Home Care Aide Rules need to change

Funds spent for long term care initiatives

SEIU 775 Pushed for and Paid for each of these initiatives – Caregiving is still in crisis. Things need to change.

Several concerning issues regarding this case:

  1.  The Administrative Hearing Coordinator did not know the laws/rules of the HCA training.  He insisted several times that there was only one training course that the applicants could take – that of the Training Partnership (SEIU 775)
  2. The Administrative Hearing Coordinator insisted that there were not problems with others completing the training and getting their certification.  He treated this applicant as if she was a failure for not completing the SEIU 775 training.

HCA applications and certificates

Data for these charts was from the Credentialing Manager, Health Systems Quality Assurance, Washington State Department of Health

completed certification

The facts were provided to the Administrative Law Judge (ALJ) by the appellant.  While the ALJ had to abide by the Washington Administrative Code, she did fully understand the frustration and barriers for both the caregivers and those needing that care.

So, in the end, this was a very expensive and long drawn out ordeal that was frustrating but also clarified the problems with these rules.  Now we need people to help get the rules changed so that our community members in need of caregivers and those who want to provide this care can both get what they need.

Longterm care initiatives Washington state

SEIU 775 Pushed for and Paid for each of these initiatives clearly outspending the coalitions (or 501 (c)(3)) that were against each of these initiatives – Caregiving is still in crisis. Things need to change.

The Department sent the appellant the Planned Action Notice which outlined she had not completed the required Basic Training to be an individual provider.  The Appellant has continued working as an individual provider after January 25, 2018, and has not been paid by the Department.

Text from “Initial Order” signed by the Administrative Law Judge on July 23 2018 below:

The undisputed evidence established the Appellant has not completed the 70 hours of Basic Training to be an Individual Provider.

The Appellant explained she had difficulty finishing the Basic Training due to being locked out of the system at some point.  The Appellant expressed frustration about all the barriers in place to becoming an individual provider.  The Appellant also expressed frustration at not being informed about other possible ways to complete the Basic Training.

An administrative law judge may not find a Department regulation in the Washington Administrative Code invalid or unenforceable.  The authority of an administrative law judge (ALJ) and a review Judge is limited to those powers granted by statute or rule.  An ALJ and review judge do not have any inherent or common law powers.  (WAC 182-526-0216).  The Appellant made compelling arguments about the need for providers and how the process to become certified is frustrating because there are so many barriers.  The undersigned administrative law judge does not have the authority to grant the Appellant any relief or an exception to the certification process based on the need for providers in the community.  The undersigned administrative law judge also does not have the authority to implement basic policy changes to the certification process or great exceptions to the Basic Training requirement.

The Appellant has not completed the 70 hours of Basic Training within the 120 days of providing paid in-home care as an individual provider as required by WAC 388-71-0875.

Since the Appellant has not completed the required 70 hours of Basic Training, the Department was required to deny her payment as an individual provider pursuant to the Washington Administrative Code regulations.   There are not exceptions to completing the required Basic Training within the time frame outlined in the Washington Administrative Code.

Follow up:  the Appellant completed training through a DSHS approved  course

May 18, 2018 – sent application for HCA to Department of Health

July 25, 2018 – Completed the 75 hours of Basic Training

August 15, 2018 – DOH Credentialing scheduled caregiver for HCA test

September 7, 2018 – Caregiver took scheduled test – passed with 97%

September 19,. 2018 – DOH updated from PENDING to ACTIVE – FINALLY SHE CAN BE PAID TO PROVIDE CARE – even after she completed the training – the bureaucratic process to almost 2 months to complete – this was time that the caregiver had no control over yet she was not able to be paid. 

This caregiver is now providing daily care to two disabled university students.  

This situation was unusual in that the caregiver and her baby moved back into her parents home during this time.  Having the family support and “free” babysitting enabled her to continue providing care free of charge since most of her living costs were covered by her own self-employment and parents.  Without this support, she would have had to quit and become another one of those who applied to become an HCA but was unable to complete the SEIU 775 demands.  Caregiver provided care for 8 months without being paid.  Also the state had not paid her for the 2 weeks in January that she was locked out of the system.

