Tuesday, January 14, 2014
NBC News had an interesting piece on a self-test for mental acuity, reportedly developed by Ohio State University in response to the growing number of Elder Boomers who apparently are concerned about distinguishing between "ordinary" forgetfulness or changes in brain function. (Really? Is that what aging boomers are worrying about?)
In any event, NBC's medical expert, Nancy Snyderman, reminds us that OSU's "Sage Test" (good name, consumer friendly!) is just one tool to assist in early identification of potential problems -- and is not an ultimate diagnosis.
Monday, January 13, 2014
A few years ago, one of the more perplexing cases handled by Penn State's Elder Protection Clinic involved the sale of deferred annuities (specifically, an annuity that would not fully mature for 20 years) to a senior, a widow in her early 80s.
The individual was a ripe target for a manipulative sales pitch, having recently been diagnosed with early stages of dementia, even though at the moment of sale she was still living independently in her home. She was able to talk and communicate; arguably she did not seem impaired. She was told the product would save on taxes -- a pitch alluring to the frugal woman -- except for the fact that she really didn't need to save on taxes.
If one lives long enough or has looming care needs even at an earlier age, an individual's post-death estate planning goals can conflict with pre-death care needs. In the clinic client's case, the woman's annual income was modest, and her total estate was not large enough to trigger other major taxes. The assets used to fund the annuity were virtually her entire savings. Several months later, her daughter learned of the purchase, while exploring care options for her mother. Her mother was facing ineligibility for Medicaid, as the purchase of the deferred annuity would be treated as transfer, while the alternative was a large penalty if she cashed in the annuity "early."
How often does this -- or worse -- happen?
In "Still No Free Lunch: Recent Regulatory Initiatives to Protect Seniors From Fraud in the Sale of Investment Products," 41 Securities Regulation Law Journal 397 (Winter 2013) (paywall protected; available on Westlaw as 41 No 4 SECRLJ Art 2), attorneys Ivan B. Knauer and Michele C. Zarychta address recent efforts to prevent or address fraudulent practices by an array of regulatory bodies. The 2013 piece updates their 2008 article (available at 36 No 4 SECRLJ Art 3). They outline several types of fraud and various financial products often marketed specifically to elders. For example, they observe:
"One of the most pressing concerns of the regulatory entities is the improper -- or at least confusing-- use of 'senior' designations by professionals, implying that a professional has expertise or training in senior-specific issues. FINRA [the Financial Industry Regulatory Authority] 'Rule of Conduct 2210 prohibits brokerage firms and brokers registered with FINRA from referencing nonexistent or self-conferred degrees or designations or referencing legitimate degrees or designations in a misleading manner.' Misleading use of such designations may also violate federal securities laws or state laws."
The authors, who are experienced in representation of investment and financial service companies, recognize that business lawyers can help clients recognize the need to "take measures to ensure that their own policies and procedures protect seniors." "Still No Free Lunch" is a reminder that attorneys who are advisers to companies can and should be a larger part of the solution, rather than be viewed as part of the problem.
In reading the article, which emphasizes regulators' programs to "educate" the public, I am struck by the likelihood that a key tipping point occurs when a senior's susceptibility to a manipulative pitch is outweighed by his or her weakened ability to recognize risk, regardless of any fraud-prevention education. That was true, for example, with our clinic's client. Her life-time frugal nature was still intact; however, her judgment about whether she needed to "save" money on taxes was diminished. More education was not the solution for her, as she had probably lost the ability to appreciate its application. Indeed, a common marketing practice to seniors -- free lunches or dinners disguised as "educational seminars" -- trades upon that very fact, thus giving rise to the "no free lunch" theme in both articles by authors Knauer and Zarychta.
The authors detail stepped up enforcement efforts, including recent measures by the Consumer Financial Protection Bureau, established in 2010.
Hat tip to Penn State Dickinson Law Professor Lance Cole, who shared this interesting article.
January 13, 2014 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Crimes, Ethical Issues, Federal Statutes/Regulations, Property Management, State Statutes/Regulations | Permalink | Comments (0) | TrackBack (0)
Tuesday, January 7, 2014
Monday, January 6, 2014
Catching up after a busy weekend at the Association of American Law Schools (AALS) Annual Meeting 2014 in New York City, I'm happy to report the presentations at the Section on Aging and the Law seemed to go smoothly and were well received, with a very engaged audience. While the weather made travel to and from NYC a bit tricky, it also seemed to "encourage" strong attendance at sessions. (I found myself skating even when not visiting the rink at Rockefeller Plaza!)
