Tuesday, August 19, 2014

Discharge from Hospice

We have blogged previously on hospice, and a new article adds to the body of literature on the subject.  The Journal of Palliative Medicine published an article by Dr. Joan Teno, Dr. Michael Plotzke, Dr. Pedro Gozalo, and Dr. Vincent Mor, A National Study of Live Discharges from Hospice. The study recognizes that there are various reasons that a person may leave hospice care, such as "patients decide to resume curative care, their condition improves, or hospices may inappropriately use live discharge to avoid costly hospitalizations." The abstract offers the following conclusion-about 20% of "hospice patients are discharged alive with variation by geographic regions and hospice programs. Not-for-profit hospices and older hospices have lower rates of live discharge."  Why is it important to study this? As the introduction to article points out, there are instances when a provider may improperly discharge a patient and the timing can be telling: improper admission to hospice at the beginning or an effort to avoid costs.  Building on existing research, this study finds similar results in some areas, but makes some important conclusions that deserve additional study

Provide and state variation raises concern that live discharges are not driven by patient preference but by provider and market behavior. Hospice programs that exceed their aggregate reimbursement caps (a marker for hospices with an excessive average hospice length of stay) had nearly double the rate of live discharges compared to hospice programs that did not exceed their aggregate cap.

The authors suggest there are certain red flags that should alert regulators that more careful scrutiny is needed for a specific hospice.

A hospice program with a high rate of live discharges deserves regulatory scrutiny especially when they have a pattern of hospitalization and hospice readmission. With increased hospice competition or potential future changes in hospice payment policies, hospices may change their enrollment and pattern of live discharges to maximize their profitability. Potentially, live hospice discharges represent a vulnerability of the Medicare Hospice Benefit. Hospices with high rate of these patterns of live discharges should trigger further regulatory review that examine whether their hospice enrollees were eligible, adequately informed about the Medicare hospice benefit before electing hospice, and whether the hospice program did a good enough job of advance care planning to avoid hospitalizations.

 

August 19, 2014 in Consumer Information, Health Care/Long Term Care, Medicare | Permalink | Comments (0) | TrackBack (0)

Monday, August 18, 2014

Housing the Elderly vs. Housing FOR the Elderly

A number of years ago I audited a very interesting course in a gerontology program with the title "Housing the Elderly."  It occurred to me at the time, however, that the title was a bit unfortunate, as it implied "warehousing" old folks rather than truly accomodating potential needs.   Fortunately, over time I have sensed a  growing appreciation of the significance of the distinction. 

I was reminded of this while reading "For an Aging Parent, an 'In-Law Suite' Can Provide a Home within a Home" in the Washington Post.  The article describes the experience of one family's decision to add a bedroom suite on the first level of their home to meet the needs of a aging parent.  According to housing experts quoted in the article "demand for in-law suites is growing." 

The article contrasts "true in-law suites" -- defined as a "living space integrated into a house to accomodate an older or disabled reative" -- with "accessory dwelling units" or ADUs.  ADUs "function as separate dwelling units and often are intenteded for rental." As I recall, a few years ago, prefabricated versions of ADUs were popular in the media and dubbed "granny pods."  Does anyone know whether granny pods ever caught on?  The article suggests that building codes and zoning codes may present barriers to certain types of supplemental construction.  I suspect that it would also be easy to trigger homeowner association restrictions.

The article suggests practical considerations:

  • The suite should be comfortable and private to foster a feeling of independence....
  • At the same time, it should be close and connected to the family living area.
  • Place the suite on the main floor so that it has access to shared living spaces without the barrier of stairs.
  • Incorporate wide hallways and doorways (at least 36 inches) in the suite and adjoining living spaces to accommodate wheelchairs, walkers and people walking side by side.
  • Integrate features that are attractive but safe and accessible, such as smooth flooring, lever handles for doors and faucets, non-skid bathroom flooring, a large curbless shower, a shower bench, a hand-held shower head, a chair-height toilet and sturdy, good-looking grab bars.

Many of these are core principles for "Universal Design," a housing construction movement that can be traced back to the early 1960s.  

Building or selecting a new house?  Consideration of universal design features may make it possible to stay at home much longer as you age.  AARP offers additional suggestions in a recent interview with Universal Design Specialist Richard Duncan.   And more info is available at UniversalDesign.com including citations to local, state or federal laws that may mandate certain elements of universal design for new construction.

August 18, 2014 in Consumer Information, Current Affairs, Housing | Permalink | Comments (2) | TrackBack (0)

Sunday, August 17, 2014

Medicare Fraud

The Washington Post ran a fascinating article on a particular Medicare scam.  A Medicare Scam That Just Kept Rolling was published August 16, 2014 and focuses on power wheelchairs. The article offers a detailed look at how this particular scam worked.

The wheelchair scam was designed to exploit blind spots in Medicare, which often pays insurance claims without checking them first. Criminals disguised themselves as medical-supply companies. They ginned up bogus bills, saying they’d provided expensive wheelchairs to Medicare patients — who, in reality, didn’t need wheelchairs at all. Then the scammers asked Medicare to pay them back, so they could pocket the huge markup that the government paid on each chair.

This eye-opening article points out that the depth and breadth of the scam remains largely unknown, but is on its way out.

But, while it lasted, the scam illuminated a critical failure point in the federal bureaucracy: Medicare’s weak defenses against fraud. The government knew how the wheelchair scheme worked in 1998. But it wasn’t until 15 years later that officials finally did enough to significantly curb the practice.

The article is accompanied by a video that shows in "four easy steps" how to perpetrate a Medicare scam as well as a sidebar with slides showing how the power wheelchair scam works.  Variations of the scam are more than 40 years old and have morphed with the times.

If you aren't shaking your head in wonder now, consider why these scams can happen:

[F]or Medicare officials at headquarters, seeing the problem and stopping it were two different things. 

