by Ruth Talbot

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

The quality of care that residents receive in a nursing home can be profoundly affected by who owns it, studies have shown. It’s not always clear who should be held accountable, though: Many nursing homes are owned by companies that are owned by other companies, obscuring who has the ultimate decision-making power. As more nursing homes are sold, information about an incoming owner’s performance in other homes becomes more relevant, as it may provide insight into how their latest acquisitions will fare.

To help navigate the confusing world of nursing home ownership, ProPublica’s Nursing Home Inspect now publishes detailed ownership information for facilities and an upgraded search to help you sift through the information.

The data comes from the Centers for Medicare & Medicaid Services, which publishes “affiliated entities” for nursing homes — lists of people or companies that have an ownership stake in or operational control over multiple nursing homes. CMS’ goal is to provide a better understanding of an owner or operator’s performance across all the nursing homes they are associated with. Some entities are affiliated with only a handful of homes, while others, like Genesis HealthCare or The Ensign Group, are affiliated with hundreds of homes across multiple states. Because CMS does not provide this data in a way that’s easy for most people to use, we’ve added it to our Nursing Home Inspect tool.

Our new affiliated entity pages allow users to easily explore data on each company or person who is responsible for nursing homes, listing all homes associated with that entity and showing recent serious deficiencies —  failure to meet care requirements — found at those homes. You can even view a list of all affiliated entities nationwide.

We also added detailed ownership information to individual nursing home pages, allowing users to see who has an ownership stake in the home, as well as who has managerial control over the facility and how long they have held that position.

To go along with these additions, we’ve also expanded the database’s advanced search capabilities so journalists and others can quickly identify affiliated entities that have a history of serious deficiencies or other problems. For instance, users can search for all serious deficiencies associated with Life Care Centers of America.

Separately, users can also now filter searches by F-tags, which are a system for specifying the types of compliance issues that may be found during a CMS inspection. These tags allow users to narrow their search beyond broad categories such as “infection control deficiencies” to more targeted queries such as deficiencies associated with reporting COVID-19 data to residents and families or ensuring staff are vaccinated against COVID-19.

ProPublica plans to continue enhancing Nursing Home Inspect with new data and features in the coming months. If you write a story using this new information, come across bugs or issues, or have ideas for improvements, please let us know!

This post was originally published on Articles and Investigations – ProPublica.

by Audrey Dutton

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.

One night in March 1976, a young advocate for people with mental illness arrived at the Idaho statehouse with a warning.

Marilyn Sword urged lawmakers not to ratify a system that would ultimately lock away some of Idaho’s most debilitated psychiatric patients in the tiny, concrete cells of a maximum security prison — a kind of solitary confinement with no trial, no conviction and often no charges.

Idaho didn’t have any psychiatric hospitals secure enough for patients whose break with reality made them lash out in fear, anger or confusion. What it did have was a maximum security prison.

Sword said putting prison officials in charge, as lawmakers were contemplating, could violate the civil rights of patients committed by the court for hospitalization. She said it would burden them with “the double stigma of being mentally ill and then being placed in a maximum security unit at the penitentiary,” minutes of the meeting show.

Idaho leaders plunged forward with the legislation anyway.

In the five decades since, Idaho has continued to ignore warnings over and over that its law fails mental health patients by sending them to a cell block, ProPublica found in a review of legislative records and news clips.

“I think it’s really tragic that it has been this many years, and we’re still at this point,” Sword, now 77, said in an interview this summer.

Marilyn Sword was among the first mental health advocates to warn Idaho lawmakers in the 1970s that Idaho’s plan to house “dangerously mentally ill” patients in prison may violate their civil rights. Sword testified in 1976 as president of the Idaho Mental Health Association. (Sarah A. Miller for ProPublica)

Governors, lawmakers and state officials have been put on notice at least 14 times since 1954 that Idaho needs a secure mental health unit that is not in a prison.

They also have been told publicly at least eight times since 1974 that Idaho may be violating people’s civil rights by locking them away without a conviction, and that the state could be sued for it.

The most recent warning came this year, when Idaho’s corrections and health and welfare directors wrote that the practice was a problem “not only because of our lack of appropriate levels of care for this population but because the treatment violates the patients’ civil rights.”

Idaho will soon be the last state to legally sanction the practice of imprisoning patients who are “dangerously mentally ill,” to use Idaho’s parlance, but who are not criminals. New Hampshire is phasing it out.

State leaders repeatedly have defended Idaho’s approach — in 1977, 2007 and 2017 — as a temporary measure while the state worked on a stand-alone clinical unit or a permanent secure wing in a hospital. Those facilities never materialized.

At the start of this year, the Legislature refused to use any of Idaho’s $1.4 billion surplus to build a $24 million mental health facility for patients, opting to continue holding them without charges at the state’s maximum security prison south of Boise.

In placing patients who have not been charged with crimes in prison instead of in a treatment facility, Idaho is at odds with the U.S. Substance Abuse and Mental Health Services Administration. Holding prisoners with mental illness in prolonged seclusion also goes against recommendations of the American Psychiatric Association, the American College of Correctional Physicians, federal courts and the United Nations.

ProPublica and Mississippi Today have reported on a related issue recently: how Mississippi keeps hundreds of people with mental illness in county jails as they await appropriate hospital beds.

Idaho’s practice touches far fewer people and typically addresses more extreme behaviors. But it also stands apart because the Idaho patients are locked up longer — an average of 110 to 160 days in recent years — and in solitary confinement, in a maximum security facility, under a program fully endorsed in Idaho statute.

C Block holds the acute behavioral health unit of the Idaho Maximum Security Institution. The prison block is divided into three sections, one of which has nine cells for men considered “dangerously mentally ill.” They include patients who haven’t been charged or convicted of a crime. (Sarah A. Miller for ProPublica)

Joe Stegner, a former Republican leader, helped bring Idaho closer than ever toward building a hospital to replace the cell block in 2007 and 2008. Yet the project he championed was no match for Idaho’s inertia and austerity.

The defeat helped seal his retirement from politics.

“I started thinking, ‘You know, if you can’t have some wins in the Legislature, why are you kicking yourself around?’” Stegner, who served as a senator, said in an interview this summer.

“I set out to make a difference,” he said.

“The Damned and the Forgotten”

Two men sat in the Idaho Maximum Security Institution’s C Block near Boise on a recent day, neither of them convicted or charged in a crime.

The cell block was silent. An occasional face peered through a cell-door window the size of a computer keyboard. Inside each cell, another tiny window offered a view of razor wire, floodlights and rocks on the prison grounds.

First image: Patients admitted to the Idaho Security Medical Program spend months, on average, in cells like this one in a state prison near Boise. Second image: A view of the prison yard and desert surroundings from a cell in C Block. (Sarah A. Miller for ProPublica)

About a half-dozen civilly committed psychiatric patients a year are housed here and at a women’s prison in eastern Idaho under the Idaho Security Medical Program, state data shows.

The men share a block of nine cells with patients facing criminal charges and needing treatment before they can stand trial. Occasionally, a convicted felon with mental illness joins the mix. The women’s prison has one isolated cell.

Patients who end up here have conditions that can trick them into believing strangers are aliens who must be destroyed, or that the phlebotomist drawing their blood is implanting something in their arm, or that a nurse intends to infect them with a lethal virus. They react with violence.

A part-time psychiatrist, a part-time nurse practitioner and a dozen full-time staff members are expected to bring the patients back from shattered realities.

Certified nursing assistant Emma Wilson makes rounds inside the Idaho Security Medical Program’s section of C Block. (Sarah A. Miller for ProPublica. Patient document blurred by ProPublica.)

Civilly committed patients with the most severe symptoms spend as much as 23 to 24 hours a day confined to cells the size of a parking space.

Confinement can become necessary because it takes time to find effective medications that stabilize a patient before cognitive and behavioral therapies can begin, corrections spokesperson Jeff Ray said in an email. Until then, he said, “it is in the patient’s best interest they be kept safely in their cell, so they do not hurt themselves or others.”

Every patient gets checked on at least twice an hour, according to the corrections department. They can leave to shower, handcuffed, shackled and accompanied by guards.

Patients who take their medications, follow the rules and remain calm are allowed to spend time in the common area. There, they can watch television, use a microwave or sit in caged-in phone booths to make calls and send email on a terminal designed for prisoners. There are metal “restraint desks,” designed for shackling a person ’s ankles, bolted to the floor.

“There’s no color. There’s no nice pictures. There’s no couches,” said Kacey Abercrombie, a statewide coordinator for the Idaho Department of Health and Welfare, whose job includes regular in-person visits to these patients at the prison.

