Rehab hospitals that assist individuals get better from main surgical procedures and accidents have develop into a extremely profitable slice of the well being care enterprise. However federal knowledge and inspection stories present that some run by the dominant firm, Embody Well being Corp., and different for-profit firms have had uncommon however severe incidents of affected person hurt and carry out under common on two key security measures tracked by Medicare.
But even when inspections reveal grave circumstances of harm, federal well being officers don’t inform customers or impose fines the way in which they do for nursing houses. And Medicare doesn’t present easy-to-understand five-star rankings because it does for normal hospitals.
In essentially the most severe issues documented by regulators, rehab hospital errors concerned affected person deaths.
In Embody Well being’s hospital in Huntington, West Virginia, Elizabeth VanBibber, 73, was fatally poisoned by a carbon monoxide leak throughout development on the facility.
At its hospital in Jackson, Tennessee, a affected person, 68, was discovered lifeless in a single day, mendacity on the ground in a “pool of blood” after an alarm that was purported to alert nurses that he had gotten off the bed had been turned off.
In its hospital in Sioux Falls, South Dakota, a nurse gave Frederick Roufs, 73, the fallacious drug, one among 26 remedy errors the hospital remodeled six months. He died two days later at one other hospital.
“I can nonetheless see Fred laying within the mattress as they shut every little machine off,” mentioned his widow, Susan Roufs. “They clicked 4 of them, after which the love of my life was gone.”
Embody, which owns 168 hospitals and admitted 248,000 sufferers final yr, has led the transformation of this area of interest business. In 2023, stand-alone for-profit medical rehabilitation hospitals overtook nonprofits because the locations the place the vast majority of annual affected person admissions happen, a KFF Well being Information and New York Instances evaluation discovered. A 3rd of all admissions had been to Embody hospitals. Such amenities are required to offer three hours of remedy a day, 5 days every week.
Throughout the nation, there at the moment are almost 400 stand-alone rehab hospitals, the majority of that are for-profit. These hospitals collectively generate earnings of 10%, greater than normal hospitals, which earn about 6%, and excess of expert nursing houses, which make lower than 0.5%, in line with the latest knowledge from the Medicare Fee Advisory Fee, an unbiased congressional company.
On the similar time, the variety of small, specialised models inside acute care hospitals — the place most rehab was once offered — has dwindled. There at the moment are round 800 of these, and most are nonprofits.
In its newest annual report, Embody, which is publicly traded, reported an 11% web revenue in 2024, incomes $597 million final yr on revenues of $5.4 billion.
Federal knowledge on the efficiency of about 1,100 of the rehab amenities present Embody tends to be higher at serving to most sufferers return dwelling and stay there. In a two-year interval ending in September 2023, Medicare rated 233 rehab amenities as performing higher than the nationwide price for this main metric, referred to as “discharge to neighborhood.” Most rehabs with higher neighborhood discharge charges are for-profit, and Embody owns 79 of them.
However knowledge from Medicare additionally reveals Embody owns lots of the rehabs with worse charges of doubtless preventable, unplanned readmissions to normal hospitals. Medicare evaluates how typically sufferers are rehospitalized for situations that may have been averted with correct care, together with infections, bedsores, dehydration, and kidney failures.
Embody accounts for about 1 in 7 rehab amenities nationally, however owned 34 of the 41 inpatient rehab amenities that Medicare rated as having statistically considerably worse charges of doubtless preventable readmissions for discharged sufferers. (General, charges of readmission after discharge ranged from 7% to 12%, with a median of 9%.)
And it owned 28 of the 87 rehab amenities — 65 of which had been for-profit — that had worse charges of doubtless preventable readmissions to normal hospitals throughout affected person stays. (The median for these sorts of readmissions was 5%, and charges for particular person rehabs ranged from 3% to 9%.)
Patrick Darby, the manager vp and normal counsel of Embody, strongly defended the corporate’s document in written responses to questions. He dismissed Medicare’s readmissions rankings of “higher,” “worse,” and “no totally different than the nationwide price” as “a crude scoring measure” and mentioned “efficiency is so related throughout the board.” He referred to as the violations discovered throughout well being inspections “uncommon occurrences” that “don’t help an inference of widespread high quality considerations.”