That’s because Medicare is an enormous system, doing one of the most difficult jobs in the federal government. It receives about 4.9 million claims per day, each of them reflecting the nuances of a particular patient’s condition and particular doctor’s treatment decisions.

By law, Medicare must pay most of those claims within 30 days. In that short window, it is supposed to filter out the frauds, finding bills where the diagnosis or the prescription seem bogus.

The way the system copes is with a procedure called “pay and chase.” Only a small fraction of claims  3 percent or less — are reviewed by a live person before they are paid. The rest are reviewed only after the money is spent. If at all.

The whole thing is set up as a kind of honor system, built at the heart of a system so rich that it made it easy for people to be dishonorable.

The article talks about comparisons--the amount of money spent on power wheelchairs as compared to the total amount of dollars spent in the Medicare universe and although the amount spent on wheelchairs is a lot, it's a small amount in that universe.  The article mentions the steps the government has taken to end the motorized wheelchair scam such as competitive bidding and rent-to-own. So if the wheelchair scam is on the decline, what's the next one? According to the article, orthotics and prosthetics. Stay tuned...

August 17, 2014 in Consumer Information, Crimes, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Medicare | Permalink | Comments (0) | TrackBack (0)

Monday, August 11, 2014

Scholarships available for NCLC's annual Consumer Rights Litigation Conference

NCLC's Consumer Rights Litigation Conference on November 6-9, 2014 in Tampa, FL has scholarships available for consumer rights advocates.   

 Deadline to apply is TODAY. Click this link to fill out the online application: click here. 
 
The conference will offers 11 CLE breakout sessions with 55 courses taught by the leaders in consumer advocacy.  It is a unique event that knits our community together in meaningful ways. NCLC expect tremendous turnout for this year's conference, with more than 800 attorneys of all levels of experience making their way to the Sunshine State.

 

The main conference offers networking lunches, a Welcome Reception at a nearby Tampa venue, the annual NCLC awards lunch, and NACA's 20th Annual Meeting and Advocacy Awards.  

 

REGISTER ONLINE TODAY by clicking on this link here: Register Online

 

Source:  National Consumer Law Center

 

August 11, 2014 in Consumer Information, Programs/CLEs | Permalink | TrackBack (0)

Thursday, July 31, 2014

10th Circuit: Defamation Case Can Go Forward Against NBC's Dateline Re "Annuity University"

As readers of this Blog may recall, back in April 2008 NBC's Dateline program aired a segment called "Tricks of the Trade" that incorporated use of hidden cameras to record portions of seminars that allegedly showed insurance salesmen trained to market certain types of deferred payment annuities.  The NBC program alleged that the sales techniques specifically and improperly targeted or misled older consumers.

Tyrone M. Clark and his company, Brokers' Choice of America (BCA), brought suit against NBC and certain employees in federal court in Colorado, claiming the Dateline program violated state law, including allegations of defamation. Clark and BCA also alleged constitutional violations. The federal district court dismissed the complaint in 2011.

On July 9, 2014 the Tenth Circuit affirmed the dismissal of the alleged 4th Amendment violations, but remanded for further proceedings on the allegations of defamation. At the heart of Clark's claim was the argument that a full, unedited viewing of his seminar for insurance salesmen would reveal that students were properly counseled that such "annuities were not for everyone" and that salespeople must give "full disclosure of various advantages and disadvantages of the annuity products."  In other words, Clark claimed Dateline's excerpts were misleading, and therefore defamatory. 

The Tenth Circuit's ruling on defamation stressed that it was reviewing the district court's ruling on NBC's motion to dismiss and thus must view the facts alleged in the complaint "as true and in the light most favorable to the nonmoving party," i.e., Clark and BCA.  The 10th Circuit concluded, "Whether these allegations will survive summary judgment remains to be seen.  The factual basis of the complaint ... is sufficient to state a plausible claim."

Further, the Tenth Circuit upheld the request by Clark and BCA to discovery of the full, unedited tapes surreptitiously recorded by NBC, production that NBC has resisted:

"BCA would be greatly prejudiced in its ability to prove the defamation claim without access to the unedited film. Dateline's First Amendment interests do not involve the disclosure of confidential information or confidential sources. The fact-finder is entitled to the best evidence available, particularly in a case like this, which asks whether the media's zeal to report and perhaps sensationalize should be tempered by its responsibility not to defame. For all of those reasons, BCA's factual allegations are sufficient to warrant discovery of the unedited film. The Colorado statue [on newsperson's privilege] is a shield, not a sword."

For additional details, see the 10th Circuit's ruling on Broker's Choice of America, Inc. v. NBC Universal, Inc. and commentary from the Colorado Bar Association's Legal Connection news. 

     

July 31, 2014 in Consumer Information, Ethical Issues, State Statutes/Regulations | Permalink | Comments (0) | TrackBack (0)

Friday, July 25, 2014

Consumer Protection and Older Adults: Key Sessions at Consumer Rights Litigation Conf.

The Consumer Rights Litigation Conference, put on by the National Consumer Law Center (NCLC), is set for November 6-9 in Tampa Florida. This is the preeminent program for consumer rights advocates and there are several sessions with a special focus on protection of older persons.  Sessions include:

 "Reverse Mortages: New Changes and Old Challenges to Foreclosure," with Odette Williamson and Margot Saunders, NCLC, focusing on "emerging issues in reverse mortgages, including the new 'ability to pay' determinations and protections for dispossessed spouses."  (Friday morning, Nov. 7)

"Retirement Benefits and Bankruptcy, Do they Mix?" by Tara Twomey (NCLC), asking whether a "fresh start jeopardizes the debtor's ability to receive social security benefits" and to what extent are "retirement savings off the table for nonsecured creditors." (Saturday morning, Nov. 8)

"Challenging Financial Fraud and Scams Aimed at Older Adults," by David Kirman (North Carolina Department of Justice) and Stephan A. Weisbrod (Weisbrod, Mattis & Coply PLLC), examining legal tools that can be used to challenge these practices, including private actions and suits brought under state statutes, such as California's Financial Elder Abuse Act. (Saturday afternoon, Nov. 8)

Details available here on registration and conference logistics.