Caregiver was not able to be paid by DSHS until September 19, 2018.  The rules state that the caregiver needs to complete the training and certification test.  Email from Case manager:

Planned Action Notice (PAN) that was sent to SG on 01/08/2018 informing her she would not be paid as of 01/25/2018. In the PAN, the WACs pertaining to the action are listed. WAC 388-71-0540 stipulation 14 indicates a provider cannot be paid if they do not successfully complete the certification requirements as described in WAC 388-71-0975.  SG was actually required to complete her HCA certification within 150 days of first starting to provide care.

The dates for completion of training and the HCA certification are based on when SG was first authorized to start providing care. SG was first authorized to start providing care on 09/28/2017.

Do You Need A Caregiver?

I and many others are well aware of the crisis that we have regarding lack of trained, qualified and committed caregivers for our community members in need.

Being aware of this crisis, I would think that the Department of Social and Health Services would want to work with their clients and independent providers to provide flexibility and alternatives so that the providers are able to complete the training.

In Washington State, independent providers can be hired by the disabled person and after having completed the 5-hour “Orientation and Safety” class, background check and fingerprints, may begin working.  They have 120 days to complete the remaining 70 hours of the Basic Training and need to have their Home Care Aide Credential within 200 days of starting to provide care.

While this may not sound difficult, in reality, many people are finding it impossible to complete for several reasons.

  1.  While working and providing care for the disabled person, the IP is also expected to travel to the SEIU training sites to attend the required evening classes.  For a person who provides care in the evening, this task is virtually impossible once caregiving duties have started.
  2. There is no “exception to rule” or extension available if unusual circumstances come up – such as family crisis, relocation, availability,  change in status.  DSHS has no flexibility for accommodations for IPs to get their training. 
  3. Even though there are alternative courses available through other DSHS approved training sites, IPs are not informed of these choices – even if they have difficulties with attending or completing the Training Partnership classes.

 

In order to be independent and involved in her community, Sarah needs to have reliable caregivers.  Sarah is able to self-direct but does need the caregiver to provide physical and personal care. Sarah had a terrific and experienced caregiver.  The restrictions of completing the 75 hour SEIU 775 training within 120 days of starting work has proven to be too restrictive for many people who have applied.

register through SEIU 775 site

This is the checklist from DSHS on steps to becoming an HCA – note that the ONLY training course information provided is the SEIU 775 training and a link to the SEIU 775 website.

The caregiver, having graduated from PIMA Medical Institute and having worked in an Internal Medicine Clinic as a Medical Assistant for 4 years in addition to having the experience of caring for her profoundly disabled younger brother, it seemed that she would fit into one of the categories that do not need to complete the full 75 hours SEIU 775 training by the criteria of “similar training”.

Unfortunately, a medical Assistant is not one of the jobs with “similar training” that is exempt from the 75 hours.  The caregiver decided that taking a Nursing Assistant  Course and becoming a Nursing Assistant – Certified (NAC). would be the best option for her.

This is where the whole issue gets more and more confusing and ridiculous when one just wants to do their job and provide appropriate and safe care to her employee.

DSHS sent a letter informing her that she would not be paid after 120 days due to not completing the SEIU 775 Training within that time frame.  DSHS sent the letter to an old address (even though they had been using her current address for not only her W-2 but other correspondence between the case manager and SEIU 775).  Due to this error on the part of DSHS, the caregiver did not receive the notice until the time limit to send an appeal had expired.  The caregiver had already taken steps before the deadline to become an NAC.

  1. January 18, 2018 – Application sent to Department of Health for Nursing Assistant Certification
  2. February 26, 2018 – appeal letter sent in to DSHS from caregiver regarding notice that she would no longer be paid since she had not completed the SEIU 775 training.
  3. March 13, 2018 – caregiver had discussion with the credentialing specialist at DOH who provided extremely useful information with some options available to gain certification.   She provided information  on the pending NAC if that was still a consideration.  (See note below) The information on the website was not totally correct with the processes and testing needed to complete the bridge program from MA to NAC and this lack of information was a barrier to completing this training.

