In years past, Allegheny County's John J. Kane Regional Centers didn't advertise, didn't admit anyone except poor patients, didn't much repair aging facilities and didn't boost staff up the career ladder.
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Certified nursing assistant Michelle Buckner wipes John Ferrari's mouth after feeding him at the Glen Hazel Kane Center. Like many nursing facilities, the Kanes face a staff shortage. (Steve Mellon, Post-Gazette) |
That didn't-couldn't-shouldn't management style that characterized longtime government operation of the Kanes appears to have gone the way of the massive old Kane Hospital itself, which was razed in Scott in 2000.
County officials say they have no choice financially today but to act more like a private nursing home, recruiting patients and staff by billboards and expanding into the assisted-living or independent-apartment realm on the Kane sites.
Changes began for the Kane operation -- consisting of four 360-bed facilities in Scott, Ross, McKeesport and Glen Hazel -- after Jim Roddey took office as the county's first chief executive. In early 2000, he appointed Thomas O'Shea as the Kanes' executive director, a position that had been unfilled for years.
"When I came to the Kanes, Mr. Roddey said, 'The clinical care is good, but the business practices leave something to be desired. ... See what you can do,' " O'Shea recalled.
The transition came at a difficult time for nursing homes generally.
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Thomas O'Shea is executive director of the Kane Regional Centers, which in the mid-1980s replaced the mammoth, 2,100 bed Kane hospital/nursing facility that once stood in Scott. (Steve Mellon, Post-Gazette) | |
Occupancy rates have been dropping nationally, and the Kanes' percentage of empty beds has been well above that of competitors. Recruiting and retaining qualified staff is more difficult than ever. Payroll, insurance and health-care costs have been climbing faster than reimbursement rates throughout the industry.
But a change in the Kanes' operations was viewed as essential. Although a proposal to privatize the county-run homes -- an idea once touted by Roddey -- has been abandoned, officials say they are incrementally becoming more like private counterparts.
That doesn't necessarily make everything better. The Kane-Glen Hazel was penalized by the state and federal governments this year for a death there in March, the first time any of the Kanes' licenses was downgraded to provisional status since 1991.
But the nursing homes are otherwise making a better impression on those inside and outside them. Bed occupancy rates have climbed again after barely surpassing 70 percent last year, though officials say they deliberately kept admissions down because of a staff shortage.
Brenda Frazier, a first-year County Council member who heads the council committee that monitors the nursing homes, remembers the common perception when she was growing up was: "You don't want to end up in the Kanes."
An impromptu recent tour and discussions with the Kanes' management and staff left her with a different impression.
"There was no smell, no regimented environment," Frazier said. "I didn't see wheelchairs lined up of people just waiting to get some air or go outside. ... From what I'm seeing, I think what's happening now seems to be going quite well."
Size was a problem
The roots of the Kanes, named for a former county commissioner, date to the opening of the county's opulent-for-its-day, 2,100-bed nursing home/hospital in Scott in 1958. Its striking features included abundant outdoor patios and fountains and indoor solariums and colors supposed to brighten the residents' lives.
But other aspects were old-fashioned, especially the wards in which 16 beds were grouped, denying residents any privacy. Another complaint was that having only one central facility put most patients far from their former neighborhoods and relatives.
And the sheer size of the original Kane made quality control difficult. State and federal regulators became increasingly critical of understaffing and conditions in the 1970s, and it endured a 16-month ban on admissions in 1977-78.
"Anytime you have that many patients or staff under one roof, it's really hard to manage," said Presbyterian SeniorCare President Paul Winkler. He was administrator of the new Ross center when the county opened the four "mini-Kanes" as a replacement in 1983-84.
Though small by comparison to the former complex, the 360 beds in each make any one of today's Kanes far larger than any other nursing home in Allegheny County.
Their size also gives the facilities an institutional appearance compared to more modern homes. The Kanes' cinder block walls are great for fire safety but terrible for conveying a sense of homelike comfort.
Now with a little tinkering -- knocking down a wall here, adding an atrium there and putting in new gardens elsewhere -- O'Shea said the Kanes are on their way to becoming more attractive. Long-deferred replacements and updating of roofs, driveways and kitchens also are under way.
One incentive prompting change is the different sense of competition today. The Kanes once cornered the market on the poorest of patients, but the decline in occupancy rates has private facilities more interested in attracting those same residents.