July 25, 2014 in Consumer Information, Crimes, Programs/CLEs | Permalink | Comments (0) | TrackBack (0)

Thursday, July 24, 2014

The Five Halves of Elder Law

The CarTalk Guys on National Public Radio have a crazy tradition of breaking their one hour radio program into "three halves" (okay, they have a lot of crazy traditions -- I'm focusing on just one).  In that tradition, I'd been thinking about how the practice of "elder law" might also have three halves, but then I realized  that perhaps it really has five halves.  See what you think.

  • In the United States, private practitioners who call themselves "Elder Law Attorneys" usually focus on helping individuals or families plan for legal issues that tend to occur between retirement and death.  Many of the longer-serving attorneys with expertise in this area started to specialize after confronting the needs of their own parents or aging family members. They learned -- sometimes the hard way -- about the need for special knowledge of Medicare, Medicaid, health insurance and the significance of frailty or incapacity for aging adults.  They trained the next generations of Elder Law Attorneys, thereby reducing the need to learn exclusively from mistakes.

 

  • Closely aligned with the private bar are Elder Law Attorneys who work for legal service organizations or other nonprofit law firms.  They have critical skills and knowledge of  health-related benefits under federal and state programs.  They also have sophisticaed  information about the availability of income-related benefits under Social Security.  They often serve the most needy of elders.  Their commitment to obtain solutions not just for one client, but often for a whole class of older clients, gives them a vital role to play. 

 

  • At the state and federal levels, core decisions are made about how to interpret laws affecting older adults.  Key decisions are made by attorneys who are hired by a government agency. Their decisions impact real people -- and they keep a close eye on the financial consequences of permitting access to benefits, even if is often elected officials making the decisions about funding priorities. I would also put prosecutors in this same public servant "Elder Law" category, especially prosecutors who have taken on the challenge of responding to elder abuse. 

 

  • A whole host of companies, both for-profit and nonprofit, are in the business of providing care to older adults, including hospitals, rehabilitation centers, nursing homes, assisted living facilities, group homes, home-care agencies and so on -- and they too have attorneys with deep expertise in the provider-side of "Elder Law," including knowledge of  contracts, insurance and public benefit programs that pay for such services.

 

  • Last, but definitely not least, attorneys are involved at policy levels, looking not only to the present statutes and regulations affecting older adults, but to the future of what should be the legal framework for protection of rights, or imposition of obligations, on older adults and their families.  My understanding and appreciation of this sector has increased greatly over the last few years, particularly as I have come to know human rights experts who specialize in the rights of older persons.

Of course, lawyers are not the only persons who work in "Elder Law" fields and it truly takes a village -- including paralegals, social workers, case workers, health care professionals, and law clerks -- to find ways to use the law effectively and wisely. Ironically, at times it can seem as if the different halves of "elder law" specialists are working in opposition to each other, rather than together. 

My reason for trying to identify these "Five Halves" of Elder Law is that, as with most of us who teach courses on elder law or aging,  I have come to realize I have former students working in all of these divisions, who began their appreciation for the legal needs of older adults while still in law school.  Organizing these "halves" may also help in organizing course materials.

I strongly suspect I'm could be missing one or more sectors of those with special expertise in Elder Law.  What am I forgetting?   

July 24, 2014 in Cognitive Impairment, Consumer Information, Crimes, Health Care/Long Term Care, Housing, Medicaid, Medicare, Other, Social Security | Permalink | Comments (1) | TrackBack (0)

Monday, July 21, 2014

What Should You Look For In An Elder Law Attorney?

ElderLawGuy (and good friend) Jeff Marshall has a great blog post on "How to Find A Good Attorney for Older Adult Issues"  He knows whereof he speaks and starts off by explaining the important reasons for asking the right questions:

"Planning for senior issues like incapacity and long term care is an important aspect of the services provided by what have become known as “elder law attorneys.”  Unfortunately, in most states any lawyer can say he or she practices elder law or hold themselves out as being an “elder law attorney” even if the lawyer has little or no experience with the issues that are especially important to older adults. This means seniors must be particularly cautious in choosing a lawyer and carefully investigate the lawyer before hiring." 

Jeff explains the significance of "certification" as a specialist and how to assess "ratings" or particular approaches to planning, such as "life care planning."  The post is useful both for consumers and young attorneys thinking about how to build a respected career.  

July 21, 2014 in Consumer Information, Ethical Issues, Legal Practice/Practice Management, Weblogs | Permalink | Comments (0) | TrackBack (0)

Wednesday, July 9, 2014

Updates on Programming at July 2014 Int'l Elder Law and Policy Conference

We've previously posted advance information about the International Elder Law and Policy Conference that will be  hosted this week -- July 10-11 -- in Chicago.  The organizers are John Marshall Law School; Roosevelt University, College of of Arts and Sciences; and East China University of Political Science and Law.

The conference will have an interesting format, combining presentations from a range of professionals with experience working with or for older persons, and working sessions to draft a model "International Bill of Rights for Elderly Persons, in parallel with U.N. sessions on ageing. 

As an example of the breadth of participation and coverage at this conference, my session  on Thursday focuses on "Health Care, Caregving for Older Persons and Legal Decision Making," and will be co-moderated with Professor Walter Kendall at John Marshall.  The panel includes the following topics and speakers:

  • "Dementia and Planning Death: The Challenge for Advance Directives," by Meredith Blake at University of Western Austalia Law School
  • "Social Change and Its Apparent Effect on Senior Care Services: A Comparative Study of Post-Soviet Union Russia and the U.S.," by Amy Delaney, partner at Delaney, Delany & Voorn in Illinois, and Alina Risser, a lawyer from Russia, currently studying law at John Marshall;
  • "Rights are Not Good for Older Persons in Long-Term Care Settings? Experience from the European Union," by Nena Georgantzi, Legal Officer for AGE Platform Europe;
  • "Bridging the Caregiver Gap: Does Technology Provde an Ethically and Legally Viable Answer?," by Donna Harkness, University of Memphis School of Law;
  •  "The Insufficiency of Spiritual Support of Urban Elders in China and Suggestions on Legislation," by Jun Li, East China University of Political Science and Law.