Your Pending Nursing Assistant Certified (NAC) will stay pending for 300 days. At that time, you will be sent a 30 day warning letter. That gives you 30 days to respond letting us know if you would like to keep your NAC open. All you need to do is simply respond to that letter via email or by phone and we will extend it another 300 days. There is no limit to how many times you can extend it out as far as I know. This will keep your already submitted $65 payment and NAC application applicable to completing the NAC application process at a later date if you would like.

There is also a 24 hour bridge training program you can take after you have an Active Home Care Aide license as well. If you would like to pursue your Home Care Aide license for now and complete the NAC application process at a later date via bridge training, you would need to submit the following: (You’ve already submitted the application and $65 payment)

4.  April 9, 2018 – DSHS filed a Motion to Dismiss  claiming the caregiver had no right to appeal. A hearing was heard with the judge and the Department Administrative Hearing Coordinator – Mr. Korff.

5.  April 19, 2018 A pre-hearing appointment with the Judge and Department Administrative Hearing Coordinatore was set for

  • “Mr. Korff stated at the motion hearing April 9, 2018 that the Department first learned of my change of address on March 1, 2018 when they received my request for an appeal. I believe that the evidence I have provided indicates that the Department had my current and correct address on record as I was receiving mail and payments from November 2017.  I did my part and updated my address with the case manager and evidently there was a break in the system after that”

  • “I was working for free from January 26, 2018 and am currently still working for free for Sarah due to the fact that there are so few providers that are able to work and I do not want to leave Sarah without the needed care. My plan was to complete the certification for a CNA as soon as I could and then submit the license to DSHS and resume being paid for the care I provided.”

  • “I had sent in my appeal to the Office of Administrative Hearings with the hope of being able to extend my temporary status and complete the HCA training. My concerns I raised are appropriate and I believed that common sense and possibly an exemption to the rule could be used to enable me to continue the HCA training (at my own expense) and also be paid to provide care to Sarah”

  • “It has been clear by my actions that I have been attempting to accomplish training and complete the required steps in order to have a HCA credential and be paid for care-giving. It has been through a series of unfortunately timed events that I was unable to complete the steps in the required time set by the Department.”

  • “Things are again stalled due to the Department refusing to allow me to have an appeal and instead changing the hearing to a “prehearing conference”. There is still no decision on the part of the Department.”

  • Below are the actions that I am requesting:

    • I receive payment for the two weeks I worked in January, 2018 that I was unable to document due to being locked out of the IPOne system. (Allow me access to the system so that I can update it and submit my hours)

    • I would like an exemption to the rule of 30 days to appeal and to extend the temporary contract.  I would like an extension of 60 days which will give me time to complete all the required training for the HCA.

    • I would appreciate being paid for the time going forward while I complete my training (at my own expense) and continue to provide the caregiving that Sarah requires. I plan to have my HCA training completed within 60 days from now.  I would greatly welcome the opportunity to continue working for Sarah during this time but I also need to be paid for my work.

6. April 26, 2018 – Mr Korff objected to each of the 9 documents that appellant submitted regarding the Motion to Dismiss  on the grounds of relevance – stating all were irrelevant.

7. May 7, 2018 – Order Denying  Department  Motion to Dismiss issued –  Judge found the appellant’s request for an appeal hearing was timely.

8.  May 8, 2018, Caregiver submitted HCA Application to DOH  choosing to complete the HCA training at a DSHS approved training site rather than the NAC since it would be quicker at this point to complete and get the certification.

9. June 13, 2018 – Administrative Court Hearing with Judge and Department Administrative Hearing Coordinator, Mr. Korff.   Mr. Korff again stated that there were no other options to take the HCA training and that SEIU 775 was the only course available.

