Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
Attention: MDS Coordinators, Reimbursement Specialists, Facility Owners and Management Teams. This is a news release you need to read. Falsifying MDS assessments has very serious consequences as does falsifying staffing records!
“Five individuals and two for-profit skilled nursing facilities in Southwestern Pennsylvania have been indicted by federal grand jury in Pittsburgh on charges of conspiracy to defraud the United States and related health care fraud charges, United States Attorney Cindy K. Chung announced today.
The 15-count Superseding Indictment, returned on August 5, 2022, named
- Sam Halper, age 39, of Miami Beach, Fla.
- Eva Hamilton, age 35, of Beaver, Pa.
- Susan Gilbert, age 61, of Lawrence, Pa.
- Michelle Romeo, age 46, of Hillsville, Pa., and
- Johnna Haller, 41, of Monaca, Pa., as co-defendants.
Also named in the Superseding Indictment were two nursing facilities operating in Western Pennsylvania, Comprehensive Healthcare Management Services, LLC d/b/a Brighton Rehabilitation and Wellness Center and Mt. Lebanon Operations, LLC d/b/a Mt. Lebanon Rehabilitation and Wellness Center.
The Superseding Indictment alleges that Halper, the CEO and part-owner of the two indicted skilled nursing facilities, among others, conspired with others to defraud the United States and commit healthcare fraud. The Superseding Indictment alleges two schemes: first, that management-level employees at two nursing facilities, Brighton Rehabilitation and Wellness Center and Mt. Lebanon Rehabilitation and Wellness Center, knowingly provided, or directed others to provide, falsified staffing records to the Pennsylvania Department of Health (DOH) during federally mandated surveys; and second, that the facilities, under the direction of Halper and two other regional directors, Michelle Romeo and Johnna Haller, made false statements in resident assessments, also called Minimum Data Set (MDS) assessments, provided to the government to increase Medicare and Medicaid reimbursements.
Count One of the Superseding Indictment charges Halper and the former Director of Nursing, Eva Hamilton, with, from in and around June 2018, to in and around January 2020, conspiring to defraud the United States by obstructing and interfering with the lawful governmental functions of the Centers for Medicare and Medicaid Services (CMS); that is, co-defendants Halper and Hamilton, as well as other co-conspirators conspired to interfere with and obstruct DOH in its ability to conduct valid federally mandated surveys of the care provided to residents at Brighton by knowingly falsifying staffing sheets provided to DOH in order to show that the facilities were in compliance with the conditions of participation in Medicare and PA Medicaid. Among other acts, co-defendants Halper and Hamilton, as well as other co-conspirators added the names of nursing staff who were not in the building on the dates listed on records provided to DOH to make it appear as though these nurses were working and providing direct care to residents. The co-defendants allegedly engaged in these acts in whole or in part, to avoid government sanctions, including a denial of payments for new admissions, additional monitoring, the imposition of civil monetary penalties, and other potential penalties.
Count Two of the Superseding Indictment charges these same individuals as well as Brighton, with, between on or about July 18, 2018, to on or about January 22, 2020, falsifying, concealing or covering up by trick, scheme or device material facts in connection with the delivery of or payment for health care benefits; that is, the co-defendants engaged in a scheme to provide falsified staffing sheets to DOH in order to show that Brighton was in compliance with the conditions of participation in Medicare and Medicaid, including that the facility had “sufficient” nursing staff to meet residents’ needs and that the facilities were operating and providing services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Counts Three through Seven of the Superseding Indictment charge Hamilton and Brighton with making false statements in staffing records with the intent to impede, obstruct, and influence the investigation and proper administration of a matter within the jurisdiction of CMS, an agency of the United States.
Count Eight of the Superseding Indictment charges Susan Gilbert, the former Administrator of Mt. Lebanon Rehabilitation and Wellness Center and the current Administrator of another facility owned by Halper, with, from on or about October 10, 2018, to in and around March 2020, conspiring to defraud the United States by interfering with and obstructing DOH in its ability to conduct valid federally mandated surveys of the care provided to residents at Mt. Lebanon. Among other acts, the Superseding Indictment alleges that Gilbert and/or other co-conspirators directed administrative and management-level nursing staff and other employees to “clock-in” for shifts not actually worked. In doing so, Mt. Lebanon Rehabilitation and Wellness Center created falsified timecard documentation provided to DOH that made it appear as though these individuals were providing direct resident care, when in fact they were not in the building and therefore not providing direct resident care.
Count Nine charges Gilbert and Mt. Lebanon, with, on or about November 13, 2019, and continuing to on or about February 20, 2020, participating in a scheme to falsify, conceal or cover up by trick, scheme or device material facts in connection with the delivery of or payment for health care benefits; that is, the co-defendants engaged in a scheme to provide falsified staffing sheets to DOH in order to show that Mt. Lebanon had “sufficient” nursing staff to meet residents’ needs and that the facilities were operating and providing services in compliance with all applicable Federal, State, and local laws, regulations, and codes.
