Monday, October 23, 2017

The Latest in Off-Label Prescriptions for Dementia Patients: "The Little Red Pill"

My thanks to my colleague Dermot Groome for pointing me to the CNN investigative series on "The Little Red Pill Being Pushed on the Elderly." The prescription drug in questions is Nuedexta, approved to treat PseudoBulbar Affect or PBA, a "disorder marked by sudden and uncontrollable laughing or crying." (Perhaps you have seen commercials for treatment of PBA with actor Danny Glover effectively portraying the disorder).   

According to the CNN report:

Since 2012, more than half of all Nuedexta pills have gone to long-term care facilities. The number of pills rose to roughly 14 million in 2016, a jump of nearly 400% in just four years, according to data obtained from QuintilesIMS, which tracks pharmaceutical sales. Total sales of Nuedexta reached almost $300 million that year.
 
Concerns about unnecessary prescription, side effects (including a higher incidence of falls), and federal reimbursements for cost are raised by critics:
 
Nuedexta is approved by the Food and Drug Administration (FDA) to treat anyone with PBA, including those with a variety of neurological conditions such as dementia. But geriatric physicians, dementia researchers and other medical experts told CNN that PBA is extremely rare in dementia patients; several said it affects 5% or less. And state regulators have found doctors inappropriately diagnosing nursing home residents with PBA to justify using Nuedexta to treat patients whose confusion, agitation and unruly behavior make them difficult to manage.
 
 
"There has to be a diagnosis for every drug prescribed, and that diagnosis has to be real ... it cannot be simply made up by a doctor," said Kathryn Locatell, a geriatric physician who helps the California Department of Justice investigate cases of elder abuse in nursing homes. "There is little to no medical literature to support the drug's use in nursing home residents (with dementia) -- the population apparently being targeted."
The article notes that Medicare pays for much of the use of this drug in the nursing home setting, and as we've been reported before on other off label prescriptions of  medications, federal regulators have the power to investigate and sanction improper use (not just off-label use) under the False Claims Act and similar anti-fraud regulations.  

October 23, 2017 in Cognitive Impairment, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Medicare, Science, Statistics | Permalink | Comments (0)

Friday, October 20, 2017

Health Affairs Blog: Hospice Doc Leads Us on a Journey through the Valley of the Shadow of Death

I recommend a fascinating piece on the Health Affairs Blog by Joanne Lynn, who among her many callings is a "hospice and long-term care physician. " You don't see that as a specialization very often!

The title is Traveling The Valley of Shadow of Death in 2017.  Drawing upon both her work and personal experiences, Dr. Lynn points out:

  • "First, the life possibilities of an elderly person with increasing disabilities is profoundly depending upon the surrounding community...." 
  • "Second, the preferences and priorities of elders in this phase of life vary much more than in earlier phases...."
  • "Third, we need more reliable and reasonable financing plans. Working-age people still don’t realize that they need to provide for themselves in old age. Policies need to change to make vehicles for saving affordable and reliable...."
  • "Fourth, sick and disabled elders living in the community need continuity and reliability across time, instead of the cut-up care system we provide...."

She seems to advocate a unique form of deregulation, concluding:    

We need an era of innovation and testing, shaped by the facts of the situation. We need a new set of policies for our new way of living at the end of our lives. Let’s try substantial innovations, mostly by relieving communities of the burdens of past policies and regulations, and let’s learn quickly so we can count on living comfortably and meaningfully in the last years of our lives.

I recommend the whole essay.  

October 20, 2017 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Ethical Issues, Health Care/Long Term Care | Permalink | Comments (0)

Thursday, October 19, 2017

Fountains of Youth (Or Just Spending?): A Positive Take on "Anti-Aging" Industries

Every day I fight with my email in-box, trying to delete the stuff that just isn't necessary to open, much less read.  For example, I know more or less which emails -- no matter how tempting the regarding line -- are what I call "junk science" emails that claw their way past my spam filter.  A lot of them involve "anti-aging" theories that promote foods, exercises, vitamins or minerals that "May" prevent cognitive or physical decline.  "May" with a capital "M."  

But United States District Judge Roslyn Silver, from Arizona, recently shared an article she's using with a class she is teaching at Arizona State's law school. In the June 2017 issue of Smithsonian Magazine, the subtitle for the article explains: "Backed by digital fortunes of Silicon Valley, biotech companies are brazenly setting out to 'cure' aging."  The author profiles the work of controversial author Aubrey de Grey and "Chief Science Officer" from SENS, a biotech research enterprise in California.  The author summarizes:  

The basic vision behind SENS is that aging isn’t an inevitable process by which your body just happens to wear out over time. Rather, it’s the result of specific biological mechanisms that damage molecules or cells. Some elements of this idea date back to 1972, when the biogerontologist Denham Harman noted that free radicals (atoms or molecules with a single unpaired electron) cause chemical reactions, and that these reactions can damage the mitochondria, the powerhouses within cells. Since then, studies have linked free radicals to all sorts of age-related ailments, from heart disease to Alzheimer’s.

 

De Grey takes this concept further than most scientists are willing to go. His 1999 book argued that there could be a way to obviate mitochondrial damage, slowing the process of aging itself. Now SENS is working to prove this. Its scientists are also studying other potential aging culprits, such as the cross-links that form between proteins and cause problems like arteriosclerosis. They’re looking at damage to chromosomal DNA, and at “junk” materials that accumulate inside and outside cells (such as the plaques found in the brains of Alzheimer’s patients).