Section Chair Susan Cancelosi (Wayne State) was snowed out -- but I suspect Susan would be pleased by the reaction to the program she planned. Thank you, Susan, for putting together the theme, securing speakers, making sure we were all on track, and creating a back-up weather plan. We've decided you should be the moderator next year, if you don't mind!
Dick Kaplan (Illinois) led off the panelists, using his best "Dr. Phil" style to walk us through (both literally and metaphorically) the latest changes to Medicare triggered by the Affordable Care Act and other recent legislation. Recognizing that many in our audience do not teach elder law or health care law, Dick offered information useful to all academics who "expect" to retire. For example, recent information from the Employee Benefit Research Institute supported his forecast that a 65-year old person retiring in 2012 would need substantial saving just to cover out-of-pocket medical expenses, in the range of $122,000 -$172,000 for men and between $139,000 - $195,000 for women (with projections also affected by prescription drug usage). Dick reminded us that this figure does NOT include any costs for long-term care.
Next on the panel was Laura Hermer (Hamline), who is new to our Section -- and a very welcome addition. Using her health law background, Laura outlined the maze of programs, including state plan innovations and waiver programs under Medicaid, that may provide "long-term services and supports" (or LTSS -- the latest acronym that seems to be an intentional step away from a "care" model) for older persons. Her presentation emphasized the shift to home or community based care, but Laura made clear that this shift depends heavily on unpaid care by family members.
Incoming Section Chair Mark Bauer (Stetson) made effective use of visual images of 55+ communities in Florida to demonstrate his concern that exemptions from civil rights protections that permit age-restricted communities may not be matched by actual benefits for the older adults targeted as residents. Mark stressed the percentage of housing that is not designed to match predictable needs for an aging population. Examples included multi-story designs without elevators, steps into even ground-level units, and bathrooms without wheel-chair accessibility. Mark's presentation expanded on his recent article in the University of Illinois' Elder Law Journal.
Speaking last, my topic was the latest state law developments tied to federal laws that authorize nursing homes to compel a "responsible party" to sign a prospective resident's nursing home contract. States are creating potential personal liability for costs of care for family members, agents or guardians, or transferors or transferees of resources, if the resident is deemed ineligible for Medicaid. Here are links to a copy of the slides I used for my presentation on "Revisiting Nursing Home Contracts," as well as to a related short article I was invited to write for the Illinois State Bar Association's Trusts & Estates Section in December 2013.
The panel presentations were followed by great questions and observations from the audience, further highlighting the financial challenges of aging. Plus, it was wonderful to see several new members volunteering to join the planning committee for future programs for the Aging and Law Section of AALS. And welcome back to the board to Alison Barnes (Marquette Law).
January 6, 2014 in Consumer Information, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Medicaid, Medicare, Programs/CLEs, Retirement, State Statutes/Regulations | Permalink | Comments (0) | TrackBack (0)
Thursday, January 2, 2014
A recent, interesting "over the transom" email came from a continuing care provider group based in southern Texas. Morningside Ministries was the sender, listing its "top 5" free videos, available on its mmLearn.org website. All five had interesting descriptions -- some addressing provocative and underdiscussed topics -- and when I took a look, I found them professionally presented, often with a welcome dash of humor to lighten the mood. I could see using one or more to initiate class discussions, additional research or conversations.
Here's the list and the links, although in the interest of space, I've shortened the descriptions:
Caring for a sometimes hateful or difficult patient can be difficult, and it can take a toll on the caregiver. .. Dr. Weiss will help you understand some of the reasons for this behavior as well as give you tips for dealing with the difficult situation.
Tuesday, December 31, 2013
The Consumer Financial Protection Bureau (CFPB) has issued preliminary results on its evaluation of "pre-dispute arbitration provisions," used in many contracts for consumer financial service products, such as credit cards, checking accounts or pay-day loans. Congress commanded the study as part of the Dodd-Frank Wall Street Reform and Consumer Protection Act of 2010.