 We'll report more after the events on Thursday and Friday!  

July 9, 2014 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Discrimination, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Health Care/Long Term Care | Permalink | Comments (0) | TrackBack (0)

Wednesday, June 18, 2014

What Happens to Upfront Fees Paid by Residents of CCRCs -- Especially in Bankruptcy Court?

Last week's news of a Chapter 11 Bankruptcy proceeding in the Texas-based senior living company Sears Methodist Retirement Systems, Inc. (SMRS)  has once again generated questions about "entrance fees" paid by residents at the outset of their move to a Continuing Care Retirement Community (CCRC).  CCRCs typically involve a tiered system of payments, often including a substantial (very substantial) upfront fee, plus monthly "service" fees.  The upfront fee will carry a label, such as "admission fee" or "entrance fee" or even entrance "deposit," depending on whether and how state regulations require or permit certain labels to be used. 

As a suggestion of the significance of the dollars, a resident's key upfront fee at a CCRC operated by SMRS reportedly ranged from $115,000 to $208,000. And it can be much higher with other companies.  So, let's move away from the SMRS case for this "blog" outline of potential issues with upfront resident fees.

Even without talking about bankruptcy court, for residents of CCRCs there can be a basic level of confusion about upfront fees. In some instances, the CCRC marketing materials will indicate the upfront fee is "refundable," in whole or in part, in the event the resident moves out of the community or passes away.  Thus, residents may assume the fees are somehow placed in a protected account or escrow account.  In fact, even if the upfront fee is not "refundable," when there is a promise of "life time care," residents may assume upfront fees are somehow set aside to pay for such care. How the facility is marketed may increase the opportunity for resident confusion. Residents are looking for reassurances about the costs of future care and how upfront fees could impact their bottom line. That is often why they are looking at CCRCs to begin with.  "Refundable fees" or "life care plans" can be important marketing tools for CCRCs. But discussions in the sales office of a CCRC may not mirror the "contract" terms.

One of the most important aspects of CCRCs is the "contract" between the CCRC and the resident. First, smaller "pre move-in" deposits may be paid to "hold" a unit, and this deposit may be expressly subject to an "escrow" obligation.  But,  larger upfront fees -- paid as part of the residency right -- are typically not escrowed. It is important not to confuse the "escrow" treatment of these fees.  Of course, the "hold" fee is not usually the problem.  It is the larger upfront fees --such as the $100k+ fees at SMRS -- that can become the focus of questions, especially if a bankruptcy proceeding is initiated.

The resident's contract requires very careful reading, and it will usually explain whether and how a CCRC company will make any refund of large upfront admission fees.  In my experience of reading CCRC contracts,  CCRCs rarely "guarantee" or "secure" (as opposed to promise) a refund, nor do they promise to escrow such upfront fees for the entire time the payer resides at the CCRC.  In some states  there is a "reserve" requirement (by contract or state law) for large upfront fees whereby the CCRC has a phased right to release or use the fees for its operation costs.  Thus, the contract terms are the starting place for what will happen with upfront fees. 

Why doesn't state regulation mandate escrow of large upfront fees?  States have been reluctant to give-in to pressure from some resident groups seeking greater mandatory "protection" of their upfront fees.  There's often a "free enterprise, let the market control" element to one side of regulatory debates. On the other side, there is the question of whether life savings of the older adult are proper targets for free enterprise theories.  Professor Michael Floyd, for example, has asked, "Should Government Regulate the Financial Management of Continuing Care Retirement Communities?"  

My research has helped me realize how upfront fees are a key financial "pool" for the CCRC, especially in the early years of operation where the developer is looking to pay off construction costs and loans.  CCRCs want -- and often need -- to use those funds for current operations. and debt service.  Thus, they don't want to have those fees encumbered by guarantees to residents. They take the position they cannot "afford" to have that pool of money sitting idle in a bank account, earning minimal interest.  This is not to say the large entrance fees will be "misspent," but rather, the CCRC owners may wish to preserve flexibility about how and when to spend the upfront fees.

The treatment of "upfront fees" paid by residents of CCRCs also implicates questions about application of accounting and actuarial rules and principles. That important topic is worthy of a whole "law review article" -- and frankly it is a topic I've been working on for months. 

In additional to looking for actuarial soundness, analysts who examine CCRCs as a matter of academic interest or practical concern have looked at whether CCRC companies and lenders may have a "fiduciary duty" to older adults/residents, a duty that is independent of any contract law obligations. Analysts further question whether a particular CCRC's marketing or financial practices violate consumer protection or elder protection laws. 

There can also be confusion about what happens during a Chapter 11 process. First, during the Chapter 11 Bankruptcy process, a facility may be able to honor pre-bankruptcy petition "refund" requests or requests for refund of fees for a resident who does not move into the facility.  Second, to permit continued operation as part of the reorganization plan, a facility will typically be permitted by the Court to accept new residents during the Chapter 11 proceeding and those specific new residents will have their upfront fees placed into a special escrow account, an account that cannot be used to pay the pre-petition debts of the company. 

But what about the upfront fees already paid pre-petition by residents who also moved in before the bankruptcy petition?  Usually those upfront fees are not escrowed during the bankruptcy process.  Indeed, other "secured" creditors could object to refunds of "unsecured" fees. The Bankruptcy Court will usually issue an order -- as it did in SRMS's bankruptcy court case in Texas last week -- specifying how current residents' upfront fees will be treated now and in the future.  A bit complicated, right?  (And if I'm missing something please feel free to comment.  I'm always interested in additional viewpoints on CCRCs.  Again, the specific contract and any state laws or regulations governing for handling of fees will be important.)