Despite the controversies associated with the work of de Grey and other anti-aging proponents, the article points to a "mini-boom of private investment in Silicon Valley, where a handful of labs have sprung up in SENS' shadow, funded most notably by tech magnates."

One of the early critics of de Gray concedes that anti-aging theorists have attracted needed money and energy into age-related research beyond "just" the 1,000-year-old human goal:

More than a decade later, [University of Massachusetts Medical School Professor] Tissenbaum now sees SENS in a more positive light. “Kudos to Aubrey,” she says diplomatically. “The more people talking about aging research, the better. I give him a lot of credit for bringing attention and money to the field. When we wrote that paper, it was just him and his ideas, no research, nothing. But now they are doing a lot of basic, fundamental research, like any other lab.”

I can definitely see how this article would be useful in a law school class on aging, elder law, or estate planning.  It raises fundamental questions in governance, economics and human rights, including implications from disparities in life expectancy that already exist and are increasing,  associated with comparative wealth.  

For the full article, see Can Human Mortality Really be Hacked? by Elmo Keep.

October 19, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Estates and Trusts, Ethical Issues, Health Care/Long Term Care, Statistics | Permalink | Comments (0)

Wednesday, October 18, 2017

Voluntary Stopping Eating & Drinking (VSED) When Capacity Lacking?

You may have read recently about a woman who had an advance directive that addressed artificial nutrition and hydration. The SNF where she lived was hand feeding her, over her husband's objections. The trial court sided with the SNF and the state ombudsman who had argued that "state rules to prevent abuse required the center to offer residents three meals each day and provide help eating, if needed."  Can one provide in her advance directive that she refuses in advance oral fluids and foods at some point in the future? The Kaiser Health News article, Dementia Patient At Center of Spoon-Feeding Controversy Dies, explores the specific case as well as the issue.  The patient, as the title explained, died last week. 

Here's the issue illustrated in this matter.

At issue is whether patients with Alzheimer’s and other progressive diseases can stipulate in advance that they want oral food and liquid stopped at a certain point, hastening death through dehydration. It’s a controversial form of what’s known as VSED — voluntarily stopping eating and drinking — a small but growing practice among some terminally ill patients who want to end their lives. In those cases, people who still have mental capacity can refuse food and water, usually resulting in death within two weeks.  .... “The right to VSED is reasonably well-established, but it’s when a person isn’t competent that’s the issue,” said Paul T. Menzel, a retired bioethicist at Pacific Lutheran University in Tacoma, Wash., who has written extensively on the topic.

So in thinking about a person saying no to food and fluids, "VSED doesn’t require a law or a doctor’s approval. But the question of whether it’s possible for people who can no longer actively consent to the procedure remains ethically and legally unclear. That’s especially true for patients who open their mouths to accept food and fluids...." 

Have you looked at your state's laws to see if there is a position on this?  According to the article, almost 24 states have laws on "assisted feeding" some of which "specifically prohibit withdrawing oral food and fluids. Other states address only artificial feeding or are unclear or silent on the issue [and] ... Idaho — appears to sanction withdrawal of assisted feeding by a health care proxy" according to an expert quoted in the article. However, "Idaho state law also prohibits any form of assisted suicide and requires “comfort care” for patients if artificial nutrition and hydration is withdrawn. It’s not clear whether a request to halt assisted feeding would be honored" said an expert on Idaho's statute on Medical Consent and Natural Death Act.

 

 

October 18, 2017 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Federal Statutes/Regulations, Food and Drink, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (1)

Thursday, October 12, 2017

Daughters' Hidden Video Camera In Mother's Nursing Home Documents Caregiver Abuse; 10th Circuit Affirms $1.2 Million Damage Award

The 10th Circuit in Racher v. Westlake Nursing Home Limited Partnership, d/b/a/ Quail Creek Nursing & Rehab Center, affirmed an award of $1.2 million in compensatory damages to the estate of  Mrs. Mayberry,  a 90+ year old resident.  Key evidence included five video recordings, from a camera hidden in the resident's nursing home room by her daughters, that showed:

... [Employee] Gakunga slapping Mrs. Mayberry in the face with latex gloves, wadding up the gloves, stuffing them in Mrs. Mayberry's mouth, and forcibly holding them there as Mrs. Mayberry attempts to push Gakunga's hand away. . . . .  [A second employee] Kaseke is seen in the videos watching this take place. . . . . The videos then show Gakunga and Kaseke roughly lifting Mrs. Mayberry from her wheelchair into bed and Gakunga pushing on Mrs. Mayberry's face in what appears to be an attempt to make her lie down. . . . One clip shows Gakunga pointing her finger at Mrs. Mayberry and apparently scolding her or perhaps threatening her. . . . Finally, the video clips show Gakunga “performing some sort of compressions with both hands to [Mrs. Mayberry's] torso.” . . . .  Plaintiffs assert that this action was intended to force Mrs. Mayberry to empty her bladder so the caretakers would not have to change her diaper as often. . . . .  Quail Creek and the caretakers denied any knowledge of this practice, but acknowledged that there was no medical justification for the action.  