“It is prison,” Abercrombie told a roomful of attorneys and judges at a July Idaho State Bar meeting. “And when you think about this population in that setting, it is probably dawning on you how wild this is.”

The men spend hours peeling paint from the walls of their cells, a habit so universal that prison workers debate whether it makes sense to repaint between patients.

First image: Members of the prison staff try to keep patients occupied with worksheets, word searches, sudoku puzzles, radios and, in some cases, activities outside their cells. But the men often spend time in isolation peeling paint off the walls. Second image: A phone for the men in this section of C Block is inside a metal cage. (Sarah A. Miller for ProPublica)

“We try to do what we can with what we’re given,” said Mallory Logan, a prison social worker who works with civilly committed patients. But she said her unit can’t match the resources of a true forensic hospital.

Prison employees keep an imaginary barrier between convicted inmates who are in C Block for mental health care and the other patients with no convictions or charges.

There’s a “C” taped to the door of “civil” patients, a reminder that the person inside is not there as punishment. Signs around C Block remind staff members not to let the “civils” commingle with the inmates when they’re out of their cells.

Signs throughout C Block remind staff members not to let the “civils” commingle with criminally convicted inmates when they’re out of their cells. (Sarah A. Miller for ProPublica)

Little else separates patients. They are guarded, medicated and fed by the same prison employees. They have the same rules and reward systems that can allow them to have a radio or buy candy from the commissary.

Like many other states, Idaho can hospitalize people against their will under a court-ordered involuntary mental health commitment. At least two professionals must agree that such patients are likely to injure themselves or others or are “gravely disabled” due to mental illness.

If patients lash out — maybe punching or threatening to kill hospital workers — Idaho’s law says the state can ask the court to declare them “dangerously mentally ill” so they can be moved to a maximum security facility.

The typical patient isn’t a character who “really tugs on your heartstrings,” says Walter Campbell, chief psychologist for the Idaho Department of Correction.

“These are the damned and the forgotten,” he says.

Idaho is one of two states known to put people with mental illness in a prison without a criminal charge. The other, New Hampshire, just broke ground on a 24-bed secure mental health facility that will allow the state to end the practice — but not before a patient died last spring.

Psychiatrists and legal scholars commissioned by SAMHSA, the federal government’s main mental health agency, say it shouldn’t happen, period. In a 2019 report prepared for the agency that describes “principles for law and practice” in treating mental illness, the authors wrote, “Unless already incarcerated for a criminal offense, or facing criminal charges … no person who has been committed should be placed in a correctional facility for treatment services.”

One former patient’s mother provided ProPublica with copies of her son’s medical records and documentation of 15 uses of force on him during his stays in the Idaho Security Medical Program while under civil commitment. ProPublica is not naming the 38-year-old man to protect his privacy.

The records show that he was alone in his cell for days on end, aside from showers and short check-ins from staff. He didn’t always take his medications as required under his court-ordered commitment, so officers were called to hold him down for the drugs to be injected. Once, they fired pepper spray through a hatch in the cell door before entering.

His mother said she believes his confinement in a prison cell made it harder for him to recover. It was months before he was released last June to a state psychiatric hospital, where he remains.

The number of times force was used on the patient is unusually high, according to Ray, the prisons spokesperson.

“This is an extreme case which is not representative of the typical patient’s experience,” Ray said, adding that the use of pepper spray “is rare but on some occasions necessary.”

While acknowledging that prison is not the most therapeutic environment for people with severe mental illness, Ray described corrections officers assigned to the unit as “carefully selected, specially trained, and expected to consistently meet high performance standards.”

“They are some of the best correctional professionals in our department,” he said.

The prison psychiatrist who treated this patient wrote, in another medical record, that he told Idaho health and corrections leadership that prison was an inappropriate setting for this patient, who had been placed under involuntary civil commitment and had a history of injuring staff members at hospitals. Idaho’s health and corrections directors later asked legislators to fund a new secure mental health facility. (Obtained by ProPublica)

According to psychiatrists and researchers, forced solitude can exacerbate conditions for people with profound mental illness, making them lash out more.

“Solitary confinement is recognized as difficult to withstand; indeed, psychological stressors such as isolation can be as clinically distressing as physical torture,” Jeffrey L. Metzner and Jamie Fellner wrote in 2010 in The Journal of the American Academy of Psychiatry and the Law.

It is “the mental equivalent of putting an asthmatic in a place with little air,” according to a ruling by the 9th U.S. Circuit Court of Appeals, which covers Idaho.

Legal experts said Idaho is on shaky legal footing with its practice.

When told about Idaho’s system by ProPublica, David Fathi, director of the American Civil Liberties Union National Prison Project, called it “shocking beyond belief” and a likely violation of patients’ constitutional rights.

“I think the state has considerable exposure here,” Fathi said, “and I would urge them to discontinue this practice before they get sued over it.”

Megan Schuller, legal director for the Judge David L. Bazelon Center for Mental Health Law, said Idaho may also be violating the Americans with Disabilities Act and should invest in community-based care that keeps people from needing a secure facility.

“The bottom line is, you’re imprisoning people for having a mental health condition — for the manifestations of that condition,” Schuller said. “And that is just absolutely not equal treatment to how we treat any other type of health condition or even mental disability.”

Decades of Warnings

The idea of locking Idahoans with mental illness in a penitentiary was around as far back as 1954, when the Idaho Statesman reported that a county prosecutor had pressed for a place to incarcerate the “criminally insane.” At the same meeting where the prosecutor spoke, an influential Republican suggested putting the ward in the state prison. But Idaho’s health director argued a prison ward wasn’t appropriate; people with illnesses belonged in a hospital.

In the 1970s, a new generation of Idaho health and law enforcement officials offered an alternative. They would jointly operate a secure mental health facility, on the grounds of the new Idaho state corrections complex that was going up south of Boise.

The state health agency would provide psychiatric care, furniture, medical equipment and first aid; the state corrections agency would take care of security and room and board. The unit would house up to 17 patients including “persons considered mentally ill and dangerous” but who committed no crime.

Health and corrections leaders called it “a historical first” and “a new era” for Idaho. The Legislature approved, and the joint unit was open by 1972.

The collaboration quickly unraveled. In 1976, citing “numerous problems with management and operation,” the state prisons director pushed legislation that would give him full control over the unit.

Corrections officials were poised to start running the show, and critics were stunned.

Sword and other mental health advocates quoted in legislative records that year urged the state to keep a separation between civil patients and prisoners.

Marilyn Dorman, a regional behavioral health board chair, argued that mental health care decisions should not be made by corrections officials but by someone “who has the training in mental health and mental hygiene needed to best represent the patients.”

A supervisor at the psychiatric unit, Jeffrey Toothaker, was so outraged that he spoke out publicly against his boss, Idaho health director Milton Klein. In a letter to the editor of the Idaho Statesman, Toothaker said he found it “difficult to work with a good conscience for a department that has at its head a director that supports such a bill.”

Klein acknowledged to lawmakers that the arrangement wasn’t ideal. Without money to build a new secure psychiatric facility, he said, placing patients in the state pen was the best compromise available.

And that approach was designed to be temporary, authorized for only one year. In 1977, legislative minutes show, lawmakers said a secure unit for civilly committed patients would open in 1978 at Idaho’s State Hospital South, replacing the prison ward.

One senator said that while the U.S. Supreme Court might not look kindly upon placing civilly committed patients in prison, it would probably give Idaho a pass if a better solution was in the works.

It’s unclear what happened to construction at the hospital. But in 1979, a year after the ward was supposed to have opened, the Legislature made the civil commitment unit at the state penitentiary permanent.

It’s drawn criticism ever since.

The prison unit where civilly committed patients are housed has the trappings of a place designed for incarceration, such as these metal “restraint desks.” (Sarah A. Miller for ProPublica)

A national mental health advocate in 1990 called the unit a “dumping ground” for those with severe mental illness. “Death Row is just down the hall,” said psychiatrist and mental health advocate E. Fuller Torrey, according to an Idaho Statesman article. “Their major crime is schizophrenia.”

The same year, a complaint from a disability rights organization drew a U.S. Department of Health and Human Services civil rights investigation, according to an Idaho Statesman report. The federal agency could find no documentation of the outcome when asked recently by ProPublica.

The state’s behavioral health administrator told lawmakers in 2006 that “Idaho desperately needs a secure psychiatric facility or facilities for these people” instead of prison.

None of the criticism seemed to make an impression. Only once since 1976 have Idaho’s political leaders been united in their desire to give patients the right treatment in the right place.

Stegner, the state senator, was among those leading the charge.

The Hospital Takes Shape

Stegner ran his family’s grain-elevator business in north-central Idaho before jumping into politics. He ascended the Republican ranks to become the Senate assistant majority leader by the mid-2000s.