Consumers probably end up viewing these clauses as triggering "mandatory" arbitration, in that consumers typically "consent" by signing agreements without any real understanding of the implications. The report summarizes both pro and con arguments on the use of pre-dispute arbitration provisions.
The study makes strong use of academic research, including recent work by Peter Rutledge (University of Georgia Law) and Christopher Drahozal (Kansas Law), Jean Sternlight (UNLV Law), and my own colleague and friend, Nancy Welsh (Penn State Law).
Much of the CFPB report focuses on what it calls the "front end" of arbitration issues, identifying a host of arbitration-related factors addressed in corporate contracts, such as opt-out rights, arbitrator selection, limits on recoverable damages, time limits for claims, and allocation of costs.
Reading between the lines of the report's preliminary findings, it seems to me to support the view that companies use arbitration as a procedural barrier to consumer challenges, including class actions. At the same time, statistics cited in the report suggest that companies may dispense with arbitration when pursuing collection from defaulting consumers, instead filing suits in small claims courts (the CFPB will address federal and other state court claims in the future).
This seems consistent with what I observed during my 10+ years with Penn State Law's Elder Protection Clinic, where we frequently represented older clients on debt claims. Many of these claims were "old" debts, where our clients had been making minimum payments for years, but were no longer able to keep up with the payments after retirement, particularly if also confronted with new debt from medical crises. I don't recall any of the collection cases being initiated by arbitration. By filing in court, the companies seemed to hope for a low-cost route to default judgments.
The New York Times cites the CFPB study in a recent editorial, calling for a change in laws to permit consumers an effective legal tool when needed to challenge certain corporate practices, pointing out that:
"In disputes over financial products — involving, say, excessive fees, inflated loan balances, faulty credit reporting, or fraud and discrimination — the damages at stake may be significant for an individual but not enough to warrant the cost of a legal challenge unless grouped in a class action. Forced arbitration also fosters abuse, since there is no check on wrongdoing that takes small amounts of money from potentially millions of customers."
The CFPB notes that its December 2013 findings will be followed by a more complete report, expected in 2014.
Tuesday, December 17, 2013
One of the most important changes in U.S. funding for long-term care is the move to providing financial support for care in the home or less institutional settings, through Medicaid's HCBS waiver programs.
This month the AARP Public Policy Institute, with support from The Hartford Foundation and the (new) U.S. Administration on Community Living and the (older) Administration on Aging, issued an important report on the corresponding need for assessment not just of the recipient, but of the family members who will serve as caregivers:
"Family support is often essential for helping older people and adults with disabilities continue to live at home and in the community. Yet the work of family caregivers can be demanding—physically, emotionally, and financially. If family caregiver needs are not assessed and addressed, their own health and well-being may be at risk, which may lead to burnout—jeopardizing their ability to continue providing care in the community."
Further, the study, titled "Listening to Family Caregivers: The Need to Include Family Caregiver Assessment in Medicaid Home- and Community-Based Service Waiver Programs," reviews current practices among the states, concluding that "the concept of assessing a family caregiver's own needs is not well understood in many Medicaid HCBS program."
The report makes eight specific policy recommendations, including:
"When a family caregiver assessment is conducted, family caregivers must be directly asked about their (a) own health and well-being, (b) levels of stress and feelings of being overwhelmed, (c) needs for training in knowledge and skills in assisting the care recipients, and (d) any additional service and support needs."
The report also recommends that assessment of caregivers be recorded and made a part of the HCBS client's record, including electronic records. The report compares practices among the fifty states and D.C., identifies potential best practices, and concludes that many states' current assessment tools are inadequate.
Hat tip to ElderLawGuy Jeff Marshall for "tweeting" on this important new study.
While I'm not sure I buy all of the suggestions in the article by Wall Street Journal article writer Andrea Coombes on "How to Avoid Estate Fights Among Your Heirs," she certainly raises topics worthy of discussion. The final point is particularly interesting, encouraging us to consider writing an "ethical will," as a way to share our values. This is explained as a a non-legally binding way to pass on a life story or a family legacy of values to the next generations.
Hat tip to Dave Pearson in Albuquerque, New Mexico for this link.
