Does a County Government Have the Required Expertise or Time to Run a Nursing Home On Its Own?

August 7th's meeting of Northampton County Council's Human Services Committee was devoted entirely to one topic - county owned nursing home Gracedale.  This was certainly a response to several negative reports. First, Council member John Brown has a withering indictment of facility finances. He claims both that the home has actually lost $38 million in 2023 and 2024 and that the administration has moved funds into the institution without Council's permission. Second, the recent arrest of an LPN supplied by an outside agency raised more than a few eyebrows. She refused to leave a resident's room for two hours and was observed by a police officer as she shoved her fingers into a resident's mouth, saying the demons needed to come out. Third, a recent Controller's audit reveals that about half of $5 million in retention bonuses set aside for nonunion Gracedale workers was diverted and used instead for home expenses.  

As if this were not bad enough, Gracedale's CMS rating has dropped yet again. In February, the home jumped from three (average) to four (above average) stars. This positive development has been touted by Fiscal Affairs Director Steve Barron at a recent Finance Committee meeting. This sentiment was echoed by Council member Kelly Keegan, who said that the home's rating is four stars and that she only hears "positive things." "The only negative things that I hear are from that side [the GOP side] of the dais," she said, suggesting that Republicans rely too much on what they hear from "disgruntled" employees. 

But guess what? After its most recent survey in April, the home's overall rating has been dropped again to three stars (average).  While Gracedale's health inspection rating is four stars (above average), its quality control rating has sunk to just one star (much below average). This is because the facility includes numerous residents who suffer from dementia and Alzheimer's, and they are treated with psychotropic drugs disdained by CMS as "chemical restraints.".

Any one of these problems would by itself warrant a separate meeting just for Gracedale. But there's more.  Northampton is one of the few counties left in Pennsylvania (I believe it's down to 11) that still owns and runs its own nursing home. This is by no means limited to the public sector. Since 2020, 774 nursing homes have closed, displacing 28,421 people. There are over 68,000 less beds than there were in 2020. Twenty per cent of the homes have closed units, wings or floors because of a labor shortage.  

The problems extend far beyond Gracedale's campus. Can a part-time County Council that only meets once every two weeks by itself solve these problems? Or a full-time Executive who has a plethora of core county functions? Or a nursing home administrator who, no matter how well-intentioned, has no crystal ball from which she can predict what the future holds for geriatric care? 

Perhaps this is why, at the onset of last week's Gracedale meeting, former Ass't Administrator David Holland decided to address Council. True, he's running for County Council, but he knows the topic. He was part of a private nursing home administration - Premier Healthcare Resources - tapped by the county to turn the home around in 2011. That effort succeeded, but after his election, Executive Lamont McClure decided that an in-house administration would be better (and cheaper). 

It may have been neither. 

Holland's message was simple but clear. "Time is of the essence," he warned. He stressed that Gracedale is in direct competition with the private sector, which is moving at "lightning speed with staffing, recruitment, retention, hiring - all those things." Holland sees this firsthand. "We don't have any time to lose." He reminded everyone that the pool of available RNs, LPNs and CNAs is finite.  

Holland's remarks begs the question whether government officials with no particular expertise in a complicated nursing home industry, no matter how high-minded they might be, could ever move at lightning speed. The wheels of government are more like my run-down hybrid bike than a Tour de France road bike.  

Holland was followed by another former assistant administrator, Stephen Carl. He was terminated. He told Council that Gracedale management has a history of editing and doctoring staffing, census and financials to present the home in a favorable light. He denied that he gave agency nurses "premium shifts" He also claimed that Gracedale nurses at the meeting "were recommended not to speak by the union." 

Against this backdrop, Gracedale Administrator Michelle Morton approached the dock. She had been asked by Council to bring a number of her department heads to the meeting and she did so. In contrast to Carl's accusation, they were there for the express purpose of answering questions. Since most of them are nonunion, I seriously doubt any union had issued any recommendations to any of them. With his claims of deception and intimidation, Carl basically proved why he is a former employee.  

Morton was there to present a "strategic plan" for the home's future. I will summarize her vision tomorrow, but she was also present to answer Council questions concerning the home. Since those questions and her answers are what dominated the meeting, I thought it appropriate to start with them 

How many nursing positions are actually held by county employees, as opposed to nurses supplied by an outside agency:  "We've never been anything but honest about our nursing shortage." 

25 of 89 FT nursing positions (LPN and RNs) are filled with county employees. 

9 of 79 PT nursing positions (LPN and RNs) are filled with county employees. 

7 of 16 per diem nursing positions (LPN and RNs) are filled with county employees. 

59 of 198 FT CNAs are filled with county employees. 

14 of 192 PT CNAs are filled with county employees. 

4 of 16 per diem CNAs are filled with county employees. 

When did the nursing shortage start? - "Numbers really began shifting during COVID. Some team members didn't want to be exposed to COVID, for fear of getting it themselves [or giving it to their families]. Others didn't want to get vaccinated, so when the vaccine mandate came out, a lot of people left healthcare because they did not want to get vaccinated. And that's shift is not unique to Gracedale. It's not unique to nursing homes. It's something that occurred across the country for all healthcare. And healthcare was already facing a shortage of nursing. So direct care, especially nurses, aides, all of those. We were already facing that shortage. We knew with an aging population, unless younger people entering the workforce, that was already on the horizon. So this just really accelerated it greatly and really exhaust exacerbated that problem." 