The daughters testified their mother went downhill as a result of the incidents that occurred between February and early April 2012 and that Mrs. Mayberry died in July 2012 "just three months after the abuse was discovered."

One issue on appeal was whether Oklahoma's "statutory limitation on noneconomic damages" of $350,000 was mandatory. Apparently the statutory cap was raised for the first time in a motion to "alter or amend the judgment," 28 days after the judgment was entered in the case and more than a month after the jury trial concluded.   In its September 28, 2017 opinion, the 10th Circuit had an interesting analysis of the interplay between federal rules of civil procedure and the need to "predict" state substantive law in a diversity case,  and "agreed with the plaintiffs that the cap is an affirmative defense that [defendant nursing home] waived."  

October 12, 2017 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Wednesday, October 11, 2017

Are Guardianship Court "Oversight" Problems Pervasive?

 During the last several years, I've received calls from around the country about possible guardianship "oversight" concerns. And since The New Yorker article came out last week focusing on guardianship issues in Las Vegas Nevada, I've been getting more calls. The question arises: Is there a pervasive problem with court-appointed guardians for older adults in the United States?  

In my opinion, the answer is "no, not pervasive."  At least, that's my answer if the definition of pervasive is "universal," or omnipresent, or rife, or widespread. In the 20+ years I've been working in elder law, I've unfortunately reviewed a lot of cases of exploitation, but it is comparatively rare that I've been asked to examine a court-monitored guardianship where there was a problem created by inadequate attention by the courts, much less active misconduct by the court or agency. Granted, that is just one law professor's experience.

Still, in my opinion, the oversight problems that do exist within the U.S. are significant, periodic, sometimes recurring or persistent, and often have common elements.  The issues can exist in any county court or fiduciary administrative system. Historically, these courts -- sometimes called probate courts, fiduciary courts, surrogate courts, or orphans courts -- depended on the guardians for management of all issues, once the appointments were made. The judges trusted their appointees to take their fiduciary responsibilities seriously. But, as is sometimes said in international relations, the problem can be how best to "trust, but verify" proper behavior. With more elder boomers, there can be increased need for guardians, and thus more potential for guardians to be monitored.

  • For example, in Maricopa County, Arizona, an investigative news series, that began in 2008 with the reporting of Laurie Roberts for the Arizona Republic, described a number of mishandled older adult guardianships.  In some instances, the family members were so busy arguing about money, that the incapacitated elder was ignored, while his or her estate was diminished to pay fees.  Sometimes the question was whether a "full" guardianship was even necessary.  The problems, once investigated not just by journalists but by the courts, resulted in changes in Arizona guardianship law.
  • In Palm Beach County, Florida, complaints about appointment of a particular individual as guardian in a large number of cases, focused on conflict of interest and claims of favoritism by the court, complaints that came from a number of families. Eventually, in one case challenging the system,  a jury reportedly awarded more than  $16 million against two West Palm Beach attorneys for "breach of fiduciary duties."  The complaints also led to state investigations of Florida's entire oversight systems, and brought three years of legislative changes to Florida guardianship laws.
  • Most recently, two co-founders of a nonprofit guardianship company, Ayudando Guardianship, in Bernalillo County, New Mexico were indicted in federal court in July 2017 with criminal charges including conspiracy, mail fraud, aggravated identity theft, and money laundering.  The company was the appointed fiduciary in hundreds of cases. 

Especially when the Clark County, Nevada cases are included in this list of recent challenges to guardianship oversight systems, concerns about proper and objective oversight are real; without a equally real commitment to more careful selection, training, monitoring and accountability for guardians, the problems can be predicted to increase as the baby boomer generation of seniors get to their 70s, 80s, or 90s.  In 2016, the GAO for the United States responded to a U.S. Senate Special Committee on Aging's request for data on "the extent of abuse by guardians," and concluded that "courts lack comprehensive data on older adults in guardianships and elder abuse by guardians, but some courts have limited information."  Unreliable data certainly leaves open the potential for the occasional problems to become pervasive problems.    

Continue reading

October 11, 2017 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, State Cases, State Statutes/Regulations, Statistics | Permalink | Comments (2)

Tuesday, October 10, 2017

Pennsylvania Tightens Requirements for Notaries Public

Effective October 26, 2017, another set of requirements comes into play for notaries public in Pennsylvania. The changes, which became effective in stages over the course of many months, responded to reports of abuses.  Indeed, when I was supervising our Elder Protection Clinic at Dickinson Law,  we would occasionally come into contact with powers of attorney or deed transfers that were allegedly signed in from of a notary as a witness, but which clearly were not.  

On one occasion, we learned that another law office "routinely" had the in-office notary using her official power for documents signed in the home of the attorney's clients.  She was following her boss's direction.  Sadly, our law students had an extra lesson that day on potential obligations to report such violations to the State Bar.  

The most recent changes to Pennsylvania's law include a notary's mandated attendance at training classes. The notary was, even before the latest changes, required to have "personal knowledge" or "satisfactory evidence" of the identity of the individual whose signature was to be notarized, but the most recent changes specified documents that can be used as satisfactory evidence:  "a passport, driver's license or government-issued nondriver identification card, which is current and unexpired," or another form of government identification which is current and "contains the signature or photograph of the individual, and is satisfactory to the notarial officer." 57 Pa.C.S.A. Section 307. A third alternative is documenting identity through "verification on oath . . . of a credible witness," a vague process that seems to raise more red flags than it eliminates. 