Of course, this history is one reason some of us have been suggesting for years that prospective residents should have an experienced  lawyer or financial consultant help them understand their contracts and evaluate risks before signing and again in the event of any bankruptcy court proceeding. "Get thee to a competent advisor."   See also University of New Mexico Law Professor Nathalie Martin's articles on life-care planning risks and bankruptcy law. 

As I mentioned briefly in writing last week about the SMRS Chapter 11 proceeding, CCRC operators have learned -- especially after the post-2008 financial crisis -- that the ability of a CCRC to have a viable "second chance" at success in attracting future residents will often depend on the treatment of existing residents. Thus, one key question in any insolvency will be whether the company either (a) finds a new "owner" during the Chapter 11 process or (2) is able to reorganize the other debts, thereby making it possible for the CCRC company to "honor" the resident refund obligations after emerging from the Chapter 11 process.

During the last five years we have seen one "big" default on residents' upfront. refundable entrance fees during the bankruptcy of Covenant at South Hills, a CCRC near Pittsburgh.  A new, strong operator eventually did take over the CCRC, and operations continued. However, the new operator did not "assume" an obligation to refund approximately $26 million in upfront fees paid pre-petition by residents to the old owner. In contrast, Chapter 11 proceedings for some other CCRCs have had "gentler" results for residents, with new partners or new financial terms emerging from the proceedings, thereby making refunds possible as new residents take over the departed residents' units. 

For more on how CCRC companies view "use" of upfront fees, here's a link to a short and clear discussion prepared by DLA Piper law firm, which, by the way, is the law firm representing the Debtor SMRS in the Texas Chapter 11 proceeding. 

June 18, 2014 in Consumer Information, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Retirement, State Cases, State Statutes/Regulations | Permalink | Comments (1) | TrackBack (0)

Thursday, June 5, 2014

Is There A Private Right of Action Under the Nursing Home Reform Act?

Does a resident have a private right of action for violation of key provisions of the federal Nursing Home Reform Act? 

For example, federal Medicare/Medicaid Law specifies residents have certain "Transfer and Discharge Rights."  A certified nursing facility must permit each resident to "remain in the facility" and must "not transfer or discharge the resident" except for certain specified reasons, usually requiring 30 days advance notice.  But what happens if a facility ignores the limitations on acceptable grounds for transfer or discharge, including the 30 day notice requirement?

In its decision on May 12, 2014 in Schwerdtfeger v. Alden Long Grove Rehabilitation and Health Care Center, the federal district court in the Northern District of Illinois ruled that a discharge improper under federal law does not trigger a private statutory remedy.  As described in the clearly written decision, an abrupt transfer of the resident from the nursing home into a hospital followed the resident's "verbal dispute with a nurse" and another resident. While federal law permits transfers where there someone's safety or health is endangered, it does not appear from the decision that the nursing home claimed the verbal dispute created such a danger.  

Nonetheless, the court dismissed the resident's federal claim, concluding that the statutory language regarding discharge and transfer rights in Medicare and Medicaid law "does not manifest a 'clear and unambiguous' Congressional intention to create private rights in favor of individual nursing facility residents....  The NHRA [Nursing Home Reform Act] provides an administrative process in the state courts rather than a private remedy in federal court." 

In so ruling, the federal district court declined to follow the analysis of the Third Circuit in Grammer v. John J. Kane Regional Centers-Glen Hazel, 570 3d 520 (3d Cir. 2008), which as a "matter of first impression" ruled that the NHRA was sufficiently "rights creating" that it could trigger a cause of action regarding quality of care under Section 1983. 

My question, reflecting my teaching interests no doubt, is whether the nursing home's discharge was a breach of contract?  Most nursing home contracts I've reviewed either directly or indirectly "adopt" the protections of the NHRA as specific rights of their residents. (Indeed, I would be leery of any nursing home that did not do that.)  So, even if not a violation of federal law, wouldn't such a discharge breach the contract?  I suspect there is probably a court decision or law review article on this topic -- perhaps our readers have a citation?  

Of course, in seeking a right to sue directly under the NHRA, the resident was probably also seeking a right to claim attorneys' fees under the civil rights law; breach of contract claims, even if successful, may not make a claimant "whole" because of the likelihood of small consequential damages and no contractual right to seek attorneys' fees.  It is not clear from the Schwerdtfeger decision whether a breach of contract claim was alleged, although the federal court did "decline" to exercise supplemental jurisdiction over the plaintiff's "state law claims." 

June 5, 2014 in Consumer Information, Federal Cases, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0) | TrackBack (0)

Tuesday, May 27, 2014

CPSC recalls adult bed handles due to danger of strangulation

The U.S. Consumer Product Safety Commission (CPSC) and Bed Handles Inc., of Blue Springs, Mo., are announcing the voluntary recall of about 113,000 adult portable bed handles. When attached to an adult’s bed without the use of safety retention straps, the handle can shift out of place creating a dangerous gap between the bed handle and the side of the mattress. This poses a serious risk of entrapment, strangulation and death. Three women died after becoming entrapped between the mattress and the bed handles. They include an elderly woman, age unknown, who died in an Edina, Minn. assisted living facility; a 41-year-old disabled woman who died in a Renton, Wash. adult family home; and an 81-year-old woman who died in a Vancouver, Wash. managed care facility.  The recall involves adult portable bed handles sold by Bed Handles Inc. from 1994 through 2007 that do not have safety retention straps to secure the bed handle to the bed frame to keep the bed handle from shifting out of place and creating a dangerous gap. Recalled models include the Original Bedside Assistant® (BA10W), the Travel Handles™ (BA11W) which is sold as a set of two bed handles, and the Adjustable Bedside Assistant® (AJ1).  Consumers should immediately stop using all recalled bed handles that were sold without safety retention straps. Contact Bed Handles Inc. for free safety retention straps to secure the bed handle to the bed frame, new assembly and installation instructions for models BA10W, BA11W and AJ1 and a warning label to attach to the bed handles. The bed handles should be used only with the safety retention straps securely in place attaching the bed handle to the bed frame in order to prevent a gap.