What did Gracedale do to keep staff? -  "So, we attended all recruiting events at Trade and High School, as well as universities and colleges in the surrounding counties, highlighting the rich pension and benefit packages we offer, as well as tuition assistance and reimbursement or wellness credit, flexible schedules when we could do that, job advancement, increased pay for experience, and the free daycare coming soon.  We also hired a new marketing firm to revamp our website to enhance our social media presence and to establish a Gracedale blog and produce videos. We previously advertised on channel 69 and local billboards, and we continued to utilize Indeed." 

Why were those efforts unsuccessful? - "And as I already said, some people left to COVID and vaccination, and they decided to make healthcare altogether and not to return. And then it was also compounded by the high rates that agencies do pay and their flexibility at scheduling. So, with an agency, they can work whenever they want or not work whenever they want. So, we don't have that extreme flexibility. We try to adjust schedules when we can, but we can't offer the same thing that agencies offer. So that compounds the problem. And I would add to that that the last time I checked, and I haven't checked recently, but there were 14 states that actually put limits on agencies, because some agencies are really milking the system. Pennsylvania is not one of the states that puts any limit on agencies."

How does Gracedale handle residents with mental health issues? - So, we do have contract at mental health services in our building. We use Haven House, which offers mental health services, which include personalized behavior plans, individualized therapy, ongoing support from a certified older adult peer specialist, a collaborative holistic approach that takes him into account all of the factors impacting health and consistent communications with physicians, nurses, social services, and family members. We also use a group called Vital Health and Vital Health provides a psychiatrist, and we recently added psychological counseling to that as well. And in July, the psychiatry area saw 316 of our residents, and psychology saw 52. In addition, we're working on offering more training to our team members regarding managing persons with mental health issues. So, for example, we recently trained and certified 7 members in mental health first aid. And that's something that we're continuing to look at."

Do the administration and unions instruct employees against speaking to Council members? - "I have never heard anyone say that. I have never told anyone that none of my team has told anyone that I can say that, you know, rumor mills are big, and rumors come back to us of people having talked to certain council members and the information that we were told that they said was not correct. I can tell you how I operate and here I'm saying it in public. So, I would say to our staff the same as I tell them when I teach them about talking to our surveyors when they come. I said, I highly believe in ethics. I don't believe in hiding things. I tell them when surveyors come, you're not to lie, you're not to hide anything. You know, if we had a violation, then we accept that and figure out how do we fix it and move on."

Council member Jeff Warren discusses rumors. - Quite frankly, we I don't know about all of you, but rumors that around about me in this community. I could tell you what I do about rumors. People think I'm gay, because I wear this pin. [I have never heard this rumor, lol]. I have a wife who's a female and two daughters. The rumors abound. There's hearsay everywhere in government, federal government, to the state government, down to our local government, I don't know what to do about it." [Be proud Jeff, be proud!]

Council member Kelly Keegan on GOP Council members and agency nurses. - They're taking advantage of us. That's what they're doing. There is a name for it. It's called Cash Cows. The next thing is that's why some states did limit it and Pennsylvania's not one of them. The next thing I want to say is to [Ron Heckman], you talk about that we don't pay a lot. When I graduated nursing school, many of my friends that I graduated with went to work for Gracedale because they made so much more money than the starting salary in the hospital. That's a fact, and they probably still are working there to this day. Not only do they get paid more, but they get a pension after five years. That's a huge incentive. So, you know, the county does provide for these people. And then the other thing I want to say is, Ron, you keep saying that you don't want us to go at each other and you want this not to be political, but you keep tolerating the other side at disparaging Gracedale and then you keep saying that you don't want us to go at each other." 

Council member John Goffredo believes drastic changes are needed or we will lose Gracedale. "I love that you're optimistic. I have maybe a little bit more of a pessimistic outlook. I see the inflation, the cost of living, wages, even in the private sector, struggling to keep up. And in the governmental sector, it's going to be even worse, and that's why we're heavily relying right now on agency staffing. We can't keep up. We're trying. You know, I said something pretty radical and the people I was talking to were in the Union, you know, they were shaking their heads. I was like, 'I don't think your unions are doing enough for you.' I really think merit-based and getting people the best nurses getting paid the most, because you have basically agency staff making or the agencies getting double what our staff is getting. So how do you not get retention, unless you pay your people more? And how do you not pay your better people more and attract better employees?

"I think it's pretty obvious how to fix the problems, but it's just really hard to do under the model we're working in. You have negotiations, you have people not feeling represented people that say they can't talk. It's a broken system. And if we don't make any drastic changes soon, ... we're going to lose the home.

"We had economic development, every person that came in here was like, we're getting cut, we're getting cut, we're getting cut. Everybody could make it political and say 'Oh, yeah, big bad Trump's cutting everything.'  The end of the day, we're in debt at every level, state, federal county.  We're in debt. People have less savings; people aren't making as much. Money is an issue at every level, in every arena. If we want to see Gracedale survive, we can't keep doing the same thing."

Council member Kelly Keegan ends meeting with usual personal and partisan rant at Goffredo: - "Gracedale is not in debt. That is a lie. Stop lying to our constituents. Stop lying to the county. You have no evidence of it. 

Goffredo - Kelly, Kelly

"No, I'm talking. [shouting] I have the floor.

Goffredo - You have the floor, but you don't have the facts.

"Neither do you, and you keep telling everybody lies. So, stop it!

She droned away for another minute. As you can see from Goffredo's own remarks, he was speaking about debt in general, and although I wish he was wrong, he happens to be correct. Moreover, until Council members listen to each other and operate from a presumption that all are interested in what is best for the county, Gracedale is doomed. 

Blogger's Note: Tomorrow, I will summarize the impacts that Trump's Big Beautiful Bill will have on the nursing home industry and compare them with the rather vanilla "strategic plan" presented.