Overall, the changes are a sad reflection of the times, not the least of which are the extraordinary opportunities for identity theft triggered by data hackers. Some Pennsylvania elder law attorneys, however, are wondering whether the requirement of current, unexpired government i.d. cards will make it more difficult to meet the needs of disabled, older clients.

Continue reading

October 10, 2017 in Consumer Information, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, State Statutes/Regulations | Permalink | Comments (0)

Monday, October 9, 2017

Is There a "Diversity Problem" in Senior Living?

Steve Moran, who writes for Senior Housing Forum, a website that offers itself as a "place for conversation and collaboration," always seems willing to take on sensitive topics.  Recently, in a commentary piece entitled Black Consumers and Senior Living, he nonetheless began:

I am terrified to be writing and publishing this article.  It seems that writing anything about race is fraught with all kinds of downsides and very little in the way of upside. Except that we have an ethnic problem in senior living.  Today, based on resident populations, only white people (and Asians) seem to like senior living.

He addresses provider attempts to "explain away" the problem and arguments about whether "Blacks and Whites have different world views."  Ultimately, recognizing the need for both sensitivity and fearlessness, he concludes, "[I]f senior living is really a great thing, and I believe it is, then we have an obligation" to make it available to everyone.  

Certainly there are "marketing" reasons to reach out to a broader circle of perspective clients to offer supportive, attractive community living.  But, I think Steve's short post is a good start on other fundamental questions about what consumers want, need, expect, and cherish as they approach some invisible line that makes them eligible for senior living.  

October 9, 2017 in Consumer Information, Discrimination, Ethical Issues, Housing, Retirement | Permalink | Comments (0)

Friday, October 6, 2017

Guns, Aging & Suicide

The last few weeks have been very tough, haven't they?  As have the last few months, and perhaps even the last few years.  

Many seem to be trying to understand why a 64-year-old "retired" man in the U.S. would assemble an arsenal of weaponry, unleash it on a crowd of innocents enjoying a last few weekend hours of music, and then take his own life.  While it is, on a comparative scale, unusual for a 60+ individual to be involved in a mass shooting, "older men" apparently have a comparatively high suicide-by-gun rate.  While there may be no way to understand the motivation for the most recent murders, there are still reasons to ask whether aging and deteriorating cognitive health can be factors in gun-related deaths.  

In the search for some understanding I read Leah Libresco's opinion piece in the Washington Post:  "I used to think gun control was the answer.  My research told me otherwise." 

In that article, her research on the annual 33,000+ gun deaths in America, led her to several interesting observations and conclusions.  She writes, for example, that the statistics showed her:

  • "Two-thirds of gun deaths in the United States every year are suicides."
  • "Older men, who make up the largest share of gun suicides, need better access to people who could care for them and get help."

Libresco's essay sent me in turn to a feature story, part of a FiveThirtyEight series analyzing annual gun deaths, on "Surviving Suicide in Wyoming," by Anna Maria Barry-Jester.  She writes in greater detail about warning signs of deteriorating mental health, especially among older men: isolation, sometimes self-imposed; sleeplessness; depression; anxiety; and unresolved physical health problems. 

As these articles point out, limiting access to guns is appropriate for individuals with suicidal thoughts. That's different than "gun control laws."  And while guns may too often be the means to effectuate "rash desperate decisions," these researchers also suggest the greatest need is for better public awareness and response to warning signs, and for improved diagnosis and access to effective care, including social, mental and physical health care.    

October 6, 2017 in Advance Directives/End-of-Life, Crimes, Current Affairs, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Science, State Statutes/Regulations, Statistics | Permalink | Comments (0)

Thursday, October 5, 2017

Former Secretary of Commerce Penny Pritzker: On Her Early Business Career in "Senior Living" & Avoiding Conflicts of Interest

I'm a fan of early morning podcasts of high-profile interviews.  For me there is something about listening to them in dim light before my day gets fully started.  It allows me to fully "hear" little nuggets of information, ideas about innovations or even law-related gems.  

Recently I listened to the August 28, 2017 podcast of David Axelrod's interview of Penny Pritzker, who was Secretary of Commerce during the second term of President Obama.  I'd forgotten that Pritzker's early business career included a start-up with "Classic Residence by Hyatt," later rebranded as Vi, a form of high-end senior living communities, operated mostly in the "CCRC" model.  Pritzker talks about a family tradition of "graduating from law into business." From the interview transcript, where shes discusses her entry into the family business:

I went to law school [and] I went to business school [at Stanford]. I came back to Chicago and and arrived. And it wasn't obvious what I was going to do but I wanted I had seen my family build businesses and I figured I wanted to do that too. And but it was an environment where there were no women. There were no women, there were no women vice presidents, there were no women in the organization. There was--there were no women parking in the parking garage if you will know women eating in the dining room if you will. And so it required me to I think find what I call the white space. I had to figure out where did I fit. And I felt that the place that I fit best was to really actually create new businesses. And so I became an entrepreneur within two years of arriving back in Chicago. I--there was talk of starting a new business in senior living and I basically said to my uncle I want to do that. And that's how I started my first business which was Classic Residence by Hyatt. And it was you know I was 27 years old. I had a terrific education and I had worked during school as well but there was so much I needed to learn and I had to learn by doing. And I made a ton of mistakes. I didn't know. Some of the people I hired were wrong, some of the decisions I made were wrong. 