Counts Ten through Twelve charge Gilbert and Mt. Lebanon with making false statements with the intent to impede, obstruct, and influence the investigation and proper administration of a matter within the jurisdiction of CMS.
Count Thirteen charges Gilbert further with, in or around March 2020, participating in a scheme to falsify staffing records at another nursing facility in order to show that this facility was in compliance with the conditions of participation in Medicare and Medicaid.
In addition, Count Fourteen of the Superseding Indictment alleges, from in and around June 2014 to in and around June 2021, Halper conspired with two regional-level employees, Michelle Romeo and Johnna Haller, and others to commit healthcare fraud. Among other acts, the Superseding Indictment alleges that Romeo instructed nursing staff that completed MDS assessments at the various facilities she supervised to make changes to residents’ assessments to ensure that those facilities had certain Case Mix Index (CMI) score associated with higher reimbursements. Romeo and other co-conspirators also instructed staff at the facilities to create false documentation in residents’ MDS assessments to justify changing a resident’s Activities of Daily Living (ADL) score – a score intended to reflect a resident’s needs for assistance with daily living activities such as bed mobility, toilet use, and eating – by writing a note stating that the changes were made after “interviewing” nursing staff when in fact no such interviews were conducted.
Co-defendants Halper, Romeo and Haller and/or other co-conspirators also conspired to input inaccurate responses to certain resident questionnaires in order to falsely inflate residents’ depression scores. The Superseding Indictment alleges that Halper, Romeo and Haller directed these changes in the MDS data to increase reimbursements and not to accurately capture residents’ medical conditions or needs.
Count Fifteen of the Superseding Indictment charges Romeo and Haller, with from in and around December 2016 to in and around June 2021, with health care fraud related to their involvement in the submission of false information in the MDS assessments to receive higher reimbursements from Medicare and Medicaid.
“Our office will continue to hold individuals and facilities that break the law accountable,” said U.S. Attorney Chung. “Health care fraud is not a victimless crime. It affects everyone—individuals and businesses alike—and causes tens of billions of dollars in losses each year.”
“Through our joint investigation with the U.S. Attorney’s Office for the Western District of Pennsylvania and the Federal Bureau of Investigation, we found that Brighton and Mt. Lebanon’s senior administrators used two criminal schemes to take advantage of federal programs and make extra money while putting residents at risk,” said Pennsylvania Attorney General Josh Shapiro. “These charges today represent a dereliction of duty to report accurate information, criminal schemes designed to manipulate the system, and above all else, companies and individuals that put profits above truthful reporting. I am proud to stand with our federal partners and in unison say, we will not stand by while companies or those who run them break our laws and put people’s safety at risk.”
“Health care fraud impacts every American and destroys the basic trust between providers and patients,” said FBI Pittsburgh Special Agent in Charge Mike Nordwall. “Fraud and abuse take critical resources from across our health care system and contribute to the rising cost of health care for everyone. The FBI will continue to work with our partners to investigate and hold accountable those who exploit the health care system at the expense of patients.”
“Health care fraud will not be tolerated. It is a federal crime that carries serious consequences,” stated Special Agent in Charge Maureen Dixon of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “Working closely with our law enforcement partners, HHS-OIG remains committed to detecting and preventing illegal actions and holding parties who execute them accountable.”
“Today’s superseding indictment underscores the commitment of our office to bring this investigation to a thorough and complete conclusion,” said Yury Kruty, Special Agent in Charge of IRS-Criminal Investigation. “Actions like those outlined in the indictment are carried out for greed and can put people at risk. IRS-Criminal Investigation will continue working in a collaborative manner with our law enforcement partners to prosecute offenders who execute schemes like this.”
As to Counts One, Two, Eight, Nine and Thirteen, the law provides for a maximum total sentence of not more than five years in prison, a fine of $250,000 or both. Counts Three through Seven, and Ten through Twelve each carry a maximum possible sentence of twenty years in prison, a fine of $250,000 or both. Finally, Counts Fourteen and Fifteen each carry a maximum possible sentence of ten years in prison, a fine of $250,000 or both. Under the Federal Sentencing Guidelines, the actual sentence imposed would be based upon the seriousness of the offenses and the prior criminal history, if any, of the defendants.
Assistant United States Attorneys, Robert S. Cessar, Karen Gal-Or and Nicole A. Stockey are prosecuting this case on behalf of the government.
The Federal Bureau of Investigation, the U.S. Department of Health & Human Services – Office of Inspector General, the Pennsylvania Office of Attorney General, and the Internal Revenue Service – Criminal Investigation conducted the investigation leading the Superseding Indictment in this case.
An Indictment is an accusation. A defendant is presumed innocent unless and until proven guilty.”
[NOTE: I’ve bolded and underlined the penalties for such fraud above to emphasize the seriousness of such offenses.]