“The best and most correct cause for EHC’s success is that our hospitals present superior care to sufferers,” he mentioned, referring to Embody by its company initials.
Chih-Ying Li, an affiliate professor of occupational remedy on the College of Texas Medical Department at Galveston College of Well being Professions, mentioned in an interview {that a} analysis examine she performed discovered the revenue standing of a rehab facility was the one attribute related to greater unplanned readmissions.
“The discovering is fairly strong,” she mentioned. “It’s not like enormous, enormous variations, however there are variations.”
Alarming Errors
VanBibber was admitted to Embody’ Huntington hospital in 2021 for remedy to strengthen her lungs. On the time, the hospital was present process a $3 million growth, and state regulators had warned the corporate that areas of the hospital occupied by sufferers needed to be remoted from the development “utilizing hermetic obstacles,” in line with a well being inspection report.
In her room, which was about 66 ft from the development zone, she started having bother respiration, the report mentioned. When she informed the employees, they ignored her and shut her door, in line with a lawsuit introduced by her property. Workers members ultimately seen that she was “torpid and gasping for air,” and referred to as 911.
When the emergency medical squad arrived, the carbon monoxide detectors they wore sounded. By that point, VanBibber’s blood oxygen ranges had been dangerously low, the inspection report mentioned. She died three days later from respiratory failure and carbon monoxide poisoning, in line with the inspection report and the lawsuit. A plumber had been utilizing a gas-powered noticed within the development space, however there have been no carbon monoxide detectors within the hallways, the report mentioned.
In court docket papers, Embody and its development contractors denied negligence for VanBibber’s demise. The case is pending.
Inspectors decided Embody failed to take care of a protected surroundings for all sufferers throughout development and didn’t correctly consider different sufferers for indicators of poisoning, the report mentioned.
Since 2021, the federal Facilities for Medicare and Medicaid Providers, or CMS, which oversees well being inspections, has discovered that 10 Embody hospitals, together with the one which cared for VanBibber, had rapid jeopardy violations, federal data present. Such violations — like those that Medicare additionally present in reference to the deaths of Roufs and the affected person who fell after leaving his mattress — imply a hospital’s failure to adjust to federal guidelines has put sufferers in danger for severe harm, severe hurt, severe impairment, or demise.
Darby, the final counsel for Embody, mentioned the corporate regretted any medical issues and had promptly addressed all such findings to the satisfaction of inspectors. He mentioned Embody that has an “glorious compliance document,” together with superior outcomes from its accreditation company, and that its total variety of well being citations was tiny given what number of hospitals Embody owns and what number of sufferers it treats.
Six different corporate-operated for-profit hospitals had been additionally cited, whereas not one of the 31 stand-alone nonprofit rehab hospitals acquired such violations from 2021 to 2024. (Inspection stories for normal hospitals don’t systematically specify during which a part of the constructing a violation occurred, so rehab unit violations can’t be recognized.)
An alert referred to as a mattress alarm was on the root of rapid jeopardies at Embody hospitals in Morgantown, West Virginia, and Jackson, Tennessee. The gadgets are pressure- and motion-sensitive and emit a sound and show a lightweight to alert employees members that somebody at a excessive threat of falls has left his or her mattress.
In its Morgantown hospital, a nurse technician found a affected person face down on the ground with a big gash on her head after a faulty alarm didn’t go off, an inspection report mentioned. After she died, the nurse informed inspectors: “We’re having a whole lot of issues with the mattress alarms.”
Medicare will not be licensed by regulation to fantastic rehab hospitals for security rule violations, even ones involving deaths uncovered throughout inspections, because it has achieved with almost 8,000 nursing houses over the last three years, imposing common fines of about $28,000.
The one choice is to completely reduce off a rehab hospital’s reimbursement for all companies by Medicare and Medicaid, which cowl most sufferers. That step would almost definitely put it out of enterprise and is sort of by no means used due to its draconian penalties.
“Termination is often a final resort after working with the supplier to come back again into compliance,” Catherine Howden, a CMS spokesperson, mentioned in an electronic mail.
Because of this, as a result of there’s no graduated penalty, even essentially the most severe — and uncommon — rapid jeopardy violations successfully carry no punishments as long as the hospital places steps in place to avert future issues.
