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Darcy Grabenstein: Hello from SmartLinx Solutions! In today's podcast, we talk with Dr. Stefanie Corbett, author of The Theft Prevention Guide for Senior Living. For over a decade, Dr. Corbett has served in various senior leadership roles in healthcare organizations. She travels the country teaching HC Pros' post-acute care boot camps. She founded a healthcare consulting firm, Corbett Healthcare Solutions based out of Charlotte North Carolina, in 2014 to assist healthcare organizations with regulatory compliance and clinical and financial operations management. She previously served as the deputy director of Health Regulation for the South Carolina Department of Health and Environmental Control. Dr. Corbett has a special affinity for seniors. She especially enjoys advocating for and advancing the quality of healthcare for the older adult population. She was a member of the South Carolina Institute of Medicine, Public Health, Long-Term Care Task Force and the South Carolina Long-Term Care Administrative Board. Welcome, Dr. Corbett.
Dr. Stefanie Corbett: Thank you so much, Darcy. Glad to join you today.
DG: So, since our podcast is pretty laid back, I hope you don't mind if I call you Stefanie.
SC: Oh, that's perfectly fine.
DG: So, before we talk about theft prevention, I'd like to talk to you about quote-unquote stealing the limelight. In your bio I read that under your leadership in post-acute care administration, you rapidly transitioned a healthcare organization from a 1-star to a 5-star overall quality rating, landing a ranking in the top 10 percent of all facilities in the nation by the Centers for Medicare and Medicaid Services, which we all know as CMS. And the facility was even featured on MSN.com and in the US News and World Report for successfully achieving the highest quality ranking. It also received the American Healthcare Association's Bronze Commitment to Quality Award in 2013. How long did that process take, Stefanie, and can you share a few of your secrets on how you accomplished that? That's quite an accomplishment.
SC: Well, thank you. It's one that I am very pleased to share as much information as I can give you. What I'll say is that we began to see change, as far as transitioning from the 1-star facility, in approximately 18 months. Of course, we didn't see that full cycle until at least about 24 months. And the reason for that is, of course, the ranking process, the way that CMS administers a Nursing Home Compare 5-star rating; it does take some time for different reports to be updated over time. But I can tell you it was not an individual effort. I worked with a wonderful team, especially a core team that had all bought into the vision to become a 5-star facility. And having them onboard set the tone for the rest of the facility.
So, the first secret, of course, is just to have buy-in at the top. All of my senior leaders were brought in. What I'll also say is that we did a very focused effort, looking specifically at our quality measures, analyzing those on a monthly basis, making sure that we could track and trend our performance, how we compared against other facilities in our local vicinity and proximity, as well as those across the state and the nation. Looking at that, analyzing what our vulnerabilities were, identifying areas for improvement, and making sure of course that we reported information accurately definitely helped with this process.
In addition to that, I had to really put forth an effort to get that senior leadership team to help me promote a 24/7 survey readiness culture. So, for those who may not be familiar with the SNF setting, or skilled nursing facility setting, we are surveyed or inspected by the state government. They are contractors for CMS, and they come on an annual basis at a minimum, and they can come in and basically take a look to see whether or not you're compliant with their conditions of participation, which are also our regulations that guide our practices.
So sometimes facilities will get in a habit of just making sure they were ready to look their best during that survey window, because they would expect surveyors. But really, the key to being a compliant facility and achieving 5-star is to be survey ready every day of the week. And that means giving great care, optimal care, achieving excellence whether we're expecting an inspection or we're not. And the very last thing I would say is making sure that when the surveyors do come before us that we were clear on the expectations as far as the processes when they were in our facility, and making sure that we put on our best impression, we gave them a glimpse of excellent care that we would give any other time, whether they were there or not. But really focusing on those things helped us to make that transition very quickly.
DG: Thank you, that's really helpful. I know that all facilities strive for that 5-star rating. So thank you for sharing that.
SC: Oh yeah, definitely.
DG: Let's switch and talk about theft in senior living facilities, which is something that you probably don't want to admit goes on, but obviously it does. So, this theft though can refer to physical property as well as financial exploitation. But for today's podcast let's focus on property theft, from personal possessions to medication. My mother lived in a nursing home, and she noticed on occasion that clothing or other items would be missing on a regular basis and you know we just assumed it came with the territory, which it shouldn't be that way. But what would you say, Stefanie, are some warning signs that staffers and even residents and their family members should be aware of?