Source/more: CPSC/Bed Handles, Inc.

May 27, 2014 in Consumer Information, Other | Permalink | TrackBack (0)

Who Bears the Risk of Declining Prices During a CCRC Market Downturn?

Continuing Care Retirement Communities (CCRCs) utilize a variety of payment arrangements to attract potential residents.  One option popular prior to the 2008 recession was a "100% refundable entrance fee" model, where the new resident was promised return of his or her upfront entrance fee upon "termination," subject to certain conditions, usually including re-occupancy of the unit in question by a new resident.  During good financial times, this refund option benefited both parties.  The company could rely on a quick "resale" of the unit, either for the same or a higher entrance fee.  Thus the company often took the position it was able to "use" the original resident's entrance fee immediately, subject to any state regulations for mandatory reserves or other repayment guarantees or restrictions.

But who bears the risk of a downturn in the senior living market, especially the dramatic downturn that accompanied the 2008-2010 recession? 

In Stewart v. Henry Ford Village, Inc., the issue was whether a departing resident must accept the company's offer of a lower refund, tied to what any new resident would pay as an entrance fee to reside in that unit. The difference was hefty, as the resident had paid $137k in 1998 when she moved in, but when she left the community in  2010, comparable units were reportedly going for $89k.

In a rare court decision analyzing a refundable fee, the Court of Appeals for Michigan ruled that the parties' contract language controlled, and in this contract the contract did not provide for a lower refund amount.  Further, the company's obligation to comply with the contract terms was subject to an implied obligation of good faith (a Contract Law concept my students would, I hope, recognize!) to promptly market and "resell" the unit, thus suggesting a CCRC would not be in good faith for delaying a unit's resale as a negotiation tool.  Here is the heart of the court's analysis:

"Given the totality of the circumstances, the status of the parties, and the rights and obligations as set forth in the Agreement, the Disclosure Statement, and the [state's Living Care Disclosure Act] we find no support for the conclusion that plaintiff should or is obliged to bear the risks of a declining real estate market. To the contrary, those risks would seem properly to fall to defendant. By way of example, when a lessee properly complies with his or her lease in vacating a rental property, the lessee bears no responsibility for the fact that the landlord may need to lower the rent to attract a subsequent tenant. Rather, it is the landlord alone who must bear the consequences of the existing market risks. Additionally, plaintiff notes that if the unit was subsequently reoccupied with a higher entrance deposit, defendant would not furnish additional monies to plaintiff. Defendant has not suggested otherwise.... It strikes us as incongruous, as unsupported contractually, and as of questionable good faith (without adequate disclosure), that plaintiff be held to bear the risks of a declining real estate market without the ability to reap the rewards of a booming one."

In the "unpublished" (and therefore nonprecedential) opinion, the Michigan appellate court remanded for an evidentiary hearing.  The ruling demonstrates the importance of the contract language, state regulations, and, I suspect, the likelihood that future refundable fee CCRC contracts will provide clearly that refunds will be tied in whole or in part to "resale" amounts, at least for any so-called 100% refundable fee agreements. 

It should also be noted that refundability of admission fees is potentially a separate issue from actuarially sound practices for CCRCs in the handling of such fees.  Along that line, I note that one of the residents who pioneered concerns about financial soundness in CCRCs, Charles Prine of Pittsburgh, passed away recently. Mr. Prine's articulate advocacy included testimony before the Senate Special Committee on Aging.  Chuck will be missed. 

May 27, 2014 in Consumer Information, Housing, State Cases, State Statutes/Regulations | Permalink | Comments (0) | TrackBack (0)

Monday, May 26, 2014

Tobor to the Rescue? Home Medication Dispensers

When I was a child, there was a movie -- or maybe a tv show -- with a friendly robot named Tobor.  Tobor soon became an imaginary friend for the neighborhood children, and conveniently, someone we could blame when we forgot to close a door or knocked something over.  "Tobor did it!"

Fast forward many years and last week, during a meeting at my Area Agency on Aging, I learned the AAA had entered into a contract with a company that makes home medication dispensers to provide the devices at a modest cost to clients in the county.  "Tobor for the Boomer Generation!"

The device, about the size of a blender or coffee machine, can be pre-loaded with a large number of doses of different kinds of medications with different dispensing schedules, and with recorded messages such as "Drink with water."  The machine signals the client to take the revealed dose, and continues the signal until the medication is removed.  It can also be programmed to contact a family member about a missed dose.  Of course, there are limits to the utility of any automated device, as the client must still have the capacity to follow the directions and not simply discard the dose. 

It will be interesting to see, over time, whether (and which kind of ) Tobors are effective innovations with long-range satisfaction and utility.  I do seem to have a lot of ignored contraptions on my own kitchen counter. 

May 26, 2014 in Consumer Information, Current Affairs, Health Care/Long Term Care, Web/Tech | Permalink | Comments (2) | TrackBack (0)

Friday, May 16, 2014

An "Education Connection" for Senior Living

As readers may have noticed, I've been a long-time "student" of Continuing Care Retirement Communities (CCRCs), drawn to the industry because of its vibrancy and dynamic approach to senior living.  Along the way, I've come to know the many strengths -- and occasional weaknesses -- of individual operations, and the importance of resident engagement to long-range success.  One of my resident contacts shared with me a new PBS NewsHour spotlight on university-connected CCRCs, with a prime focus on Oak Hammock, a community developed under the auspices of the University of Florida.  Universities can offer a unique draw for alums and other college grads, including retired faculty, who value continued educational opportunities.