It struck Stegner as wrong when he learned Idaho was locking people with mental illness in prison without a conviction. In 2007, three decades after his predecessors assured people a new hospital wing for civilly committed patients was on its way, Stegner saw an opportunity to make it finally happen.

Sen. Joe Stegner, left, at the Capitol in Boise in 2005. Stegner has since retired from the Legislature. (Dianne Humble/Idaho Press Tribune via AP)

State mental health administrators who’d been making a renewed push to build a secure facility had fully scoped it out.

The building would house 300 beds for patients committed to the state as a result of their mental illness, as well as convicted criminals with severe mental illness and violent behaviors. The two groups would be kept in separate areas.

Stegner persuaded fellow lawmakers to set aside $3 million to design the facility. Construction was estimated at $70 million — roughly $101 million in today’s dollars.

Stegner still remembers driving out to the dusty sagebrush-covered land south of Boise to choose the site where the building would go: “a little low draw” behind a hill that would keep the prison out of view from the new psych unit.

State officials toured high-security psychiatric facilities in California, Kansas and Missouri.

Gov. Butch Otter put the project in his budget for the following year and highlighted it in his January 2008 State of the State address.

The House and Senate voted to allow bonds for the project, noting the demonstrated need for a standalone treatment facility.

Several legislators signed a resolution saying people placed in civil commitment and not serving a criminal sentence “should not be housed in correctional facilities.”

Stegner could see a future where Idahoans whose psychiatric diseases made them lash out would have a place to be safely treated. There was political support for it. There was money. There was even an architectural rendering.

And then nothing.

The governor’s office dropped its support, Stegner said.

Otter told ProPublica the plan stalled because of bureaucratic disputes over where to build the facility and, later, because of the 2008 financial crisis. “We all agreed we needed it,” he said of the new mental health facility, but there wasn’t enough money to go around. “And we all agreed we didn’t want to raise taxes,” he said.

Stegner believes one factor made it easier to kill the project. A year before, acting on a proposal from the Otter administration, legislators had tweaked wording in Idaho’s law governing the mental health unit to put corrections officials on firmer ground in the event of a lawsuit. It may have lessened the urgency to build a hospital.

“That was really a crushing defeat for me — one that changed my attitude about remaining in the Legislature, and one that is one of my biggest regrets in my legislative career,” Stegner told ProPublica.

Idaho officials went on to back away from or block the development of a mental health facility two more times.

Most recently, legislators this year failed to take up Gov. Brad Little’s proposal to use a fraction of Idaho’s record-breaking budget surplus to build a 26-bed facility on state land near the state prison.

One additional expense lawmakers did tack on to the budget: $750,000 to enable the execution of death row inmates by firing squad.

The Next Opening

Stegner and Sword, the activist who testified against imprisoning civilly committed patients in the 1970s, are looking to Little again in 2024. The governor made mental health care a focus of his administration when he took office in 2019. After getting nowhere on his proposal for a new secure facility this year, Little has signaled he plans to try again.

Based on a request from his administration, the state’s building advisory council gave its blessing Nov. 14 to a $25 million facility. That could bolster Little’s chances of legislative approval. Little’s press secretary told ProPublica the governor sees the building as “a critical part of our state’s behavioral health infrastructure.”

The Department of Health and Welfare would provide the mental health care for patients there. The Department of Correction would provide security. They would operate the facility together, and patients would no longer be held in prison cells.

It would be, by and large, just as state lawmakers envisioned more than 50 years ago.

This post was originally published on Articles and Investigations – ProPublica.

by Cezary Podkul

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A bipartisan group of six U.S. representatives has introduced a bill that would prohibit insurers and their intermediaries from levying fees on doctors for paying them electronically. The legislation comes in the wake of a ProPublica investigation that detailed the toll of such fees, which add up to billions of dollars that could be spent on care but are instead funneled to insurers and payment processors.

The charges are akin to having an employer deduct 1.5% to 5% to provide a paycheck electronically if an employee prefers to receive a payment directly into their bank account rather than via a paper check. Yet that’s the choice many insurers are increasingly forcing on doctors.

“We don’t tolerate paying fees to receive direct deposit of a paycheck, likewise, doctors and patients should not be forced to pay predatory fees on electronic payments on essential health services,” the bill’s lead sponsor, Republican Rep. Greg Murphy of North Carolina, said in a statement announcing the legislation. Murphy’s bill would effectively force the Centers for Medicare & Medicaid Services, the federal government’s chief regulator on health care payments, to prohibit the fees.

As it happens, that would bring the giant agency back to its original position. CMS prohibited fees for electronic funds transfers until it was lobbied by a payment processor called Zelis. The agency changed its position in 2018, then went even further in 2022, explicitly stating that such fees are not prohibited. A spokesperson for CMS said the agency does not comment on proposed legislation. Zelis did not reply to a request for comment on Murphy’s bill, but the company previously told ProPublica that its services remove “many of the obstacles that keep providers from efficiently initiating, receiving, and benefitting from electronic payments.”

CMS’s about-face was detailed in copious internal records meticulously collected by a New York City urologist, Dr. Alex Shteynshlyuger, who has made it his mission to fight the costly fees. His crusade now appears to have found a sympathetic ear in Congress: Like Shteynshlyuger, Murphy is a urologist, and he co-chairs the House GOP Doctors Caucus. Three Democrats and two Republicans thus far have signed on as co-sponsors of his bill.

The proposed legislation has the backing of the American Medical Association, whose policymaking body voted last month to adopt a new resolution opposing “growing and excessive” fees on electronic funds transfer payments. Shteynshlyuger, who has spent six years trying to convince CMS to ban the fees, introduced a proposal at New York state’s medical society that then made its way to the AMA. He said of the new federal bill: “I’m happy that the legislators got involved.”

Administrators at small medical clinics are hoping the bill will bring them relief from the fees, which are “doing nothing for us but costing us money,” said Rebecca Hamilton, who manages an arthritis and rheumatology clinic in Wichita, Kansas.

Often, it’s independent clinics like Hamilton’s that suffer the most from such fees, since medical practices collect the vast majority of their revenues through EFT payments, according to the Medical Group Management Association. The winners are the recipients of the fees: large insurers and payment processors like Zelis.

One form of electronic fee is not addressed by Murphy’s bill: charges for use of so-called virtual credit cards, which Shteynshlyuger has also been campaigning against. Virtual credit cards are temporary card numbers that are typically used for one payment. Fees for VCC use run as high as 5% versus a typical 2.5% for other kinds of electronic payments.

ProPublica’s investigation showed how Matthew Albright, a lobbyist for Zelis, used a combination of cajoling, argument and the threat of litigation to get CMS to withdraw a 2017 notice prohibiting fees for electronic payment. CMS had posted the notice, which was based on a federal rule from 2000, on its website after hearing complaints from doctors. Internal CMS emails detailed how Albright repeatedly demanded that CMS withdraw and revise the notice, and when CMS ultimately refused, a law firm representing Zelis threatened to sue the agency. Within days, CMS removed the notice. It later stated that fees are allowed.

CMS previously told ProPublica that it reversed its position because it concluded that it had no legal authority to “flat-out prohibit fees.”

Albright, like CMS, has changed his public position on the fees. Before he joined Zelis, Albright worked for the federal agency, where he wrote the rules implementing electronic health care payments. Shortly after his time at CMS, at a 2015 conference for health care business managers in Las Vegas, Albright expressed unequivocal opposition to fees for electronic payments. When Albright outlined the agency’s rules, audio of the event shows, the mere mention of virtual credit cards prompted some members of the audience to cry, “Evil!” Albright asked if that sentiment was unanimous, prompting a wave of yeses.

Doctors Shouldn’t Have to Pay to Get Paid

Before he became an industry lobbyist, Matthew Albright expressed opposition to electronic payment fees at a conference in Las Vegas in 2015.

Laughter ensued, and Albright, who has a master’s degree in divinity, joked that he was preaching to the choir. His sermon? “What other industry does not get paid for the services they’re doing, and when they do get paid, they have to pay for getting paid? What other industry, right? It’s ridiculous!”

Reached by telephone for comment, Albright said, “I can’t speak to you.”

This post was originally published on Articles and Investigations – ProPublica.

by Aliyya Swaby, with research by Mollie Simon

This story mentions attempted suicide.

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.

One Saturday morning in September 2022, Terrence Steyer, the dean of the College of Medicine at the Medical University of South Carolina, placed an urgent call to a student. Just a year prior, the medical student, Thomas Agostini, had won first place at a university-sponsored event for his graduate research on transgender pediatric patients. He also had been featured in a video on MUSC’s website highlighting resources that support the LGBTQ+ community.