She speaks candidly about the experience, admitting "we didn't really know what we were doing and we weren't sure exactly what the market [of senior living] wanted or needed."  At one point, she realized a $40 billion family investment in her business was at risk, and she talked to the then-patriarch of the Pritzker family, her uncle Jay Pritzker , and said that "if we can't turn this around in six months you should fire me and we should liquidate."  

Continue reading

October 5, 2017 in Consumer Information, Ethical Issues, Health Care/Long Term Care, Housing | Permalink | Comments (0)

Wednesday, October 4, 2017

New Yorker: Article Focuses on Clark County Nevada to Demonstrate Systemic Failures under State Guardianships

We've posted often on the Elder Law Prof Blog about problems with guardianships for older adults, highlighting reports from Nevada, Florida and Arizona, for example.

The New Yorker Magazine offers  "Reporter at Large" Rachel Aviv's feature in its October 9, 2017 issue, where she digs deeply into concerns raised by multiple cases in Clark County, Nevada where a court-favored, appointed guardian, April Parks, was often involved:

Parks drove a Pontiac G-6 convertible with a license plate that read “crtgrdn,” for “court guardian.” In the past twelve years, she had been a guardian for some four hundred wards of the court. Owing to age or disability, they had been deemed incompetent, a legal term that describes those who are unable to make reasoned choices about their lives or their property. As their guardian, Parks had the authority to manage their assets, and to choose where they lived, whom they associated with, and what medical treatment they received. They lost nearly all their civil rights. 

Parks and other individuals, including her husband, were eventually indicted on criminal charges including perjury and theft, "narrowly focused on their double billing and their sloppy accounting," but as The New Yorker piece suggests, the court system itself shares blame for years of failing to impose effective and appropriate oversight over the guardians.  

In the wake of Parks’s indictment, no judges have lost their jobs. Norheim was transferred from guardianship court to dependency court, where he now oversees cases involving abused and neglected children. Shafer is still listed in the Clark County court system as a trustee and as an administrator in several open cases. He did not respond to multiple e-mails and messages left with his bookkeeper, who answered his office phone but would not say whether he was still in practice. He did appear at one of the public meetings for the commission appointed to analyze flaws in the guardianship system. “What started all of this was me,” he said. Then he criticized local media coverage of the issue and said that a television reporter, whom he’d talked to briefly, didn’t know the facts. “The system works,” Shafer went on. “It’s not the guardians you have to be aware of, it’s more family members.” He wore a blue polo shirt, untucked, and his head was shaved. He looked aged, his arms dotted with sun spots, but he spoke confidently and casually. “The only person you folks should be thinking about when you change things is the ward. It’s their money, it’s their life, it’s their time. The family members don’t count.”

There are fundamental issues at the heart of this kind of history.  Necessary and well-managed guardianships, under the best of circumstances, change the lives of individuals in ways that no person would want for him or herself.  But when a guardianship system itself breaks down -- especially where judges or other administrators are unwilling or unable to be self-critical -- the confidence of the public in "the rule of law" is destroyed.     

My thanks to Karen Miller (Florida), Jack Cumming (California), Richard Black (Nevada -- who is also quoted in The New Yorker piece), and Dick Kaplan (University of Illinois Law) for bringing The New Yorker piece to our attention quickly. 

October 4, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Tuesday, October 3, 2017

Canadian Elder Law Conference - November 2-3, 2017

The Canadian Elder Law Conference  is again hosting a two-day program on the law and policy issues impacting older adults, in Vancouver, British Columbia on November 2-3, 2017.

After taking this course, you will:

  • be better able to identify and address the legal issues that impact your older client
  • be familiar with recent trends, developments, and research in the law with respect to elder law topics such as medical assistance in dying, mental capacity, undue influence, independent legal advice, financial abuse, and adult protection
  • better understand the legal, practical, and ethical issues in relation to older clients with mental capacity and self-neglect issues

The program this year will include a debate on "video surveillance in long-term care," a panel on medically assisted death and advance consent, and a discussion of undue influence and independent legal advice.

For more, see  Coming of Age: Elder Law in Canada and Its Future, including registration information.

October 3, 2017 in Advance Directives/End-of-Life, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Programs/CLEs | Permalink | Comments (0)

Monday, October 2, 2017

"Probable Cause" Prevents Son-in-Law/Agent from Suing for Malicious Prosecution in Elder Fraud Case

The case of Fisher v. King, in federal court in Pennsylvania, strikes me as unusual on several grounds.  It is a civil rights case, alleging malicious prosecution, arising from an investigation of transferred funds from elderly parents, one of whom was in a nursing home, diagnosed with "dementia and frequent confusion."  

Son-in-law John Fisher was financial advisor for his wife's parents, both of whom were in their 80s. He and his wife were charged with "theft by deception, criminal conspiracy, securing execution of documents by deception and deceptive/fraudulent business practices" by Pennsylvania criminal authorities, following an investigation of circumstances under which Fisher's mother-in-law and her husband transferred almost $700k in funds to an account allegedly formed by Fisher with his wife and sister-in-law as the only named account owners.  A key allegation was that at the time of the transfer, the father-in-law was in a locked dementia unit, where he allegedly signed a letter authorizing the transfer, prepared by Fisher, but presented to him by his wife, Fisher's mother-in-law.  The mother-in-law later challenged the transaction as contrary to her understanding and intention.

