Education

Raising concerns about quality

Miami

While working as the assistant director of education at ATI Career Training Center’s Fort Lauderdale campus, Dulce Ramirez-Damon said she witnessed medical assistant classes taught by instructors who lacked a bachelor’s degree, and students who didn’t understand “where the vein was, or how to grab it.”

So Ramirez-Damon delivered this message to her family: If you’re ever at the hospital, make sure to ask where the person taking care of you went to school.

“If it’s anybody from ATI, you request someone else,” Ramirez-Damon said she told them. “I told my sister, I told my brother, and I had them tell their friends as well.”

ATI is now closed. It filed for bankruptcy last year after Ramirez-Damon and six other employees filed whistle-blower lawsuits that alleged massive taxpayer fraud. But the school lives on through ATI grads, working in the field.

Just because a school is accused of wrongdoing doesn’t mean its graduates aren’t qualified. There are dedicated students, and instructors, at even the most troubled schools.

But both students and instructors at for-profits have raised concerns about the screening of enrollees and the quality of the instruction.

Florida’s “career colleges,” which are mostly for-profit, now account for about 60 percent of Florida’s healthcare graduates in fields such as nursing, ultrasound technology and medical assistant, according to the industry’s trade association. And while statistics show many who graduate don’t pass the professional exams required to enter the workplace, many do.

“They [didn’t] allow us to fail anybody. It’s all about the money,” said Tara Horsley, a registered nurse who taught at Keiser Career College and Fortis Institute. Horsley said administrators at both schools inflated the grades of students who deserved to fail.

“These nurses are not prepared. They don’t feel confident,” she said. “They’re going to go to work every day until something bad happens. And it’s going to be a relative of mine, or yours.”

Horsley recalled a student at Keiser Career College, a Vietnam veteran in his 60s who demonstrated clear evidence of mental instability. Horsley questioned whether he should have been enrolled in the first place, and there were times when his erratic behavior made Horsley fear for her safety.

One day during his clinical training at a hospital, Horsley said, and he made a mistake on a patient — exposing fecal matter onto a part of a patient’s body that needed to be sterile. The mistake could have led to an infection, Horsley said, and was serious enough that the hospital wrote up an incident report.

The student dropped out of school soon after.

In a sworn statement dated April 28, 2011, and covering 67 pages, Horsley made similar statements to Gregory Jackson of the Florida attorney general’s office.

Greenacres-based Keiser Career College has since been renamed Southeastern College, though it remains a for-profit and is still part of the Keiser family of schools. That grouping includes the much-larger Keiser University, which in 2011 converted from a for-profit institution into a nonprofit.

In an interview with the Herald, Keiser University Chancellor Arthur Keiser said Horsley was a malcontent terminated for cause. He said her complaints were investigated by the school and found to be without merit. The settlement Keiser University reached with Attorney General Pam Bondi required his schools to offer free retraining for some students while making sure that recruiters provide “true and accurate” information to prospective students. There was no admission of prior wrongdoing and nothing in the settlement addressed Horsley’s allegations.

Chancellor Keiser noted that Keiser University’s nursing program is accredited — most nursing schools in the career college sector are not — and that its passage rates on the NCLEX licensing exam are comparable to traditional universities, which is true.

“We have a huge impact, positive impact, on healthcare systems in Florida,” Keiser said. “You go anywhere, you will find one of our workers.”

The passage rate is lower — 42 percent — at Southeastern’s St. Petersburg campus, where Horsley taught.

Horsley denied she was fired, stating she resigned because of complications from a pregnancy. She provided emails from her former boss, then-nursing dean Linda Quiett, that congratulated Horsley on the birth of her twins and encouraged her to re-apply “when a position opens.”

Asked about the emails, Keiser officials said they couldn’t provide documentation of Horsley’s firing unless Horsley signed a privacy-release form, which she declined to do.

After leaving Keiser, Horsley took a job at the for-profit Fortis Institute. Horsley said she had a female student who showed up for clinical training drunk. It was her second offense of that nature, Horsley said. She sent the student home.