“Solely having a nuclear weapon has actually harm affected person security,” mentioned Michael Millenson, a medical high quality advocate.
One rapid jeopardy incident did lead to a punishment, however solely as a result of the hospital was in California, which permits its well being division to subject penalties. Embody’ Bakersfield hospital paid a $75,000 fantastic final yr for failing to regulate the blood sugar of a affected person who died after her coronary heart stopped.
Fast Development and a Troubled Historical past
Embody has accelerated its growth lately and now operates in 38 states and Puerto Rico. It plans to open 17 extra hospitals in Arizona, Connecticut, Florida, Georgia, Maine, Pennsylvania, South Carolina, Texas, and Utah by the tip of 2027, in line with its newest report.
It continuously strikes into new markets by persuading native nonprofit hospitals to shutter their rehab models in alternate for an fairness stake in a newly constructed Embody hospital, firm executives have informed traders.
The president of Embody, Mark Tarr, calls it a “win-win proposition”: The native hospitals can use their emptied area for a extra profitable line of service and Embody will get a “soar begin” into a brand new market, with associate hospitals typically referring sufferers.
Tarr, who was paid $9.3 million in compensation final yr, informed traders that Embody requires that the prevailing hospitals signal a noncompete deal. Sixty-seven Embody hospitals are joint ventures, principally with nonprofit hospitals as traders, in line with the corporate’s June monetary submitting, the latest obtainable.
Darby mentioned the corporate’s earnings permit it to construct hospitals in areas that lack intensive inpatient rehabilitation and enhance present hospitals. “Excessive-quality affected person care will not be solely according to shareholder return, however high quality and shareholder return are in actual fact crucial to 1 one other,” he mentioned.
The success of Embody is especially notable provided that it barely survived what specialists mentioned was one of many largest trendy accounting scandals in 2003.
The Securities and Change Fee charged that the corporate, then generally known as HealthSouth, overstated earnings by $2.7 billion to fulfill Wall Road analyst quarterly expectations, resulting in the ouster of its founder and administrators. In 2004, the corporate agreed to pay the federal government $325 million to settle Medicare fraud allegations with out admitting wrongdoing. Darby credited the corporate’s new leaders for acquiring a $2.9 billion judgment on behalf of shareholders towards the corporate’s founder.
The corporate modified its title to Embody in 2018 after buying Embody House Well being and Hospice. In 2019, the Justice Division introduced the corporate had agreed to pay $48 million to settle whistleblower lawsuit claims that it misdiagnosed sufferers to get greater Medicare reimbursements, and admitted sufferers who had been too sick to learn from remedy. The corporate denied any wrongdoing, blaming unbiased physicians who labored at its hospitals. Darby mentioned Embody settled the case solely to “keep away from extra years of expense and disruption.” He mentioned the Justice Division by no means filed a lawsuit regardless of years of investigation.
Treatment Harms
Rehab hospital inspection stories aren’t posted on Care Examine, Medicare’s on-line search device for customers. KFF Well being Information needed to sue CMS below the Freedom of Data Act to acquire all its inspection stories for rehab hospitals. In distinction, Care Examine publishes all nursing dwelling inspection stories and assigns every facility a star ranking for its adherence to well being and security guidelines.
So individuals now selecting a rehab hospital wouldn’t know that on the Embody hospital in Sioux Falls, South Dakota, in 2021, a nurse unintentionally gave Roufs a blood stress drug referred to as hydralazine as an alternative of hydroxyzine, his prescribed anti-anxiety remedy, in line with an inspection report. Roufs went into cardiac arrest. This sort of error, referred to as a “look-alike/sound-alike,” is one hospitals and employees members are purported to be particularly alert to.
Months earlier than, an inner security committee had recognized a development of remedy errors, together with when a nurse unintentionally gave a affected person 10 occasions the prescribed quantity of insulin, sending him to the hospital, the inspection report mentioned. The nurse had misinterpret 4 models as 40. Since Roufs’s demise, inspectors have faulted the hospital six occasions for numerous lapses, most just lately in April 2024 for improper wound care.
An Embody hospital in Texarkana, Texas, misused antipsychotic drugs to pacify sufferers, leading to an instantaneous jeopardy discovering from CMS, the report mentioned. And the corporate’s hospital in Erie, Pennsylvania, was issued an instantaneous jeopardy violation for not retaining observe of remedy orders in 2023, when a affected person had a cardiac arrest after not receiving all of his medication, in line with the inspection report.