Son-in-law Fisher, his wife, and his wife's sister were all charged with the fraud counts.  They initially raised as defense that the transactions were part of the mother's larger financial plan, including a gift by the mother to her daughters, but not to her son, their brother.  

As described in court documents, shortly before trial on the criminal charges the two sisters apparently agreed to return the funds to their mother, and, with the "aggrieved party" thus made whole, Fisher and his wife entered into a Non-Trial Disposition that resulted in dismissed of all criminal charges. At that point, you might think that everyone in the troubled family would wipe their brows, say "phew," and head back to their respective homes.

Not so fast.  Fisher then sued the Assistant District Attorney and the investigating police officer in federal court alleging violations under Section 1983 -- malicious prosecution and abuse of process. 

Continue reading

October 2, 2017 in Cognitive Impairment, Crimes, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Property Management, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Sunday, October 1, 2017

The Black, White & Gray of Consent to Sexual Relations in Long-Term Care

Eagle Crest, a 126-bed skilled nursing facility in California, once known as Carmichael Care & Rehabilitation Center, is "voluntarily" closing its doors. A major reason for parent corporation Genesis HealthCare's  decision appears to be an incident of sexual contact between two aged residents at the facility in February, 2017.  Not a violent contact and apparently not one involving physical or mental injury.  But clothing was removed and fluids were later documented.  Now residents are being transferred and more than 70 employees will reportedly be laid off. 

As one of the two residents had Alzheimer's disease, and thereby was deemed unable to consent to sexual relations, the facility "self-reported" the contact as possible abuse to appropriate state authorities.   A criminal investigation found no grounds for prosecution.  A California Department of Public Health report, however, made the recommendation to federal authorities last summer to "drop the facility from its medicare provider rolls, a drastic action that strips a nursing home of its critical government funding," according to news reports.  The actual closure action was made voluntarily by Genesis.

Those are some of the black and white facts reported by the Sacramento Bee, which has published a series of news articles tracking this facility for many months. The "gray" facts are more complicated, and raise questions at the heart of any LTC operation:

  • Is it possible the state overreacted and misconstrued a "quasi-consensual" contact between a "lonely man and a confused woman"? 
  • How far must a LTC provider go to prevent intimate contact between residents?
  • After one report of sexual contact between residents, does that mean one or both residents must be treated as a risk that requires special procedures to prevent -- or at least reduce the likelihood -- of them being involved in future sexual contact?
  • How does a long-term care facility achieve a restraint-free environment -- a federally sanctioned goal -- while also charged with protecting ambulatory residents from intimate contact?  
  • Is it possible for residents (and their family members or other health care agents?) to release a facility from liability arising from "un-consented" sexual relations among residents?

Continue reading

October 1, 2017 in Cognitive Impairment, Consumer Information, Crimes, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Thursday, September 28, 2017

"CHRONIC" - Senate Bill 870 Passes Senate With Bi-Partisan Support - Is It Significant?

On Tuesday, September 26, 2017, at the same time that there was much sound and fury, but no vote, on the Graham-Cassidy Senate effort to repeal Obamacare, the U.S. Senate quietly approved on a voice vote Senate Bill 870, titled "Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017"or "CHRONIC Care" for short.  

The vote sends the bill on to the House for any next step of action. In press releases after the vote, sponsors welcomed Senate passage as a sign of bipartisan support for "strengthening and improving health outcomes for Medicare beneficiaries living with chronic conditions," noting:  

“This bill marks an important step towards updating and strengthening Medicare’s guarantee of comprehensive health benefits for seniors,” said [Oregon's Senator Ron Wyden,] the ranking Democrat on the Senate Finance Committee. “Medicare policy cannot stand idly by while the needs of people in the program shift to managing multiple costly chronic diseases,” Wyden said. “This bill provides new options and tools for seniors and their doctors to coordinate care and makes it less burdensome to stay healthy.”

The bill that passed the Senate on Tuesday was co-sponsored by Senate Finance Committee Chairman Orrin Hatch (R-Utah), as well as Sens. Johnny Isakson (R-Ga.) and Mark Warner (D-Va.)

Initial review of the modestly ambitious bill shows that if passed in full by the House, the legislation would extend by 2 years the "Independence at Home Demonstration program," now in its 5th year, with funding otherwise set to run out at the end of September.  Additional provisions address "telehealth" services and direct studies or accounting reports on Medicare Advantage plans.  

The Independence at Home Demonstration program seems worthy of additional operation and tracking, as at least on paper it trends towards what most people seem to want, i.e., better health care access while still at home, rather than waiting for facility-based services.  For more on preliminary outcomes from the Demonstration program, see "Corrected Performance Results" from Year 2, released in January 2017.  

On the other hand, it is difficult to resist the irony that a great deal of work seemed to go into crafting the acronym, "CHRONIC," which also happens to be the street name for "very high-quality marijuana."    

 My special thanks to my newest Dickinson Law colleague, Professor Matthew Lawrence, who comes to us with fabulous experience in health care law, for helping identify this active piece of legislation.  