10. June 28, 2018 – Caregiver submitted documents to the Judge regarding appeal and request for extension as an exception to the rule together with  information from DSHS regarding alternative training available which the Department Administrative Hearing Coordinator denied existed.

 

To be continued –

 

Save Fircrest – Essential Supports

A bill has been passed to the Senate Floor to vote on closure of Fircrest School – one of our states Residential Habilitation Centers (RHCs).  The RHC houses two critical communities of care – a Skilled Nursing Facility (SNF) and an Intermediate Care Facility (ICF).

It is a fact that there does need to be some capital improvement to the facilities to provide a safe environment for the residents and this is why we support the Fircrest Master Plan Fircrest Master Plan A-2

The campus has been neglected in the capital budgets for years and this is one reason why there is a large dollar sign to this project.  When buildings are neglected, they deteriorate and become unsafe for residents.  This is the situation we face now.

This does not mean that the land should be sold and the residents forced from their homes and community.  It does provide opportunity to change and to make needed improvements and to re-access the needs.

These are the opportunities that we support:

Fircrest Master Plan Alternative A-2

Federally Qualified Healthcare Center with oversight provided by the Department of Health for Fircrest residents and adult residents in the state who live with intellectual and developmental disabilities.

Collaboration with the University of Washington, Center on Human Development and Disabilities to provide specialized and comprehensive healthcare to community members.  This collaboration would also provide training for students in the healthcare professions.

Opportunities for improvement are not an option if 2SSB 5594 passes.  This bill seeks to close Fircrest and deny current and future residents access to the necessary supports.

We need to defeat 2SSB 5594 to protect out most vulnerable citizens.  Tell your Senator to Vote NO on 2SSB 5594.

 

Washington State Institutions

Washington State has an “interesting” concept in place with regards to the campus based communities for people with intellectual and developmental disabilities.  The term used in Washington State is Residential Habilitation Center (RHC).

What makes this term very confusing is that the RHC could be a Specialized Skilled Nursing Facility (SNF), an Intermediate Care Facility for People with Intellectual and Developmental Disabilities (ICF/IDD) or both.

What makes the term RHC even more difficult is the fact that there are different rules and regulations for the SNF and the ICF/IDD so when one talks about the RHC which type of facility is one referring to?  Most people do not realize that when referring to the RHC they are actually referring to two different types of institutions.

what-is-an-rhc-2017

Nursing care is an area of concern for those who live in the ICF/IDD.  Even though the ICF/IDD is defined as a healthcare facility under the Social Security Act, Washington State does not define it that way.  The ICF/IDD also does not fit under the definition of “Long Term Care Facility” by Washington State Law but many consider it a long term care facility.  This ambiguity about what the ICF/IDD leaves the residents floundering in limbo without appropriate oversight for the care that is to be provided to the residents.

This issue is clearly seen when looking at who does the surveys and investigations in each type of facility.  The SNF has all registered nurses on these teams while the ICF/IDD rarely has a healthcare professional on the team.  Even if allegations are written concerning medical, nursing or other healthcare related problems, there is no healthcare professional on the investigation team to assess the situation.  This is a problem.

rhc-investigations-2016

There are several solutions that can be examined for this error.  The first solution would be to transfer oversight of the healthcare from the Department of Social and Health Services to the Department of Health.  Another solution would be to include registered nurses or other healthcare professionals to do the investigations and surveys.  At the minimum the healthcare professionals should be consulted for any allegation that pertains to healthcare.

 

Who are the investigators?

Concerns regarding medical and nursing neglect for residents residing in one of our state’s intermediate care facilities has led me to ask many more questions.  Questions that I should have asked long ago before harm and  permanent damage occurred and quality of life diminished.

But on the other hand, the fact that my allegations were dismissed as “unfounded” when I knew that neglect had occurred, prompted me to do my own investigation.

In Washington State we refer to the state operated institutions (both skilled nursing facilities (SNF) and intermediate care facilities for people with intellectual and developmental disabilities) as Residential Habilitation Centers or RHCs.  This presents several problems – the first one being that the SNF and ICF have different federal and state rules and regulations.  When both the SNF and ICF are combined in one campus, residents, community members and legislators fail to understand there are two distinct entities involved with different regulations to abide by.