The federal authorities’s total high quality oversight efforts are restricted. Medicare docks cost to rehab amenities for sufferers readmitted to a normal hospital throughout shorter-than-average rehab stays, however not like at normal hospitals, there are not any monetary penalties when just lately discharged rehab sufferers are hospitalized for crucial well being points.
The Biden administration introduced final yr it meant to develop a ranking scale of 1 to five stars for rehab amenities. The business’s commerce affiliation, the American Medical Rehabilitation Suppliers Affiliation, requested a delay within the creation of star rankings till the present high quality measures had been refined. The Trump administration has not decided whether or not it’s going to proceed the hassle to price rehab amenities, in line with a CMS spokesperson.
Lethal Bedsores
The household of Paul Webb Jr., 74, claimed in a lawsuit that the Embody hospital in Erie left Webb unattended in a wheelchair for hours at a time, placing stress on his tailbone, in 2021. His medical data, offered to reporters by the household, record a sitting tolerance of 1 hour.
Webb — who had been initially hospitalized after a mind bleed, a sort of stroke — developed pores and skin injury generally known as a stress sore, or bedsore, on his backside, the lawsuit mentioned. The swimsuit mentioned the sore worsened after he was despatched to a nursing dwelling, which the household can also be suing, then dwelling, and he died later that yr. In his ultimate weeks, Webb was unable to face, sit, or transfer a lot due to the harm, the lawsuit mentioned.
In court docket papers, Embody and the nursing dwelling denied negligence, as Embody has in another pending and closed lawsuits that accused it of failing to stop stress sores as a result of nurses and aides didn’t repeatedly reposition sufferers, or discover and deal with rising sores. Darby mentioned Webb’s demise occurred three months after his Embody keep and was not associated to his care at Embody. He mentioned no hospital with long-term sufferers might forestall each new or worsening stress sore, however that Embody’ charges had been just like the 1% nationwide common.
One among Webb’s sons, Darel Webb, recalled a warning given to the household as they left an appointment their father had with wound specialists: A physician introduced up Christopher Reeve, the actor who performed Superman in motion pictures within the Seventies and Nineteen Eighties.
“He goes, ‘Keep in mind, Superman was paralyzed from falling off the horse, however he died from a bedsore,’” he mentioned.
Jordan Rau has been writing about hospital security since 2008. Irena Hwang is a New York Instances knowledge reporter who makes use of computational instruments to uncover hidden tales and illuminate the information.
METHODOLOGY
To look at the medical rehabilitation hospital business, we obtained and analyzed a database of inspection stories of freestanding rehabilitation hospitals from the federal Facilities for Medicare & Medicaid Providers, or CMS. We additionally obtained inspection stories from a number of states by means of public data requests.
We analyzed inpatient rehabilitation facility traits and affected person quantity knowledge contained in hospital knowledge recordsdata from the Rand Corp., a nonprofit analysis group. This dataset compiles value stories all hospitals submit every year to CMS. For every facility for the years 2012 to 2023, we categorized annual discharges by facility sort (freestanding rehabilitation hospital or unit inside an acute care hospital); facility possession standing (for-profit, nonprofit, or authorities); and which hospitals had been owned by Embody Well being below its present or prior title, HealthSouth.
Monetary details about Embody Well being was obtained from the corporate’s Securities and Change Fee disclosure filings.
We examined the readmission charges for all inpatient rehabilitation amenities that CMS publishes in its high quality knowledge. CMS evaluates the frequency with which Medicare sufferers had been readmitted for probably preventable causes to an acute care hospital throughout their rehab keep. Individually, CMS additionally evaluates the frequency of doubtless preventable readmissions to an acute care hospital inside 30 days of discharge from rehab. We additionally examined the speed of profitable return to dwelling or neighborhood. Figures for all three metrics had been obtainable for about 1,100 of the roughly 1,200 rehab amenities within the CMS knowledge. The newest readmission knowledge coated Medicare discharges from October 2021 by means of September 2023.
We examined nursing dwelling penalties from the final three years from CMS’ knowledge on nursing houses.
