during the same month that CMS issued a penalty, Frontier qualified for a quality incentive program under the CARES Act. The program automatically rewards nursing homes for achieving low infection and mortality rates. The data show that Frontier received $120,000 from the program as of October, money they never even had to apply for.

“I'm not happy about that at all. I don't think that makes any sense,” Jansen said when she learned about the incentive from the I-Team’s PJ Randhawa. “It's almost like that they're fining just to say, yes, you've been fined and you've been slapped on the wrist, but now we're going to give you more money so that you can continue whatever you're doing.”

Brian Lee, executive director of the nonprofit Families for Better Care, also told 5 On Your Side there are issues with giving an incentive to nursing homes that the same agency was trying to discipline.

“When these facilities are supposed to be held accountable through, like I said, to this enforcement system, we're just handing these monies back to them and these bonus payments. And it's, to me, it's unconscionable,” said Lee.

“The whole point of enforcement and in nursing homes is to incentivize better performance, better behavior by providers to keep our loved ones safe and alive,” he added. “When you give awards back to facilities that have committed wrongdoing, it just totally makes the enforcement a wash. It de-incentivizes better performance.”

In Missouri and Illinois, CMS issued penalties to 258 nursing homes during 2020 and earlier this year for infection control deficiencies. Of those, 220 also received incentive payments for low COVID-19 transmission rates.

The largest infection control-related penalty for any nursing home across the two states in 2020 went to Life Care Center of St. Louis. CMS issued a penalty of almost $500,000 in May for issues that inspectors said “placed all residents in the facility in immediate jeopardy.”

So far, Life Care Center has reported eight residents’ deaths due to COVID-19 to CMS.

In October, the facility received nearly $60,000 in incentive payments.

At Crystal Creek Health and Rehab Center in Florissant, 13 residents died of COVID-19. For infection control deficiencies in February and September 2020, CMS issued a $153,842 penalty. The next month, Crystal Creek received an incentive payment from HHS. By December, the incentive payments totaled $146,088, almost completely wiping out the penalty.

Across Missouri and Illinois, almost 200 nursing homes received incentive payments that were greater than their infection control-related penalties from 2020 or 2021.

A statement from the Health Resources & Services Administration, which administers the incentive program, said that there are two criteria for an actively certified nursing home to receive an incentive payment: “First, a facility must demonstrate a rate of COVID-19 infections that is below the rate of infection in the county in which they are located. Second, facilities must also have a COVID-19 death rate that falls below a nationally established performance threshold for mortality among nursing home residents infected with COVID-19.”

However, the calculations for the incentive payments do not take into account whether a facility has a previous or ongoing deficiency from a CMS inspection.

“Instead of giving bonus payments to the nursing homes, they could have used those monies to require more staff to be hired and people given jobs and the residents would be safe,” said Lee.

An HRSA statement said the incentive money must be spent in certain ways: “Nursing home QIP recipients must utilize the resources they receive to continue to protect their residents and staff against this devastating pandemic and they must attest to the terms and conditions outlined in the program for payment. For example, quality incentive payments may be used for costs associated with administering COVID-19 testing for both staff and residents; reporting COVID-19 test results to local, state, or federal governments; hiring staff to provide patient care or administrative support; efforts to improve infection control, including activities such as implementing infection control 'mentorship' programs with subject matter experts, or changes made to physical facilities; and providing additional services to residents, such as technology that permits residents to connect with their families if the families are not able to visit in person.”

Jansen said she hopes they spend the money helping her stay connected to her mother. So far, Frontier is still not allowing window visits for family.

“Like if they have $130,000 then, OK, let's get some more iPads, let's get some more staff to help connect them with their families,” said Jansen.

When asked to comment on nursing homes with recent penalties receiving incentive payments, an HRSA representative wrote:

“Nursing homes have been disproportionately impacted by this pandemic given their congregate nature and many located in communities seeing surges in COVID-19 cases face an increased challenge to controlling infection within their facilities. The Nursing Home Infection Control Quality Incentive program was first announced in September and the goal was to incentivize and provide added relief and support to nursing homes working hard to preserve the life of vulnerable nursing home residents during the periods outlined in the methodology document. Nursing homes are being held to strict standards that require them to utilize the resources they receive to continue to protect their residents and staff against this devastating pandemic and they must attest to the terms and conditions outlined in the program for payment.” 