Saturday, December 14, 2013
New York Times writer Alina Tugend reports on community and state responses to concerns over older drivers in "An Alternative to Giving Up the Car Keys." An excerpt:
"While that is a scary thought for some people, the common perception, that the only real choice is between ignoring the difficulties faced by elderly drivers and taking away the car keys, is wrong. 'We’re evolving in our thinking,' said Jodi Olshevski, a gerontologist and executive director of the Hartford insurance company’s Center for Mature Market Excellence. 'We’re not just looking at the transition from driver to passenger, but how we can empower drivers to extend their driving as long as possible.'”
Sunday, December 8, 2013
Recently I was invited to give the keynote address for an annual meeting of MaCCRA, the Maryland Continuing Care Residents Association, held at Vantage House in Columbia, Maryland. As always happens, I learned a great deal from the opportunity to meet with individuals who care deeply about their communities and want to see them continue to succeed. Maryland is home to some 37 Continuing Care Retirement Communities (CCRCs), with close to 20,000 residents.
MaCCRA has a long and especially interesting history of advocating for appropriate protections for current and future residents of Continuing Care Retirement Communities. Most recently, between 2008 and 2012, MaCCRA supported a series of legislative efforts, including some that were ignored or soundly defeated, but culminating in passage of Senate Bill 485 and House Bill 556 in 2012 that amended of Maryland's CCRC oversight laws (Md. Code. Ann. Hum. Serv. Sections 104-1 et seq.). For example, the amendments require:
- greater disclosure of how entrance fees will be used or held, including a requirement of express disclosure about whether fees will or can be used for purposes unrelated to the community;
- greater disclosure of ownership interests in the community;
- disclosure of annual budgets (not just financial statements);
- increase of operating reserves from 15% of net operating expenses to 25%, with a ten-year phase-in; and
- certain restrictions on encumbrances of operating reserves
Such successes have required perseverance, with MaCCRA playing an important role in educating residents across the state as well as legislators. Indeed, MaCCRA understands that grass root movements alone may not be enough, and the organization has worked for twenty years with an experienced lobbyist, thus helping to assure institutional memory while working in small and large ways to urge greater accountability by providers.
One of the questions I frequently am asked during interactions with CCRC resident groups around the country is whether the most appropriate administrative unit of state government to provide oversight is the department of insurance. My response is that the name on the door is not as important as the state's commitment to hiring knowledgeable individuals with finance-specific training and who are not captives to the industry, regulators who are willing to take a balanced approach to oversight. The current operation of the unit of Maryland's Department of Aging charged with oversight of CCRCs strikes me as providing a good example of that commitment.
MaCCRA is a chapter of the National Continuing Care Residents Association (NaCCRA); during my visit to Maryland I learned that a MaCCRA member was an early leader in forming NaCCRA.
Friday, December 6, 2013
A recent issue of the ABA's Dispute Resolution Magazine (Fall 2013) included an article on "Elder Mediation: Coming of Age," authored by two mediation trainers, that tracks the growth of mediation for elder disputes in a variety of settings. The authors conclude: "Skilled, dedicated professionals can help parties find paths to agreements on some of the toughest and most emotional issues that families face."
Included within the article was a listing of elder dispute resolution resources:
- Alaska Court Program
- ABA Commission on Law and Aging
- Bet Tzedek
- Center for Civic Mediation, Elder Care Mediation Program
- Center for Dispute Resolution, Missouri State University
- Center for Social Gerontology
- Circuit Court of Cook County Elder Law & Miscellaneous Remedies Division
- Elder Decisions
- Elder Mediation Program of Mosaica Center for Consensual Conflict Rsolution
- Good Shepherd Elder Dispute Services Program
- LGBT Elder Care Intitiative
- Multi-Door Division of the Superior Court of the District of Columbia
- Northern Virginia Mediation Service
- Wise and Healthy Aging
Hat tip to my colleague at Penn State Dickinson, Professor Nancy Welsh, for sharing a copy of the issue. Nancy is co-chair for the editorial board for Dispute Resolution Magazine.
Tuesday, December 3, 2013
First Court Challenge FiledTo State Statute Restricting Assistance to Consumers Seeking ACA Coverage
Monday, December 2, 2013
At the heart of comparative research is the opportunity to rethink your own system. I was reminded of this point last week when meeting Claire Keatinge, the Commissioner for Older People in Northern Ireland (COPNI). Commissioner Keatinge is -- in a word -- dynamic, and it is impossible not to be impressed with her dedication to meeting the needs of older persons in her country. She is a leader, both actually and symbolically, for a hard-working team tackling a number of issues in ageing policy.
