When I was asked to write this commentary, I assumed I too would take the familiar position dictated by my “corporate instinct” and rush to the defense of our industry, because one of our own was being attacked. “Let him without sin cast the first stone,” right?
I asked John, who has become one of my favorite writers if he would be willing to write an insiders perspective. This is what he sent me and it is terrific. – Steve Moran
When I was asked to write this commentary, I assumed I too would take the familiar position dictated by my “corporate instinct” and rush to the defense of our industry, because one of our own was being attacked. “Let him without sin cast the first stone,” right? Those of us who can claim the moniker of senior housing “veteran” know all too well the challenges we face with a transient employee base, 24/7 operations and the risks and potential for human error inherent in an industry that seeks the promotion of decision making and independence in a frail population.
After all, who among us can claim to be deficiency free in 100% of our surveys? Anyone receive a call or letter from a current or former employee complaining about being short staffed? Anyone else make decisions driven in large part by the requirement to make the bottom line?
I think we can agree that perfection may be something we strive for, but the reality of achieving and maintaining it is rare in any business. When I read and saw the expose on Emeritus, I felt that many of the criticisms arguably fell into the category of “reasonable imperfection.” Human error will be here as long as there are humans. I touched on this in my piece, “The Dirty Secret about Assisted Living.”
Come with me on a little metaphorical trip. You’re driving with your family when you come upon a sign that states, “Warning – Structurally Deficient Bridge Ahead! – US Dept. of Transportation” Would you drive yourself and loved ones over the oncoming bridge span? Maybe, if you were being chased by an angry international drug cartel firing bullets at your vehicle and this was the only escape. How about a bridge with the same warning sign that happens to be part of your daily commute? Fact: one in nine bridges in our nation are currently classified as “structurally deficient.” That’s roughly 66,000 bridges, on which more than 260 million trips are made each day. But, according to the Federal Highway Administration, the fact that a bridge is classified as “structurally deficient” does not imply that it is unsafe. I imagine that the people who lost friends and family in 1997 when the Interstate 35 Bridge collapsed in downtown Minneapolis might disagree.
Using the above scenario, replace the “bridges” with Assisted Living communities; cars and their passengers with residents; and the number of trips across the bridge with resident days. In our industry, we have to “do it right” 100% of the time – each day a resident lives in our community (each trip across the bridge) has to be safe. Does a survey deficiency, a complaint, a fall or medication error make a community unsafe? Does it make all communities unsafe? No. But I imagine that many of the family members of residents who’ve experienced negative outcomes – like those featured in the PBS documentary – might disagree.
Now, here’s where I take leave of my comfort zone. Maybe it’s my Jerry Maguire moment, although I hope not…I don’t like Tom Cruise movies in general. There are several very troubling issues highlighted in the PBS expose that from all appearances seem to be driven – either intentionally or not – from Emeritus’ corporate office. The either tacit or overt direction to disregard state regulations to expedite move ins, the low priority given to staff training, and the culture of revenue over residents are egregious and shameful.
Having worked in nearly every community-level position before moving into regional and corporate roles in the industry, I can tell you that there are many executives in our industry that have lost sight of our residents – if they ever had it. If you have a passion for seniors and work in this industry, hearing the term, “heads in the beds” should make you nauseous. A corporation can create brochures and beautifully crafted mission statements, but – as I point out in, “Pop Rocks for Dinner,” this is meaningless unless backed up with actions and resources. One truth I’ve learned in my 27 years in senior housing is that there are far too many people sitting around corporate conference room tables that shouldn’t be there. I can give you a few names if you’d like.
Before you think me naïve, I am all too well aware that this is a business; and no one benefits from a poorly run or failing business; not the residents, not the staff, not the stake holders – not us. I’m continually reminding colleagues that this business requires a constant balancing of the head and the heart; of compassion and business sense. If, as a community, regional or corporate level manager, you are not in a constant state of conflict, then you’re doing something wrong – something is out of balance. Ladies and gentlemen of the jury, something appears to be dramatically out of balance at Emeritus, and it’s to our collective shame.
I hope and pray that this public exposure of what can and will happen when a company gets out of balance, placing the desires of shareholders over the needs and rights of the residents, will be a wake-up call for our industry – especially for those of us fortunate enough to work in the decision-making positions of senior housing. A former company executive with whom I worked, would often respond to my residents-should-come-first objections to bottom-line driven decisions, with the trite phrase, “We follow the golden rule. Whoever has the gold makes the rules.” Hmm, maybe that should have been on our brochure. Besides, aren’t the residents really the ones with the gold? Someone forgot to tell me that our mission statement to “do the right thing” stopped at the door to the conference room.
What’s your mission statement? Is it being lived out? Prioritized? Funded?
No doubt this publicity will prompt renewed calls for federal oversight of our business, or for increased state regulations. If you’ve been in senior housing for any length of time, you know that the states are struggling to keep up with adequate oversight of assisted living. This lax oversight creates an opportunity for some providers to skirt safeguards and regulations in favor of greater expense control, occupancy growth and increased revenues. But, we can do better. Our staff deserve it. Our residents deserve it. Our shareholders deserve it.