SC: You know, I have to agree with you, Darcy. I've even had loved ones in nursing facilities that have been subject to items getting missing. And it's something that often triggers in the top three complaints of residents that stay in a skilled nursing facility, as well as those that are in assisted living and other long-term care facilities. And you know, I have to say, it's primarily attributed to a few things. One thing I would say is, you know, it's an environment where you're taking care of lots of people. And when you're washing clothes for seniors that sometimes change clothes throughout the day because of accidents and other reasons, it can very well get lost in the laundry. We also deal with a population that sometimes serves demented and Alzheimer's residents, who have a tendency to sometimes wander in others' rooms and, you know, confiscate items. It does happen. And also we do have the problem of theft. This population is very vulnerable, they're very trusting of all the generations that we serve in healthcare. And for this reason, they don't necessarily stay alert. And in some cases they're unable to protect their items as we would see in other areas of healthcare.
So as far as warning signs, a couple things that I would recommend. First things first, if you're a family member who is admitting a loved one to a facility, make sure that, of course, all of their items are in fact identified as theirs. So if it's a shirt, a pair of pajamas, on the inside labels or tabs, even with their — what do you call those lovely things? — the tags inside of their clothes, write their names in there so that if and when they are given to a laundry, that information will not rub out of the clothes and it can be returned to the appropriate resident.
But how can you really protect against someone who may be of suspicion to steal things? Well, this is an interesting question because we want to be very careful that we don't assume everyone would steal, we want to be very careful to be sensitive not to profile people. But we always need to go with our gut feeling. If you feel as though a staff member is paying extra attention to your loved one's room, or if you're a senior in a facility and you notice that maybe a caregiver or staff member is in and out of your room when you're not present, and that concerns you, it should be brought to the attention of the management.
What I'd also say is, if you notice that you tend to have staff that hover around residents who may or may not be able to advocate for themselves or may have cognitive deficits, where they may not readily recognize suspicious behavior, advocate for those residents as well. Any cases where you may see, for example, staff members or volunteers, or even your contracted vendors, in areas of the facilities that they should not be in, definitely bring it to the attention of management. You know, in long-term care we have so many partners that help us, whether they're church group or a volunteer group, or maybe just our pharmacy representatives that may have different couriers deliver medications to the facility. They should only be visiting specific areas within the facility. So, as a result, our staff, our resident, those that are in our facility should be on high alert at all times when they're outside of those authorized areas.
In addition to that I would also say, if you notice that you have employees that, for example, may exhibit the habits of someone who has a substance-abuse issue, that's something that should also be brought to the attention of management. It is a known fact, and it has been proven, that many employees in all different industries and fields that have a substance-abuse issue are likely to somehow be involved in theft activity on the job. So, you want to look out for those signs and symptoms, which may include someone who wears long sleeves when it's not cold outside or cold in the facility, someone who has very frequent absences, someone who tends to hover around areas of the facility that may have medications and drugs under close surveillance or lock and key. Someone who likes to switch assignments very frequently, someone who asks frequently to work with residents who aren't able to advocate for themselves. These are just a couple of different things. Some other things you may want to consider, someone who is moody, someone who appears to be very drowsy or sleepy on the job, taking frequent breaks. Those are all signs and symptoms of substance abuse. And besides the fact that they may have a tendency to be involved in theft activity, we also want to make sure that they don't put our residents at risk as it relates to providing care.
DG: Sure. All good tips. I have to laugh, and it so true though, about putting names in the clothing. It reminds me of summer camp. But it really does help.
SC: It does help. You know, you take for granted sometimes too. When residents come to a nursing facility, especially if they're only there for a short time, a short-term stint, then they're just there with a couple pairs of sweats, maybe pajamas, you know, just a few of the minimal things. And you'd be surprised how many seniors have the same taste. Some cases they like the same things.
DG: Stefanie, what are the four key actions you identify that facilities can take to protect their residents from theft? And in addition to that, what kind of policies should they have in place, you know, to prevent these incidents?