“Do you know that student passed that course?” Horsley said. “They had a meeting without my knowledge.”

The parent company of Fortis, Education Affiliates, confirmed that Horsley taught there, but it said her employment had been “contracted by an outside agency,” and therefore the company had no records and couldn’t comment.

Confident in quality

As the executive director of the Florida Association of Postsecondary Schools and Colleges (FAPSC), Curtis Austin represents the career college sector, which is mostly for-profit colleges but includes some nonprofits such as Keiser University. He said he’s confident in the quality of medical professionals trained by his schools. If disturbing anecdotes like Horsley’s were a true picture, he said, “you’d have chaos going on out there, and you don’t.”

“Every time that I go to my doctor, the person who takes care of all of my medical stuff is a Keiser graduate and I’m always happy to be there,” Austin said. “I would go to anybody that’s been trained in our sector.”

But Anna Small, a healthcare attorney and former vice president of the Florida Nurses Association, has doubts. She said that when the Florida Board of Nursing used to approve new schools, it had a reputation for tough scrutiny. In 2009, after Florida lawmakers diminished the board’s role in the process, everything swung to “really the opposite end of the spectrum,” she said.

Technically speaking, the Board of Nursing still signs off on new schools, but the Legislature removed the discretion the board had in rejecting programs. The board’s role is now to inspect school applications and make sure that all the required paperwork is there.

If so, Florida law states the board’s course of action is to “approve the application.”

With less oversight, there’s been a boom in new nursing programs — from 175 in 2009 to 366 in 2014. There are also troubling signs.

The explosion of mostly for-profit nursing schools has coincided with a drop in Florida’s passage rate on the license exam. Once in the middle of the pack among states, Florida’s overall RN passage rate dropped from 88.4 percent in 2009 to just under 72.6 percent in 2014, second to last among the 50 states.

Florida’s new nursing schools often advertise that they are “approved by the Board of Nursing,” which can falsely suggest that a rigorous screening process took place before the school opened.

More than 12,000 Florida nursing graduates took the RN exam in 2014. The Miami Herald analyzed those results, based on the type of school the students attended.

Students from public colleges or universities performed the best, with an 84.4 percent RN passage rate. Students from nonprofit schools, including the Keiser campuses, were close behind, at 80.9 percent.

For-profit college students had a pass rate of 52 percent.

A degree in 24 hours

One safeguard under Florida law requires that nursing schools administrators and faculty have specific qualifications. For an RN program, 50 percent of the program’s faculty members must be registered nurses who have a master’s or higher in nursing or a bachelor’s degree in nursing, and a master’s or higher degree in a related field.

It doesn’t say from where. At the Academy for Nursing and Health Occupations in West Palm Beach, at least 10 instructors are listed as having nursing or other credentials from Corllins University — a “virtual campus” not recognized by the U.S. Department of Education.

Corllins’ website says a master’s or PhD., based on life experience, can be secured in 24 hours. “Total course fee” is $6,291, payable in advance.

Asked about the Corllins credentials, Academy President Lois Gackenheimer, who lists both a master’s and a doctorate from Corllins, declined to comment.

“What is this all about?” said Gackenheimer “I wish not to answer.”

At Dade Medical College, the director of nursing, Giselle Scheuermann, sent at least five emails to students between July and December of 2013 representing herself as a master’s-level Advanced Registered Nurse Practitioner. She wasn’t at the time. According to Florida records, she did not obtain her ARNP state license, enabling her to prescribe medicines, until July of 2014.

Under Florida law, that is a misdemeanor offense.

Asked about the emails, Scheuermann said: “I’m not sure what you’re talking about.” She passed the cellphone to her boss, co-CEO Raul Mendez, who said questions must be submitted in writing.

Dade Medical College owner Ernesto Perez, in an email to the Herald, wrote that “Ms. Scheuermann did and does hold an NP degree, however since she is in the field of education she was not required to register as she was not practicing. This is the equivalent of a doctor from Washington not being able to practice in Florida until he registers with the Bar.”