It is clear to me that "independence" is at the core of the role for the COPNI. What do I mean by independence? The COPNI is funded with public dollars, but the job includes making an independent evaluation of the needs and interests of the demographic, and then reporting and advocating for appropriate response by the government or other sectors. By comparison, I wonder whether state officers or offices charged with policy and laws in the U.S.are more likely to be serving a governmental agenda, and trying to sell that agenda to voters. This strikes me as a potentially important, if subtle, difference in systems.
A small example of the importance of independence: One of the COPNI's several goals is to identify and improve "uptake" of benefits available to older persons in the country. In Northern Ireland, and elsewhere in the U.K., there are official statistics on the dollars (whoops, I mean pounds) left on the table by individuals who fail to seek available public benefits or services. In N.I., there is a known gap. By comparison, I would be surprised to learn that we keep similar statistics on either the state or federal level in the U.S., much less have a policy of trying to reduce any gap.
Claire Keatinge also stressed that an individual assessment of need for health care, social care and security, should be exactly that, and not simply an assessment of what services are available. Helping individuals or their family members access services in the public, private and voluntary sectors is part of the COPNI plan of action, but, it strikes me that the emphasis on evidence-based policies may result in development of new services or better funding for existing programs.
Tuesday, November 26, 2013
From WBUR public radio in Boston Massachusetts, a story and podcast on "at-home funerals."
For a number of years I have invited an attorney with expertise in alternative funerals to speak to my classes. In fact, that is how I first learned that Costco carries urns and caskets (with a choice of standard or expedited shipping -- which strikes me as a trick question). As outlined by WBUR in the article, there is a surprising amount of freedom, if that is the right word, in the law of many states for families to choose informal funerals and burials.
Hat tip to Ann Murphy at Gonzaga Law for sharing this link. Our readers definitely are the key in helping to make this a "full service" blog!
Thursday, November 21, 2013
Somehow I had missed this particular incarnation of predatory lending. The National Consumer Law Center (NCLC) recently circulated a consumer impact statement on pension-based loan scams. Often advertised as "cash advances," in reality the individual is agreeing to assign future pension payments to the lender, with repayment terms that include an outrageously high interest rate. In 2011, NCLC and attorneys with the National Association of Consumer Advocacy were successful in a class action suit in state court in California, in which they challenged loans requiring "assignments" of military pay or pensions as violating federal law. The court ordered restitution to the class members.
The New York Times ran a 2013 feature on "Loans Borrowed Against Pensions Squeeze Retirees," by Jessica Silver-Greenberg, part of a series on "A Vulnerable Age," that examined financial traps that can face older adults, especially during a tight economy. A sidebar to the article detailed an example of a loan to a disabled military veteran for $10,000, with a $353 monthly payment for 60 months, leading to total costs over the life of the loan of $21,180, representing an interest rate of 36.4%.
Thursday, November 14, 2013
Via the Senate Special Committee on Aging:
If you or someone you know suspect you’ve been victim of a scam or fraud aimed at seniors, the U.S. Senate Special Committee on Aging has set up a new toll-free hotline to help. The hotline was unveiled today to make it easier for senior citizens to report suspected fraud and receive assistance. It will be staffed by a team of committee investigators weekdays from 9 a.m. to 5 p.m. EST. The investigators, who have experience with investment scams, identity theft, bogus sweepstakes and lottery schemes, Medicare and Social Security fraud, and a variety of other senior exploitation issues, will directly examine complaints and, if appropriate, refer them to the proper authorities.
Anyone with information about suspected fraud can call the toll-free fraud hotline at 1-855-303-9470, or contact the committee through its website, located at http://www.aging.senate.gov/fraud-hotline. As chairman and ranking member of the committee, Sens. Bill Nelson (D-FL) and Susan Collins (R-ME) have made consumer protection and fraud prevention a primary focus of the committee’s work. This year the panel has held hearings examining Jamaican lottery scams, tax-related identity theft, Social Security fraud and payday loans impact on seniors.
The hotline’s unveiling also coincides with the committee’s launch of an enhanced senior-friendly website. The site’s new features include large print, simple navigation and an uncluttered layout that enables seniors to find information more easily and conveniently. Online visitors can also increase text size, change colors or view a text-only version of the site.
