Review Findings – Belle Care Nursing and Rehabilitation Center

Review Findings - Belle Care Nursing and Rehabilitation Center

BY ELECTRONIC, OVERNIGHT AND REGULAR MAIL

Mr. Donny Schwartz, Administrator
Belle Care Nursing and Rehabilitation Center
439 Bellevue Ave
Trenton, NJ 08618

Re: Review Findings - Belle Care Nursing and Rehabilitation Center

Dear Provider:

This letter serves to inform you that the New Jersey Office of the State Comptroller, Medicaid Fraud Division (OSC) completed its review of the staff-to-resident ratio of Belle Care Nursing and Rehabilitation Center (Belle Care) for the period from July 1, 2023 through July 31, 2023. The purpose of this review was to determine whether Belle Care satisfied state requirements pertaining to the required minimum staffing requirements (i.e., staff-to-resident ratio). As explained more fully below, OSC found that Belle Care routinely failed to satisfy the direct care staff-to-resident ratio requirements. Accordingly, OSC is seeking to recover the Medicaid funds paid for the dates for which Belle Care failed to meet these requirements and a civil monetary penalty based on the pervasive and serious deficiencies OSC identified.

OSC conducted its review based on documentation OSC obtained from Belle Care. Specifically, OSC reviewed copies of professional licenses, timesheets, and payroll records of Belle Care's staff, including Certified Nursing Assistants, who provided direct care assistance. Based on its review, OSC found that Belle Care violated N.J.S.A. 30:13-18 and N.J.A.C. 10:49-9.8 by consistently providing staffing levels that were significantly below the minimum legal requirements. OSC's finding that Belle Care routinely failed to meet minimum staffing levels raises serious concerns because there is considerable evidence showing that staffing levels correlate to quality of care, with higher staffing ratios corresponding to higher quality and lower levels to lower quality.[1]

Pursuant to N.J.S.A. § 30:13-18a, nursing homes shall maintain the following minimum direct care staff-to-resident ratios:

1) One certified nurse aide to every eight residents for the day shift;
2) One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be certified nurse aides, and each staff member shall be signed in to work as a certified nurse aide and shall perform certified nurse aide duties; and
3) One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a certified nurse aide and perform certified nurse aid duties.
Moreover, pursuant to N.J.A.C. 10:49-9.8(a), "providers shall certify that the information furnished on the claim is true, accurate, and complete."

Based on its review, OSC determined that for each of the 31 days in July 2023, for at least two shifts every day, Belle Care failed to provide the minimum number of direct care staff to appropriately render services to its residents. Out of the 93 shifts that constituted the three shifts (day, evening, and night) for the 31 days in July 2023, Belle Care did not adequately staff 83 of the 93 shifts (89 percent). On average, Belle Care provided 4 fewer direct care staff members per shift than required, a shortage of 48 percent. When broken down by shift, the results are as follows: during the day shift, on average, Belle Care staffed its facility 57 percent below the minimum legal requirement; during the evening shift, on average, Belle Care staffed its facility 36 percent below the minimum legal requirement; and, during the night shift, on average, Belle Care staffed its facility 51 percent below the minimum legal requirement.

When viewed from a patient care perspective, OSC's findings raise serious concerns. Belle Care's failure to adequately staff its facility meant that each direct care staff member, on average, provided services to approximately 30 beneficiaries during the day shift, which was 275 percent more than permitted by law. During the evening shift, each direct care staff member, on average, provided services to approximately 22 beneficiaries, which was 116 percent more than permitted by law. Finally, during the night shift, each direct care staff member, on average, provided services to approximately 35 beneficiaries, which was 147 percent more than permitted by law. Furthermore, OSC also found that for 3 of the 93 shifts tested, Belle Care did not have any direct care staff members present to care for 82 residents present at that time. These findings, taken as a whole, demonstrate that Belle Care's failure to provide adequate staffing undoubtedly adversely affected its residents and caused staff that were present to face workloads that were, at times, far in excess of the limits established by state law. See Appendices I and II for details.

As outlined above, Belle Care failed to meet its statutorily required staffing levels for each day in July 2023. Despite that, when Belle Care submitted claims to the Medicaid program for payments for these dates in July 2023, it asserted that it had complied with all laws and requirements. Those representations were not "true, accurate and complete" and, thus, Belle Care violated N.J.A.C. 10:49-9.8(a). In fact, given how pervasive its staffing deficiencies were, Belle Care knew or should have known that its Medicaid claims were not true, accurate and complete.

Based on the findings above, OSC is seeking to recover from Belle Care the payments that the Medicaid program paid to Belle Care for each day in July 2023, which is $215,768. In addition, given Belle Care's knowledge of its deficiencies, as well as the pervasiveness and seriousness of the findings outlined above, OSC is imposing a civil monetary penalty of $431,536 against Belle Care. In total, Belle Care must repay the Medicaid program $647,304. Finally, to address the staffing deficiencies identified above, within 30 days from the date of this letter, Belle Care must provide OSC with a Corrective Action Plan (CAP) outlining the steps it will take to correct these deficiencies.

Enclosed please find password protected files containing a detailed analysis and calculations of the direct care staff-to-resident ratios, along with each shift's staffing requirements and a presentation highlighting staffing shortages. To obtain the password, please contact OSC's Supervising Senior Auditor.

PLEASE TAKE NOTICE: If, after reviewing OSC's analysis, you believe that Belle Care provided patient care in accordance with the relevant state requirements, you may submit to OSC a written explanation with relevant supporting documentation within 30 days of the date of this letter. Should you submit such a written explanation within this 30-day time period, OSC reserves the right to obtain additional records, conduct on-site visits, and perform any additional analysis necessary to conclude this review. Should you fail to respond in writing to OSC within this 30-day period, OSC may take further appropriate action, including but not limited to: issuing a Notice of Claim, Certificate of Debt, and Notice of Withholding, which would withhold a portion of your future claim's payments, and any other remedy available to OSC by law.

If you agree with OSC's conclusion, please mail a Certified Check, Bank Check, or Attorney Trust Account Check for the above stated amount made payable to "Treasurer, State of New Jersey" to the address below.

Treasurer, State of New Jersey
Division of Revenue
200 Woolverton Street, Building 20
Lockbox 656
Trenton, New Jersey 08646
Attn: Processing Bureau

In addition, please forward a copy of your certified payment by email or by US Mail to the Office of the State Comptroller, Medicaid Fraud Division, P.O. Box 025, Trenton, New Jersey, 08625-0025,. Should you have any questions regarding this letter please contact OSC.

This letter documents and seeks a recovery relating to Belle Care's failure to meet state minimum staffing levels and its improper billing of claims to the Medicaid program. Given this finding, Belle Care immediately must cease inadequately staffing its facility and submit to OSC a CAP, as outlined above. If Belle Care fails to take these actions, it may be subject to additional penalties and/or administrative sanctions for such failure.

Please be advised that this letter is a public document and, as such, may be placed on the OSC/MFD website.

Sincerely,

KEVIN D. WALSH
ACTING STATE COMPTROLLER

By: Sanjeev Bassi
Assistant Division Director (Audit)
Medicaid Fraud Division

[1] Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide January 2025, p. 6: https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/downloads/usersguide.pdf; see also, Abt Associates, Nursing Home Compare Five-Star Quality Rating System: Year Five Report, p. 17: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/NHC-Year-Five-Report.pdf.