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Now, Agostini and his once-lauded study had set off a political firestorm. Conservative activists seized on one line in particular in the study’s summary — a parenthetical noting the youngest transgender patient to visit MUSC’s pediatric endocrinology clinic was 4 years old — and inaccurately claimed that children that young were prescribed hormones as part of a gender transition. Elon Musk amplified the false claim, tweeting, “Is it really true that four-year-olds are receiving hormone treatment?” That led federal and state lawmakers to frantically ask top MUSC leaders whether the public hospital was in fact helping young children medically transition. The hospital was not; its pediatric transgender patients did not receive hormone therapy before puberty, nor does it offer surgical options to minors.

The dean’s call went to voicemail. A person familiar with the call shared the voice message with ProPublica.

After reassuring Agostini that he had done nothing wrong and wasn’t in trouble, Steyer pressed him for more detail about his research. “I’m really getting some pressure from the state Legislature and the leadership at MUSC,” he said in the message. He asked Agostini to give him “in particular the number of people at each age that was seen and the youngest child who received gender-affirming therapy for transgender issues.” Agostini declined to comment for this story. Steyer did not respond to a request for comment, but an MUSC spokesperson told ProPublica that Steyer wanted to “ensure we had all the facts as the situation was unfolding.”

Excerpt of the Dean’s Voicemail

The day after a student’s research on pediatric transgender patients came under attack on social media, Terrence Steyer, dean of the Medical University of South Carolina’s College of Medicine, left the student a message acknowledging the pressure he was facing from lawmakers and university leaders.

(Obtained by ProPublica)

It had been three months since South Carolina’s Legislature had banned the state’s flagship medical university from using public money to provide any treatment “furthering the gender transition” of children under 16. Before and after the directive went into effect, hospital leaders told lawmakers and reporters that they didn’t use state money to care for transgender patients. And the chief of children’s and women’s care said that the ban would not affect the services the hospital offered, according to an email he sent to colleagues, which was among hundreds of MUSC emails that ProPublica obtained through a public records request.

Then came the blowback from Musk’s tweet. (Musk did not respond to an email seeking comment.)

In the months after the tweet, as conservative lawmakers and activists sought more information on the hospital’s transgender patients, MUSC employees expressed concern that hospital leaders went too far to appease lawmakers, according to emails. The emails show hospital leaders eventually buckling under the pressure and excluding doctors and other key employees from the decision-making process.

By the beginning of December, the hospital’s leaders came to an agreement that MUSC would cut off access to hormones for gender transition for minors of all ages — including 16- and 17-year-olds, which went beyond what the Legislature sought. At the time, MUSC leaders told reporters that they were no longer legally allowed to offer the care, an about-face from their initial pronouncement that the Legislature’s action would not impact regular functions. They also gave no public explanation of how providing the care to older teens could be considered illegal.

In response to ProPublica’s questions, MUSC spokesperson Carter Coyle called cutting off care for older teens an “operational decision made by hospital leadership,” but failed to elaborate. She said MUSC and its providers “took immediate steps” to comply with the state’s ban once it went into effect.

The hundreds of emails released to ProPublica do not indicate exactly why or when MUSC leaders made these decisions. But from last September through this spring, the emails show leaders painstakingly attempting to avoid the appearance of support for transgender people or LGBTQ+ causes on social media, concerned about garnering further political backlash.

In banning state funding, South Carolina lawmakers wielded one of many tools conservative-run states are using to restrict access to gender-affirming care. Over the last several years, Republican elected officials in many states have elevated anti-transgender issues in their political platforms, used misinformation about transgender people when introducing bills to restrict gender-affirming care and spent public money waging extended court battles to limit access to care for trans children and adults.

More than 20 states have passed bills that restrict care for transgender young people. Several of those laws are facing court challenges, including one in Tennessee, where opponents have petitioned the U.S. Supreme Court to take up the case. South Carolina conservatives tried and failed to get a ban passed this year and are expected to try again when the Legislature reconvenes in January. These attempts contradict the recommendations of major medical associations, which support access to gender-affirming care for transgender young people.

Even before states pass outright bans, hospitals and clinics, especially those reliant on state contributions, often bow to political pressure. In Mississippi, for example, the University of Mississippi Medical Center decided to stop providing puberty blockers and hormone therapy to trans youth months before state lawmakers banned care. Mississippi Today obtained emails showing UMMC cut off care after receiving pressure from lawmakers who were angry that the facility was providing any gender-affirming care to youth. UMMC declined to comment either to Mississippi Today or for this story.

In South Carolina, after it became clear last December that MUSC was halting transition-related care for all minors, conservative lawmakers celebrated their victory. “I went after the Medical Center of South Carolina with 19 other of my door-kicking, rock-ribbed, and South Carolina’s most Conservative legislator friends,” Republican state Rep. Thomas Beach wrote in a Facebook post. “It feels good to be a gangster.”

Some transgender youth and their families found out the care was no longer available well after the decision was made. Max, a 17-year-old transgender patient at MUSC, didn’t know until this spring that he’d be cut off from testosterone therapy after more than a year on it, time in which he’d become more confident in his body and gender. “I can’t watch myself go back in time like that,” he recalled thinking. “I was like, ‘I don’t think I’m gonna survive this.’”

In the days after Musk’s tweet, hospital staff and executives were scrambling to minimize the damage and to telegraph to the Legislature that they were not violating the ban.

“It’s been a whirlwind few days, with LOTS of cooks in the kitchen,” MUSC communications director Heather Woolwine wrote on the morning of Sept. 20 to the hospital’s director of LGBTQ+ health services. Woolwine asked him to review “the messaging that has been approved at the leadership level, after much back and forth.”

In her email, Woolwine reported that staff was checking all of the hospital’s online pages for “about 35 key terms to see if there is any other content out there that might place us in anyone’s crosshairs.” (Those terms included “affirming providers,” “questioning” and “queer.”) She acknowledged that the hospital didn’t want to “swing too far in the other direction” in responding to the threat of political retaliation. “We MUST keep respect of our patient, family and employee audiences at the forefront of any decision-making,” she wrote.

But that commitment was already faltering. By the time she sent the email, MUSC had determined that it would no longer provide hormones or puberty blockers to transgender children under 16.

The recipient of Woolwine’s email, MUSC’s first top-level employee focused exclusively on LGBTQ+ health, quickly wrote back. Chase Glenn explained that the hospital’s principal provider of gender-affirming care for transgender youth had told him about the lack of “any direct communication to her patients under 16 and their parents about the current legal reality.” One of her patients had come in the day before, he noted, only to learn that the care was no longer available.

“The patient’s mother was extremely angry and of course that’s out of concern for their child,” Glenn wrote, adding that the doctor herself “is hoping for some proactive, thoughtful, patient-centered communication that would at least make impacted patients/parents aware of the situation.”

Woolwine asked Glenn to help tackle that problem and suggested getting hospital leaders together for a discussion. But the emails over the following several months suggest that plan fell by the wayside. Woolwine didn’t respond to ProPublica’s questions. Glenn declined requests for comment.

Within days, U.S. Rep. Nancy Mace, a South Carolina Republican, posted a video on social media attacking political opponent Annie Andrews, a pediatrician at MUSC who was not connected to the endocrinology clinic. The video scrolled white block letters over a photo of Andrews: “Sex change surgery, puberty blockers, gender changing hormones for children?! That’s not protection. That’s child abuse.” Andrews took unpaid leave from her job and worked with MUSC to coordinate extra security for herself and her kids.

About a week later, MUSC leaders discouraged pediatric residents who wanted to send a letter to all hospital leaders defending Andrews against Mace’s political attacks. “They left me out on a limb,” said Andrews, who has since resigned from the hospital. “What disappointed me so deeply was their refusal to support these vulnerable youth in our community by making a statement that gender-affirming care is not child abuse.”

MUSC told ProPublica it reminded residents that state guidelines prevent public institutions from using state resources to advocate for political candidates. “If MUSC had issued a public statement it could have been interpreted as an endorsement of a candidate running for office,” Coyle said in an email.

In October, conservative politicians and activists started filing public records requests with MUSC to get the data behind Agostini’s abstract. Activists called the pediatric endocrinology clinic pretending to be parents of trans children, attempting to catch providers violating the clinic’s own stated policies regarding gender-affirming care. At least one lawmaker took to social media to threaten MUSC’s $188.9 million in state funds — 3.5% of its budget. “If MUSC is mutilating or castrating children, I won’t stop until they are stripped of public funding,” Beach, a member of the far-right Freedom Caucus, tweeted. Beach did not respond to a request for comment.