The rise in for-profit nursing schools has been accompanied by a rise in for-profit RN programs that are not accredited. Accreditation is conferred by the Accrediting Commission for Education in Nursing (ACEN) or the Commission on Collegiate Nursing Education (CCNE) and signifies that a school meets certain standards. Completed classwork at accredited institutions can transfer to traditional schools.

In a 2012-2013 survey by the Florida Center for Nursing, only 2 percent of responding for-profit associate’s degree (two-year) programs were accredited. Only 33 percent of for-profit bachelor’s degree programs that responded were accredited.

Among nonprofits that responded, 80 percent of associate’s degree programs were accredited, and 100 percent of bachelor’s degree programs.

Baptist Health South Florida, which gives preference to students from accredited programs in its hiring practices, told the Herald “accreditations guarantee that students are receiving a top-notch education from the best instructors in their field.”

Understanding a program’s accreditation status can be tricky. On the Board of Nursing website, there are three categories: accredited, accepted and probation. Accredited is self-explanatory. “Accepted” translates to unaccredited. “Probation” means the school’s scores on the NCLEX have been at least 10 points below the national average. Schools on probation can lose their license to operate if graduates keep failing the test.

Board in a squeeze

In 2013, Miami-area Rep. Carlos Trujillo attached an amendment to an unrelated bill allowing for unaccredited physical therapy assistant programs.

Trujillo’s measure alarmed some physical therapy professionals. Debra Stern, Nova Southeastern University’s director for clinical education for physical therapy, said unaccredited programs create a “bigger risk” of medical errors, including refractures, patient falls or even heart attacks.

Accreditors scrutinize the quality of the faculty and also conduct interviews with local employers who have experience with a school’s graduates. Stern, who was offering her own opinion and not speaking on behalf of Nova, said she is “embarrassed” that Florida would permit unaccredited programs — something that, according to the American Physical Therapy Association, no other state has done.

In the coming months, hundreds of students are expected to graduate from unaccredited programs, mostly from Dade Medical. Citing public safety concerns, Florida’s Board of Physical Therapy had been reluctant to allow them to take the state licensing exam.

But at a February 2015 meeting, the board encountered political pressure. Mark Murray, an attorney for Dade Medical College, introduced himself as “one of the attorneys who intends to sue you.” Miami Gardens state Sen. Oscar Braynon II drove to Gainesville for the meeting. Braynon, who spoke at Dade Medical’s graduation ceremony last year, said the Legislature wants these students to sit for the test.

Larry Harris, an assistant attorney general who advises the physical therapy board, told board members, “I understand the conundrum that you feel yourselves to be in, with your duties to protect the public, but at the same time, the Legislature has spoken. You work for them.”

If board members didn’t go along, Harris said, they would “certainly face repercussions” when it came time for their reappointment.

The board relented. One board member — William Quillen, director of the physical therapy program at the University of South Florida — resigned two days later.

In an interview, Quillen said the clincher for him was when Harris publicly told board members that if they stuck to their position and were sued, the attorney general’s office might not defend them.

“If my attorney general is not going to represent me in doing the right thing, in protecting the public safety, then I knew it was time for me to get off the board,” Quillen said.

In Perez’s email, he rejected the idea that Dade Medical is “unaccredited.”

“That is an outright lie!!” he wrote. He then named three different accreditations his school does have. None of them specialize in physical therapy.

Practice on patients

The for-profit industry and some state lawmakers say licensing tests prevent unprepared students from advancing into the workforce and potentially harming patients.

But there’s an exception: While in school, all students — including those who eventually end up flunking the license test — get hands-on experience with patients during supervised “clinical” training rotations. An example is the Vietnam veteran described by Tara Horsley.

The Herald reported last year that Dade Medical College, which has three campuses on state probation, was awarded valuable ultrasound clinical slots at Jackson Memorial Hospital after signing a pay-for-slots contract that netted the hospital nearly $390,000. At the same time, the public hospital ended its partnership with Miami Dade College, which had previously gotten the slots for free.

