Operators of small care homes feel stress of increased scrutiny

Pennsylvania has stepped up enforcement of rules.

STATE LINE, Pa. (AP) — Diane Clippinger has operated the Morning Glory Retirement Home on a quiet residential street near the Maryland state line for nearly a decade, “taking care of God’s children,” as one of her brochures puts it.

About 60 miles to the east in Red Lion, Linda Axe has spent 23 years caring for elderly and disabled residents in a wooden-frame duplex built in the 1800s whose bay windows overlook a busy downtown thoroughfare.

Both women pride themselves on providing small, comfortable homes for adults who need supervision and help with daily living, but not 24-hour medical care. They wonder how much longer they can stay committed to their vocations, however, as state regulators cast a more critical eye on personal-care homes, after cases of fraud, abuse and neglect in the industry in recent years.

“It’s hard to be perfect,” said Clippinger, 48, a former banking compliance officer who previously worked as a respiratory therapist. “It’s so micromanaged ... you feel so defeated.”

Department of Public Welfare officials acknowledge that they are strongly enforcing new regulations imposed in 2005 to improve the health and safety of residents of Pennsylvania’s more than 1,500 personal-care homes — and make no apologies for it.

“Our total interest is in making sure the consumers are well-treated and well-supported,” said Kevin Casey, deputy secretary of developmental programs.

That said, the state is not inflexible. It does not require 100 percent compliance with regulations for a home to pass inspection. Most homes that are cited are allowed to stay open, pending fixes, because officials say the violations are not severe enough to pose an immediate threat to residents’ health and safety.

But the extra scrutiny has been difficult for some operators of smaller homes, who feel the state may have gone too far.

Clippinger says her morale is eroding amid what she regards as nitpicking by state inspectors, such as being cited for running out of paper towels.

Axe’s home lacks a second-floor fire escape, deficiency inspectors documented this year. She is wrestling with how to install one without placing the fire exit in a resident’s bedroom, which the state would frown on, and isn’t sure if she can even afford it.

“We don’t have the means to do everything [regulators] want us to do,” Axe said.

This year is the first year that inspectors are fully enforcing the regulations. Some rules were held up by an unsuccessful lawsuit by care-home operators, and the state gave the homes extra time to comply with others.

More than 50,000 people live in personal-care homes, where they are assisted with tasks such as bathing, dressing and taking medications.

The homes — found in nearly every county, but highly concentrated around Pittsburgh and Philadelphia — provide care in a wide range of settings. They can serve as few as four people in a private home or as many as 100 or more residents in sprawling campuses marketed as “assisted living” communities.

The homes are not medical facilities, so they are not required to employ nurses or other medical staff. Prospective administrators can qualify as operators in a variety of ways, such as having an associate degree in any discipline or a state license in nursing or nursing-home administration. Operators of homes with eight or fewer residents need only a high school diploma and two years’ relevant work experience.

Financially, the facilities rely primarily on residents’ or family members’ paying the costs out of pocket, although some long-term care insurance plans cover personal-care home expenses.

Low-income residents can qualify for a mix of state and federal government assistance through the Supplemental Security Income program. About 20 percent of all care-home residents receive the aid, according to the department, but not all homes will accept them.

The department has faced challenges of its own in enforcing the 2005 regulations.

In the same year the rules took effect, a married couple who operated five Lebanon County personal-care homes was accused of feeding residents rotten food and making them stuff inserts into newspapers while working in an unheated garage. Clifford and Tina Fake were sentenced to lengthy prison terms after pleading guilty to charges including neglect, assault and theft. Three residents died while under their care since 2000.

In March, the department revealed that nearly 75 percent of all personal-care homes were operating with expired licenses because of an inspection backlog — prompting criticism from lawmakers.

By the end of October, with help from 30 retired state workers who were recruited as temporary inspectors, the department had eliminated the backlog. It is taking steps to avoid a relapse and now has 70 full-time residential licensing staffers — up from 43 in 2005.

Among the worst offenders, the most common violations are inadequate staffing, a lack of cleanliness and failure to follow fire safety rules, Casey said.

Between January and September — the most recent figures available — the department had taken enforcement actions against 45 homes, including the revocation or nonrenewal of licenses, according to a review of records by The Associated Press. Many of those homes had histories of problems, according to department spokeswoman Stacey Witalec.

One of the most notorious cases involved a Scranton-area home owned by a doctor accused of neglecting a female Alzheimer’s patient who died last year. Peggy Rogers, 69, died two months after she was brought to a hospital from the Birch Hills Residence home, suffering from breast cancer that authorities said was left untreated.

Dr. Gregory Salko is free on bail, awaiting trial on two counts of neglect of a care-dependent person. He also is accused in a separate investigation of unnecessarily prescribing painkillers that caused four fatal overdoses.

Earlier this month, the state closed two personal-care homes in York County after inspectors found violations such as illegal drug use by staffers at one home and a lack of running water in the other.

Operators of larger facilities consider themselves lucky to have larger budgets and staffs to keep up with the requirements, but even they contend that the inspections seem excessively bureaucratic.

A personal-care home housing 35 residents is among a range of residential options at Cornwall Manor, a nonprofit retirement community in Lebanon County. The home was cited for a handful of minor violations this year, such as not using the exact form required by the state for recording medical evaluations, said Ed Peifer, administrator of health services, who sympathizes with operators of small facilities.

Department inspectors are “so focused on procedures, rather than outcomes,” Peifer said. “If I were trying to operate a stand-alone facility in the community, I have no idea how I would be able to get close to complying.”

Axe, 55, contends that the department’s tougher regulatory approach holds mom-and-pop operations such as hers to an unfair standard.

“Why doesn’t somebody spend time in these small homes and find out how they are actually run?” she said. “My people are treated like family. I don’t give them fast food. I cook. I treat them like I’d want my family to be treated.”

Clippinger’s charges include George Butts, 88, who entered Morning Glory two years ago because his son, who lives up the street, was unable to care for him. Butts, a retired Mack Truck assembly-line worker, suffers from congestive heart failure and an ulcerated stomach.

The place feels like home to Butts, who said he enjoys his independence despite his health woes.

“I’ve seen some nursing homes, and I wouldn’t want to go into one,” Butts said, sitting in a reclining chair in his room.

Despite Clippinger’s frustrations, she is trying not to lose sight of what compelled her to enter the personal-care home industry and stay small: a desire to provide more individualized care than she thought larger facilities could offer.

These days, she finds herself rereading laudatory letters she has received over the years from residents’ relatives to boost her morale.

“I never thought that I would ever say, ‘Maybe I shouldn’t have ever opened up a retirement home,’” she said. “I have to keep reminding myself why I started, to keep going.”