In an Oct. 5 email, MUSC leaders shared a news article about Oklahoma’s governor threatening massive budget cuts to the children’s hospital affiliated with the public hospital if it continued to offer gender-affirming care. “Could be the road we end up on,” wrote Mark Scheurer, chief of children’s and women’s care.

MUSC leaders also repeatedly pulled back on messaging related to LGBTQ+ issues, overriding the decisions of their LGBTQ+ health director. Glenn, a transgender man and longtime LGBTQ+ activist, had joined MUSC in 2021 to help the institution become a vanguard of LGBTQ+ health care in the state. By spring of 2022, Glenn had successfully organized the hospital’s first LGBTQ+ Health Equity Summit, bringing providers and students together virtually to learn about challenges in serving queer patients.

But as tension built that fall, Glenn found he had less and less power to do his job.

In November, Woolwine sent Glenn an email discouraging him from promoting a meeting that MUSC students had with the Department of Health and Human Services’ assistant secretary for health, Rachel Levine, the first openly trans person confirmed by the U.S. Senate. Several months prior, the hospital had proudly touted Levine’s appearance at the health equity summit Glenn had organized. Now, officials worried that promoting her involvement would make the hospital a target.

Glenn agreed to stand down. “I’ll note though that the fact that Admiral Levine is transgender is not the emphasis of the post,” he wrote back.

That same month, Woolwine advised a drastic edit to a social media post Glenn had helped draft to commemorate the annual Transgender Day of Remembrance, honoring “the memory of the lives lost due to acts of anti-transgender violence.” Woolwine stressed that lawmakers in the Freedom Caucus would soon be receiving information they had requested from the hospital about the state of gender-affirming care. “I have no doubt that in the week or two that follows, there’s going to be some sort of external messaging from them on transgender issues and their ‘findings,’ probably in social and in news media,” she wrote. “That post for the remembrance day, as written, may then have us looking like we are ‘firing back,’ since lives lost messaging may be interpreted as a shot across the bow.”

The resulting post barely mentioned transgender people at all.

On Dec. 1, an email from Patrick Cawley, the CEO of MUSC Health, landed in the inboxes of three of the hospital’s top leaders: “We need to update the website,” he wrote, referring to the page that described services for pediatric transgender patients. Cawley followed up with another email the next day, giving his preferred edits in red text. To the preexisting sentence that read, “We do not offer surgical treatments,” he added “or gender affirming hormonal interventions.” David Zaas, then the CEO of the Charleston division of MUSC Health, and Scheurer quickly agreed to the change.

Though MUSC Health’s CEO had been ready to make the change public on the website, the decision to cut off the care had not been communicated to Glenn. He asked MUSC leaders about the edit in an email the next day: “Can you confirm for me if this is accurate?” Cawley, Zaas and Scheurer did not respond to ProPublica’s requests for comment.

For some families, the news that their child’s care would be cut off came not from their MUSC provider but from media coverage, including a December Post and Courier article. As the information reached the public in mid-December, Glenn emailed MUSC leaders yet again to push them to communicate with patients. “After the news pieces began airing, I started receiving texts and emails and panicked Facebook messages from concerned parents who wanted to know exactly what this was going to mean for them and their children,” Glenn wrote. “Frankly, I’m frustrated that this communication is indirectly falling on me and embarrassed that we have left many of these patients scared about how they’re going to be able to continue this treatment.”

In response to ProPublica’s questions, MUSC spokesperson Montez Seabrook wrote that the hospital chose to have its providers reach out directly to affected patients during regularly scheduled visits instead of sending out a broader message to trans youth and their families: “This was to ensure that patients and families had an opportunity to discuss any concerns directly with their providers.” He also said, “This personalized approach took a little time to complete.”

In early January, Glenn resigned. “I strongly object to a number of actions recently taken by MUSC leadership that have directly impacted LBGTQ+ individuals’ access to health care services, health care providers’ access to educational resources specific to LGBTQ+ care and my ability to fulfill my responsibilities,” he wrote in a letter explaining his decision.

“[MUSC’s leaders] have created a hostile environment where it will no longer be possible for me, in good conscience, to represent MUSC as a leader in LGBTQ+ care.”

—Chase Glenn, in his letter resigning from his role as LGBTQ+ health services director

He criticized leaders for removing pages of LGBTQ+ resources from MUSC’s website and “unilaterally” postponing the next LGBTQ+ Health Equity Summit just three months before it was going to be held. He also cited leadership’s decision to voluntarily stop providing hormone therapy for 16- and 17-year-olds as one of the reasons for his resignation.

“These decisions and others have created a hostile environment where it will no longer be possible for me, in good conscience, to represent MUSC as a leader in LGBTQ+ care in our state and within the LGBTQ+ community– my own community,” he wrote. “I wish the MUSC all the best in the future and hope that there will come a time when they will meaningfully renew their commitment to being a leader in LGBTQ+ health care.”

When asked about its response to the letter, MUSC told ProPublica it could not comment on a personnel matter.

As the news of Glenn’s resignation spread through the hospital, at least one top employee shared his frustration.

“This is, in my opinion, both terribly sad and entirely predictable,” MUSC pediatrician and Chief Quality Officer Dr. David Bundy emailed other members of the Charleston division’s leadership team. Bundy’s son Eli, who is transgender and attends college out of state, has frequently addressed the Legislature to oppose anti-transgender bills. “MUSC needs to take a long look in the mirror and ask ourselves what our values are.” Bundy declined to comment.

This March, months after MUSC cut off hormone therapy for young transgender people, pediatric endocrinologist Dr. Deborah Bowlby asked Scheurer and the pediatrics chair for guidance on how to communicate the decision to patients. Bowlby was the main doctor who had been treating transgender youth who experienced gender dysphoria, and she repeated concerns she had shared with Glenn the previous fall.

“I have been told that the current policy is that the pediatric endocrinology clinic is not to be providing endocrine care regarding gender transition for pediatric patients. I want to abide by MUSC policies and am not comfortable seeing these patients,” she wrote. “Are you going to arrange to have these patients taken off my schedule and advise them that we are not providing endocrine care regarding gender transition for pediatric patients?”

Scheurer advised Bowlby to refer patients who wanted gender-affirming care to the adolescent medicine providers, who would help coordinate further care. Bowlby was not the only one who was confused. That week, an employee in the psychiatry department emailed colleagues to ask how they were notifying parents and families that they could no longer provide gender-affirming hormone therapy for minors.

At the time MUSC doctors were pleading with leaders for guidance, 17-year-old Max was unaware that MUSC had cut off his care. (Because Max is a minor, ProPublica is protecting his identity by using just his first name and not identifying his parents.) Max, who’d been treated by Bowlby since 2021, had little reason to think anything was amiss when he’d gone in for a follow-up visit in February 2023. His medical notes from that visit reference his preexisting testosterone prescription, as well as his history of gender dysphoria and suicidal ideation. Bowlby did not inform Max or his parents that MUSC had decided to end his hormone therapy.

In late March, Max’s father reached out to Bowlby for a testosterone prescription refill. She didn’t respond. Confused and a little concerned, Max’s dad called the endocrinology clinic’s office and was told by an administrative staff member that his son could no longer get hormone therapy at MUSC.

If you or someone you know needs help, call or text the National Suicide Prevention Lifeline: 988

For Max and his parents, the journey to find the right doctor and medical care was hard-fought. Even when Max was in elementary school, the idea of going through a cisgender girl’s puberty — getting a period and wearing a bra — felt terrifying. At the beginning of high school, Max’s parents took him to a therapist to help with his mental health struggles. The therapist recommended Prozac to address his anxiety and depression. It didn’t work. Max’s anxiety spiked and his gender dysphoria worsened. He began experiencing thoughts of suicide.

In May 2021, he tried to kill himself and was committed to inpatient psychiatric care at MUSC. Once he was released, Max and his parents decided he should see an MUSC pediatric endocrinologist so he could finally start hormone replacement therapy. He immediately trusted Bowlby, who seemed much more knowledgeable about transgender health than some of his previous doctors. Over the course of several months, she guided the family through the process of assessing whether Max was a good candidate for testosterone, patiently explaining the steps she would take to understand his dysphoria.

For Max, getting on testosterone in early 2022 sparked a second puberty at age 16. His voice cracked, he felt hungrier, his skin broke out in acne. “But I felt happier,” Max told ProPublica. “I just mentally felt more relieved, like I’m excited to continue transitioning and things are feeling right.”

Max said he believed that Bowlby would advocate for him. He remembers her referencing the bans on gender-affirming care that were starting to pass in conservative states and reassuring him that she would never stop providing treatment.