September 28, 2017 in Current Affairs, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, Social Security | Permalink | Comments (0)

Wednesday, September 27, 2017

"Assisted Living Compare" Database in the Works?

The federal Medicare website offers a"Nursing Home Compare" website, which provides useful information on Medicare and Medicaid certified skilled care facilities across the country.  The available information includes: 

  • How nursing homes have performed on health and fire safety inspections
  • How the nursing home is staffed with nurses and other healthcare providers
  • How well nursing homes care for their residents

But, as we write about so often on this Blog, the majority of senior care occurs outside of nursing homes, with exponential growth in Assisted Living facilities.  Thus, it is interesting to hear that a commercial entity has announced it will soon offer access to data on assisted living places.  From McKnight's Senior Living News:  

“For the first time, the seniors housing industry will have a single source for assisted living asset analysis, reputation evaluation, portfolio monitoring, operator benchmarking, clinical analytics, market analysis and consumer education, with a key benefit being that the burden is not on assisted living providers to submit the data,” Arick Morton, CEO of VisionLTC, said in a statement.

 

“We've categorized the citations so you can see where areas of concerns are within the different assisted living facilities based on some of the citation standardization work that we've done,” Jessica Curtis, Formation Healthcare Group vice president of clinical systems and analytics, told McKnight's Senior Living.

Unfortunately, in the short run, it appears the database will be marketed exclusively to commercial players, including "operators, real estate investment trusts, lenders, investment groups and clients [of developer Formation Healthcare Group] who have expressed interest."  Curtis explained:  

“It will be a paid subscription-type service for them,” Curtis said. “As a future development opportunity, we certainly see the need for this type of information to be available for consumers and the general public, and so that may be a consideration for a future version,” she added.

For more, read "Nursing Home Compare-Like Site For Assisted Living to Launch Next Month."

September 27, 2017 in Consumer Information, Ethical Issues, Health Care/Long Term Care, Housing | Permalink | Comments (0)

Tuesday, September 26, 2017

Rental Housing and Seniors -- the Live-In Care-Giver Problem?

Recently, our law school's Community Law Clinic represented a woman who had been living with her brother for more than a year at his 2-bedroom rental apartment.  The landlord was fully aware of the situation.  Both brother and sister were 70+, and the sister's presence meant that the brother had appropriate assistance, including assistance in paying his bills (and rent!) on time.  However, a few weeks ago the brother was hospitalized on an emergency basis, and then required substantial time in a rehabilitation setting, and may not be able to return to his apartment.  

What's the problem?  When the landlord learned that the brother had been living away from the apartment for several weeks, and was not likely to return, the landlord notified the sister she could not "hold over" and eventually began eviction proceedings against her.  Fortunately, the Clinic was able to use state landlord-tenant law to gain some time for the sister to find alternative housing (and to arrange for her brother's possessions to be moved), but both brother and sister were unhappy with the compelled move.

Lots of lessons here, including the need to read leases carefully to determine what that contract says about second tenants, who aren't on the lease.  In this situation, the landlord's attempted ouster was probably triggered by the sister making a few reasonable "requests" for improvements to the apartment.  The landlord didn't want a "demanding" resident!

The question of "rights" of non-tenant residents happens often in rental housing -- without necessarily being tied to age.  

I was thinking about this when I read a recent New York Times column, which offered an additional legal complication -- New York City's rent control laws, and the needs for "dementia-friendly" housing, that can involve caregivers. See Renting a Second Apartment for a Spouse Under Care. 

 

September 26, 2017 in Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Housing, Property Management, State Cases, State Statutes/Regulations | Permalink | Comments (2)

Monday, September 25, 2017

Video: Elder Law Attorney Uses Her Experiences to Explain Why Graham-Cassidy Repeal of ACA Isn't Right Answer

In a 3-minute YouTube video, Texas Elder Law Attorney Jennifer Coulter explains how the Affordable Care Act has affected her clients -- and herself -- in a positive way.  She makes a principled, compelling case for why "getting it right" on health care is far more important than political sound bites and rushed repeal measures.  

 

September 25, 2017 in Consumer Information, Current Affairs, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, Social Security | Permalink | Comments (0)

Thursday, September 21, 2017

The "Well-Meaning Friday Child" Syndrome and Long-Distance Caregiving


St._Nicholas_(serial)_(1873)_(14596944999)There's an old rhyme that's been running through my head lately, the one about Monday's child (who was fair of face) and so on.  In the rhyme, "Friday's child is loving and giving."

I like to think of myself as Friday's child, even as I confess I don't quite live up to the standard of being truly giving.  For example, I haven't changed jobs or given up my job to be a more direct caregiver for my parents. I'm the child who flies across the country on long-weekends to my parent's home town, and tries to demonstrate my loving and giving nature by fixing all of their problems.  I have the "well-meaning Friday child" syndrome.  And there are a lot of us out there; I'm often seated next to someone attempting this same care mission on red-eye airplane flights.

Mostly, this pattern tends to drive my folks and my sister, who lives about 30 minutes from my parents' home, a bit crazy.  I rationalize my behavior by telling myself, "They asked me to fix XYZ problem!" But doing so on the run is often a less-than-successful strategy.  When my father was alive and still at home, he used to respond to my arrival with an immediate question, "when are you leaving?"  I used to try to explain away that response by thinking, "he just wants to know so that he can get in an extra ride to the airport, one of his favorite outings."  But now my mom is asking me the same question and she doesn't enjoy airport rides.    