I remember when our industry reached out and began serving the dementia population by developing secured care units and alarmed wings within our assisted living communities. We ratcheted up the stakes by expanding the scope of our services, and increased our rates as well as our risk. Caring for the most vulnerable of the senior population – those with high physical and mental needs – requires even more heart, compassion and care – but even more – it requires additional training, resources and a clear understanding and acceptance by providers of this great responsibility.
Many of us saw this evolution as a huge opportunity to provide innovative services and programs to a population that had been underserved, in an environment that still promoted independence and dignity. I know many communities are striving to do just this. Unfortunately, some in our industry are all too eager to accept the increased revenue without ensuring their ability (or willingness) to provide the necessary resources under mounting pressure to perform financially.
Perhaps because of ignorance, perhaps driven by greed, and perhaps because of a disconnect that occurs once a company becomes too large to ensure that its vision, mission and priorities to the field aren’t distorted as it filters through the many layers of management; but for some providers, accepting higher acuity residents and those afflicted with dementia and related diseases – and all that goes with this – may have been going a bridge too far.
To me, this article comes across as very fair and unbiased. I have not had to deal with a senior assisted living facility for a long time, and I hope it will be many more years before I have to again. This is a very tough field to be in, at least for those on the front lines. If you have ever had to take care of a loved one in the home, or help to do so, you will realize the difficulty. “Rock and a hard place” comes to mind. Hopefully, shining a light on deficiencies will make the industry better.
Thank you for this insightful article.
I encourage colleagues to share “How to Evaluate the Quality of Residential Care for Persons with Dementia” with prospective and existing resident families. It was recently published by researchers at Vanderbilt Center for Quality Aging with funding provided by The Pat Summitt Foundation, and is available at https://www.abesgarden.org/resources. In addition to being a valuable tool for discerning quality care, it has the potential to continually remind the weakest assisted living providers that consumers need not rely on glossy brochures to make residential dementia care decisions.
Thanks, Beth. I will definitely check this out.
john
Thank you for this article. I did watch the piece on July 30th and I thought it was very biased. But it also showed areas of our business that is true. As professionals – we know what’s going on in the field. I joined this industry 10 years ago with an open heart and personal mission to teach my staff to treat the elderly with dignity and respect for the adult that they are today. The elderly may be frail because their bodies are slowing down. This does not give us permission to overlook the senior. But once I started moving to other owner/operators or third party management companies, my rose colored glasses was not accepted as part of my management uniform. I still believe in the greatest benefit of assisted living – socialization. Seniors are in great danger by living alone. Quality of life is enhanced once an isolated senior is given a chance to socialize. When I asked some local RCFEs in my county about the piece – many were not even aware of it being on the air. hmm….
Kira, hang in there. Our residents need strong advocates at all levels of a company. there has to be room for the Head and the Heart at the boardroom table. I don’t think being resident-centric is the equivalent to wearing rose-colored glasses at all. That perspective is invaluable to our industry’s decision-makers – similarly, companies who have an open-book approach to management are better able to give management and staff the vision from the other side of the table, so they can interpret decisions and see why the balance is needed. I often conduct trainings with staff that start with, “Alright. You know own this community. What do you do today?” Almost always someone proposes that they get a big fat raise and a bonus; then when the other staff begin to object, the person will propose that everyone get a big fat raise and a bonus. “OK, now what?” Someone proposes dramatic increases I staffing, new carpeting, etc. After I write down all of the proposals, the anticipated costs, we start doing some math and inevitably find that the business will fail in short order. “OK, now you own a failed building. Your residents must find new homes, your friends must find new jobs, and you owe the bank one heck of a lot of money.” It’s a great exercise. Thanks again, Kira.
john
Thank you for this excellent article, I am new to this industry and hold a sales/marketing position. I thought the Front Line piece was important to raise what is the most important issue, Federal regulation. Perfection is the goal but not possible to attain with such an inherently fragile population. However, there are significant problems with Assisted Living and Memory Care communities that can be addressed immediately. Regulation and nation wide standardized guidelines are imperative. Significant fines should be issued for those communities not living up to the guidelines. The focus on “move ins’ and “shutting the back door” needs to be reined in. This is an industry that attracts employees on the community level who have real empathy and a passion to serve seniors. Corporate Management often resorts to brow beating their employees by not providing adequate staffing and by placing the emphasis on getting census up at almost any cost. The balance is tipped too far in making huge out of sight profits for the owners over providing excellent care and respect for both employees and the residents they strive so hard to serve. Thank you again for your insights.
Melinda, thank you for your perspective. I’m convinced that the best way to effect change and improvement in our industry is through the power of a free marketplace, instead of increasing government regulations. The type of public scrutiny generated from stories such as the PBS piece will empower our consumers with knowledge that will help them make better choices and demand better services. Companies that hear these voices will prosper, while those that do not will suffer.