When Bowlby abruptly stopped responding to their messages after Max had been on testosterone for more than a year, Max’s dad wrote a second message to Bowlby in the patient portal: “You know how amazingly supportive and grateful we are for your advocacy over the years in these matters, while trans kids (and parents) are under attack. I just wish the office had told us that your office was no longer prescribing testosterone. Now we are a bit behind the 8 ball trying to remedy this.” Bowlby never responded, according to Max’s dad. She declined to be interviewed for this story.

“I’ve been trying to reach everyone and make sure they have a plan for care but it’s been very slow going.”

—Dr. Elizabeth Wallis, of efforts to communicate changes to MUSC’s policies regarding pediatric transgender patients

MUSC staff recommended Max’s parents connect with Dr. Elizabeth Wallis, the adolescent medicine provider who had volunteered to help coordinate care. “I’ve been trying to reach everyone and make sure they have a plan for care but it’s been very slow going,” Wallis wrote to Max’s dad in response to his email. She apologized for the “colossal mess” and promised to help them find a solution. But Max’s dad said that didn’t work out either. (Wallis did not respond to ProPublica’s requests for comment.)

After about a month, Max’s dad found a Facebook group for parents of trans young people in South Carolina, who suggested the family try Planned Parenthood. Max got a renewed prescription soon after.

Now back on testosterone, Max looks forward to turning 18 early next year, which will help ensure he can access gender-affirming care. South Carolina considered a bill earlier this year that would ban medical transitions for anyone younger than 21, but it didn’t go anywhere.

Max and his father still have questions: Why did MUSC cut off Max’s hormone therapy when the state Legislature didn’t even mention 16- and 17-year-olds in its ban? Couldn’t MUSC have prevented the chaos by communicating better with its patients? Why did Bowlby disappear instead of warning them?

“Knowing what happened would be nice,” Max’s dad said. “We figured it out — but we had to figure it out.”

Coyle, the university spokesperson, told ProPublica that MUSC did communicate the change to its doctors. “Physicians are notified of regulatory changes regarding medicine in various ways, including department leadership discussions, discussions with colleagues, information from specialty societies, and mainstream media,” Coyle wrote.

But as recently as May, some MUSC providers were unsure about the policy.

On the afternoon of May 23, after a conversation with her department chairperson, an OB-GYN sent an email to a physician’s assistant in family medicine, an adult endocrinologist and Bowlby. The subject line was “Question about transcare for teens.” She had only just learned that MUSC doctors were “restricted from prescribing transgender affirming care for people under 18yo,” she wrote. “Is this the case? How are y’all navigating that?”

“I have referred to Deb in the past,” the physician’s assistant responded, referring to Bowlby, “but MUSC has made some changes.”

This post was originally published on Articles and Investigations – ProPublica.

by Rose Lundy, The Maine Monitor

This article was produced for ProPublica’s Local Reporting Network in partnership with The Maine Monitor. Sign up for Dispatches to get stories like this one as soon as they are published.

One lunchtime in 2021, a longtime resident at Woodlands Memory Care of Rockland started throwing up. His fingernails turned purple, and his skin became red all over. He was lethargic and fidgety, and his breathing grew shallow, according to the facility’s daily care notes.

The resident was well known at this residential care facility in Maine’s Midcoast region. Former facility employees told The Maine Monitor and ProPublica that he was a nationally renowned concert pianist who continued to play a portable keyboard in his room even as his Alzheimer’s disease advanced.

It wasn’t until a family member arrived and asked if the resident had eaten peanuts that employees realized that he was having an allergic reaction to the peanut butter sandwich that he had been served for lunch, according to the facility care notes. Staff used an EpiPen to treat his anaphylactic shock and took him to the hospital. He died days later, though no official records were made available that show the cause of his death.

The employee who gave the sandwich to the resident wrote in the facility care notes the day after the incident that they “didn’t know” that the resident “was allergic to peanuts.”

In interviews with the Monitor and ProPublica, however, four former employees said the resident’s severe peanut allergy had been documented throughout the facility: in his resident profile, in his room and posted in the kitchen.

“It said it everywhere you looked around him that he was allergic to peanut butter,” said Stacy Peterson, who served as the human resources coordinator at Woodlands of Rockland from 2018 to 2020.

So it was a mystery to the former employees how the resident had been served a peanut butter sandwich that day for lunch.

After receiving an anonymous complaint, the Maine Department of Health and Human Services investigated the incident and cited Woodlands of Rockland for two resident rights violations — first by failing to protect the resident from a severe allergic reaction and the second time by not reporting the case to the state. (The citations do not identify the resident.)

Under state regulations, the health department had the power to impose a fine of up to $10,000 or issue a conditional license that would bar Woodlands of Rockland from accepting new residents for up to 12 months. But it did neither. Instead, it simply required the facility to submit a report, called a plan of correction, stating how it intended to address the deficiencies.

In that plan, Woodlands of Rockland acknowledged that the resident’s allergy had been documented but disputed the health department’s characterization that the facility violated the resident’s rights in the incident. Still, it promised to discipline the employee who served the sandwich and to retrain others on how to handle allergies and to report incidents.

The Maine Department of Health and Human Services found that Woodlands Memory Care of Rockland violated a resident’s right to be free “from abuse, neglect or exploitations” by serving him a peanut butter sandwich despite his documented peanut allergy. (Obtained by The Maine Monitor and ProPublica. Highlighted by ProPublica.)

The health department’s modest response to the peanut allergy incident exemplifies its approach to oversight, an investigation by the Monitor and ProPublica found. The health department rarely imposes fines or issues conditional licenses against the state’s roughly 190 largest residential care facilities, classified as Level IV, which provide less medical care than nursing homes but offer more homelike assisted living alternatives for older Mainers.

From 2020 to 2022, the health department issued “statements of deficiencies” against these facilities for 59 resident rights violations and about 650 additional violations — involving anything from medication and record-keeping errors to unsanitary conditions and missed mandatory trainings. Despite these violations, however, it imposed a fine only once: a $265 penalty against a facility for failing to comply with background check rules for hiring employees. And it issued four conditional licenses: three in response to administrative or technical violations and one in response to a variety of issues, including a violation of a resident’s privacy rights.

By contrast, Massachusetts, which has 269 assisted living facilities, doesn’t shy away from imposing stiff sanctions. From 2020 to 2022, the state suspended eight facilities’ operations for regulatory violations.

The paucity of sanctions in Maine comes at a time when Level IV facilities like Woodlands of Rockland — which are similar to what are known generally as assisted living facilities in other states — are expanding their presence in the state. The share of Maine’s population that is 65 or older, 21.7%, is the highest percentage in the country.

As the Monitor and ProPublica have reported, the state’s decision in the mid-1990s to tighten the requirement to qualify for nursing home placement helped spur thousands of older Mainers, many with significant medical needs, to move to these nonmedical facilities — which are subject only to state regulations that hold them to much lower minimum staffing, nursing and physician requirements than nursing homes, which face both state and federal scrutiny.

In stark contrast to how rarely Level IV facilities face sanctions, nursing homes in Maine are often hit with considerable fines for regulatory violations.

Health department spokesperson Jackie Farwell said that plans of correction are often sufficient for improving conditions at facilities. She added that as part of an effort to improve the long-term care system in Maine, the state has been considering rules changes to “establish fines and sanctions as more meaningful deterrents.” But she declined to elaborate on the specifics.

Dan Cashman, spokesperson for Woodlands Senior Living, which runs 14 Maine facilities including the one in Rockland, said the company has “a zero-tolerance policy” and has taken disciplinary actions against any employees who were found to have violated residents’ rights.

Cashman added that the company is in favor of stronger state action against individuals found to have violated residents’ rights to prevent them from working in residential care settings again.

But long-term care advocates say the health department is not doing enough to crack down on facilities, as opposed to individuals, and is allowing poor conditions to persist for vulnerable residents.

Richard Mollot, executive director of the Long Term Care Community Coalition, a national advocacy group focused on improving nursing homes and assisted living facilities, said stiff sanctions should be imposed more, so that there’s a “meaningful ladder of sufficient penalties to ensure that facilities are properly motivated to take steps to ensure resident safety.”

Otherwise, Mollot said, facilities have no incentive to change their behavior. “To pussyfoot around resident neglect or abuse,” he said, “is essentially encouraging. It’s allowing it to happen.”

A review by the Monitor and ProPublica of state inspection records from 2020 to 2022 shows that the health department employed the lowest intervention possible, even for some of the most serious abuse and neglect incidents.

In the summer of 2021, for instance, a resident at Crawford Commons in midcoast Maine was found to have sexually abused another resident multiple times, according to the state’s investigation. The health department cited the facility for two resident rights violations but only required it to submit a plan of correction.