There is also confusion regarding “long term care facility” and “healthcare facility” and which state agency should provide oversight and licensing.  In Washington State, the ICF is not included in the definition of “long term care facility” but does fit under the definition of “healthcare facility” by the services provided at the ICF.

This issue is particularly troubling when the state ensures that those who reside in the ICF receive all their healthcare needs on campus by state employed medical providers and nurses.

The Federal Regulations are clear with these issues but Washington State is confused.

Here is just one example of an issue that at this point is unsolvable given the system that Washington State has in place for oversight, surveys and investigations.

There are allegations of multiple medication errors over several years – medications documented as being administered but the pharmacy did not dispense enough medication to account for all the documented (by licenses nurses) administrations.  The pharmacy only dispensed 12-46% of the medication the nurses documented.  There was harm done by not administering the prescribed medication.  This was the practice at the ICF for 9 medications over 5 years time – many, many nurses signed off as administering these medications.  If one looked at the medication administration record you would assume that the client received ALL the medication as prescribed –

BUT – there is another story when trying to match the pharmacy records to the nursing administration records.  There is a MAJOR problem with the SYSTEM.

The ICF is licensed by DSHS.  That means that DSHS is the state agency providing oversight and investigations.  When the state investigator goes in to look at these allegations they see the medications were documented as given, meaning that the allegations are unfounded – no medication errors and the nurses provided the care.

There are clear violations of some state nursing standards (State Nurse Practice Act),

  • Willfully or repeatedly failing to make entries, altering entries, destroying entries, making incorrect or illegible entries and/or making false entries in employer or employee records or client records pertaining to the giving of medication, treatments, or other nursing care;
  • Willfully or repeatedly failing to administer medications and/or treatments in accordance with nursing standards

Failing to meet these standards could lead to disciplinary actions but DHSH does not consider these violations because the nurse documented administration and an error was not observed.

Unfortunately, in this situation, the State Department of Health and the Nursing Care Quality Assurance Commission are unable to do anything since they are not the licensing agency for the ICF and the error is not attributed to one identified nurse. The licensing agency needs to address these violations but DSHS (the licensing agency) does not see these medication errors as violations or errors.

So – how do we as advocates, healthcare providers, parents and legislators ensure that these standards are met?

As stated in the Code of Federal Regulations and the Social Security Act Section 1905 (d)  the “primary purpose of the ICF/IID is to furnish health or rehabilitative services to persons with Intellectual Disability or person with related conditions”.

Given that the ICF is a healthcare facility and its purpose is to furnish health services, we need to have healthcare professionals involved in the oversight, surveys and investigations of the healthcare provided – Washington State is not providing the needed oversight of healthcare to this vulnerable population.

investigations-by-rns

 

 

 

 

“Allegations Unfounded” ?

Medication error rates of 52-89% on several medications is neglect.

Failure to apply splint correctly 85% of the time is neglect.

Neglect occurs when a person, either through his/her action or inaction, deprives a vulnerable adult of the care necessary to maintain the vulnerable adult’s physical or mental health. Examples include not providing basic items such as food, water, clothing, a safe place to live, medicine, or health care.

Signs of neglect. (from Washington State Department of Social and Health Services)

The above examples of error rates are just a few that have occurred to my son while living at a state operated intermediate care facility for those with intellectual and developmental disabilities (ICF/IDD).  These issues and others have been reported to the administration and there have been several investigations done and the conclusions returned have been “allegations unfounded.”  I find these conclusions indefensible given the documents that have been submitted for review.

One such issue that went on for several weeks started when my son developed swelling and pain in his right ankle – the ankle that had very recently recovered from a serious sprain.   The lack of response from the medical and nursing team from the very beginning of this injury being reported to the day I removed the splint was met with frustration. It was a very simple and straightforward issue that could have had a very simple and straightforward response – it turned into something totally different.