Over time, one of the things I've learned is that rather than trying to impose solutions, it's better to use these short trips to identify options.  For example, as it became clear (at least to me) that my father might not be able to stay at home for the rest of his life, even with round-the-clock assistance, I suggested to my mother that we make a long list of different types of care settings and visit one each time I was home.  Sometimes we even saw two spots.  Sometimes we made a second visit to a spot we'd looked at earlier. Eventually my mother, worn out and worn down by the care needs of her husband, called me and suggested it "was time" to select a spot, and she already knew which spot was the right one. That process took more than eight months of visits.  It meant my sister, my mom and I needed to be on the same team for this big change.

The spot Mom chose -- one of the first on our visit list -- wasn't the fanciest, but it proved to be perfect for Dad.  The first few weeks were rough on everyone, but Dad did settle in and sometimes, out of the blue, he would say, "This is a wonderful place, isn't it?" For him it was actually a better place because he had five safe acres of freedom to roam, rather than being trapped in a multi-storied house that made movement much more dangerous and him more anxious. He calmed down, my mom calmed down, my sister got some breathing space, and I relaxed a bit on those still-frequent weekend visits.

Elder Law attorneys know all about the well-meaning child, and they tend to keep the decks clear on Fridays for the meetings with "out-of-town" children, often with one or both parents in tow.  The experienced attorney knows how to find the balance between "rush" and "enough time," in order to help families make the best decisions for the future.    

September 21, 2017 in Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Housing | Permalink | Comments (0)

Tuesday, September 19, 2017

Dispute Between Texas Senior Living Providers Sheds Light on Marketing Labels Such as "Assisted Living"

We have written on many legal issues that arise from the attempt by the senior care living industry to market their housing products.  For example, see here, here and here for coverage of recent disputes and proposals affecting so-called "assisted living" or "personal care" providers.

Recently In Texas, two competitors have been arguing over the definition of assisted living.  

In LMV-AL Ventures, LLC d/b/a The Harbor at Lakeway vs. Lakeway Overlook, LLC., a licensed assisted living facility, Harbor, is attempting to block operations by a new competitor, LTIL, arguing that despite the competitor's attempts to self-identify as offering only "independent living," it is really an unlicensed assisted living community.  Harbor earlier had negotiated with the developers of the large-scale community for a deed restriction that would have prevented a competitor offering "assisted living" from moving in.  

On May 20, 2017, the United States District Court for the Western District of Texas denied Harbor's motion for  preliminary injunctive relief, concluding that Harbor had failed to satisfy its burden to establish "a substantial likelihood of success on the merits."

Part of what is interesting in this dispute is the magnitude of Harbor's efforts to prove their theory that LTIL was an assisted living community in disguise.  Harbor hired a private investigator to pose as a prospective client for LTIL.  The investigator tape-recorded a sales representative for LTIL.  

Arguably, it  seems the representative walked a very narrow line between emphasizing ways in which the planned community would meet the assistance needs of an older and potentially disabled client, while also attempting to characterize the menu of services available for purchase from an on-site home-health company as more affordable than the similar services offered by an "assisted living" facility.

 During the meeting, Ms. Parker described some of the amenities and services LTIL expected to offer. She explained that LTIL intended to offer three meals a day for residents prepared by an onsite chef, housekeeping, and transportation services. . . . Ms. Parker also described how LTIL features 140 apartments with a variety of floor plans. . . .  Ms. Parker stated Capitol [a "home health provider compamy]would be renting space inside LTIL and could provide care such as bathing assistance an elderly resident might need. . . .  She indicated personnel would staff the concierge desk twenty-four hours a day and residents would be given a pendant to call for assistance.  

Ms. Parker also explained the difference between LTIL and an assisted living facility. According to Ms. Parker, “with[ ] assist[ed] living you're paying a little bit more money but you're also getting care givers that are there on site, uh, all hours of the day. ... and you kind of pay for, the different services that you need. Some medication reminders, bathing and stuff like that. Uh, our community is an independent living.... so the residents that live there are pretty much independent. We don't provide caregivers to help do these things all the time.” . . .  Ms. Parker further described how a resident may later need to move to a place that “can give her more care or an assisted living [facility]” when she needs more help. 
 
One one level, the case demonstrates the level of competition that exists among companies marketing senior living properties to prospective residents.  Lots of providers are trying to be "the best choice" for aging adults.
 
But, on another level, the case shines a light on why states often do attempt to regulate senior care providers beyond the usual "nursing home" identity.
 
Without clear and enforceable rules about how a provider can market to the public, it seems likely that sales representatives could be tempted to fudge the line of what their facility offers, to match the prospective resident's desires about services and price.
 
Indeed, misrepresentation is at the heart of the allegations in the California class action case we discussed earlier this month, filed by care-needing residents against Brookdale Senor Living's "assisted living" operations, alleging unfair trade practices and consumer rights violations.  

September 19, 2017 in Consumer Information, Current Affairs, Ethical Issues, Federal Cases, Housing, Property Management, State Statutes/Regulations | Permalink | Comments (0)