A year later, a resident in Jed Prouty Residential Care Home in the Penobscot Bay region was found around 6:30 a.m., naked and asleep on the floor, “soaking wet with urine,” after falling sometime after 10 p.m. Witnesses said the resident had been crying for help and complaining of thirst until medics responded. No efforts had been made by staff to move the resident from the floor or provide clothing, according to the state’s investigation. Again, the health department cited the facility for a resident rights violation but only required it to submit a plan of correction.

Similarly, in 2021 and 2022, the health department also investigated Woodlands of Rockland for two other serious incidents. In one, a certified nursing assistant at the facility slapped a resident who had spit at and attempted to bite her, according to the state’s investigation. In the other, a resident wandered out to the facility’s locked courtyard, but employees didn’t notice that she was missing until they went to give her medications nearly two hours later, according to the state’s investigation. When the resident was found outside in the snow at around 8:40 p.m., employees wrapped her in blankets and called for emergency medical care. The resident died in hospice days later, and the state investigation cited the cause as “complications of hypothermia.” In the end, both incidents also led to plans of correction.

The Maine Department of Health and Human Services cited Woodlands Memory Care of Rockland for not protecting “a resident’s health and welfare” after the resident wandered out unsupervised into the facility’s locked courtyard. (Obtained by The Maine Monitor and ProPublica. Highlighted by ProPublica.)

Woodlands of Rockland has been disputing the health department’s characterization that the facility violated the resident’s rights in the courtyard incident. But Cashman declined to elaborate on the specifics.

Edward Sedacca, CEO of Magnolia Assisted Living, which runs Jed Prouty, said his company took over the operation of the facility in August 2022, a month before the incident, and has since made it a priority to enhance its staffing and training. “The staff we inherited was lacking in overall general knowledge,“ he said. “Magnolia has built an infrastructure well beyond that required under regulation to enable us to provide a higher level of care to all of our residents.”

Crawford Commons did not respond to requests for comment.

For Maine’s nursing homes, however, the response to similar incidents has been very different.

From 2020 to 2022, more than half of nursing homes in Maine received fines — 98 penalties in all, totaling nearly $700,000 — according to U.S. Centers for Medicare and Medicaid Services reports. These fines were imposed in response to a range of violations, including not following COVID-19 infection prevention protocol, making medication errors, not reporting unexpected deaths and failing to protect residents from harm.

In 2020, for instance, an employee at Pinnacle Health & Rehab, a nursing home in Canton in western Maine, “lost it” when a resident became combative, according to CMS investigation records. The employee punched the resident, who ended up with a black eye and bruising around the eyebrow. CMS fined the facility $41,650.

A year later, a resident at Heritage Rehab and Living Center, a nursing home in central Maine, wandered off the premises at night using a walker and was found later by police by the side of a road in the rain. No one at the facility had noticed that the resident was missing, according to CMS investigation records. CMS fined the facility $71,243.

Ken Huhn, administrator of Pinnacle, said the employee was fired, and he made it clear that “that type of behavior would not be tolerated” at his facility.

Heritage did not respond to requests for comment.

Even without the involvement of CMS, which does not regulate assisted living facilities around the country, the health department has the power to adopt a tougher approach toward Level IV facilities. Under state regulations, for instance, it can impose a fine when an incident poses “a substantial probability of serious mental or physical harm to a resident.”

Long-term care advocates told the Monitor and ProPublica that under this standard, some of the egregious abuse and neglect incidents in recent years at Level IV facilities should have resulted in stiff sanctions.

“Because the incidents are so egregious and show such disregard for the well-being of residents, they would have warranted some significant penalty and not just a pro forma requirement that the facility submit a plan of correction,” said Eric Carlson, director of long-term services and support advocacy at Justice in Aging, a national legal advocacy nonprofit focused on ending poverty among seniors.

Paula Banks, who has served as the executive director of another Woodlands facility in Cape Elizabeth and as an assistant administrator of a Maine nursing home, said the fear of such sanctions would be effective. If she were still helping run a residential care facility, she said, it would spur her to take immediate action to address any problems.

“What’s the impetus to change if there’s no consequence?” said Banks, who now runs a geriatric consulting and care management firm.

But Dr. Jabbar Fazeli, who has served as medical director at multiple residential care facilities and nursing homes in Maine, said that rather than imposing sanctions, the state should require more medical attention by increasing nursing hours and requiring a medical director to be on the premises.

“If they had more medical care, I would say 50% of these issues will self-resolve,” Fazeli said.

The health department metes out sanctions in only a small percent of the incidents it hears about each year. Most of the time, it hardly does anything.

To better understand the health department’s process for looking into potential issues, the Monitor and ProPublica analyzed a database of incidents reported to the state by Level IV facilities themselves. Unlike the state inspection records, the database of facility-reported incidents gives a window into what happens earlier in the health department’s enforcement process.

Level IV facilities are required to report an incident to the state when a regulatory violation may have occurred or when a resident’s safety was put at risk. We focused particularly on reports of incidents with the potential for direct harm: the cases of abuse and neglect.

From 2020 to 2022, the state received more than 550 reports of abuse and neglect incidents from Level IV facilities, according to the Monitor and ProPublica analysis. Of those, 342 cases involved residents abusing other residents, 102 cases involved “elopement,” in which residents wandered away unsupervised, and 61 cases involved a staff member abusing a resident.

The analysis shows that in nearly 85% of these incidents, state investigators took “no action” — which, according to Farwell, means that the health department decided not to investigate. She said this could have been for a range of reasons, such as when a facility has already taken corrective action, when state investigators do not expect to find a regulatory violation, or when an incident is being investigated as part of another case or is expected to be reviewed later.

The analysis also shows that the health department did not step up its enforcement even when individual facilities repeatedly reported similar issues.

From 2020 to 2022, 13 Level IV facilities, including Woodlands of Rockland, each had at least 10 abuse and neglect incidents, collectively reporting 348 cases to the state. Even after these facilities had reported multiple cases, the health department still took no action in 91% of them, the analysis shows.

Farwell said state investigators do pay attention to repeated incidents. “If patterns are observed, specific issues may be flagged for follow-up at the next scheduled survey,” she said.

But such follow-ups might not happen for many months, depending on the timing of the next inspection required for license renewal, which takes place only once every two years.

Dionne Mills, who served as the program coordinator at Woodlands of Rockland from 2019 to 2021 and also worked at two other Level IV facilities, said she became aware of the lack of state oversight during her time at the Rockland facility. She said she reported multiple incidents to the state until eventually a state investigator told her that they were too overwhelmed with complaints and that she would have more success taking her concerns to the media.

“The state is so super busy that they only have time to look into the absolute worst-case scenario,” Mills said.

Dionne Mills outside her home in Northport, Maine (Tara Rice for ProPublica)

Farwell disputed Mills’ account, noting that state investigators made seven visits to Woodlands of Rockland from 2020 to 2022, the time period when the facility was under investigation for the courtyard, peanut allergy and slapping incidents. Mills’ account “is inconsistent with the number of onsite visits that were conducted at this facility,” she said.

According to Farwell, the health department has 13 investigators — and is in the process of hiring two more — to inspect more than 1,100 assisted housing facilities in the state for license renewals and to investigate any incidents.

Mollot, of the Long Term Care Community Coalition, said the health department needs to do more against facilities with a history of repeated incidents, such as requiring independent monitoring and, possibly, revoking licenses.

“Faced with the fact that these facilities have reported over and over and over and over and over again incidents of abuse and neglect, why have there been a paucity of enforcement acts?” Mollot said.

Several former employees told the Monitor and ProPublica that the history of repeated incidents at Woodlands of Rockland illustrates what can happen to a facility’s standards when the health department takes little enforcement action.

Stacy Peterson, a former human resources coordinator at Woodlands Memory Care of Rockland, said facility managers made little effort to address recurring problems when she worked there. (Tara Rice for ProPublica)

From 2020 to 2022, Woodlands of Rockland had the highest number of abuse incidents reported by a Level IV facility — 48 cases in all, including 38 in which a resident abused another resident, according to the health department database.

But the health department investigated only five of the incidents that Woodlands of Rockland reported, took no action on the rest and imposed no sanctions other than requiring the facility to submit one plan of correction.

With little pressure from the health department, efforts to address recurring problems “were nonexistent when I worked there,” Mills, the former program coordinator, said.

Joshua Benner, who served as a residential care aide at Woodlands of Rockland from 2018 to 2020, said he found it concerning that when the facility was cited by the health department, none of the managers at the facility shared with employees what problems had been found.