It was not until I was totally frustrated that I even mentioned the word “NEGLECT” and that is when the superintendent “self-reported” to Residential Care Services  (RCS) and the first investigation was done.  That investigation took several months to complete and the allegations were deemed unfounded.  During those months I was not allowed to talk with anyone at the facility regarding the care since it “was under investigation.”

This is a link to the email exchanges that I had with the Health Care Coordinator (HCC – RN), the Nurse Manager (RN4), the Habilitation Plan Administrator (HPA) and the ICF/IDD Superintendent.

neglect-with-foot-splint-at-fircrest-june-2015

splint-on-wrong-foot-upside-downsplint-on-left-foot-should-have-been-on-right-foot

 

Since that time, I have requested to have the issues investigated again and have provided more documentation to RCS.  I have felt as if I have been the one being investigated because each conversation that I have had with an investigator has started with what they have heard about me – trying to find issues with what I have reported or how I have acted.

The only thing that they have been able to say is that the photos that I have provided are not “proof” because I could have photo-shopped them.  Their “proof” is the documents and charting of their nurses and staff (which now have been found to be in error when trying to reconcile medications dispensed to medications documented as administered).  They have not and will not consider email correspondence or medical charts from outside medical providers.  They have not enlisted healthcare professionals to review the allegations of medical and nursing neglect until this very last investigation involving almost countless medication errors.  Yet, I am the one who is looked at for wrong doing.

In doing the research for these allegations I have learned that the Department of Health and therefore the Nursing Care Quality Assurance Commission has no ability to investigate since they are not the licensing agency for the healthcare provided at the ICF/IDD.  Since the issues are systemic to the nursing care at the ICF/IDD it is up to the licensing agency to investigate.  Here is a link to the letter I received from the Nursing Care Quality Assurance Commission – Discipline Section, Health Services Consultant.

dshs-needs-to-look-again-at-nursing-neglect

So, it’s back to the drawing board of contacting DSHS and asking for explanations of why the allegations are unfounded.

All residents are at risk of harm until these and other issues are acknowledged and corrected.

 

Whistleblowing

Someone needs to speak up and I’ll keep speaking up until some of these serious issues of healthcare inequity are actually looked at and corrected

A recent blog posting entitled “The Journey of a Whistleblower: The Challenges, the Pains and the Price ” identifies some of the issues when one is faced with some ethical decisions.

While my son was a resident at a state operated intermediate care facility, I brought issues of concern to the administration and the medical director.  When no action was taken, I approached the Human Rights Committee of the facility.  They did not think that the issues of healthcare neglect and injury were a concern of theirs.  I then went to the advocacy group for the residents of the facility.  The president told me that their goal was only to keep the facility open – they had no say in assessing or measuring standards of care.

Obviously the healthcare and quality of life for the residents was not on the radar of any of these groups.

So, I keep trying to get people, organizations, legislators and agencies to see the serious concerns with medical and nursing care at some of these facilities.

If your loved one was dependent on the care provided in a healthcare facility, would it be important to know that all the prescribed medications and treatments were administered?  Or would it be okay for the nurses to only administer sometimes but document that all prescribed administrations were completed?

Would medication compliance rates of 11-46% be acceptable to you?  These rates are certainly not acceptable to me.

But it’s not just the low compliance rates I’m concerned about – it’s the years of falsified records across the board on a variety of medications by many nurses that is a huge concern.  Who is to know if the medications are really administered with so little oversight?

Who monitors medication administration – apparently no one and this is a major problem that needs immediate attention.

There is immediate jeopardy to all residents of the facility until the medication administration problems are examined and corrected. It is shameful on the part of our state agencies that these practices have been and still are accepted practice.

As a nurse myself, I know this practice is unethical and illegal to falsify these documents.  I question the level of integrity of the nurses working at this facility who routinely engage in this illegal activity.

This time has come to go outside the state organizations and inform others.  It is not just about keeping a facility open, it is about providing safe, quality care.  Care that is not happening at this time.