SC: You know there are four key action steps that I would recommend. The first one is to prevent. So that means implementing training and fostering awareness. This is really the part of the business that establishes the culture of the organization. Everyone that's within the four walls of the facility has the opportunity as well as the obligation to make sure that we safeguard our residents as well as their property. This includes when we hire new staff as well as when we contract with new vendors or we bring on new volunteers, making sure of course they have the background checks that would indicate whether or not they've been found to have a history of criminal activity. We also need to check to make sure that they are not excluded from participating in federal reimbursement programs such as Medicare/Medicaid that would indicate, of course, through the Office of the Inspector General [OIG] whether or not this is someone who has been accused of fraud, abuse, or waste. But making sure we do very thorough background checks, screening, and ongoing training. You know, we do a really great job of training our new hires and contractors and volunteers when they first start, but that training really should carry out the extent of their contract or their employment with us. And, at a minimum, it should always be a very thorough comprehensive refresher on an annual basis.
I would also say the second step is to recognize or to spot the warning signs and take action. This is speaking up from something suspicious; it only takes overlooking that one suspicion, unfortunately, that can lead to a very adverse outcome. So, speaking up and making sure that you take quick action, whether that's reporting it to management or actually interceding and approaching someone who may be in the wrong area of the facility, for example.
The third step I would say is to record. This is really where we drop the ball sometimes. We need to make sure that we document our findings. This allows us to recognize whether or not there may be a pattern of suspicious activity and, if so, to not miss an opportunity maybe to make a policy or procedure change, or for that matter to just change our practices. Or, maybe we need to invest in different types of technology or equipment to protect our residents more effectively. We can't do that if we don't establish a record or a pattern, so we definitely want to record.
And then the final step would be to report. That's to tell the appropriate authorities and to respond as necessary. We have a number of different authorities that oversee the healthcare setting. I've often heard people say that, next to nuclear, we're the highest regulated. So we have a lot of —
DG: I've heard that as well.
SC: And it's not too far off the grid. I haven't tested it positive myself but having worked in long-term care a long time, it certainly does feel like it. So, we've got so many people to respond to and answer to, but the very first people that we protect, of course, are our residents. And when we recognize that we haven't always done that. In the example that things have maybe gotten missing or they've been stolen, we need to make sure that we report that to the law enforcement agency, depending on the nature of the criminal activity. If it's personal property usually local law enforcement is fine. If it's drugs or medications we want to take an extra step and contact the Board of Licensing, so that they can then investigate the individual who may be a licensed nurse, for example, and make sure that even though that authority may not pose a risk in your facility anymore, the Board of Nursing is able to track where else they may be employed and certainly remove that individual from working elsewhere. And then also, we have an obligation in some cases to report, let's say, for example, if money is stolen or identity theft or accounts have been compromised. In those cases, we also need to contact the office of the Inspector General. So, there are a couple of different authorities that need to be notified depending on the nature of the activity. But those four steps again are: to prevent, to recognize, to record, to report.
DG: Thank you, that's really helpful. It puts it all in perspective. Stefanie, what are some of the consequences — and I'd say both from HR and a legal perspective — what happens when a staffer is caught stealing personal property? And what about medications — I would assume that the legal ramifications are much greater when we're talking about controlled substances. Is the staffer automatically fired, suspended? What happens? And what about hiring or rehiring someone who has been involved in those types of situations?
SC: These are wonderful questions. And I wish they were ones that everyone knew as common knowledge. But, unfortunately, these are only privy to those who usually work in facilities or those who have somehow suffered from a theft activity. So, I'm glad you asked. A couple of things that I would say. Yes, you're exactly right, when we're talking about drugs, we certainly up the ante. Because we're now talking about a criminal activity, that has higher consequences, of course, more stringent consequences than just regular theft. Now, in cases where residents have suffered theft, our employees would have due-process investigation. And if in fact that investigation did substantiate that a resident's personal property was stolen, the very first step is to suspend that employee. We want to remove that employee from the situation, from the facility, away from the resident, of course, and all other residents who may potentially be at risk for having their items stolen. So, first step is suspension. That suspension is pending the outcome of the investigation, so it could be a couple of days or it could be a more extended length, just depending on the nature of the activity.
Now once that has been substantiated, that employee would be terminated. And the reason for that is, we have had new federal regulatory changes in the last several years under the Elder Justice Act, which protect seniors from mental exploitation, abuse, theft, and the like. And with this federal regulation, we are really required and obligated to take quick action and make sure that we can prevent future occurrences. So, yes, in most cases employees are terminated.