Monday, November 11, 2013
The November 7 issue of the Chronicle of Philanthropy provides great coverage on the importance of Legal Aid organizations in disaster relief. But what first caught my eye were the photos that accompanied "A Nonprofit Pushes to Make Legal Aid Key Part of Disaster Services," by Nichole Wallace, depicting a mobile "Legal Help Center" operated by New York Legal Assistance Group.
The article explains:
"Less than a year old when [Hurricane Sandy] struck, the 41-foot vehicle is a joint project with the New York State Court's Access to Justice Program. The idea is to take legal services into neighborhoods to reach people who have trouble getting assistance because they lack transportation or child care, have a disability, speak little English, or fear coming into the office because of their immigration status.
The Mobile Legal Help Center can accomodate up to 17 people at a time, and has videoconferencing capabilities that allow access to judges for emergency proceedings, such as unlawful evictions and orders for protection in domestic-violence cases."
What a creative approach! And wouldn't mobile units be useful in providing legal services for older clients, with or without a natural disaster as the reason?
Monday, November 4, 2013
In a lengthy article, Pro Publica (in collaboration with Frontline) discusses quality of care problems along with the history of assisted living regulation. As an additional resource, Pro Publica also has developed a state-specific summary of key assisted living regulations.
In addition, California Advocates for Nursing Home Reform released a report on problems in California's assisted living facilities. The report's recommendations for reform include adoption of a tiered level of care system, annual inspections, and an on-line consumer information system.
The Assisted Living Consumer Alliance played a role in each of these examinations. ALCA board members Eric Carlson, Toby Edelman, Richard Mollot and Lori Smetanka each were quoted in the Pro Publica quality of care article. ALCA board member Jody Spiegel was part of the CANHR team that produced the report on California assisted living.
Friday, November 1, 2013
The theme of the recent LeadingAge national meeting was "Expanding the Possibilities." Consistent with that theme, at one of the general sessions, the speaker was Dan Pallotta, author of two books:
Uncharitable: How Restraints on Nonprofits Undermine Their Potential (Tufts Univ. Press 2008)
Charity Case: How the Nonprofit Community Can Stand Up for Itself and Really Change the World (Jossey-Bass Press 2012)
The presentation was both interesting and provocative, using Pallotta's experience in nonprofit fundraising and advocacy, to frame an argument that the nonprofit sector is functionally constrained by outmoded policies, thus inappropriately limiting effectiveness. His talk was organized around five points: Compensation, Advertising and Marketing, New Revenues, Time, and Risk.
Nonprofits are, of course, a huge segment of the long-term care, senior living and aging services industries. In fact, after teaching elder law and running an elder protection clinic, a few years ago I added a course on Nonprofit Organizations Law to my Penn State Law teaching package because of my growing appreciation for the importance of nonprofits.
Pallotta made the case that in analyzing the success of any nonprofit, it is wrong to focus narrowly on what percentage of a donation goes to services versus overhead. As he asks, what makes us think "overhead" is not an integral part of the cause? He urged a role for "charity defense councils" to counteract the image of nonprofits as mere handmaidens to a larger for-profit industry. He rejected an image that ties nonprofits to low wages or volunteer-only staffing.
Good food for thought, yes?
Thursday, October 31, 2013
Since 1999, Remembering When has been implemented in communities throughout North America to help thousands of older adults learn strategies to help them live safely at home for as long as possible. The program’s foundation remains the same: the 16 key safety messages–eight fire prevention and eight fall prevention–developed by experts from national and local safety organizations and focus group testing in high fire-risk states. The program will continue to be implemented through group presentations, home visits, and as part of smoke alarm installation and fall intervention programs. All of the revised training materials are available online.
“Over the next decades, the population of older adults will increase dramatically,” said Karen Berard-Reed, senior project manager for NFPA. “The new version targets adults who are just entering their older years. We hope to encourage these ‘younger’ older adults to develop important safety habits that will carry them through their senior years and help those around them develop safer behaviors.”
Representatives of fire departments and home visit agencies across the United States and Canada that have been chosen to participate in the Remembering When conference December 1-3, 2013 in Boston, will be the first trained with updated materials.
Photo by Kim Dayton. All rights reserved.