Where were the families of the victims in this very biased expose? You cannot outsource caregiving – the families could have easy seen foot sores and similar and pulled their mother out or complained
Seems to me that a lot of families simply “dump” their demented parents into these places
Just watched the PBS video yesterday and had some mixed feelings about it. First and foremost, my thoughts go out to those families that were featured during this documentary. It was pretty easy to see that these events have had a large impact on them as people and families.
Its real tough, healthcare is a business like none other in that it deals with the fragility of life. This isn’t building widgets, trading stocks electronically, or drilling for natural resources…this is literally holding a person’s life in your hands and trying to help them recover and/or live more comfortably, an enormous task for anyone regardless of their training and experience. The amount of unknown variables that exist are infinite, meaning any number of possibilities and outcomes could occur! Healthcare is a team effort – everyone has to be in the know and on the same page if the outcomes are to be the best they can possibly be. That being said, Mr. Cobb did say that mistakes do happen, and even though they’d like to be perfect and always on their A game, they can’t expect to be in the right 100% of the time. It’s unfortunate that when mistakes happen in healthcare, it’s people’s lives that are directly impacted.
Now, just as you did Mr. Gonzalez, I’m going to flip sides and mention what really got to me…
Seeing how some of the Emeritus employees were treated when they tried to point out problems internally was definitely NOT ok. Watching Emeritus employees on camera claim ignorance of the problem or (even more disturbing) not know the answers to questions was NOT ok. Finding out that Emeritus’ people aren’t being trained is NOT ok. Emeritus, along with everyone else in the industry, needs to take this film for what it’s worth and make sure they have their stuff together when it comes to how they handle their employees, their vendors, and of course, their residents. With the large number of customers expected to enter into this market the next 10 years, having that strong team unit in place at each facility is more important than ever.
Thank you Michael. Excellent points.
John, thank you for this article. With your integrity, I would follow you anywhere. Are you no longer with SSA?
I have been rather depressed about the PBS documentary and the push back that will hit the good providers. I hope no rash judgment is made by legislators or regulators until a balanced perspective is reached.
Thank you for such an intelligent and thoughtful piece!
Jen, I am humbled by your comments. Thank you. Yes, I’ve decided that it was time to do more to improve the course of our business and put my livelihood where my heart (and mouth) is…The most encouraging thing so far is once I began sharing my perspective and experiences of senior care and housing, I’ve discovered so many kindred spirits, who share my vision for the future of our business. I’m proud to have worked alongside people who sincerely care about our residents, who are passionate about the opportunities we have to do something life-changing on a daily basis, and with those who desire to lead in our industry with integrity. Since starting my company, I’ve been pleasantly surprised how many more of us there are out there. 😉
John Gonzales, I firmly applaud all you say in your response to Frontline’s Life and Death in Assisted Living. I do so as a retired sales/marketing executive for a major insurance company, a former independent consultant to benefit plan administrators, a ten plus year resident of a Continuing Care Retirement Community (CCRC), a past Resident Director member of my Community’s Board and an active member of organizations that represent CCRC residents, present and potential.
Frontline’s program tilts to the left but is neither radical nor biased. The information it provides is complete and accurate. It delivered a much needed wake-up call to the assisted living business, the health care industry as a whole, and American consumers of their services. Thank NPR for its effort, It is difficult to imagine other media responding with equal or greater effectiveness.
That said, the Frontline program leaves huge unanswered questions. What standards did the Executive Committee for the Emeritus Board establish to measure CEO performance? How were they utilized when the Board evaluated the accomplishments of Grander Cobb and Daniel Baty and approved their compensation packages?
In going in and out of eldercare communities for the last seven years, the only bias that I saw in the program was they only talked about Emeritus. As was stated before, there are good, bad, and ugly everywhere. One does have to do their research before making a decision. There is Nursing Home Compare to help, however that is still old information and dependent upon the state surveyors knowledge and discretion.
Jon, you should now look at oral health conditions in assisted living and nursing homes. I include AL because the acuity levels in many AL’s are equal to those in nursing homes and memory care. Federal mandates for AL’s won’t help the problem. That is evident by observing how the mandates for nursing homes are being ignored. Caregivers in nursing homes admit that they don’t even try to brush the residents’ teeth. Day after day, year after year, the bacteria builds up. A great majority of nursing home residents have broken teeth, decay, and gum disease and no one knows it, not even the sons and daughters if the residents who believe that the care takers are providing this basic need. I have had the Director of Quality and Initiatives for an nursing homes association, who had previously been a state surveyor, say there isn’t enough information on how oral health affects overall health and maybe more research needs to be done! This is a convenient cop out and used as an excuse to not address what is a critical health care concern. I believe the oral neglect could be equated to abuse in many cases. You should all explore it. Again, there are those who are great resident advocates but you could still choose almost any nursing home and check oral conditions. You will be shocked!!