Here's the link to "Why More Seniors Are Going Back to College -- to Retire."

Although short (about 8 minutes), I find the piece to be balanced, especially in that it hints at the financing terms often needed to make such communities attractive and therefore viable. Some of the people interviewed explain the need for sophisticated mangement to counsel university-based programs, as development of CCRCs can be quite different than simply building a senior's version of  "dorms." My own university stumbled a bit at the starting gate in its early efforts to get a community fully occupied, with the 2008 recession added to the challenges.

Thanks, Karen, for sending us the link!    

May 16, 2014 in Consumer Information, Current Affairs, Health Care/Long Term Care, Housing | Permalink | Comments (0) | TrackBack (0)

Friday, May 9, 2014

ABA Bifocal Topics: Health Care Advance Directives, Guardianships and More

The April 2014 issue of the American Bar Association's Bifocal publication is now available.  Current articles include:

By the way, while most Bifocal articles are written by practicing attorneys, American Univesity Washington College of Law student, Karna Sandler, is the author of the article on how state laws may affect a guardian's health care authority.  Karna's an intern at the Commission on Law and Aging.  Way to go, Karna!

 In addtion, the issue provides details about AARP Foundation Scholarships to assist individuals in attending the 2014 National Aging and Law Conference to be held in Washington D.C. on October 16-17.  Deadline for the scholarship applications is June 15, 2014. 

May 9, 2014 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Federal Statutes/Regulations | Permalink | Comments (0) | TrackBack (0)

Wednesday, May 7, 2014

Planning Ahead: Extend Malpractice Insurance for Retiring Lawyers?

In part 6 of the ABA Journal's series on retirement issues, retiring lawyers are reminded that one important option is to purchase "extended reporting endorsements" (ERE) or "tail coverage" for existing professional liability insurance policies.  Such an endorsement permits a longer period to report  claims for coverage.  Mark Bassingthwaighte, an attorney and risk manager for Attorneys Liability Protection Society (ALPS) explains, "Tail coverage ... [is] not a new policy."  Rather, the existing policy explains the terms of any ERE coverage option, with the cost set as a fixed percentage of the expiring policy's premium. 

"'I recommend that the retiring partner talk with other partners and request to be kept in the loop within the applicable state statute of limitations for malpractice should the firm dissolve; even formalize an agreement that works best to protect all parties involved,' says Matt Lubaroff, ALPS director of client services. 'The firm's ERE can only be purchased at the time of dissolution, and for certain firms the best answer would be upon the first retirement.'"

Additional planning topics for retiring lawyers appear in "Retirement Reset" by Susan Berson in the May issue of the ABA Journal.

May 7, 2014 in Consumer Information, Legal Practice/Practice Management, Retirement | Permalink | Comments (0) | TrackBack (0)

Tuesday, May 6, 2014

Honor Older Veterans by Helping Them Access Services

Last Sunday, the Philadelphia Inquirer carried an Op-Ed by Patrick Murphy, an Iraq war veteran, and Karen Buck, executive director for SeniorLAW Center in Philadelphia.  Their words provide a welcome reminder, contrasting with the news I reported earlier today about allegations of inadequate care for veterans in Arizona.  In part they write:

"Experts estimate that 14 percent of the adult homeless population has served in the U.S. military. After valiant service, beterans deserve the most basic of human needs:  safe shelter, protection from abuse, enought to eat. 

 

What can we do to change this story for older veterans? 

 

First, know who the veterans are in  your daily life and thank them for their service.  Peace at home is a gift made possible by the harsh sacrifice of others; it's easy to take for granted.  Join  us in doing more by showing gratitude through action.

 

...Help connect an older veteran with the services he needs -- and encourage him to access them.  Many older veterans don't know what resources are available or they associate asking for help with weakness.  Yet, from the VA, they may be eligible for income supports, home-based or nursing home care, health care, burial assistance, education, and other benefits.  Nonprofits can help provide free legal assistance to address issues that arise over housing, family, health care, consumer issues, elder abuse, and financial exploitation.  Legal services rank among the top unmet needs of veterans, but we can all become advocates to help vets get the support they need and deserve."

As Patrick and Karen demonstrate, support for local legal service organizations in your area can be effective in helping veterans access key benefits, while also providing another important watchdog to help reduce or prevent the likelihood of fullblown VA scandals.

Experts estimate that 14 percent of the adult homeless population has served in the U.S. military. After valiant service, veterans deserve the most basic of human needs: safe shelter, protection from abuse, enough to eat.

What can we do to change this story for older veterans?

First, know who the veterans are in your daily life and thank them for their service. Peace at home is a gift made possible by the harsh sacrifice of others; it's easy to take for granted. Join us in doing more by showing gratitude through action.

Volunteering is one form of action. Help connect an older veteran with the services he needs - and encourage him to access them. Many older veterans don't know what resources are available or they associate asking for help with weakness. Yet, from the VA, they may be eligible for income supports, home-based or nursing home care, health care, burial assistance, education, and other benefits. Nonprofits can help provide free legal assistance to address issues that arise over housing, family, health care, consumer issues, elder abuse, and financial exploitation. Legal services rank among the top unmet needs of veterans, but we can all become advocates to help vets get the support they need and deserve.

Read more at http://www.philly.com/philly/opinion/20140504_Don_t_forget_key_work_of_U_S__vets.html#qwbXm13qk5jXlIby.99

Experts estimate that 14 percent of the adult homeless population has served in the U.S. military. After valiant service, veterans deserve the most basic of human needs: safe shelter, protection from abuse, enough to eat.

What can we do to change this story for older veterans?

First, know who the veterans are in your daily life and thank them for their service. Peace at home is a gift made possible by the harsh sacrifice of others; it's easy to take for granted. Join us in doing more by showing gratitude through action.