“Every other health care place that I’ve ever worked, you have interventions, usually after the state comes in, to go over what you’re dinged on and what can be improved,” said Benner, who has worked at a nursing home and two other residential care facilities.

Cashman, the Woodlands spokesperson, denied that Woodlands of Rockland had “an ongoing or systemic problem” with abuse incidents, noting that the bulk of the cases involved a small number of residents “whose progressively worsening dementia-related behaviors became more and more challenging.”

In response to these residents’ behaviors, Cashman said Woodlands of Rockland has been proactive and taken “multiple interventions,” including resident care plan updates, medication modifications, referrals for hospital treatment and discharge planning.

Cashman said Woodlands of Rockland and its employees have been doing “their best to manage what can be extremely difficult behaviors by individuals living with significant cognitive impairments.”

But Banks said something is amiss if any facility has repeated incidents, noting that she would have been alarmed to see more than one or two incidents of abuse in three years, let alone 30 or more as Woodlands of Rockland did.

“When you have people in your building and you took them in and you told their families you would take care of them and you took their money,” Banks said, “I don’t care what’s going on. I don’t care if you have a staff of three. You’ve got to take care of your people.”

Mariam Elba contributed research.

This post was originally published on Articles and Investigations – ProPublica.

by Audrey Dutton

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When the U.S. Supreme Court last year overturned Roe v. Wade, it greenlighted the kind of near-universal abortion restrictions that Idaho lawmakers had spent the previous two years crafting. Gov. Brad Little said the state should turn to helping women who might otherwise have terminated pregnancies.

“We absolutely must come together like never before to support women and teens facing unexpected or unwanted pregnancies,” said Little, a Republican who supports the abortion ban. About 1,700 to 2,000 people a year in Idaho had abortions before the court ruling. “Families, churches, charities, and local and state government must stand ready to lift them up and help them and their families with access to adoption services, health care, financial and food assistance, counseling and treatment, and family planning.”

But since the June 2022 decision, Idaho has failed to deliver — even as other conservative states with abortion bans took steps to enhance their safety nets for families during pregnancy and after birth.

Idaho legislators disbanded a state committee that investigated the root causes of maternal deaths, making it the only state in the nation with no such mortality review.

They allowed two bills to die that would have put Idaho on the same track as nearly every other state with abortion restrictions — including Florida, Kentucky and Texas — by extending postpartum Medicaid coverage to 12 months. Idaho’s Medicaid coverage ends two months after birth, the minimum under federal law.

They turned down $36 million in federal grants to support child care this summer, while other states with new abortion restrictions — Alabama, Louisiana and Missouri among them — made investments in early childhood education and day care. Idaho lawmakers at the time attributed the decision to a pending audit of a different batch of grants.

Democrats generally support these kinds of measures, but Idaho Republicans dominate the state capitol and therefore control which bills move forward.

Rep. Brent Crane, a longtime Republican leader who chairs the House State Affairs Committee, said GOP lawmakers last year had hoped to put forward bills to improve health care and support for kids and families after the Supreme Court struck down federal protections for abortion rights. They instead got bogged down in debate over exceptions to the abortion ban.

“Idaho has some work to do,” Crane said. “Be patient with us.”

The need is urgent, according to Emily Allen, policy associate for the nonprofit Idaho Voices for Children. The state, she said, needs health care funding and other support in place to adjust to life after the abortion ban.

“Things have changed,” Allen said. “We can either bury our head in the sand, or we can respond with good policy that is very family-centric.”

But Blaine Conzatti, president of the Idaho Family Policy Center and a leading anti-abortion lobbyist, is not bothered by the lack of government support. Pregnancies, births and child care are not the purview of the government, he said, but of families, communities, charities and, most of all, churches.

“The Bible is clear, and the history of Christendom broadly is clear, that it’s the church’s responsibility to meet the needs of the poor and to ensure that people have the services that they need to live flourishing lives,” Conzatti said.

No action set Idaho apart from other abortion-ban states more than when the Idaho Legislature allowed its Maternal Mortality Review Committee to die this year. The committee had been granted unique powers to review private health care and other records of women who died during or within a year after pregnancy and draw conclusions about the root causes of those deaths.

Its budget of $10,000 a year came only from federal funds, so keeping the committee going seemed pro forma. Every single state, New York and Texas alike, had put one in place. But in Idaho, a lobbyist for an ultraconservative political nonprofit stood up and spoke against it at a hearing.

Fred Birnbaum, legislative affairs director of Idaho Freedom Foundation, said studying the causes of Idaho’s roughly 10 to 15 preventable maternal deaths each year risked inviting a push for more government support to help keep people from dying. And government support was anathema to his group.

“You know the old saying, ‘All roads lead to Rome,’” said Birnbaum, who testified against the committee’s creation on similar grounds in 2019. “Well, all government-created committees lead to the call for more government spending.”

Birnbaum’s assessment was partly correct. Idaho’s maternal mortality committee had made recommendations that could increase public spending, such as extending Medicaid coverage postpartum, expanding access to naloxone to prevent death from opioid overdose and providing better housing and child care support. But of the 52 recommendations in the committee’s final report, most called for no new government spending.

The role of such committees has not been so controversial in other Republican-led states.

The Texas Maternal Mortality and Morbidity Review Committee, for example, has been around for about a decade and is now “part of the entire effort” to reduce tragic outcomes from pregnancy and birth, said Chris Van Deusen, director of media relations for the Texas Department of State Health Services.

The Texas committee’s findings in 2018 that patients had bled to death in childbirth helped push the state to adopt recommendations and protocols for hospitals to train their employees to measure blood loss and to educate people on what is abnormal bleeding. Birth-related hemorrhage deaths started to fall the following year, Van Deusen said.

He said the committee has generally had the support of Texas lawmakers, who voted last year to adopt one of its recommendations and extend postpartum Medicaid coverage to 12 months.

Advocates for the creation of Idaho’s committee in 2019 pointed out how other states had helped reduce maternal death rates: seat belt laws in Nevada; substance use disorder treatment in Michigan; urgent messages to doctors and hospitals in Florida.

Lucky Bourn, the longtime Republican coroner of Minidoka County and a member of the maternal mortality committee, said its demise means Idaho will have no window into maternal deaths in the wake of its abortion ban, because the committee’s final report used data from 2021.

“I was very disappointed in the Legislature when they did not continue the funding of it,” Bourn said. “The thought that comes to my mind is, ‘With the change in the abortion laws in the state of Idaho, do you think that might have a correlation in the rise of the mortality rate of the women who don’t want to be pregnant?’”

The number of maternal deaths since the abortion ban took effect has not yet been reported. The committee believed it would have had 10 maternal deaths to evaluate from 2022 if it had continued.

ProPublica identified at least two deaths during pregnancy and childbirth that the maternal mortality committee could have evaluated. One death was from complications during childbirth in 2022, according to the woman’s obituary. The other was a murder-suicide this year that claimed the life of the pregnant mother and her toddler, according to the sheriff in the rural North Idaho county where she lived.

Little’s staff told ProPublica that he will bring forward a proposal in 2024 “to continue the work of this important committee.”

Lawmakers are also poised to consider other proposals that have previously gone nowhere. Idaho House Majority Leader Megan Blanksma, a Republican from Elmore County, said she is working on bills that would improve prenatal and postpartum health care, resume the study of maternal deaths and “support young families.”

Blanksma also said she will revive legislation to extend Medicaid coverage for postpartum care to a full year, a concept she said she dropped last session because of the ballooning cost of Medicaid.

Idaho state Rep. Megan Blanksma asks Rep. Dori Healey about the rationale for continuing the state’s Maternal Mortality Review Committee, which studied the root causes of preventable deaths during and within a year of pregnancy. Both lawmakers are Republicans. (Video screen capture from Idaho In Session)

“We are working on a full package to introduce come January,” Blanksma told ProPublica.

Conzatti, the anti-abortion lobbyist, advocates a more hands-off approach from the state.

Idaho has at least 16 “pregnancy resource centers” spread across every region of the state. Many in Idaho are Christian-oriented organizations that offer counseling, referrals and some material support like diapers. According to the American College of Obstetricians and Gynecologists, the centers’ goal back when Roe v. Wade was in effect was to persuade women to carry their pregnancies to term rather than have abortions.

Few Idaho centers offer medical care beyond pregnancy tests and “heartbeat” ultrasounds.

But those centers are where Conzatti said people who have unplanned pregnancies should now look to for help. They embody his vision of a world before legalized abortion and before Medicaid got involved in the lives of poor families.

Crane, the Republican House leader, wouldn’t rule out state-funded support for pregnancy centers if there’s political will for it among lawmakers.

“Every option is on the table,” he said.

This post was originally published on Articles and Investigations – ProPublica.