5 On Your Side contacted Frontier, Life Care Center, Crystal Creek and three other facilities that received both an infection control-related penalty and an incentive. We asked how those facilities spent the money.

A representative for Frontier Health & Rehabilitation wrote:

The penalties assessed against Frontier Health & Rehabilitation on both 2/16/21 and 2/22/21 are for not reporting our COVID infection tracking information to the CDC’s National Healthcare Safety Network in a timely manner…we provided our information one-two days late for both deadlines. This information includes COVID testing results for residents and staff, number of residents and staff recovered from COVID, vaccination data on residents and staff and related information over the previous two-week period. These penalties are not related to the quality or level of care provided to our residents or our infection control protocols that were being utilized. This oversight in our reporting procedures has been addressed and corrected.

Frontier Health & Rehab has addressed all issues raised in our Centers for Medicare and Medicaid Services (CMS) inspection surveys on 10/30/2020 and 06/30/2020, and these issues have been cleared by CMS. A plan of correction was written and accepted by the Missouri Department of Health & Senior Services and CMS that addressed all areas of concern related to these inspections. These plans include additional staff education and review of processes and policies to ensure we continue to provide care and services in accordance with changing state and federal regulations. 

A representative from Life Care Center of St. Louis sent this statement:

In May 2020, Life Care Center of St. Louis received an infection control survey from CMS. We did receive citations, and those were corrected. We received follow-up visits from surveyors and were back in substantial compliance by the end of May.

There are policies in place regarding infection control processes, and those policies follow the state, federal, CMS and CDC guidelines. Our associates are trained often on these guidelines. If our associates make a mistake, which can and does happen because we’re all human, we see it as an opportunity to retrain associates and ensure the mistakes are not systemic.

The Life Care Center of St. Louis team has learned so much in the past year, just as the rest of the health care community has. We are thankful for the lessons we have learned and for the ongoing vigilance of our staff because what matters most to us is providing consistent quality care for our residents.

A CommuniCare representative wrote the following about Crystal Creek Health and Rehab Center:

As of last fall the facility is in compliance and has been cleared of citations. Since the start of the COVID pandemic, we have aggressively taken measures to ensure that employees are supplied ample PPE spending more than $7 million on the equipment. All employees wear the required PPE per state and federal guidelines including n95 and surgical masks, gowns, face shields and routinely change and dispose of such items in accordance to guidelines set by health officials.

The statement 5 On Your Side received from Stearns Nursing and Rehabilitation Center reads:

Stearns Nursing and Rehabilitation Center pre-emptively implemented policies and protocols to combat the spread of Covid, and in compliance with all subsequent CMS guidelines. As a result, Stearns has successfully managed to contain the virus since August 2020, despite subsequent spikes around the country and in Madison County, specifically. Stearns has at all times worked cooperatively with IDPH throughout their survey processes, and while it disputes some of the issues identified during an early September 2020 survey, the facility promptly took action to ensure that all staff were properly implementing its pre-existing policies and met any concerns of the state survey agency. Authorities since that time have deemed the facility to be in substantial compliance with pertinent regulations and have found no deficiency in Stearns’ infection control protocols. The facility continues to do its best to combat the spread of the virus and to proactively monitor its residents and staff, including through testing as required by federal and state regulations and by continued adherence to all reasonable measures available to it to keep the facility COVID-free. Through retraining and corrective action, Stearns’ staff understands what it takes to keep our residents safe so that we can continue to provide the quality of care our residents and their loved ones expect from us.

5 On Your Side did not receive statements from Integrity Healthcare Belleville or Grand Manor Nursing and Rehabilitation Center.

How to learn more about a nursing home's history

All Medicare-eligible nursing homes have inspection records available on the Medicare Care Compare website. Anyone can read full inspections to see what Medicare's surveyors saw when they performed inspections in a facility.

With a nursing home's address, you can access their latest reports about the number of COVID-19 cases and deaths at the facility on the COVID-19 Nursing Home Data page provided by Medicare.

The data for this report that showed each facility's infection control deficiencies and the resulting civil money penalties came from Quality Certification & Oversight Reports, operated by the Centers for Medicare and Medicaid Services.

All numbers for Quality Incentive Payments to nursing homes came from the CDC data portal as provided by HRSA.