The only time employees may not be terminated is if and when the theft actually wasn't substantiated in the investigation. However, what we usually see, even if we can't prove it, we've had a breakdown in process somewhere along the way if a resident or family member or staff member alleged there was theft activity. So, we may not be able to get to the bottom of it and prove that someone witnessed it, or be able to put all the different pieces of the investigation together, but we may be able to say, you know what, this employee really didn't have a reason to be in this resident's room on this hall at this time of the night. So, as a result of that, they may violate our policies and procedures, which may warrant progressive corrective action. So, we may give an employee a first written warning, or we may, of course, follow through whatever steps that may be in that corrective action process.
Now if it's medications, on the other hand, it's a little bit different path. If in fact we suspend and then terminate an employee for theft, because we've proven it, in most cases if it's not medication we'll contact local law enforcement and they'll follow through with another investigation from a, of course, criminal law perspective. When it's drugs we do the same thing. But we also take another step, to call the Board of Licensing. Depending on the physician, it could be a different board. If it's the nursing board, if it's NA, nurse assistants board, it may even be a pharmacy board. It just depends on that particular employee's credentials. That court conducts its own investigation in addition to the one from law enforcement and in addition to the one that the facility has completed. And I know that seems like a waste of resources, because we're all looking usually at the same documentation, but because we're looking at it from different angles, it does help to make sure that we've covered all of our bases from every angle.
So, they will follow through with their own investigation and use a lot of the information from law enforcement, as well as the facility's investigation. And then they will formulate a conclusion based on what their findings are. In most cases it is in alignment with what's already been substantiated through law enforcement and the facility. In those cases, they would then move forward with either suspending that person's license or terminating it. They have varying levels of punishment according to how the employee responds, whether or not that employee serves time, and whether or not that employee takes any steps towards remediation. Now in the case of substance abuse or drug diversions, where medications are taken from a facility, in some cases we recognize that there are good people, employees, who may very well have an illness, you know, as it relates to substance abuse. Different boards do allow for some employees to take advantage, for example, of a substance-abuse program, and upon graduating from that program and establishing a record of good behavior, and being clean and sober for a certain period of time, their license may be reactivated.
So, yes, very serious when we're talking about drugs there. Depending on how much or the value of the theft, we could very well also get the Office of the Inspector General involved. And we also, of course, would get them involved especially as it relates to identity theft, so we're talking about credit cards, bank accounts, finances. If those personal items were stolen, then we would take an additional step to involve the Office of the Inspector General.
Now as far as the legal ramifications, they're a little bit different because residents as well as their family members may take legal action against the individual and/or the facility. In most cases they take action against the facility because, of course, the facility is licensed to provide care and protect the residents. But now, we've seen where individuals who have committed these horrible activities have had action taken against them as well. And the corporations are not required to protect those employees who have been found guilty of violating in most cases corporate policies as well as criminal statutes. So as far as the legal ramifications, you can be sued as an individual. But you also kind of blow your chances to ever be rehired. If you are found guilty and put on the Office of the Inspector General exclusion list, for example, you may not work in any facility ever again in any capacity that accepts Medicare or Medicaid reimbursement or federal funding. It also includes, for example, being able to take a federal full student loan. So, you really blow your chances for having a future in a lot of cases, as it may relate to a second chance in the healthcare industry.
DG: Right, because all these facilities take Medicare/Medicaid and federal funding, so that kind of knocks everything out of the park, right.
SC: It knocks everything out of the park. In some cases, you may have an employee that was guilty and terminated for a theft, but unfortunately that individual may have gone across town and applied across town and was hired in the same position in another facility. The reason that there's a gap there is because you may not have reached a level of severity where it had to be reported to the Office of the Inspector General. So, for your common everyday theft — let's say a resident's sunglasses were stolen, for example — we still take that very seriously as we would identity theft, but it may not warrant a level of severity where the OIG would then add you on its list of exclusions.