Volunteering is one form of action. Help connect an older veteran with the services he needs - and encourage him to access them. Many older veterans don't know what resources are available or they associate asking for help with weakness. Yet, from the VA, they may be eligible for income supports, home-based or nursing home care, health care, burial assistance, education, and other benefits. Nonprofits can help provide free legal assistance to address issues that arise over housing, family, health care, consumer issues, elder abuse, and financial exploitation. Legal services rank among the top unmet needs of veterans, but we can all become advocates to help vets get the support they need and deserve.

Read more at http://www.philly.com/philly/opinion/20140504_Don_t_forget_key_work_of_U_S__vets.html#qwbXm13qk5jXlIby.99

May 6, 2014 in Consumer Information, Health Care/Long Term Care, Retirement | Permalink | Comments (1) | TrackBack (0)

Friday, May 2, 2014

Impact of Change in Assisted Living: Social Science Research

"The Facade of Stability in Assisted Living," an article by social scientists at University of Maryland Baltimore County, published in the May issue of the Journal of Gerontology (Series B: Social Sciences), takes a hard look at assisted living settings, using research from 17 different facilities.  Key findings include:

"Our ethnographic research in 17 diverse AL settings (2004-to the present) has found evidence that what may appear to be quite stable is, in fact, a facade.  First, our research indicates that stability -- in many senses -- is not the norm for ALs. . . . Changes occur at multiple levels of person (residents, family members, staff, or managers) collectives (groups or types of residents, staff or managers), organizations (owners or corporations) and external environments (economies or competitors). . . . Second, among these multiple levels and dimensions of change/instability, only a few have been examined substantially in research to date. . . . The changes in AL communities contradict their outward appearance or facade of stability and may profoundly affect the quality of life for residents."

The research, which the authors recognize has limitations because, for example, it was based on evaluation of AL facilities in a single state (Maryland), nonetheless is a reminder that families seeking reliable information about placements for aging loved ones should use caution about "old" data about any specific facility or provider "branding."  The authors caution, "changes driven by new owners or managers and altered competitive pressures challenge contemporary ALs to provide services beyond the original intention of this sector under the social model of care that dominated its origins." 

May 2, 2014 in Consumer Information, Health Care/Long Term Care, Housing | Permalink | Comments (0) | TrackBack (0)

Sunday, April 27, 2014

Press #1 for Frustration: Automation, Hospitality and Aging

During the years when I supervised Penn State Dickinson's Elder Protection Clinic, I was often struck by how much time our law students spent tracking down basic information on behalf of clients, such as credit card or mortgage histories, Social Security records, or insurance coverage details. The information was, in theory, equally available to the clients themselves, but often our clients, who tended to be on the older side of "aging," simply didn't have the energy, patience or skills needed to navigate the dense, automated systems typically associated with modern record-keeping and billing.  One of our student-lawyers made the apt observation that if you weren't "old" before you called some of the customer service "help" lines, you would be by the time you got an answer.

I was reminded of this recently while attempting to make a hotel reservation by telephone.  In my first attempt, I didn't have enough time to wait, so after 10 minutes of less-than-interesting music, I gave up. The second time, a day later, I was routed through a series of automated messages, apparently intended to entice me into becoming an "honors" guest of the hotel's larger chain.  I was using a cell phone, so each time the automated voice indicated a series of choices available, I had to take the phone away from my ear and look for the button in question.  I listened to four sets of automated instructions, even though each time my goal was the same, pressing whatever button I was told to press "if" I wanted to book a reservation.  Gee, are there that many other reasons why someone calls a hotel reservation number?  It took several minutes before I reached a live person, who with a very bored tone insisted I give several items of personal information before I was allowed to ask whether there was a room available for my specific date. You could tell she was reading from a script. By this point I had become distinctly grumpy about the lack of hospitality in this so-called hospitality venue.

As you have probably already guessed, there was "no room at the inn" for that date.  I asked to speak to a supervisor, not so much because I thought I could change the outcome, but because I wanted to register my feeble complaint about frustration with their system. That took another 10 minutes with more "music." But I was determined not to give up.

Amusingly, once I finally reached a "supervisor," the individual immediately agreed with my comments about the weakness of their automated system. That did a lot to dispel my annoyance.  And then -- shock -- she actually offered to solve the problem by calling the local hotel (which as it turns out I was not speaking with).  She found me an available room to book for the night in question. The encounter with the real human wasn't particularly fast, but I was content to wait, knowing a caring individual was trying to help.

This micro-experience, a minor annoyance, nonetheless gave me reason to think about two things:  (1) how much more difficult automation could be for someone who has a hearing problem, slowed reflexes, impaired vision, or diminished cognitive abilities, and (2) how often I'm positively impressed during my communications with well-run long-term care facilities.

When I telephone my father's assisted living community, for example, a live person answers the phone and often recognizes my name and my father's name. My whole family notices how well the staff members know their residents and remember helpful details about the residents' families. It isn't a fancy place, but the staff outshines most high-end resorts with their professionalism and good-natured hospitality.  And it is contagious, as I often see my father smiling in response to the staff members' kind words.

Also, when I visit CCRCs across the country for work-related reasons, I'm impressed by the very personal relationships I witness between residents and front-office management.  Admittedly, CCRCs are often at the upper end of the long-term care "pay" spectrum, but my impression over the years that I've been visiting such multi-level care facilities, including their skilled care units, is that management and staff at the most successful operations place a high value on human contact with residents and the public.  The best ones seem to embrace the notion that a hospitable, caring demeanor during direct interactions goes a long way to lowering the potential for confusion or angry disputes and thus increases the likelihood that someone will be a "client" and recommend new clients. 

So, is it possible that the long-term care industry, often portrayed negatively in the media, has something important to teach other segments of  industry about why automation is not the best, nor even the most cost effective, solution to customer relations, and why the personal touch still makes a difference?  

April 27, 2014 in Consumer Information, Health Care/Long Term Care | Permalink | Comments (0) | TrackBack (0)