Two PA Nursing Homes and Staff Indicted on Health Care Fraud

Philadelphia nursing home lawyers are closely monitoring a recent indictment of two Pennsylvania nursing homes accused of health care fraud. On August 5^th, 2022, The United States District Court for the Western District of Pennsylvania issued an indictment against two nursing homes and five of their employees. Comprehensive Healthcare Management Services, LLC which operated a skilled nursing facility known as Brighton Rehabilitation and Wellness Center is the first named defendant. Mt. Lebanon Operations, LLC which operated the skilled nursing facility known as Mount Lebanon Rehabilitation and Wellness Center was the second named defendant.

In addition to the named facilities, the following people were cited as defendants:

• Sam Halper – had ownership interest in and served in a management role for approximately 16 nursing facilities, known collectively as CHMS Facilities, including Brighton and Mt. Lebanon
• Eva Hamilton – Director of Nursing of Brighton from March 2014 through November 2020
• Susan Gilbert – Administrator of Mt. Lebanon from November 2017 through March 2020
• Michele Romero – served as a regional, management level employee with oversight of all Registered Nurse Assessment Coordinators (RNACs) and Licensed Practical Nurse Assessment Coordinators (LPNACs) for CHMS facilities
• Johnna Haller – Served as the Director of Social Services at Brighton from April 2015 through November 2016. From November 2016 through May 2021, she served as a regional, management level employee with oversight over the social workers at the CHMS Facilities.

The indictment included fifteen counts against the defendants. Our Philadelphia nursing home lawyers have reviewed the indictment and summarize the counts in article below.

Staffing Falsification Conspiracy

Both Brighton and Mt Lebanon are accused of knowingly defrauding the United States government through a staffing falsification conspiracy.

Federal and State Staffing Requirements

To participate in and receive funding from Medicare and Pennsylvania Medicaid programs, skilled nursing facilities are required to adhere to standards of care. These standards of care require nursing homes to provide services to assure resident safety and help resident achieve or maintain their highest practical level of well-being. Federal requirements dictate that nursing facilities maintain enough licensed nurses to provide care to residents according to the care plans. Additionally, Pennsylvania law requires nursing homes to provide a minimum of 2.7 hours of direct nursing care per resident each day. Federal or state survey agencies regularly monitor nursing homes for adherence to these requirements.

Alleged Staffing Conspiracy

The indictment alleges that the defendants, including Sam Halper, Eva Hamilton, and Susan Gilbert, knowingly and willfully conspired to defraud the United States by obstructing the Pennsylvania Department of Health in its ability to conduct valid surveys of resident care provided either at Brighton and Mt Lebanon.

According to the indictment, the defendants knew that staffing levels were low, especially during evenings, weekends, and holidays. They also understood that low staffing levels had resulted in complaints related to poor outcomes and adverse incidents, such as falls and pressure ulcers.

Despite this knowledge, the defendants falsified staffing information provided to surveyors to demonstrate that Brighton and Mt Lebanon were providing sufficient care and meeting minimum staffing requirements required by law. Falsification of staffing information provided during oversight surveys included:

• Defendants directed staff to improperly include hours worked for management level employees who were not providing for resident care
• Defendants directed staff to include lunch breaks and time off-duty
• Defendants included staff who were not working at the facilities in staffing reports to make it appear as if those employees were working during those time periods
• Defendants provided the Department of Health with falsely inflated per-patient-day staffing levels during oversight surveys
• Defendant directed administrative nursing staff to “clock in” for shifts that were not actually worked and subsequently created falsified timecard documentation to support that they were providing resident care. Defendants paid staff a bonus to “clock in” for shifts they did not actually work.

Reasons for the Staffing Falsification Conspiracy

According to Philadelphia nursing home lawyers reviewing the indictment, the defendants knowingly falsified these records to avoid federal and state sanctions. Sanctions for nursing facilities who fail to meet staffing requirements can include:

• Denial of payment for new admissions
• Civil Monetary penalties
• Termination of Provider Agreements with Medicaid and Medicare
• Public Reporting of Deficiencies

By falsifying staffing information to oversight agencies, the defendants were able to continue to operate the facilities under unlawful staffing patterns, save labor expenses, and avoid the repercussions from failing to meet federal and state guidelines.

Conspiracy to Manipulate Residents’ Assessment Documentation to Increase Reimbursement

In addition to the staffing conspiracy, the indictment singles out defendants Sam Halper, Michelle Romeo, and Johnna Haller for conspiring to commit fraud to increase Medicare and Medicaid reimbursements

Requirements for Accurate Assessments

Nursing homes that participate in the Medicare and Medicaid programs are required to complete assessment forms known as Minimum Data Sets (MDS) Form on all residents upon admission and quarterly thereafter. These assessments must provide an accurate and complete assessment of each resident’s needs and abilities, and it is used to formulate a resident’s care plan. Additionally, Medicare and Medicaid use the residents’ MDS to calculate reimbursement to the facility for resident care.

Reasons for the MDS Documentation Conspiracy

The defendants knowingly conspired to commit health care fraud by submitting fraudulent information for residents at the CHMS nursing homes. The indictment alleges that the staff who complete the MDS, known as the RNACs and LPNACs, were instructed to make changes to resident MDS records to inflate reimbursement.

The defendants carried out this conspiracy by:

• Instructing staff to fabricate responses to questionnaires to inflate resident’s depression scores
• Instructing staff to falsify ADL scores to reflect that residents had a greater need for assistance with bed mobility, transfers, toilet use, and eating than they actually required.
• Creating fake physician orders and visits to induce higher reimbursement rates.
• Neglecting to accurately date stamp some PA 162 forms as required to avoid lower reimbursement rates
• Falsifying medical diagnoses on the MDS form to improve their quality ratings and desirability to prospective residents
• Pressuring staff to order and provide therapy services that were unnecessary to resident’s actual needs.
• Pressuring staff to delay resident discharge to maximize Medicare payments
• Pressuring staff to delay resident discharge to reach occupancy goals and receive Medicaid bed hold payments

Nursing Homes Used Criminal Schemes

According to Pennsylvania Attorney General Josh Shapiro, “Brighton and Mt. Lebanon’s senior administrators used two criminal schemes to take advantage of federal programs and make extra money while putting residents at risk.”

This indictment is a sad reflection of a nursing home industry plagued with bad actors and operators who seek to prioritize profits above resident care. While this indictment only cites two facilities, the nursing home neglect lawyers Philadelphia trusts to litigate high value cases has seen many instances of understaffing and medical records falsification. It’s only by holding nursing homes liable – both for fraud and for personal injuries stemming from understaffing and neglect – that the industry will begin to improve and provide the care that our seniors and disabled residents truly deserve.

Contact the Nursing Home Understaffing Lawyers at the Wieand Law Firm, LLC

While many nursing homes provide appropriate care to their residents, there are some facilities that neglect to meet resident needs. If you have suffered an injury at a Pennsylvania nursing home due to neglect, abuse, or understaffing contact the lawyers at the Wieand Law Firm, LLC. Our lawyers have extensive experience in litigating cases against unscrupulous nursing homes and assisted living providers. Call 215-666-7777 today, or you can send us a message via the online form on this website to speak directly with an attorney for a free case evaluation.