Dade Medical also made more than $1 million in charitable donations to Miami Children’s, Memorial Regional, and Mount Sinai hospitals — securing coveted clinical spots from all three.

Those three hospitals said there was no connection between the charitable donations and the newly awarded training spots. Jackson’s contract with Dade Medical expired in August, and was not renewed, the hospital said.

Perez’s email said there was nothing wrong with the donations, and that the payments to Jackson were to make sure his students “received the best possible training money could buy!!”

While Dade Medical gained access to elite hospitals, some students of the school complained about the education they were receiving. One radiology student, whose name is redacted in state records, wrote to Florida’s Commission for Independent Education on June 23, 2013, that the school’s training was so poor that it puts graduates at risk of committing malpractice, and “poses a huge threat to patients on many levels.”

In its response, Dade Medical College said the student had been kicked out of school for poor grades.

In June 2014, a Dade Medical nursing student wrote that teachers “continually pass students, even those that do not get a passing grade,” adding that “they also have shown a total disregard for the well-being of the future patients, enabling total incompetency and lack of training at their bedsides. This could potentially endanger or even kill someone.”

In its response, Dade Medical wrote that “patient care and safety is of utmost importance to the College and its faculty.”

In January 2015, a physical therapy assistant program student wrote: “They do not offer any anatomy courses, which I think is the foundation of the physical therapy program. The professors that are hired are not qualified to teach ... we skip thru most of the chapters in chunks at a time.”

In its response, Dade Medical acknowledged that its curriculum had lacked anatomy courses but said this “deficiency” that had been rectified.

The June and January complaints were quickly dismissed.

Linda Quick, president of the South Florida Hospital & Healthcare Association, said the complaints show students aren’t getting the education they paid for.

“They know it,” Quick said. “And they’re uncomfortable, as they ought to be, putting themselves in a position where they’re being asked to do something they don’t know how to do.”

Legislator of the year

Sen. Denise Grimsley, a registered nurse, was the sponsor of the 2009 and 2010 laws that made it easier to open a nursing school in Florida. She says the Board of Nursing deserved to be cut out of the picture because it was holding up nursing school applications over trivial issues.

“Because they didn’t like the color of the wall the offices were painted,” she said. “It was just crazy stuff like that.”

Ann-Lynn Denker, a nursing teacher at Barry University who served on the nursing board until recently, was skeptical that the rejected schools that year — or any other year — lost because of their color scheme.

“I suspect that the schools were upset that they weren’t getting permission to open for legitimate reasons,” she said.

Grimsley acknowledged that her laws made it easier for problem schools to pop up, but she said “it also created the environment for a lot of good schools and a lot of good programs to open up.”

FAPSC named Grimsley “Legislator of the Year” for her nursing legislation.

Last year, Grimsley sponsored a bill that required all nursing schools be accredited. It passed, but it won’t take effect until 2019.

In the meantime, the industry was able to attach an amendment that gave underperforming for-profit colleges an instant benefit: Nursing programs on probation for low passage rates on the NCLEX exam would get three years to lift performance before being shut down, instead of two years, as long as progress was being made.

Grimsley said that amendment, added by Miami Rep. Erik Fresen, was pushed by Dade Medical College.

“That was theirs,” she said. Fresen denied his amendment was done to benefit Dade Medical or any other school with campuses on probation. In an interview, Fresen said failing K-12 schools are allowed to stay open if they show improvement.

“We pretty much took the same methodology that school districts ask us to apply,” Fresen said.

Denker, the Barry teacher who served on the Board of Nursing, said the state should go back to the old system of allowing the board to fully evaluate new programs. She said contrary to Grimsley’s statement about rejecting schools over color schemes, the board always welcomed quality nursing schools.

A report by the staff of the Florida Legislature said that, in the year-and-a-half before the law change diminishing the board’s role, the nursing board received 18 applications to open nursing programs. It approved 17.

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