So, what do facilities do to prepare for that and to try to avoid that? The best-case scenario is to make sure that you always call previous places of employment. And, unfortunately, we really rely on employees to provide that information on their applications. So, with that, even if they're not listed as an employment reference, we always need to do due diligence to call previous employers and just simply ask, is this employee eligible for rehire. And if that employee has been found guilty of theft, and they were terminated, the answer will always be no. And, regardless of the level of detail that a person or facility may feel comfortable providing, if the answer is no they're not eligible for rehire, the best-case scenario is to just stay away from it, and know that if they're not eligible for rehire across town, they're probably not a quality hire at our facility either.
DG: So, based on everything you said, it underscores the importance for facilities to have policies in place, correct?
SC: Absolutely, it all starts with policies.
DG: So, we at SmartLinx, we've developed workforce management technology for long-term care facilities. So I'm curious how technology can be used to control and even prevent theft in facilities. Stefanie, could you talk a little about this?
SC: Yes. We are in a wonderful time where we are able to take advantage of so many of the instruments and technology, which has not always been new to healthcare but especially not in long-term care. You know, long-term care is usually the sleepy stepbrother of the hospital, and we take for granted that we also are serving a very vulnerable population and should exhaust every effort, including technology, to keep them safe and protected.
I would say that, at a minimum, you know, some of the very minimal things that we could look at are staffing models. Technology helps us to look at acuity in our facilities, making sure that we have adequate staff as well as supervision. This doesn't only incorporate the level of care that we provide for our residents, but it also introduces the accountability factor for employees to look out and be under high alert as it relates to suspicious activity. When we're working short and we have mismanaged models for staffing, we usually have our staff stretched so thin they're not able to readily recognize in some cases even very subtle suspicions.
So, I definitely think technology helps with our staffing models, making sure too that we take advantage of cameras. You know whether that's closed circuit or otherwise, there are some areas of our facility that can benefit from cameras. We have seen in long-term care different advances as it relates to knowing at all times who's in your facility. We take advantage of technology to see what our log-in process is, and identifying whether or not you're a guest, whether you're a vendor, a volunteer, or regular employee. Are you a family member, you know. These things are important to know because if you're recognized as a family member, we would expect that you be in a resident's room. But if you're someone who is making a delivery of copy paper, we should never see you in a resident's room. And that would, of course, be suspicious.
Technology allows for us to recognize these differences in guests in different ways. I've seen where different types and levels of access are given based on a badge color. So, you have a printed disposable name tag when you come through the door. If it's green, you have all access to resident areas. If it's red, you don't. So, technology certainly helps to supplement that surveillance that we expect of our staff.
Also, clocking in and out. You know, we take for granted we're a 24/7 operation. We have moving parts all day, every day. And many of those are staff employees who may very well turn over very frequently. So, it's always a good practice to have, whether it's a thumbprint or whether it's a keypad or a password login, we have an ongoing record of all employees that are in our facility, and we have a list according to what departments and positions they hold.
So those are just a couple things. I would also say that there are opportunities, of course, for technology to be used whether that's using keypads on medication storage rooms, keeping those controlled substances not just under lock and key, where those can be easily broken, but under a keypad. So, we have a record of which nurse last accessed the room according to which keypad was punched.
Making sure that even things on the front end of the business, so our count, our medical records, our admissions documentation, those things are very important to protect as well. And the way that we rely on technology to help with that is only limiting access to certain types of resident records according to what your level or type of employment is. So, for example, only our clinical staff need access to a resident's records, OK, their medical record. But, on the other hand, only those who actually help to manage a resident's financial account would need access to their financial records. So clinical staff, based on technology, should not have access to financial records and vice versa.
So that's just a handful of different ways that technology can help in securing our facilities a bit better.
DG: Thank you, yes, that makes sense. And just to our listeners, we didn't plan this ahead of time, I did not ask you to talk about time clocks, although we do provide those at SmartLinx. But no, it's a very important factor, to have that fingerprint or some other recognition or a password for access to safeguard the residents.
So I have to thank you, Stefanie, for sharing your expertise with us today. And to all our listeners, thank you for tuning in. Stefanie's book, The Theft Prevention Guide for Senior Living, is available at HCMarketplace.com and look for it under the long-term care tab. And for more information on her healthcare consulting services, visit CorbettHealthcareSolutions.com. And if you'd like to learn more about SmartLinx Solutions and our fully integrated suite of workforce management solutions, visit us online at SmartLinxSolutions.com.