At the same time, the Kanes are trying to admit more non-Medicaid patients, who bring higher reimbursements. About 90 percent of the Kanes' residents are Medicaid-reimbursed now, compared to an industry average of 68 percent.
The Kanes' occupancy rate is still low, about 79 percent compared to an industry average around 87 percent. The county subsidizes their operation by providing in-kind services from other government departments and by using general revenues to cover the debt on the nursing homes' bonds.
To reimburse part of those contributions and reduce their drain on the county budget, the Kanes need to have an occupancy rate of 80 percent or more. To care for that many residents, officials say they need more staff.
"That's what's driving us to grow our own," O'Shea said, referring to a new staff-training partnership with Community College of Allegheny County. Thirty-eight nursing aides at the Kanes are enrolled in courses provided on site, after work shifts, in which their tuition and books are paid for as they study to become licensed practical nurses.
A death
Whatever their other problems, the four Kanes had a mostly unblemished record with state and federal regulators until the day James Quinlan died at Glen Hazel.
The 84-year-old widower, a former railroad car inspector from Hazelwood, had dementia and was unable to walk from a degenerative joint disorder. A former coma patient, he could receive nourishment only by feeding tube.
Somehow, on the morning of March 13, Quinlan received solid food that ended up in his larynx, choking him, according to a state Health Department report. Staff efforts to revive him by cardiopulmonary resuscitation failed, and state investigators faulted them for failing to call 911 for transport to a hospital.
The case resulted in a $4,250 fine from the state Health Department and a six-month provisional license, which is supposed to put the facility under closer scrutiny. The federal Centers for Medicare & Medicaid Services followed with a $117,000 fine of its own, unusually high for the agency.
The county is appealing the punishments, contending they are excessive if warranted at all. Officials acknowledged that nurses did not follow proper procedures in calling for emergency assistance, but the county has not accepted responsibility for Quinlan's death.
A statement from Kane officials said an investigation determined that no staff members gave Quinlan solid food, although it left unclear how he might have gotten it.
The statement said that "the resident did not receive any contraindicated food from the staff of the Regional Center, nor was there any miscommunication between staff members regarding the dietary requirements of the resident."
Quinlan's daughter, Rose, of Greenfield, is outraged by circumstances of her father's death, however it happened.
"I want my pound of flesh, and I don't care, because I don't have anything left in this world," said Rose Quinlan, who cared for her father herself for several years at home after her mother died.
Neil Rosen, a lawyer she hired who specializes in medical malpractice, said civil litigation can be far more costly to nursing homes than government penalties. His firm receives about 50 calls a year from families with troubles in nursing homes. He was not familiar with many other complaints about the Kanes, however.
"I do think overall it's a well-run place, and a pretty responsible place, but on occasion you're going to have these problems," Rosen said.
The Glen Hazel facility was restored to a regular license Aug. 2.
Quality of care praised
County and Kane officials maintain the general quality of care at the homes remains high, and in fact is getting better because of new options and programs at each of the four sites.
The Glen Hazel facility is the primary example. One floor of the building has been converted to a locked unit overseen by the clinical staff of Western Psychiatric Institute & Clinic. Many nursing homes have added special dementia-care units, but Glen Hazel's 60-bed program also specializes in those with other serious behavioral problems.
In addition, Glen Hazel is where the Kanes are venturing into assisted- and independent-living housing. A $4.5 million state grant will help convert part of the building's rear space into 20 apartments by spring for people who can still largely function on their own, but whose meals would be provided.
The new housing is the kind of innovation recommended in 2000 by a panel Roddey chose to analyze the Kanes' future. Nursing home alternatives may be added at the three other sites as well, if funding materializes.
But the transition committee, headed by Jewish Healthcare Foundation President Karen Feinstein, also recommended a much bigger change: creation of an independent authority to operate the Kanes, similar to how Pittsburgh International Airport and Community College of Allegheny County are run.
The thinking was that the innovations needed to move the nursing homes forward into the 21st century was difficult under the county's bureaucracy, and Feinstein believes that's still the case.
"I'm sure good things are happening -- I don't doubt that -- but we were looking for more serious transformation," Feinstein said. "I think the Kanes need to be looked at as a system by people with a strong business background, as well as people who are at the clinical frontier of geriatric care."
Roddey doesn't oppose the committee's recommendation for a new structure, but said he hasn't pushed it because he doubts County Council would accept such a move. He intends instead in 2003 to create an advisory board for the Kanes, made up of professional experts and consumer representatives.
"If we can achieve results from that, I'll be satisfied with that," Roddey said.
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